Analysis of sharp-end, frontline human error: beyond throwing out "bad apples".
Sharp-end, frontline human error occurs close to the delivery of patient care. The purpose of this article is to examine the mechanism of human error and cognition, and to explore the antecedents, attributes, and consequences of frontline human error. Fallible decision-making and actions leading to patient injury are explicated in a case study. The discussion includes strategies for preventing patient injury by refining system flaws.
Kennedy
Diane
D
School of Nursing, University of Kansas, Kansas City, KS 66160, USA. dkennedy@kumc.edu
D003071:Cognition; D003627:Data Interpretation, Statistical; D003657:Decision Making; D006801:Humans; D019300:Medical Errors / Q000379:methods / Q000517:prevention & control* / Q000523:psychology / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000379:methods*; D018570:Risk Assessment; D012307:Risk Factors; D017751:Safety Management / Q000379:methods*; D013597:Systems Analysis; D016526:Workload