Core concepts in patient safety - RCN Page 1 of 3

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Core concepts in patient safety

This section provides you with access to materials that reflect core concepts In patient safety. These are Important for all members of the
nursing team to understand to be best able to develop their knowledge and skills In promoting patient safety. Three particular models
are described:

• Reason's Swiss cheese model

• Reason's three-bucket model
• Iceberg near-miss model.

Reason's Swiss cheese model

Reason's Swiss Cheese model Is based on an understanding that every step In a process, or every layer of a system, has weaknesses
that can lead to failure. Reason likened processes or systems to slices of Swiss cheese laid side by side. The holes in the Swiss cheese
represent potential weaknesses at each particular stage or layer. Some of these holes are considered "active" - an Individual making an
error - and others are considered "latent" (these weakness are Inherent to the system and may Include poor organisational design or
weak management systems).

If one of the holes Is penetrated (that Is, a failure occurs at that point), the chances are that the layer behind will block any further
failure. Each slice of "cheese" therefore acts as a "defence" against further failure and represents an opportunity to stop or avoid an
error.

But If the holes In each layer come Into alignment, the potential for failure at each and every stage becomes real. This can lead to
catastrophic failure.

Explore the Interactive model to see how seemingly small problems can ultimately become very significant. Every stage or layer has the
potential for failure and, If the "holes" line up, defences against errors at each stage become nullified and failure becomes Inevitable.

As you consider the model, try to reflect on an event In your workplace where this has happened and what might have been done to
prevent It. If you Identify a work practice In your clinical setting that could be Improved, you might find the 'action plan' template In the
'Taking action' useful for working through a possible solution. You may wish to print the action plan and share It with your colleagues or
manager. You may also wish to save It In your portfolio as evidence of your learning,
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Reason's Three bucket model

Reason's three-bucket model is based on the understanding that frontllne staff can help to stop errors and unsafe practice occurring
If they adopt a risk-aware and 'error-wise' mindset. This will enable them to recognise situations with a high risk of error occurring
and improve their ability to correct errors early.
The 'buckets' In the model represent 'self', 'context' and 'task'. The model's contention Is that the possibility of error or unsafe action In
any given situation depends to a large extent on how much 'bad stuff' Is In those three buckets at any particular time. For Instance, 'bad
stuff' In the 'self' bucket that might contribute to an error or unsafe practice could Include a nurse:

• being unprepared or untrained to perform a particular task

• being Intimidated about challenging senior staff decisions
• having unrealistic perceptions of his or her own competence
• being under stress at work or home
• being physically or mentally tired.

While this list of 'bad stuff' appears In the 'self' bucket, It also flags up failures at organisational level, and many such failures can be
reflected In the 'context' bucket. 'Bad stuff' In the context bucket might Include:

• poor maintenance and servicing of equipment

• ease or difficulty of use of some pieces of equipment and lack of adequate training In their use
• bad lighting or an otherwise Inappropriate environment for work
• Inadequate structures and support for exchange of Information
• weak leadership with unclear or Inadequate lines of authority
• staff having no access to senior staff for support or supervision
• undue or excessive organisational pressures to complete tasks
• weak or absent safety cultures at organisational level
• aloof or aggressive management styles
• staff being very busy or not enough trained staff being on duty.

Finally, 'bad stuff' related to the specific process being undertaken can be found In the 'task' bucket. The 'task' bucket Is all about the
actual task at hand and how dangerous that particular task Is: for Instance, administering chemotherapy may be considered more
dangerous than administering a single paracetamol tablet. In other words, certain procedures may be more dangerous than others: It Is
the task In hand that defines how full the 'task' bucket ls.'Bad stuff' In the bucket Includes:

• tasks being left Incomplete

• errors occurring due to lack of concentration brought on by overfamlllarlty with the task
• Inability to correctly make calculations associated with the task
• lack of time and support to prepare for new or unfamiliar tasks
• distractions, or too many tasks being undertaken simultaneously
• the environment In which the task Is being carried out, such as In the patient's own home.

The three buckets are constantly emptying and filling at any point In time In response to whatever Is happening at that time: an empty
bucket In the morning does not necessarily mean an empty bucket In the afternoon. The key Is having an awareness of the state of the
buckets and developing strategies to empty them when they look full.

The three-bucket model equips nurses and other frontllne staff with the consciousness to Identify when 'bad stuff' such as these
examples Is present. While It does not claim to be foolproof - full 'buckets' do not mean an error or unsafe act will Inevitably occur, and
empty ones do not guarantee safety - the model does provide staff with awareness and knowledge that can help them assess the risk In
any given situation and act accordingly.

Explore the 'Three buckets' Interactive model and as with the previous model, try to reflect on a situation In your workplace where you
can see the model applies and attempt to devise an 'action plan' for a possible solution. You may wish to print the action plan and share
It with your colleagues or manager. You may also wish to save It In your portfolio as evidence of your learning.
Core concepts in patient safety - RCN Page 3 of 3

The Iceberg model

The 'Iceberg' near-miss model works on the understanding that what Is hidden under the surface In relation to statistics on accidents
anderrors may In fact be more significant that what Is above, just as with an Iceberg.

'fh!J part of the 'Iceberg' above the surface represents errors that cause major harm. These errors understandably attract great attention.
Below the surface, however, lurk 'no-harm' events or those that cause only minor Injuries, and near misses (Incidents that did not cause
actual harm at the time but which had the potential to do so).

In addition, a particular error that results In no harm one day may have a much more serious outcome on a different day with a different
patient. It may be the same error, but the consequences may be very different. For Instance, mis-selecting a particular medicine for
administration may In one patient cause no harm, but In another (where this patient may be severly allergic) may be catastrophic - even
If the same medicines are Involved.

For every death, there are many dress rehearsals. Following extensive research In the early and mid 20th century, the Industrial safety
pioneer Heinrich suggested that for every event that causes major Injury, there are 29 that cause minor Injury and 300 with no Injury.
This finding has become the basis of the Iceberg model, which teaches us that many untoward Incidents, serious and not-so serious,
share common root causes, meaning that attention to common and less-serious events and near misses can help prevent more serious
Incidents. This emphasises how Important It Is not to Ignore common and less-serious events and near misses, but to formally
Investigate and report them.

Explore the 'Iceberg' Interactive model and as with the previous two models, think about a situation In your workplace which was
considered a 'lucky escape'. In light of what you know about the Iceberg model and Its relevance for patient safety, how has your view of
that situation changed? Reporting 'near misses' Is just as Important as reporting actual Incidents. You may wish to use the 'Reflective
learning record' template In the 'Taking action' section to record your thoughts and Insights based on this learning. You may wish to print
It and share It with your colleagues or manager. You may also wish to save It In your portfolio as evidence of your learning.

© 2017 Royal College of Nursing