Active Error – error that occurs at the frontline:  effects felt immediately (sharp end)

Latent Error – error in the design organization, training, and/or maintenance that lead to operator errors, effects may lie dormant or unnoticed in system for a period of time (blunt end) 

Adverse Event - injury resulting from a medical intervention

Preventable Adverse Event - An injury that occurs as a result of medical error

Violation - conscious failure to adhere to procedures/regulations

Potential Preventable Adverse Event (near miss) - a medical error that could have resulted in injury to the patient

System - A set of interdependent elements interacting to achieve a common aim

Threats - factors that increase the likelihood of error; may relate to environment, staff, patient

Latent Threats - aspects of the organization that are not always easily identifiable, but predispose to commission of errors

Team - two or more people who achieve a mutual goal through interdependent and adaptive actions, not a “group” which achieves its goal through independent, individual contributions

Elements of a Team - common purpose and shared goals, interdependent actions, accountability, collective effort

Types of Distractions – 1) Personal – Compartmentalize, 2) Personnel - interpersonal conflicts, 3) Environmental - cold/heat, noise, 4) Physical - fatigue, illness, injury, 5) Situational - differences of opinion, 6) Organizational - job ambiguity

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