Taxonomy of Errors: Adverse Event/Near Miss Analysis

Errors in healthcare delivery cause many deaths each year. These errors may be caused by individual lapses or mistakes that are inevitable or they may be caused by latent conditions within an organization. Any given error may result in either an adverse event or a near miss. The large difference in outcome between an error that causes harm and the same error that results in a near miss may be as simple as chance or may be related to the presence or absence of one or more latent conditions. Correcting or preventing latent conditions and maximizing the system’s defenses can either prevent errors or mitigate the consequences of errors and reduce subsequent harm.