Patient safety: latent risk factors

Abstract

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.

Lack of standardisation between specialties for human factors content in postgraduate training: an analysis of specialty curricula in the UK

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Analysis of Critical Incidents during Anesthesia in a Tertiary Hospital

“…Everyday experience would suggest that staff shortages, cognitive overload of members of staff, distractions, poor communication, haste, and fatigue are common contributory factors [43]. Prevention of drug errors must take into account the whole range of factors from those related to patients to organizational systems.…”

Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery

“…As reported in the literature, the ''human factor'' approach should be more focused on the human component within a complex organizational system and on the pre-existing organizational factors that set up the conditions for an error to occur rather than on the individual who makes an error [8,[28][29][30][31].…”