Sharp End-Blunt End Concept

     All complex systems contain latent factors or failures, but only rarely do they combine to create the trajectory for an accident. It is useful to depict complex systems such as health care, aviation and electrical power generation as having a sharp and a blunt end. At the sharp end, practitioners interact with the hazardous process in their roles as nurses, physicians, technicians, pharmacists and others. At the blunt end of the health care system are regulators, administrators, economic policy makers, and technology suppliers. The blunt end of the system controls the resources and constraints that confront the practitioner at the sharp end, shaping and presenting sometimes-conflicting incentives and demands.

     When we look at the role of sharp end practitioners in various research investigations, we see that people make safety in the face of the hazards that are inherent in the system. System operations are seldom trouble free. There are many more opportunities for failure than actual accidents. Groups of practitioners pursue goals and match procedures to situations, but they also resolve conflicts, anticipate hazards, accommodate variation and change, cope with surprise, workaround obstacles, close gaps between plans and real situations, detect and recover from miscommunications and mis-assessments. In these activities, practitioners at the sharp end block potential accident trajectories. In other words, people actively create safety when they can carry out these roles successfully.

     For example, Sharp End: People use time, procedures, tools, knowledge about the patient, expectancies, coordination between healthcare providers, and information to create safety. The sharp end experiences pressures that conflict with those of blunt end people.

     Blunt End: The organization decides what is available (tools, people, access to expertise) and the rules of the game (policies and procedures.) Previous experience with the organization determines workers’ priorities. For example, there is no point in asking for something if you know the answer will be "no." The blunt end experiences pressures which conflict with those of sharp end people.