Table 1

Categories of active and latent breaches in safety10 15

BreachDefinitionBehavioural example
Active failure
 Situational awarenessFailure to have conscious, mindful observation of one's own environment or recognition of patient conditionObstetrician became task saturated upon entering room, did not ‘hear’ correct data from nurse, distracted by family questions
 Standardised communication
  • Closed loop communication

  • Situation, background, assessment, recommendation response

Failure to communicate to a specific person that is acknowledged by the receiver and then affirmed by the sender. (eg, Verb order reed back) Failure to use technique of communication about a critical situation that involves clear specification of Situation–Background–Assessment–Recommendation–ResponsePhysician called lab orders ‘in the air,’ nurse did not write them down or acknowledge and forgot them by time she got to the phone
Anaesthesiologist entered operating room and neither physician nor nurse told him what was going on with the urgency of the patient condition
 Shared mental modelFailure of a team to articulate common understanding of the problem and/or the plan. Everyone is not ‘in the same movie’Pharmacist had difficulty in finding the epinephrine during infant resuscitation, but did not share his concern with the neonatal team
Latent condition
 Policy or protocolPolicy—procedure not followed (lack of role definition, knowledge, skills or training)No patient identification band was placed on patient
People showing up for infant code did not know their roles
 Equipment/environmentTechnical, equipment or environment failure or not availableNo infant isolette or stethoscope in operating room for resuscitation
Very loud in the operating room
 Process issueSystem process failure (interdepartment or unit services/support/communication)Lab did not know where to go when they heard the code, when they arrived in operating room no orders and no paperwork to obtain the emergency blood