The Swiss Cheese Model
HCM 370 Quality and Risk Management in Healthcare
Colorado State University- Global Campus
Professor Cheryl Chance
March 1, 2015
The Swiss Cheese Model
Every institution ran by humans’ faces the risk of error. Errors can be anything from a missing file, to operating on the wrong patient. These errors can have serious consequences, such as malpractice suet. The Swiss Cheese Model shows the reasons behind why errors occur. It explains that it is not necessarily one event that leads to an error, but a series of events. Errors in an institution are considered losses; the role of risk management is to prevent losses from occurring.
The Swiss Cheese Model explains that every institution/organization is made up of defense layers to prevent losses. These defense layers could include, procedures, policies, alarms, control room operators, automatic shutdowns, and so on (Reason, 2000). In a perfect world, all of these defense layers are intact, looking like a single slice of cheddar cheese. But the reality is that these defense layers are full of holes, errors, or faults, causing it to look more like a slice of Swiss cheese, full of holes. “The holes in the defenses arise for two reasons: active failures and latent conditions” (Reason, 2000). Active failures refer to the mistakes that people who are in direct contact with the patient make (Reason, 2000). These are simple mistakes, or procedural violations that have a short lived impact on the integrity of the defenses of the organization, such as an overworked nurse forgetting to add a note to a patient file (Reason, 2000). Latent conditions come from decisions made by management, such as understaffing, or inadequate equipment (Reason, 2000). These conditions can create lasting holes in the defense systems, and when these holes line up, a major error is made. The role of risk management is to prevent these latent conditions from occurring, in turn preventing losses to the organization.
Health care organizations main concern is patient care, their secondary concern is to maximize profits of the organization (University, 2007). Mistakes can be costly to an organization, risk Managers are responsible for the policies and procedures which reduce injury to patients, staff members, and visitors within an organization (University, 2007). Risk management in a healthcare organization can either be proactive, or reactive (Hall, 2015). Proactive risk management works hard at collecting data and developing plans, to prevent a major incident from occurring (Hall, 2015). They survey the hospital, meet with senior leadership, research new developments in the industry, to keep up on how to keep the organization safe (Hall, 2015). Keeping up with new developments in the industry allows for risk mangers to update the practices within the organization. Surveying the hospital, or “doing rounds”, gives risk managers a first-hand view on how policies and procedures are being implemented. It also allows them to see where the mistakes are being made. Meeting with Senior Leadership gives the risk managers an opportunity to discuss new policies and the mistakes that are being made, as well as get ideas on where policies and procedures can be improved. Risk managers examine all of the defense layers of the organization, and evaluate where the mistakes are being made. Using this information they develop plans, policies, and procedures, to attempt to decrease the chances of the occurrence of a major error (Hall, 2015). Reactive risk management is basically damage control. This type of risk management attempts to minimize losses to the organization once an incident has occurred (Mind, 1996). Reactive risk management does not plan for ahead for problems, instead it attempts to deal with them as they come along (Mind, 1996). The issue with organizations that have this type of risk management is that they tend to deliver a lower quality,...
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