[NEW] Swiss Cheese Model to Assess Medical Errors and Patient Safety | swiss cheese model – Pickpeup

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Patient safety and risk management are major aspects of healthcare that should be intertwined in any healthcare organisation (Fisher and Scott 2013). Patient safety is where the patient does not experience unnecessary suffering or harm during treatment while risk management is described to be any activity, processor policies that are taken up to reduce liability exposure (World Health Organisation (WHO), 2017). Medical malpractice claims demonstrate the significance of potential hazards that can occur in healthcare organisations (Spath 2011). Medical malpractice tends to cover a wide range of conditions and severity. Example of some of these claims includes administering medication without a diagnosis, improper prescription of medication, mishandling of patients and lack of ethics among healthcare professionals (Spath, 2011).

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In this account, human factors and key issues will be discussed as they were identified using the Swiss Cheese Model of error in part one of this portfolio and from the Risk Assessment Tool (see appendix —–); however, the focus will mainly be on the medication errors of the junior sister in the acute medical ward.

The Swiss Cheese Model has developed to be a dominant paradigm used for analysing medical errors and patient safety incidents (Reason 2000). This model is often referred to and generally accepted by patient safety healthcare professionals. They use the model to explain the occurrence of system failures such as medication error (Reason 2000). According to Morath and Turnbull (2005) the Swiss Cheese Model, in any complex systems, risks and hazards with the potential of causing harm are prevented by a series of barriers. However, each barrier has its weaknesses (Holes) which are inconstant. This means that these holes are continuously opening, shutting and shifting their location. By chance, if all holes align the risks and hazards are able to reach the patient and cause harm (Morath and Turnbull 2005).

The Swiss Cheese model shows that most accidents do not occur from one mistake or error. However, it happens because of multiple small causes, each insufficient to generate an accident, although possibly deadly when all merged (Morath and Turnbull, 2010). Thus, the implementation of the Swiss Cheese model in patient safety is used for defences, barriers, and safeguarding the potential victims and resources from hazards (Reason 2000).

A risk is a term that is commonly used to refer to a chance or likelihood of an undesirable event occurring. Based on Fisher and Scot (2013), risk typically refers to a possibility that an act or activity may occur and that has the potential to cause harm. A risk in healthcare is considered to be a sensitive issue as it has the potential of causing significant damage to the caregiving process and ultimately the patients or even to the healthcare professionals (Holden et al. 2011). A risk in healthcare compromises patient safety and reduces the quality of care given to a patient by a healthcare practitioner (Fisher and Scot 2013). Health care risk has grown to be very prevalent in many healthcare organisations. Some of the causes of risks in healthcare include lack of enough healthcare professionals and ignorance of healthcare practitioners whilst offering healthcare services (RCN, 2010).

 In this case, it shows that Sarah’s attitude towards the staff and the patient in the acute medical ward was out of control (NMC 2018). As a junior sister, she should be familiar with the environment of the ward and aware of how to approach confused older people. Sarah looks like that she lost her temper to one of the confused patients who talk loudly during the night. She also failed to deliver a safe and effective practice in the administration of medication (NICE Guidelines, 2015).

 It was incumbent upon Sarah to show compassion to her patients and avoid mishandling them. Sarah’s did not demonstrate competence to her role as a junior sister as it seems like that, she failed to carry out a risk assessment before giving the care to the patient and administered un-prescribed sedative to the confused older patient, which could have been the cause of unconsciousness, cognitive impairment and death as the side effect of the sedative (REFERENCE). Alzheimer’s Society (2015) stated that it can be challenging for healthcare professionals to precisely assess cognitive function in older persons. However, this is one of the most significant assessments of the healthcare professionals make, especially those working in older people in psychiatry and geriatric medicine. Mental Capacity Act (MCA) (2005) highlighted that, it is always requirement to make an assessment of capacity prior to undertaking any care or treatment for the individuals.

Risk assessment is defined as the overall method or process that is followed to identify hazards or threats that have the potential of causing harm (HSE 2014). The process analyses and evaluates the risk factors that are associated with the risk or hazard and also determines the best suitable ways to implement to eliminate or reduce the potential of the risk occurring (Vincent 2010). According to Health and Safety Executive (HSE) (2014), there exists a variety of steps that need to be followed when carrying out risk assessment this includes: Step one is identifying of hazards, thus, refers to anything within the healthcare organisation that has the potential of causing harm. Hazards can be classified into physical, mental, chemical or biological. Step two is identifying who is at risk of falling victim of the hazard in this case-patients were more likely to fall victim of the risks. Step three involves analysing and assessing risk and take relevant action, this includes the health practitioners identifying the risk factors and identify the best approach that can be used to mitigate or reduce the likelihood of the risk from occurring. Step four includes making a record of the findings this will help in proof of assessment and finally, regularly reviewing the risk assessment.

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Sarah’s level of knowledge, skills, and expertise was in question here, as it does not show that she was competent to handle this group of patients (NMC, 2018 and MCA 2005). As a junior sister, she should be aware with her working practices, policies, procedures and protocol of the trust (NMC 2018, Fisher and Scott 2013). The Francis Report (2013) highlighted that patients must come first at all times and should be protected from unnecessary harm.

The risk factors that was mentioned were probably caused by a variety of factors which include long working hours, as the role of nurses especially in acute wards continually expands from the bedside to the boardroom and waiting room (Royal College of Nursing (RCN) 2010). Also, there exist a shortage of healthcare professionals mostly in acute wards in hospitals, thus there is an increased workload on the shoulders of the few healthcare practitioners (Cloete, 2015). This causes fatigue and reduces the level of efficiency in terms of care delivery to patients, it decreases the objectivity of the healthcare practitioner and reduces their performance, and thus it is possible for the nurse to administer wrong medication to patients (Fisher and Scott 2013).

According to the study of Policy Research Unit in Economic Evaluation of Health & Care Interventions (EEPRU) (2018), an estimated two hundred and thirty-seven million medication errors occur in the medication process in the National Health Services (NHS) in England per year. However, seventy-two per cent have little or no potential of causing harm. It is probably that many errors are picked up prior in reaching the patient.

Medication error can be defined as a failure in the treatment process that brings about or has the potential lead to harm of a patient (Fisher and Scott 2013). It includes dispensing of inappropriate medicine, administering medication without prescription to mention a few (NICE Guidelines 2015).

When nursing patients in the hospital, it is one of the duties and responsibilities of a registered nurse to follow the medication guidelines of the trust for the safety of the patient, especially to those patients who were taking more than one medicine (NICE Guidelines 2015). Nursing and Midwifery Council (NMC) code of conduct (2018) highlighted that all registered nurses should always follow the recommendation of the National Institute for Health and Care Excellence (NICE) Guidelines with regards to administration in medication. The actions of Sarah as a junior sister violated the NMC (2018) code of conduct, NICE Guidelines in medication administration (2015) and the six fundamental values that nurses are bound to operate in (Department of Health (DH) England 2012). They include Care which is any healthcare organisation’s core business. Compassion which is how care is given through relationships based on empathy. Competence which means that those in caring roles need to be able to understand a patient’s needs and be able to deliver adequate care. Communication which is central to a successful, caring relationship. Courage which enables the care provider to do the right thing and finally commitment which is fundamental to the care process so as to improve care. These are known as the 6 C’s (DH England 2012). The 6C’s which underpin the compassion in practice strategy, they were implemented as a way of articulating the values that are needed to underpin the practice and culture of healthcare organisations.

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However, Sarah’s actions could have been because of her burnout caused by the workload in the ward and with the very challenging patient cases that she had when on duty (Waddill-Goad 2016). In her intent to provide the best care to her patients, she did it in an unsafe and unacceptable way where she could put the staff, the organisation and the older patients at risk of harm. Fisher and Scot (2013) specified that error or mistake normally happens when the individual is trying to do the right thing, yet in fact does the wrong thing.

Research has shown that nurses in hospitals show a very high burnout rate and most are likely not to be satisfied with their jobs, it revealed that large scale of nurses reported physical, mental and emotional exhaustion (RCN, 2010). These risk factors have adverse effects on patient safety and quality of care as it will reflect in the care that he or she is giving and reflects in the attitude towards colleagues and the patients (Yoder-Wise, 2015). Nurses who are feeling burned out and stressed, cannot focus in the same way or treating people in the same way (Bolton et al. 2012). In this case, Sarah looks like she was working to get the job done and was losing compassion to her patients, and this will give a negative impact on patient satisfaction or experience (NMC 2018).

As Sarah failed to work within the legal and professional codes, she was then suspended and at the end was jailed for two years. NMC (2017) lack of competence specified that nurses could make mistakes or error of their judgement from time to time, yet if this extremely serious and involve an undesirable below standards of professional act, which could compromise the safety of the patient. This will then demonstrate that the nurse has lack of knowledge, clinical skills and clinical judgement, the registered nurse is then not safe in practice (NMC, 2017).

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Based on the above discussion, all nurses and other healthcare professionals must adhere in the NMC (2018) code of conduct, NICE Guidelines (2015) safe medication administration, HSE (2014) risk assessment and with trust policies and procedures that clearly define the procedures and operations necessary to improve patient safety and quality of care. It is important to always carrying out risk assessment to enable the healthcare organisation and professionals take necessary measures for the purpose of patient safety and health protection. Nurse managers should regularly organise a medication management training and regularly remind all the nurses about the safe medication guidelines for nurses to avoid or reduce medication error.

In conclusion, patient safety is among the major objectives of healthcare. Patient safety is the base that guides the actions and operations of any healthcare organisation. However, there are various risks that are associated with the care operations like medication error. Some of the risk factors include burnout, stress and fatigue of healthcare practitioners. However, it is essential that healthcare organisations and practitioners take up risk assessment and management seriously as it helps identify the root cause, effects and management strategies of the hazards posing a threat to patient safety.

REFERENCE LISTS

  • Oig.hhs.gov. (2018). [Online] Available at: https://oig.hhs.gov/oei/reports/oei-01-03-00050.pdf [Accessed 2 Dec. 2018].
  • Labrague, L., McEnroe-Petitte, D., Papathanasiou, I., Edet, O., Tsaras, K., Leocadio, M., Colet, P., Kleisiaris, C., Fradelos, E., Rosales, R., Vera Santos-Lucas, K. and Velacaria, P. (2017). Stress and coping strategies among nursing students: an international study. Journal of Mental Health, 27(5), pp.402-408.
  • Morath, J. and Turnbull, J. (2010). To do no harm. San Francisco: Jossey-Bass.
  • Perneger, T. (2005). The Swiss cheese model of safety incidents: are there holes in the metaphor? BMC Health Services Research, 5(1).
  • The Health and Social Care Act 2012. (2012). Journal of Paramedic Practice, 4(5), pp.253-253.
  • A vision of compassion. (2012). Practice Nursing, 23(10), pp.481-481.
  • Fisher, M. and Scott, M. (n.d.). Patient safety and managing risk in nursing.
  • NMC revised code unveils 25 standards for good practice. (2018). Nursing Management, 21(10), pp.7-7.
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  • Health and Safety Executive (2014) Risk assessment: A brief guide to controlling risks in the workplace
  • http://www.hse.gov.uk/pubns/indg163.pdf
  • Vincent, C (2010) Patient Safety 2nd edition, Oxford: Wiley-Blackwell
  • Alzheimer’s Society (2015) Helping you to assess cognition: A practical toolkit for clinicians https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/alzheimers_society_cognitive_assessment_toolkit.pdf
  • Waddill-Goad, S. (2016) Nurse Burnout: Combating stress in nursing, USA: Sigma Theta Tau International
  • World Health Organisation (WHO) (2017) The Patient Safety: Making health care safer http://apps.who.int/iris/bitstream/handle/10665/255507/WHO-HIS-SDS-2017.11-eng.pdf;jsessionid=584D421430DA1F484078C4A1E69C94A3?sequence=1
  • Royal College of Nursing (RCN) (2010) Guidance on safe nurse staffing levels in the UK http://www.weds.wales.nhs.uk/sitesplus/documents/1076/rcn%20safe%20staffing%20levels.pdf
  • Holden RJ, Scanlon MC, Patel NR, Kaushal R, Escoto KH, Brown RL, Alper SJ, Arnold JM, Shalaby TM, Murkowski K, Karsh BT (2011), A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. BMJ Qual Saf. 2011 Jan; 20(1):15-24. https://qualitysafety.bmj.com/content/20/1/15
  • Bolton, L.R., Harvey, R.D., Grawitch, M. J., & Barber, L.K. (2012) Counterproductive work behaviours in response to emotional exhaustion: A moderated meditational approach. Stress and Health, 2 8,222-223
  • NMC (2017) Lack of Competence https://www.nmc.org.uk/ftp-library/understanding-fitness-to-practise/fitness-to-practise-allegations/lack-of-competence/
  • Cloete L. (2015) Reducing medication errors in nursing practice. Nursing Standard. vol (29), no. 20, pp. 50-59. https://rcni.com/sites/rcn_nspace/files/ns.29.20.50.e9507.pdf
  • NICE Guidelines (2015) Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes https://www.nice.org.uk/guidance/ng5/chapter/Introduction
  • Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office
  • Francis R. (2015) The final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry https://webarchive.nationalarchives.gov.uk/20150407084231/http://www.midstaffspublicinquiry.com/report
  • Fisher, M. & Scott, M. (2013) Patient Safety and Managing Risk in Nursing. London: SAGE
  • Morath, J. M. & Turnbull, J. E. (2005) To Do No Harm, Ensuring Patient Safety in Health Care Organizations. California: John Wiley
  • Spath, P.L. (2011) Error Reduction in Health Care: A System Approach to Improving Patient Safety. California: John Wiley
  • Yoder-Wise, P. S. (2015) Leading and Managing in Nursing 6th edition. Missouri: Elsevier Mosby
  • Reason, J. (2000) Human error: models and management. British Medical Journal. 18;320 (7237):768-770
  • NMC (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates.  https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

 

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Reason Swiss cheese model || loss causation model || example on covid 19


The Swiss cheese model of accident causation is a model used in risk analysis and risk management, including aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth.

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Reason Swiss cheese model || loss causation model ||  example on covid 19

The Swiss Cheese Model for Cyberattacks


Today defense against cyberattacks is becoming more and more difficult. Companies and organizations spend millions of dollars to protect their systems and data and ensure their information security.
Information security may be achieved in many ways, and multilayer defense is one of the most used.
Today my topic is the Swiss Cheese Model, a model to understand the importance of layering: using several security defense layers against cyber attacks.
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The Swiss Cheese Model for Cyberattacks

What is SWISS CHEESE MODEL? What does SWISS CHEESE MODEL mean? SWISS CHEESE MODEL meaning


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What is SWISS CHEESE MODEL? What does SWISS CHEESE MODEL mean? SWISS CHEESE MODEL meaning SWISS CHEESE MODEL definition SWISS CHEESE MODEL explanation.
Source: Wikipedia.org article, adapted under https://creativecommons.org/licenses/bysa/3.0/ license.
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The Swiss Cheese model of accident causation is a model used in risk analysis and risk management, including aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and defense in depth. It likens human systems to multiple slices of swiss cheese, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are \”layered\” behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize, since other defenses also exist, to prevent a single point of weakness. The model was originally formally propounded by Dante Orlandella and James T. Reason of the University of Manchester, and has since gained widespread acceptance. It is sometimes called the cumulative act effect.
Although the Swiss cheese model is respected and considered to be a useful method of relating concepts, it has been subject to criticism that it is used over broadly, and without enough other models or support.
Reason hypothesized that most accidents can be traced to one or more of four failure domains: organizational influences, supervision, preconditions, and specific acts. For example, in aviation, preconditions for unsafe acts include fatigued air crew or improper communications practices. Unsafe supervision encompasses for example, pairing inexperienced pilots on a night flight into known adverse weather. Organizational influences encompass such things as reduction in expenditure on pilot training in times of financial austerity.
In the Swiss Cheese model, an organisation’s defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices. The system produces failures when a hole in each slice momentarily aligns, permitting (in Reason’s words) \”a trajectory of accident opportunity\”, so that a hazard passes through holes in all of the slices, leading to a failure.
Frosch described Reason’s model in mathematical terms as a model in percolation theory, which he analyses as a Bethe lattice.
The Swiss Cheese model includes both active and latent failures. Active failures encompass the unsafe acts that can be directly linked to an accident, such as (in the case of aircraft accidents) pilot error. Latent failures include contributory factors that may lie dormant for days, weeks, or months until they contribute to the accident. Latent failures span the first three domains of failure in Reason’s model.
The same framework applies in healthcare. For example, a latent failure could be the similar packaging of two drugs that are then stored close to each other in a pharmacy. Such a failure would be a contributory factor in the administration of the wrong drug to a patient. Such research led to the realization that medical error can be the result of \”system flaws, not character flaws\”, and that greed, ignorance, malice or laziness are not the only causes of error.
Lubnau, Lubnau, and Okray apply the model to the engineering of firefighting systems, aiming to reduce human errors by \”inserting additional layers of cheese into the system\”, namely the techniques of Crew Resource Management.
This is one of the many models listed, with references, in.
Kamoun and Nichofound the Swiss Cheese Model to be a useful theoretical model to explain the multifaceted (human, organizational and technological) aspects of healthcare data breaches.

What is SWISS CHEESE MODEL? What does SWISS CHEESE MODEL mean? SWISS CHEESE MODEL meaning

How To Make Swiss Cheese | Authentic Cheesemaking in Switzerland’s Emmental Valley (Bern Day Trip)


Ever wondered how Swiss Cheese is made? And why does it have holes? Let’s take a little adventure today to the Emmental Valley in the Swiss Alps, the home of Swiss Cheese. In this hilly landscape just east of Switzerland’s capital, Bern, you will find the Emmentaler Schaukäserei (cheese dairy). Here you can have the chance to not only witness authentic cheesemaking and enjoy fresh cheese fondue, but you can also make your very own cheese! On top of that, the farm has a super retro audiovisual tour showing guests the amazing history of Emmental Cheese and even a fun cheesethemed playground! A visit to this cheese farm is a fantastic idea for a day excursion while visiting Bern. And there, you will finally hear the answer to that mysterious question, \”Why does Swiss Cheese have holes?\”
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How To Make Swiss Cheese | Authentic Cheesemaking in Switzerland's Emmental Valley (Bern Day Trip)

Reasons Swiss Cheese Model


James Reasons Swiss Cheese Model is a simple metaphor to visualise how patient harm happens, based on a systems approach.
This metaphor shows us that in a complex healthcare system, errors are prevented by a series of Defences, Barriers, and Safeguards; represented by slices of cheese.

Reasons Swiss Cheese Model

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