Patient safety: latent risk factors.
The person-centred analysis and prevention approach has long dominated proposals to improve patient safety in healthcare. In this approach, the focus is on the individual responsible for making an error. An alternative is the systems-centred approach, in which attention is paid to the organizational factors that create precursors for individual errors. This approach assumes that since humans are fallible, systems must be designed to prevent humans from making errors or to be tolerant to those errors. The questions raised by this approach might, for example, include asking why an individual had specific gaps in their knowledge, experience, or ability. The systems approach focuses on working conditions rather than on errors of individuals, as the likelihood of specific errors increases with unfavourable conditions. Since the factors that promote errors are not directly visible in the working environment, they are described as latent risk factors (LRFs). Safety failures in anaesthesia, in particular, and medicine, in general, result from multiple unfavourable LRFs, so we propose that effective interventions require that attention is paid to interactions between multiple factors and actors. Understanding how LRFs affect safety can enable us to design more effective control measures that will impact significantly on both individual performance and patient outcomes.
van Beuzekom
M
M
OR Centre, J4-Q, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, The Netherlands. m.van_beuzekom@lumc.nl
Boer
F
F
Akerboom
S
S
Hudson
P
P
D000776:Anesthesiology / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D011785:Quality Assurance, Health Care; D012307:Risk Factors; D012308:Risk Management / Q000379:methods*