PS 102 Lesson 2: Understanding Unsafe Acts
Most people commit unsafe acts all the time while they’re driving. They fail to stop completely at a stop sign, forget to signal when turning, or chat on their cell phones. These kinds of unsafe acts happen in health care, too — and sometimes they have serious consequences for patients. In this lesson, you’ll learn how the human brain is wired to make certain kinds of mistakes. You’ll also learn to identify four kinds of unsafe acts, as defined by psychologist James Reason: slips, lapses, mistakes, and violations.
Estimated Time of Completion: 25 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Compare and contrast the different types of unsafe acts as defined by James Reason, which can lead to preventable patient harm.
2. Define lapses, slips, violations, and mistakes as they pertain to safety in health care.
Contributors
Author(s):
Doug Bonacum, MBA, CSP, Vice President for Safety Management, Kaiser Permanente View Profile
Editor(s):
Kathleen Vega, BA, Freelance Writer, Kathleen B. Vega, Inc View Profile
Reviewer(s):
Barbara Edson, RN, MBA, MHA, VP, Clinical Quality, Health Research & Educational Trust (HRET) View Profile
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health View Profile
Requirements
You must be a registered IHI.org user to take this lesson.
You must achieve a minimum score of 75% to successfully complete this lesson.