error may or may not cause harm. A medical error that does not cause harm does not result in an adverse event.)
In addition, we define the following:
Serious Error: An error that has the potential to cause permanent injury or transient but potentially life- threatening harm.
Minor Error: An error that does not cause harm or have the potential to do so.
Near Miss: An error that could have caused harm but did not reach the patient because it was intercepted.
Preventable adverse event: An injury (or complica- tion) that results from an error or systems failure. Even if one agrees that individual errors are often the end result of systems failures, they are still perceived by patients and caregivers as very personal events. It
is useful to distinguish three categories:
Type 1: Error by the attending physician.
Example: technical error during performance of a procedure
Type 2: Error by anyone else in the healthcare team
Examples: a nurse gives wrong medication to patient; a resident makes a technical or decision error;
a radiologist misses a lesion.
Type 3: Systems failure with no individual error.
Examples: IV pump failure that causes drug overdose;
Failure of system to communicate abnormal lab results to ordering physician.