Background Concept 2: Errors in Complex Systems
{"Image DocumentName": "Background Concept 2: Errors in Complex Systems", "Image ImageDescription": "The sharp end refers to the personnel or parts of the health care system in direct contact with patients. Personnel operating at the sharp end may literally be holding a scalpel (eg, an orthopedist who operates on the wrong leg) or figuratively be administering any kind of therapy (eg, a nurse inserting a Foley) or performing any aspect of Foley care. The blunt end refers to the background of policies, administrative priorities, process designs, etc. where decisions are made that impact the sharp end downstream.", "Image XResolution": "37", "Image YResolution": "37", "Image ResolutionUnit": "Pixels/Centimeter", "Image Software": "SlidePlayer", "Image YCbCrPositioning": "Centered"}