error chain

error chain

Linked events that ultimately result in an adverse patient outcome.
References in periodicals archive ?
This investigation uncovers no single point of failure; instead, there were numerous links in the error chain leading up to the grounding-had any one of which been appropriately addressed, the grounding would have been prevented," Haney said.
There was a screw up getting it re-registered and an error chain in the forms has dragged on with the FAA, work gets in the way, there was winter, of course, and the appeal of local hops has dried up.
The bridge team didn't allow an error chain to form.
Determining the factors that contributed to the error, and removing one of these factors from the error chain, is far more beneficial.
This helps to identify likely mishap causes early, allowing command personnel to break the error chain before a major mishap occurs.
In each case, an error chain developed, which, if left unchecked, could have led to a disaster.
In the past, these small acts of leadership would have been recognized at the watchstation, but the rest of the team would have been unaware of the total error chain, how it was developing, and how it was stopped.