Article Text

Download PDFPDF
9 Little room of horrors
  1. Elizabeth Akers
  1. Great Ormond Street Hospital


Latent error A type of error, or defect in a system, which does not have immediate consequences but increases the potential for harm later. The error may not become apparent until certain other conditions occur.

Following a literature review and discussions with teams about the recognition and impact of latent errors, a hospital wide patient safety programme has been developed to improve the safety of clinical spaces through raising awareness of hazards and potential risks.

The objective is to aide the ‘critical eye’ of those undertaking the work- to see harm before it is harmful. This has been developed reflecting similar work undertaken in several centers.

A clear objective was ensuring that this remains focused a non-punitive approach to learning and to the very important safety outcomes.


  • Gathering data via Datix and individual reports of risks that could be replicated.

  • Pre–implementation audit of designated clinical spaces as per existing Bed–space Audit Tool

  • Data collection regarding attitudes to patient safety via a surveymonkey audit– pre and post intervention*

  • Ad–hoc audit of designated clinical spaces as per existing Bed–space Audit Tool

  • Weekly* LRoH sessions following the pathway

  • Monthly feedback of data and wider communication of results

  • Evaluation and review of process

Method*This programme has been underway since June 2019- initial review of date and adaptations have been made. Mid and post intervention data collection has therefore not been undertaken to this time.

*Initial data and feedback suggests weekly sessions are not achievable, this has been moved to monthly, and this change will be measured and taken into account as part of the overall project evaluation

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.