Latent conditions predispose active errors to harmful outcomes.
Many slips, lapses, mistakes, and violations do not
result in severe harm, as we have seen. This is often
because defence mechanisms prevent serious adverse drug
events. The GMC study8 revealed that 1.7% of medication
errors were potentially lethal but were detected by other
health-care workers before they were put into action.
Removal of some of these lines of defence, for example,
reducing the number of clinical pharmacists on the wards,
serves as an example of a latent condition. It would not be
noticed until an unsafe medication order was prescribed
and then, unchecked, carried out.
Latent conditions can be described in terms of six ‘Ps’.20