The Health Care System: The Swiss Cheese Model

Medical Errors account for 98,000 deaths per year in the US. They increase disability, costs, and decrease confidence in the US health care system (Pham, Aswani, Rosen, Lee, Huddle, Weeks, & Pronovost, 2012). One of the main goals of quality and risk management is to minimize medical errors in order to improve the overall quality of medical care. In addition, healthcare organizations developed risk management program in order to protect their financial assets from medical malpractice. Healthcare is a complex environment in which people suffer as a result of system failure. According to James Reason (2000), an effective risk management requires detailed analysis of mishaps, incidents, and near misses, and free lessons in order to identify the
Nearly all adverse events involve a combination of 2 sets of factors: active failure and latent conditions. Active failures are the unsafe acts committed by people who are in direct contact with the patient or system. They take a variety of forms: slips, lapses, fumbles, mistakes, and procedural violations. Active failures have a direct and usually short-lived effect on the integrity of the defenses (Reason, 2000). On the other hand, latent failure includes lack of team work and communication, poorly design work schedules or work environment, and variations in the design equipment (Gabay,
This means that they need to create effective defenses in order to prevent or trap active failures and latent failures before they cause harm. Being a high- reliability organization can prevent active and latent failures. The characteristics of high-reliability organization are preoccupation with error prevention, appreciation of the complexity of errors and reluctance to simplify the causes or the strategies to prevent errors, focus on system failures rather than individual performance including nonpunitive approaches to addressing errors, ability to learn from errors and continually improve, and flat organization hierarchy in which staff of any level can effectively voice concerns and make