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only should a medical intervention proceed properly and safely, it should be the correct intervention for the particular condition. This report addresses primarily the first concern, errors of execution, since they have their own epidemiology, causes, and remedies that are different from errors in planning. Subsequent reports from the Quality of Health Care in America project will consider the full range of quality-related issues, sometimes classified as overuse, underuse and misuse.15

Latent and Active Errors

In considering how humans contribute to error, it is important to distinguish between active and latent errors.16 Active errors occur at the level of the frontline operator, and their effects are felt almost immediately. This is sometimes called the sharp end.17 Latent errors tend to be removed from the direct control of the operator and include things such as poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations. These are called the blunt end. The active error is that the pilot crashed the plane. The latent error is that a previously undiscovered design malfunction caused the plane to roll unexpectedly in a way the pilot could not control and the plane crashed.

Latent errors pose the greatest threat to safety in a complex system because they are often unrecognized and have the capacity to result in multiple types of active errors. Analysis of the Challenger accident traced contributing events back nine years. In the Three Mile Island accident, latent errors were traced back two years.18 Latent errors can be difficult for the people working in the system to notice since the errors may be hidden in the design of routine processes in computer programs or in the structure or management of the organization. People also become accustomed to design defects and learn to work around them, so they are often not recognized.

In her book about the Challenger explosion, Vaughan describes the "normalization of deviance" in which small changes in behavior became the norm and expanded the boundaries so that additional deviations became acceptable.19 When deviant events become acceptable, the potential for er-



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