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: |
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Active |
Latent |
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