Swiss Cheese Model
The Swiss Cheese Model
Natalya Semeryuk
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
Natalya Semeryuk
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
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