Overview
Definitions of Error
Basic Tenets of Human Error
Human Factors Engineering
Human Performance
Vocabulary
Types of Errors
Systems to Reduce Errors
Stroop Test
Swiss Cheese Model
Toxic Cascades
Lessons from Other Industries
Basic Safety Principles
Summary

Vocabulary

There is a vocabulary associated with errors.

Processes may be referred to as having sharp and blunt ends.

  • Sharp end – the actualizer of the process—the person actually doing the task (e.g., the nurse administering a medication; the surgeon holding the scalpel)
  • Blunt end – parts of the process farther away from the action itself. At its extreme, the blunt end is the environment in which we deliver healthcare. Regulators, accreditors, administrators, and designers function at the blunt end.

In between are many other steps and factors influencing the sharp end’s operation.

  • Active errors occur at the sharp end of the process.
  • Latent errors occur at the blunt end. These are decisions made away from the bedside that impact the care. Examples may include:
    • Equipment design flaws that make the human-machine interface less than intuitive (as mentioned in the bed example earlier)
    • Organizational flaws, such as staffing decisions made for fiscal reasons which increase the likelihood of error

Check your understanding:
Moving progressively away from the sharp end of the process of administering medication to a patient, what steps and people can you identify?


Classify each of the following as active or latent errors:    

 

Active
Latent
Taking the turn to go to work on your day off, when you intended to go elsewhere

Unclear handwriting on a new patient prescription

A hospital keeping sound-alike medications on formulary, when the name similarity has caused mix-ups elsewhere
A corporation delegating to a temporary agency the responsibility for doing criminal checks on new hires, without verifying that these are being done
Saying one word when you intended to say another
A software bug that turns off your computer in mid-task

 

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