One day, all this confusion almost lead to a mistake. A patient came in with high blood pressure, which is not unusual for people who are about to have numerous procedures done. Although she was on medication, her blood pressure was still very high; thus, Nova decided to give her some time to calm down. Nova told her that we were going to wait a little while until her blood pressure went down. Nova brought her a magazine and told the patient that she would be back. When Nova rechecked it in 15 minutes, it was still high. At this point, the dentist spoke with the patient and asked whether she wanted to continue to wait or reschedule her appointment for another day. The patient chose to wait, so they obliged.

During the next hour, the entire staff had to hurry a little more because they had the same number of patients scheduled but one less room to treat them in because of the waiting patient. They were in overdrive mode when they returned to this particular patient. Usually, when a patient is at risk for any type of cardiovascular episode, they use an anesthetic without epinephrine. The dentist asked her assistant to prepare the anesthetic, but the assistant got caught up with another patient who had wandered out of his room. To be helpful, the dentist prepared the infection herself.

She did not know, however, that she selected one with epinephrine. A few days earlier, the anesthetic had been ordered from a different company that color-coded its vial differently. Usually, the green and red vials were anesthetics with epinephrine, and the blue was without epinephrine. The new company made blue vials with epinephrine. No one had informed the dentist because it was usually the assistants who prepared the injections.

The dentist returned to the treatment room and was about to inject the anesthetic when the assistant walked in with her prepared injection. She saw that the dentist had the wrong colored vials, immediately realized the mistake, and simply said, "Doctor, we have an emergency and we need your help." Of course, the dentist left the room without administering the anesthetic. The assistant walked into the dentist's private office where no one would overhear and explained the situation. The dentist returned to the patient, explained there wasn't an emergency after all, and gave the correct injection.

1. Distinguish between a slip and a mistake
2. How does differentiating between these two types of errors help us in the redesigning system of care to improve patient safety
3. What would have happened if this patient had received the wrong anesthetic?
4. Describe the contributing factors to the system error in this case
5. What human factors contributed to the error?
6. What changes would you suggest to make this clinic a "high-reliability organization"