Medical errors, as well as other incidents, are not solely the result of individual mistakes. Instead, they are often caused by systematic or organizational factors that allow them to occur.
The Swiss Cheese model is a useful tool for understanding system safety. Each layer represents a protective action or protocol, such as a read-back or checklist. The holes in each layer represent latent errors, such as human errors, communication lapses, caregiver fatigue, and other weaknesses.
When these holes align, the result can be harm to the patient. This highlights the importance of recognizing and addressing the root causes of medical errors, rather than solely blaming the individual involved.
#SystemSafetyInHealthcare #PreventingMedicalErrors #RootCauseAnalysis #PatientSafetyFirst
Alisa Sano is a public health research assistant.
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