During preparation for an operation, a vial of the neuromuscular blocking agent (succinylcholine) is inadvertently used instead of a reconstitution agent (sodium chloride). Both vials have a similar appearance. The anesthesiologist catches the substitution before any drug is administered.
A. Identify whether this case is an error, a near miss, or a violation. Briefly explain your reasoning.
B. Analyze this case in terms of the Swiss Cheese Model. Identify latent conditions and active failures (if any).
C. Propose an intervention to prevent similar incidents from happening in the future. (hint: use system thinking perspective.)