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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?