Root cause analysis is being performed after a client who was supposed to be on falls precautions fell while trying to walk to the toilet. Which finding of the investigation would be considered to be a latent error?
A) The documentation forms on the unit have no specified location where falls precautions should be noted.
B) The client's primary nurse went on a scheduled break without reporting off to a colleague.
C) The nurse manager mistakenly admitted the client into a room far out of site of the nurses' station.
D) A nursing assistant on the unit admitted to ignoring the client's call light before the client fell.
Ans: A
Feedback:
An omission on the documentation forms that are in use on a unit is an example of a latent error that can culminate in an adverse event. Each of the other listed actions are active errors that specific individuals made, all of which contributed directly to the client's fall.
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