Case 1 (An Endogenous Error) An endogenous error arises solely from within an individual, from a random and unpredictable cognitive event such as miscalculating a dose or prescribing a drug at a dose appropriate for the next medication being contemplated.
Case 1 A physician ordered a heparin infusion with directions to follow a weight-based nomogram for laboratory monitoring and dose adjustments. Later that evening, the nomogram indicated that an intravenous (IV) bolus dose of heparin 1,700 units should be administered based on the patient’s activated partial thromboplastin time (aPTT) level.
