error chain

error chain

Linked events that ultimately result in an adverse patient outcome.
References in periodicals archive ?
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.