latent condition

Latent conditions occur when individuals such as managers or administrators take actions and/or make decisions that affect technical or organizational policy and procedures or the work environment. Their actions and decisions may have unintended consequences in the future that negatively impact patient care.

Latent conditions can be thought of as occurring at the "blunt end" of the continuum of patient/donor care. Individuals at the blunt end influence the structure of the work process.In fact, the higher up in the organization a "blunt end" decision-maker is, the greater his or her potential for harm. Because of this person’s position and influence, a single decision may have far-reaching affects.

Latent conditions may exist unnoticed over a long period of time with no ill effect. However, when latent conditions combine with an active human error, an event occurs.

There are two major types of latent conditions:

1. technical factors – occur when there are problems with physical items, such as equipment, software, or paper-based material.

Examples

• software has design flaw
• form is difficult to use
• lot number of filters has defect
• new instrument is installed that does not allow for simple identification of correct buttons to press

2. organizational factors – occur when organizational elements, such as culture, procedures, and leadership decisions, adversely affect safety.

Examples

• manager does not allow for adequate training period for new, inexperienced technologist before putting him on night shift
• procedure is not clear
• staff commonly perform task in a certain way, despite official procedure

List of Terms

MERS-TM

The Medical Event Reporting System for Transfusion Medicine (MERS-TM) is a powerful yet practical system that provides a method for:

• collecting event data in a standardized manner
• analyzing and interpreting this data
• using the information to design system improvements aimed at reducing patient/donor risk

As a local management tool that is integrated into the existing quality assurance activities, MERS-TM enables organizations to focus on the subset of events posing the greatest risk to patients and to the organization. It also provides investigative tools that look beyond human error for identifying the root causes of high risk events. In addition, MERS-TM emphasizes that any potential system changes should be based on a complete picture of all the relevant root causes of the event, or on a complete picture of the root causes of similar events over time.

A major strength of MERS-TM is that it takes into account near miss events (e.g., mistakes that were almost made) as well as actual events. Examining near miss events provides a wealth of information that would otherwise be lost.

In addition to functioning as a local management tool, the standard methodology for event management enables information to be compared across participating sites at a national level for identification of national trends, data mining, and providing feedback to the transfusion medicine community.

The merging of standardized anonymous data can be used for benchmarking,

List of Terms

misadventure

A misadventure is an event in for which there was no recovery and in which the patient has been harmed or the mission of the organization has been harmed or compromised.

MERS-TM categorizes events into three types: misadventures, no harm events, and near miss events. Represented in the iceberg model as the tip of the iceberg, misadventures occur least often among the three event types but generally receive the most attention.