Types of Errors - Latent Conditions

Types of Errors – Latent Conditions

Latent failures occur when individuals such as managers or administrators take actions and/or make decisions that affect technical or organizational policy and procedures or the allocation of resources.

Their actions and decisions may have unintended consequences in the future that negatively impact patient care.

Latent failures can be thought of as occurring at the "blunt end."

Individuals at the blunt end influence the structure of the work process. These individuals may include administrators, supervisors, designers, and engineers who determine the work force, work environment, and/or various resources.

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.

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