RT Book, Section
A1 Wachter, Robert M.
A1 Gupta, Kiran
SR Print(0)
ID 1146176699
T1 The Ahrq Patient Safety Network (AHRQ PSNET) Glossary of Selected Terms in Patient Safety
T2 Understanding Patient Safety, 3e
YR 2017
FD 2017
PB McGraw-Hill Education
PP New York, NY
SN 9781259860249
LK accessmedicine.mhmedical.com/content.aspx?aid=1146176699
RD 2024/04/25
AB Active  error  (or  active  failure)—The  terms  active  and  latent  as  applied  to  errors  were  coined  by  James  Reason.  Active  errors  occur  at  the  point  of  contact  between  a  human  and  some  aspect  of  a  larger  system  (e.g.,  a  human–machine  interface).  They  are  generally  readily  apparent  (e.g.,  pushing  an  incorrect  button,  ignoring  a  warning  light)  and  almost  always  involve  someone  at  the  frontline.  Active  failures  are  sometimes  referred  to  as  errors  at  the  sharp  end,  figuratively  referring  to  a  scalpel.  In  other  words,  errors  at  the  sharp  end  are  noticed  first  because  they  are  committed  by  the  person  closest  to  the  patient.  This  person  may  literally  be  holding  a  scalpel  (e.g.,  an  orthopedist  operating  on  the  wrong  leg)  or  figuratively  be  administering  any  kind  of  therapy  (e.g.,  a  nurse  programming  an  intravenous  pump)  or  performing  any  aspect  of  care.  Latent  errors  (or  latent  conditions),  in  contrast,  refer  to  less  apparent  failures  of  organization  or  design  that  contributed  to  the  occurrence  of  errors  or  allowed  them  to  cause  harm  to  patients.  To  complete  the  metaphor,  latent  errors  are  those  at  the  other  end  of  the  scalpel—the  blunt  end—referring  to  the  many  layers  of  the  healthcare  system  that  affect  the  person  “holding”  the  scalpel.