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PubMed · 15077828

Analysis of sharp-end, frontline human error: beyond throwing out "bad apples".

Diane Kennedy
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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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CognitionData Interpretation, StatisticalDecision MakingHumansMedical ErrorsQuality Assurance, Health CareRisk AssessmentRisk FactorsSafety ManagementSystems AnalysisWorkloadJournal ArticleReview

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Diane Kennedy. Analysis of sharp-end, frontline human error: beyond throwing out "bad apples".. https://doi.org/10.1097/00001786-200404000-00008

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