Nearly all adverse events involve a combination of these two sets of factors. Active failures are unsafe acts committed by people who are in direct contact with the patient or system. Active failures have a direct and usually short-lived impact on the integrity of the defenses. ALL such acts, he says, have a causal history that extends back in time and up through the levels of the system. These latent conditions arise from decisions made by designers, builders, procedure writers, and top-level management.
Safety involves a lot of tradeoffs.
Still, he continues, much can be done to analyze the holes and eliminating them. Errors must be re-enacted immediately after an error occurs, whether fatal or not. Lessons can and must be learned from every accident. Lev says the ministry has been encouraging human-factor engineering experts at the Technion in Haifa to work in the field. The ministry will launch a program encouraging the hospitals to collect detailed data on medical accidents that occurred and use experts on human-factor engineering to propose effective changes to reduce the risks.