Types of Errors - Active Errors

Types of Errors – Active Errors

Active errors or failures occur when individuals are in direct contact with the work process, such as a nurse providing care to a patient or a medical technologist performing tests.

Their actions and decisions may result in failures that can immediately or directly impact patient safety.

Active failures can be thought of as occurring at the "sharp end."

Individuals at the sharp end are in direct contact with the work process itself - for example, giving medication to a patient or setting up equipment for use with a patient.

There are three major types of active failures:

1. knowledge-based failure – occurs when individuals are unable to apply their existing knowledge to new situations or when a trainee is expected to perform a task they are not trained to

Examples

technologist in training unable to identify an antibody
experienced technologist unable to operate a new instrument

2. 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

3. 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