• J Nurs Care Qual · Apr 2004

    Review

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

    • Diane Kennedy.
    • School of Nursing, University of Kansas, Kansas City, KS 66160, USA. dkennedy@kumc.edu
    • J Nurs Care Qual. 2004 Apr 1;19(2):116-22.

    AbstractSharp-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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