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Table 1 Definitions, descriptions and examples of the error types described in the amplified version of GEMS [4,5]

From: Exploring patterns of error in acute care using framework analysis

  Error type Definition Example from previous work [4]
Description of error Evidence from scenario (S) or debrief (D)
Original GEMS categorisations Skill-based slips and lapses errors which result from some failure in the execution [slip] and/or storage [lapse] stage of an action sequence” [5] Patient’s notes not checked for current medications as possible cause of hypoglycaemic coma Junior (D): “I completely forgot about the kardex [drug chart], that’s when I was going to read that he was diabetic, and then the phone went
Rule-based mistakes (RBMs) the mistake arises from the application of a ‘bad’ rule or the misapplication of a ‘good’ rule [a rule of proven worth]” [5] Juniors aware that senior help is not arriving for 20 minutes and patient having a major post-operative bleed Tutor (D): “Did 2222 [emergency call] cross your mind?” Junior: “Yes it did at one point.” Tutor: “Why didn”t you call it?“ Junior: ”I felt like the patient’s consciousness wasn’t impaired.”
Knowledge-based mistakes (KBMs) Mistakes arising from “the more laborious mode of making inferences from knowledge-based mental models of the problem space” [5] Recognition of partial airway obstruction but no simple manoeuvres attempted and no advice sought Junior (S): “He’s sounding very obstructed; he’s got an obstructed airway.” Reply from other junior: “We can’t do anything about it, can we?
Violations Deliberate deviations from those practices deemed necessary to maintain the safe operation of a potentially hazardous system” [5] Feels patient’s pulse but does not count rate or ask for any monitoring Junior (S): “He’s got a pulse as well; I can’t tell the rate, I don’t have a watch.”
Novel error types Compound errors Errors occurring solely because of a preceding error, from own or others’ misperception or misinterpretation of information Junior uses observation chart as a surrogate for current physiology and then provides insufficient oxygen to patient Junior (D): “We had the patient on a Hudson [variable performance] mask… 97% sats [oxygen saturation] so I didn’t think we needed to jump in with all guns blazing.”
Submission errors Errors occurring when a junior doctor was dissuaded from taking the most appropriate course of action by a colleague advocating less appropriate measures Aware patient is bleeding; one junior keen to use blood as primary resuscitation fluid but persuaded by other junior not to request any blood from blood bank Junior (S): “I think we should just give more fluid.” Reply from other junior: “But if she’s bleeding blood then we should give her blood.” Junior: “…can we not just keep giving her saline, or jelly [colloid] or something?