Active and Latent Errors

It is therefore useful to distinguish between active and latent errors or failures. An active human error has an immediate effect in that it either directly causes a hazardous state of the system or is the direct initiator of a chain of events which rapidly leads to the imdesirable state. 

Roles and responsibilities will define the types of leadership skills that are necessary to support the safety management system and avoid or reduce the potential for active and latent errors that lead to loss-producing events. The following are examples of some assigned safety roles for each category ... 

Many leaders still believe that changing employee behaviors is all that is necessary. The misconception is that unsafe actions/at-risk behaviors or active human errors only apply to employees with the belief that the employee alone needs to change behavior. In reality, everyone including the leadership team are influenced by the peer pressure and other factors that results in active and latent errors (US DOE, 2009a Roughton Crutchfield, 2008). 

As discussed in Chapter 2, a combination of both active and latent errors creates potential loss-producing events. The potential for error is not just at the line employee level but involves all members of the organization. A decision made by a member of senior leadership team can directly impact the acceptance of risk. A purchasing manager may receive praise for reducing expenses but that saving be lost as cost of injuries and maintenance increase. 

Because errors are frequently recoverable, it is also appropriate to define another category of errors, recovery failures. These are failures to recover a chain of events leading to a negative consequence (assuming that such a recovery was feasible) before the consequence occurs. This includes recovery from both active and latent failures. 

The study of patient safety is the study of complexity. The study of complexity invites us to understand key concepts that can be applied to patient safety. Basic concepts from the fleld of patient safety are sharp and blunt end active and latent failure the Swiss Cheese Model of Accident Causation slips, lapses, and mistakes and hindsight bias and the fundamental attribution error. Key concepts from organizational analysis, such as normalization of deviance, diffusion of responsibility, tightly coupled work processes, and sensemaking, introduce practical lessons from high-reliability organizations. Application of specific lessons to health care are explored in Chapter Five. 

For example, if supervisors have little control over maintenance, hiring practices, trairung, budget, time, quality, etc., then they have little control over the elements that create the potential for a loss-producing event. In this scenario, if supervisors are held accormtable for injuries that may occur, they are being held accormtable for human and latent errors that are not under his or her control (Volume 1 Concepts and principles, human performance improvement handbook, 2009). The best approach is to have clearly defined, tangible responsibilities for preloss activities and lines of authority. 

The systems approach seeks to identify situations or factors likely to contribute to human error. James Reason s analysis of industrial accidents revealed that catastrophic safety failures almost never result from isolated errors conunitted by individuals. Most incidents result from smaller and multiple errors in components and environments with underlying system flaws. Reason s Swiss Cheese Model describes this phenomenon. Errors made by individuals can result in disastrous consequences due to flawed systans that are represented by the holes in the cheese. Reason believed human error would happen in complex systems. Striving for perfection or punishing individuals who make errors does not appreciably improve safety. A systems approach stresses efforts to catch or anticipate human errors before they occur. Reason used the terms active errors and latent errors to distinguish individual errors from system errors. Active errors almost always involve frontline personnel. They occur at the point of contact between a human and some element of a larger system. Latent errors occur due to failures of the organization or designs that allow inevitable active errors to cause harm. The terms sharp end and blunt end correspond to active error and latent error. The systems approach provides a framework for analysis of errors and efforts to improve safety. 

In addition to the above classifications there is one final distinction which is crucially important to the understanding of human error, its causality and to error reduction and that is Reason s distinction between active and latent failures (for example, Reason 1987, 1990). 

Detailed information from both the active and latent failures identified which can be used to consider whether such errors could impact elsewhere in the mine (or indeed the company) to ensure that lessons are learnt wherever they are relevant. 

Operation. Upon activation, a latent Fault produces a SAV Error, and when this Error affects the delivered service, a Failure occurs. 

Figure 5 illustrates the relations between factors influencmg on possibility of latent error commitment which can induce active human errors. Relevant factors should be considered during analysis of protection layers, especially the alarm system and human machine interface (Scarborough et al. 2005). 

The safe actions and satisfactory performance of personnel are essential aspects of maintaining safety across a wide range of high-risk industries. Accepted models of accident trajectory typically include both active failures of personnel and systems, as well as latent conditions which may lie dormant in an organization s operational system for considerable time (Reason, 1990). Closely aligned to the concept of active failmes and latent conditions are the terms error and threat respectively, coneepts which have recently been the focus of considerable research in the commercial aviation setting. 

Human error as a simple catch-all explanation for accidents is now discredited. The term, if it means anything at all, does not provide an adequate description of the many ways in which the failure of people at all levels in organisations can contribute to the complex phenomenon we call an accident. It is more useful to think about human failure , which involves both errors and violations, and also to distinguish between active failures and latent failures. 

What is the history of latent and active human error Is the current focus on just employee errors (primarily active) or are latent errors (leadership team and administrative, engineering design/development issues) open for discussion ... 

The two error types are latent errors from job and operational design and active errors from actions taken. These errors can create loss-producing events immediately or remain hidden creating a long term potential for loss producing events. 

Inadequate ergonomic design in areas such as control panels and the labeling and placement of valves on the plant can also be regarded as a latent failure because it will increase the probability of active errors. For example, a worker may misread process information from a poorly designed display. Poorly labeled and situated valves can cause the wrong valve to be selected, with possibly disastrous consequences. 

Define latent and active failures and the role each plays when a medication error occurs. 

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