Medical Errors Of The Swiss Cheese Essay

Medical Errors Of The Swiss Cheese Essay

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Medical Errors account for 98,000 deaths per year in the US. They increase disability, costs, and decrease confidence in the US health care system (Pham, Aswani, Rosen, Lee, Huddle, Weeks, & Pronovost, 2012). One of the main goals of quality and risk management is to minimize medical errors in order to improve the overall quality of medical care. In addition, healthcare organizations developed risk management program in order to protect their financial assets from medical malpractice. Healthcare is a complex environment in which people suffer as a result of system failure. According to James Reason (2000), an effective risk management requires detailed analysis of mishaps, incidents, and near misses, and free lessons in order to identify the roots of the errors. The Swiss Cheese Theory is one of the leading theories about systems failure and how they can be applied to medical errors in healthcare setting. This theory helps healthcare organizations, healthcare providers, healthcare professionals, and so forth in understanding and addressing the causes of medical errors.
The Swiss Cheese Model illustrates how multiple failures, though singularly insufficient in allowing harm to reach the patient, can align and cause an adverse event (Gabrielli, Layon, & Yu, 2009). Nearly all adverse events involve a combination of 2 sets of factors: active failure and latent conditions. Active failures are the unsafe acts committed by people who are in direct contact with the patient or system. They take a variety of forms: slips, lapses, fumbles, mistakes, and procedural violations. Active failures have a direct and usually short-lived effect on the integrity of the defenses (Reason, 2000). On the other hand, latent failure includes lack of team...


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...uses or the strategies to prevent errors, focus on system failures rather than individual performance including nonpunitive approaches to addressing errors, ability to learn from errors and continually improve, and flat organization hierarchy in which staff of any level can effectively voice concerns and make recommendations.
In addition, creating a culture of safety is also essential in preventing active and latent failures. Cohesive teamwork, leadership support for patient safety, nonpunitive response to errors, transparency regarding errors for the purpose of learning, work-hour restrictions, appropriate staffing ratios, workload distribution, effective communication and care transition processes, effective policies and procedures for care delivery, and ergonomically sound physical workplace are some of the fundamentals of culture of safety (Kline & Haut, 2015).

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