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Analysis of sharp-end, frontline human error: beyond throwing out "bad apples"
1School of Nursing, University of Kansas, Kansas City, KS 66160, USA. dkennedy@kumc.edu
Journal of Nursing Care Quality
|April 14, 2004
Abstract:
Sharp-end, frontline human error occurs close to the delivery of patient care. The purpose of this article is to examine the mechanism of human error and cognition, and to explore the antecedents, attributes, and consequences of frontline human error. Fallible decision-making and actions leading to patient injury are explicated in a case study. The discussion includes strategies for preventing patient injury by refining system flaws.
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Error is the deviation of the obtained result from the true, expected value or the estimated central value. Errors are expressed in absolute or relative terms.
Absolute error in a measurement is the numerical difference from the true or central value. Relative error is the ratio between absolute error and the true or central value, expressed as a percentage.
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Systematic or...
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Errors can be classified by source, magnitude, and sign. There are three types of errors: systematic, random, and gross.
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