Patient Safety Reflection on the Swiss Cheese Model: Checklists and Near Misses
According to Johns Hopkins, medical errors is the third leading cause of death in the United States right after cancer and heart disease. This statistic is alarming! In this reflection I will highlight Dr. Laura Ardizzone’s patient safety lecture on the Swiss Cheese model, the use of checklists and reporting “near misses” to fix potential future adverse events from occurring.
Multicausal Theory of Errors and Safety “Swiss Cheese” Model
Dr. Laura Ardizzone mentioned the Swiss Cheese Model during her patient safety presentation. She mentioned that this explained why medical errors occurred as there are often many holes in the systems or process. She goes on to explain that if one safety barrier fails, it has the potential to fall through other safety barriers and cause harm to the patient. Interestingly, there have been more research on this explaining that there can be 5 slices that can address these holes. The five slices are as follows: (1) training, (2) technology (3) checklists (4) the culturally expected scripted or standardized communication and (5) institutional policies and procedures (Stein & Heiss, 2015).
I thought that her advocacy for checklists was telling. I, too, often use checklists and I find it helps me with efficiency. Instead of remembering everything we have to do in our heads, a checklist ensures all tasks, menial or not, are completed. In our principles of anesthesia lab class last semester, while emulating the scenario of malignant hyperthermia, it was evident that anxiety was lessened and the chaos of a potentially fatal event was under control with the use of a checklist. When one person was designated as the leader of the team, assigned roles, and read everything off the list to ensure that every guideline was followed and not missed, the task of protecting our patient was done in a timely manner.
As a CRNA, I know that I will often be faced with a difficult situation especially in the case of securing and maintaining the airway. The setting when I cannot intubate, cannot ventilate is one that I am most afraid of. However, with the help of the difficult airway algorithm, like a checklist, where we ensure nothing is missed along with our training during school; I can address this in the clinical setting in an organized efficient manner.
Another topic Dr. Ardizzone mentioned were the cases of “near-misses” and the number of planned and unplanned events. The thought of an unplanned event with no safety mechanism in place is unsettling. This is partly due to the number of underreported events. In a 2018 study by Hamilton et. al, “Only 1 of 137 observed events was reported in the handwritten variance system.” The study shows that despite multiple reporting systems, many observed faults in processes were not reported. This is even more concerning to me as a future provider. I think we need to enforce “just culture” throughout the healthcare system of focusing mistakes on learning and not punishment. It should be everyone’s responsibility to report an observable near- miss error. Thus, we can prevent such future errors from happening.
I believe that understanding the holes in the systems can allow us to operate more efficiently. By employing the above-mentioned strategies of following the “slices” of the cheese, as well as promoting just culture after reporting “near misses” we can work together to provide safe, effective and high-quality patient care for our patients.