The working interface Where exposure to hazard can occur

The working interface Where exposure to hazard can occur 

The working interface is the configuration of equipment, facilities, processes, systems, and behaviors that define the interactions among patients, staff, and technology. The working interface can 

Thomas R. Krause, Leading with Safety (Hoboken, NJ John Wiley Sons, 2005), p. 147. 

By exposure to hazard we mean any condition, decision, behavior, activity, cultural standard, process, or system (or lack thereof) that increases the probability of the patient s suffering a preventable adverse event. In short, any malfunction in any element of the blueprint that increases the patient s jeopardy constitutes an exposure and is a root cause of preventable adverse events. By preventable adverse event we mean healthcare-caused harm, i.e., a patient injury that is not an inevitable or necessary outcome of the patient s illness but rather the result of the care he or she received. Table 2-2 shows some common healthcare safety exposures and related preventable adverse events. 

Failure to identify the patient with whom you are interacting Performing an operative procedure on the wrong patient 

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