Aims to continuous increase operational processes to achieve quality services and
promote productive culture
A particularly effective system lacks standardization & waste (very common)
,Sharp end ✔✔ The individuals and part of the healthcare system in direct contact
with patients Corresponds with errors from "active failures"
Blunt end ✔✔ Refers to layers of the healthcare system not in direct contact with
patients Influences the "sharp end"
Refers to those who set policy, manage, design equipment...etc.
Root of Medical Error ✔✔ Sharp end vs. blunt end.
, Picture a triangle. Top = sharp end. bottom = blunt.
Sharp end has causes going towards it, as blunt end has investigations.
Mistake ✔✔ Category of error
Failures during intentional behaviors or incorrect choices typically involving
insufficient knowledge
ex: failure of planning
Rule Based Mistake ✔✔ Wrong-rule applied, wrong diagnosis
Knowledge Based Management ✔✔ Did not take correct cause of action, new
clinical situation
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