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Summary
We develop the concept of latent errors-uncorrected deviations from procedures and policies that have no direct adverse consequences-and examine the complex relationships between organizational antecedents, latent errors, and adverse consequences. Latent errors, with varying levels of frequency, are present in all organizations whereas extreme adverse outcomes are rare. Thus, all organizations become potential objects of study in research on errors. Latent errors enable the design of ex ante studies of errors that avoid sampling on the dependent variable. The basic elements of our framework focus on two critical linkages. First is the role of antecedent factors such as incentives and goals in contributing to the presence of latent errors. Second, we explore how positive and negative feedback systems and external triggers link an acceleration of latent errors with adverse organizational outcomes. We also discuss how variations in context (e.g., whether work activities are co-located or distributed) may affect these factors. Implications for research on high-reliability organizations are discussed. Copyright (C) 2003 John Wiley & Sons, Ltd.
Introduction
Latent errors, as conceptualized in this paper, represent a different approach to understanding adverse organizational consequences. Latent errors refer to uncorrected deviations from procedures and policies that potentially can contribute to adverse organizational consequences. Such deviations represent a pervasive phenomenon in the routine operations of all organizations (Reason, 1998). Examples include deviations from trading practices in a financial institution, from medication administration procedures in a hospital, and from quality control practices in a manufacturing plant. In each of these examples, there is a deviation from standard practices but not direct adverse consequences. Although these deviations by themselves do not produce adverse organizational consequences, they create conditions that make such consequences more likely to occur.
The goals of this paper are to examine: (1) the nature of latent errors and how they differ from other constructs in the literature on errors, (2) the complex relationships between antecedents, latent errors, and adverse consequences, and (3) contextual features that might modify these relationships.
Latent errors can be observed in the pre-history of most disasters (Vaughan, 1999). Analyses of major organizational accidents consistently conclude that these accidents were preceded by overlooked warning signs-known and persistent deviations from safety practices, that is to say, latent errors (Turner & Pidgeon, 1997; Vaughan,...