and may be more careless. In fact,
Awareness of
they may develop a mindset that
adverse outcomes are not their
problem but the responsibility of
management.
Swiss Cheese Effect
The system nature of accidents can
best be understood by a “Swiss
cheese” diagram. Figure 2 shows
how latent and active errors are
present in the multiple layers of
safeguards of a policy or procedure
and how such defects must line up
for an error to reach a patient
Image Not Available
(Reason 1990, 208).
how deficiencies in each of these
defensive layers contributes to an
adverse outcome can facilitate the
development of necessary feedback
loops, which will identify and correct
defects.
COMMUNICATION AND
RISK MANAGEMENT
Improving communication seems to
be part of any solution to a persistent
healthcare issue. Senior management
MEDICAL ERROR | 11