Читать книгу Kelly Vana's Nursing Leadership and Management - Группа авторов - Страница 209

Errors are often noticed at the point of care, where nurses and other clinicians interact with patients. This is considered the “sharp end” of a triangle (Cook & Woods, 1994). These errors are considered active errors because they occur at the point of interface between humans and a complex system. Clinicians often blame themselves when errors happen. However, their work with patients is influenced by many factors and decisions made before an actual error occurs. These factors and decisions are considered the “blunt end” of the triangle.