Organization Swiss cheese model

The study of patient safety is the study of complexity. The study of complexity invites us to understand key concepts that can be applied to patient safety. Basic concepts from the fleld of patient safety are sharp and blunt end active and latent failure the Swiss Cheese Model of Accident Causation slips, lapses, and mistakes and hindsight bias and the fundamental attribution error. Key concepts from organizational analysis, such as normalization of deviance, diffusion of responsibility, tightly coupled work processes, and sensemaking, introduce practical lessons from high-reliability organizations. Application of specific lessons to health care are explored in Chapter Five. 

The associations of distinct detection mechartisrrts to differerrt types of errors led Thomas to propose an organic approach according to which variability in performance and human error requires parallel defense strategies and an adaptive approach and not the traditional serial protective layers as illustrated by Reason s Swiss Cheese Model. 

The systems approach seeks to identify situations or factors likely to contribute to human error. James Reason s analysis of industrial accidents revealed that catastrophic safety failures almost never result from isolated errors conunitted by individuals. Most incidents result from smaller and multiple errors in components and environments with underlying system flaws. Reason s Swiss Cheese Model describes this phenomenon. Errors made by individuals can result in disastrous consequences due to flawed systans that are represented by the holes in the cheese. Reason believed human error would happen in complex systems. Striving for perfection or punishing individuals who make errors does not appreciably improve safety. A systems approach stresses efforts to catch or anticipate human errors before they occur. Reason used the terms active errors and latent errors to distinguish individual errors from system errors. Active errors almost always involve frontline personnel. They occur at the point of contact between a human and some element of a larger system. Latent errors occur due to failures of the organization or designs that allow inevitable active errors to cause harm. The terms sharp end and blunt end correspond to active error and latent error. The systems approach provides a framework for analysis of errors and efforts to improve safety. 

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