The Genesis of Medication Errors
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Errors can be classified into two broad categories: ‘mistakes’ and ‘slips or lapses’.
THE GENESIS OF MEDICATION ERRORS
Errors
can be classified into two broad categories: ‘mistakes’ and ‘slips or lapses’.
The former occur when something is wrong with the premise on which an action is
based. For example, the action in case 3, when the patient was given a dose of
tuberculin PPD intradermally that was appropriate for a multiple punc-ture,
represents a mistake. This was an error in the planning of an action as the
junior doctor was not aware of the difference dosage requirements needed for
the two methods of conducting a tuberculosis test. By contrast, Case 2, in
which a momentary lapse of attention led to air, instead of contrast medium,
being injected into a patient’s carotid artery illustrates a slip, which is an
error of the second sort, occurring during the execution of a planned action
(Reason, 1990). To some extent, training and education will help to over-come
mistakes, but it is difficult to prevent slips and lapses by training, because
they represent defects in tasks that are not under conscious control.
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