Active Error (or Active Failure):
The terms
"active" and "latent" as applied to errors were coined by
James Reason.(1,2)
Active errors occur at the point of contact between a human and some aspect of
a larger system (eg, a human-machine interface). They are generally readily
apparent (eg, pushing an incorrect button, ignoring a warning light) and almost
always involve someone at the frontline. 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.
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 (eg, an
orthopedist who operates on the wrong leg) or figuratively be administering any
kind of therapy (eg, a nurse programming an intravenous pump) or performing any
aspect of care. 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 health care system that affect the person "holding" the
scalpel.
1. Reason
JT. Human Error. New York, NY: Cambridge University Press; 1990. [
go to PSNet listing ]
2. Reason
J. Human error: models and management. BMJ. 2000;320:768-770. [
go to PubMed ]
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