QSEN Lesson 2: Understanding Unsafe Acts

A potential hazard James Reason calls unsafe acts errors or violations committed in the presence of a potential hazard. Errors can be further divided into slips, lapses, and mistakes. They may or may not actually result in harm, but the potential for harm is present.

Anita had a memory failure, which is a classic lapse. She understood what should be done and created a good plan. She even discussed it with a co-worker. However, in the midst of a busy clinic schedule she likely got distracted and forgot to implement the plan.

This is a violation because Mike made a deliberate decision to disregard standard procedure when he changed antibiotics for this patient without the prescriber's authorization. This change may result in harm if the levofloxacin does not treat the organism and site of infection.

It allows us to change the conditions under which humans work Having a systems view of health care allows us to change the conditions under which humans work by recognizing that humans are not perfect and systems have a significant role to play in safety. This view is applicable in all patient care settings, as all care settings these days are complex

Lapse Signs and other reminders are good strategies for addressing lapses, specifically memory failure, which is what the leadership believes is generally happening in this hospital. While these types of campaigns may also address violations or mistakes, they are generally less successful in these areas.