active failures or active errors

Active failures (errors) occur when the actions and decisions of these individuals result in failures that can immediately or directly impact patient safety.

Active failures can be thought of as occurring at the sharp end of a continuum of decisions, environmental factors, and actions that affect patient care.

Individuals at the sharp end of the continuum are in direct contact with the work process itself — for example, a nurse giving medication to a patient or a medical technologist performing tests. (See latent conditions for an explanation of the "blunt end" of the continuum.)

There are three major types of active failures:

knowledge-based failure – occurs when individuals are unable to apply their existing knowledge to new situations.

Examples
- technologist in training unable to identify an antibody
- experienced technologist unable to operate a new instrument
rule-based failure – occurs when a person fails to carry out a procedure or protocol correctly or chooses the wrong procedure. This type of failure could happen because the person:
- assessed a situation incorrectly and selected the wrong rule
- was not qualified to carry out the task
- failed to communicate adequately with other team members
- planned or executed a task poorly.
Examples
- patient's special requirements not being verified before crossmatch
- clerical person performing technical tasks
- incoming shift not being updated about the new patient with multiple antibodies
- wrong reagent used when performing test
skill-based failure – occurs when a person fails in the performance of a routine task that normally requires little conscious effort. Most of us operate in the skill-based mode for many of the activities that we perform on a daily basis. If a routine is changed or interrupted, an error may occur.

Examples
- pushing wrong key when entering information into computer
- tripping and dropping blood bag when placing it in storage
- locking keys in car when distracted by children in driveway

List of Terms

antecedent event (See consequent event)

An antecedent describes the preceding event, condition, or cause. Therefore, antecedent events are those actions and decisions that led up to the consequent event.

An event may have multiple antecedent (or preceding) events leading up to the consequent event.

Antecedent events and conditions can be discovered by asking why of the consequent event.

List of Terms

barrier (See recovery – planned and unplanned)

A barrier is any action or process built into the work flow to check for accuracy or quality and that may prevent an event.

For example: On completing a quality control check list prior to the start of the shift, the tech notices that an expired reagent was placed into use for that day�s testing. The quality control check list was the barrier that facilitated the needed correction or recovery.

Although barriers are designed to avert accidents (or facilitate recovery), recovery does not always occur as the result of a barrier.

List of Terms

blame free culture

A blame free culture is one that reserves no right of disciplinary action regardless of the individual�s conduct. This type of culture goes against a broadly held view of accountability and is the opposite of a culture that focuses solely on blame and punishment. (See punitive culture.)

A type of culture that provides middle ground between a blame free culture and a punitive culture is the just culture – one that holds people accountable for their actions while supporting a safe environment for reporting events.

List of Terms