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- Latent Error (or Latent Condition)
The terms active and latent as applied to errors were coined by Reason. Latent errors (or latent conditions) refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. For instance, whereas the active failure in a particular adverse event may have been a mistake in programming an intravenous pump, a latent error might be that the institution uses multiple different types of infusion pumps, making programming errors more likely. Thus, latent errors are quite literally "accidents waiting to happen." Latent errors are sometimes referred to as errors at the blunt end, referring to the many layers of the health care system that affect the person "holding" the scalpel. Active failures, in contrast, are sometimes referred to as errors at the sharp end, or the personnel and parts of the health care system in direct contact with patients.
- Learning Curve
The acquisition of any new skill is associated with the potential for lower-than-expected success rates or higher-than-expected complication rates. This phenomenon is often known as a learning curve. In some cases, this learning curve can be quantified in terms of the number of procedures that must be performed before an operator can replicate the outcomes of more experienced operators or centers. While learning curves are almost inevitable when new procedures emerge or new providers are in training, minimizing their impact is a patient safety imperative. One option is to perform initial operations or procedures under the supervision of more experienced operators. Surgical and procedural simulators may play an increasingly important role in decreasing the impact of learning curves on patients, by allowing acquisition of relevant skills in laboratory settings.