The Individual Error...

Bob Latino blatino at RELIABILITY.COM
Wed Dec 18 20:15:12 UTC 2013


I find the only near misses investigated, are the ones 'under the light' as well.  Under these circumstances there is usually a regulatory driver as well to provide incentive.

However, the near misses that do not rise to that regulatory threshold of potential severity, are not looked in any depth.  These add to the concept of normalization of deviance and eventually could play a role in a SSE.   They become 'acceptable'.

The same deficient organizational systems (roots) that contributed to the error chain resulting in the near miss, will still be there after the near miss.  The difference is that if the near miss is not looked at in any depth, we will not learn about that latent error chain and it will eventually lead to an SSE where someone was not lucky enough to 'catch it'.


Robert (Bob) J. Latino
CEO
Reliability Center, Inc., P.O. Box 1421, Hopewell, VA  23860
(O) 804.458.0645  (F) 804.452.2119
blatino at reliability.com<mailto:blatino at reliability.com> l http://www.reliability.com<http://www.reliability.com/>

From: Ross Koppel [mailto:rkoppel at sas.upenn.edu]
Sent: Wednesday, December 18, 2013 2:59 PM
To: Society to Improve Diagnosis in Medicine; Bob Latino
Subject: Re: [IMPROVEDX] The Individual Error...

IMO, it's great to study near-misses....as long as you always remember they may not be representative of errors/misses.  Heck, they will almost certainly be not very representative of actual errors.
Like many, I've studied near misses a lot....because often those are the only ones we know about -- they were caught...and that's why we know about them!     Yes, a dose that kills is often investigated.  Yes, an arterial cut is known and perhaps studied.  But those obvious sort of errors are where we keep getting better and better at avoiding: i.e., wrong site surgery.  We're like the drunk looking for his keys under the lamp post.  We improve our key looking/finding processes and technology when lighting is plentiful.

Alas, Dx errors are often in the less illuminated parts of medical care.

In lightness and shadows,

Ross


Ross Koppel, Ph.D. FACMI

Sociology Dept and Sch. of Medicine

Senior Fellow, LDI, Wharton

University of Pennsylvania, Phila, PA 19104-6299

215 576 8221 C: 215 518 0134
On 12/18/2013 2:17 PM, Bob Latino wrote:
Is it appropriate to include in your definition of Individual Error,  'near misses' where the error chain did not complete and thus did not cause damage or death?

Robert (Bob) J. Latino
CEO
Reliability Center, Inc., P.O. Box 1421, Hopewell, VA  23860
(O) 804.458.0645  (F) 804.452.2119
blatino at reliability.com<mailto:blatino at reliability.com> l http://www.reliability.com<http://www.reliability.com/>










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