4.2 Analyzing and Mitigating Medical Errors

Question 1

Swiss Cheese Model

Answer 1

• Locates the cause of an error in the system as opposed to an individual
• Focuses on complex randomness of error rather than negligence or maleficence

Each layer of cheese represents a barrier to prevent errors
- Adequate training
- EBP policies and procedures

Each hole in the cheese represents weaknesses in barriers
- Incomplete training
- Policies not followed

• If all flaws in barriers become active (staff fails to complete training AND policies are not followed) than an error will happen.

Question 2

Fishbone Diagram

Answer 2

• Cause and effect diagram
• Helps analyze errors in context of the system rather than individual.

Question 3

Highly Reliable Organizations

Answer 3

• Look at errors as symptoms of bigger problems
• Pay attention to what is happening at the front line
• Encourage diverse perspectives and opinions rather than uniformity
• Committed to detecting, containing, and bouncing back from adverse events