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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