latent error


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latent error

A flaw in the design or organization of health care delivery systems that may allow, on occasion, injuries to occur to patients.
See also: error
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* Possible latent error: Having one centralized location for nurses and patient care technicians (PCTs) to station themselves and chart.
Reason (1995) distinguished between latent errors, namely, the root cause of accidents, and active errors, such as human error and technical failure, which trigger accidents.
Latent errors refer to the errors caused by higher decision-making or are decisions made at a higher level which impact on the practical working conditions such as policies, staffing pressures, time pressures and competing priorities.
Using the conservative ROI of 85 percent, the following calculation shows that $6 million spent on IV&V reduces the cost of latent errors by about $11 million:
(9) Latent errors are difficult to discover unless that process is dissected and evaluated based on each step in the process.
The topics include creating a just culture, reducing latent errors, alarm fatigue, safety considerations for patients on home therapies, access site preparation and needle insertion as a patient safety issue, pressure ulcer prevention, and a list of patient safety resources available on the internet.