Instead, it is the cause of the procedural violation that we can manage. Procedural violations are like errors in that they are not directly manageable. Rule 4 - Each procedural deviation must have a preceding cause.It is the cause of the error, not the error itself, which leads us to productive prevention strategies. For every human error in your causal chain, you must have a corresponding cause. It can be a system-induced error (e.g., step not included in medical procedure) or an at-risk behavior (doing task by memory, instead of a checklist). You must investigate to determine WHY the human error occurred. Unfortunately, the discovery that a human has erred does little to aid the prevention process. Most of our mishaps involve at least one human error.
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