What is the Swiss Cheese Model of Harm?
The 2012 Patient Safety Summit last month had an amazing slate of speakers that were inspiring! Dr. Bob Wachter’s presentations provided keen insights into historical perspectives of patient safety and contributing factors of medical mistakes. One example was that physicians today manage on average 150 medications where as the iconic “Marcus Welby, M.D.” would have managed 20 medications.
This alone is not enough to cause harm. Just as swiss cheese has holes at different places and angles, different aspects of medical care may have weaknesses. All participants have a part to play. When the holes line up, mistakes are more likely to happen. An example was given that included 17 distinct errors, none of which on their own would have caused the medical mistake to occur.
Many of the “holes” that were aligned have been shrunk through initiatives such as utilizing at least two patient identifiers (yes even if the patient is your next door neighbor!), checklists to ensure all safety precautions are followed, developing multidisciplinary teams that include physicians, nurses and patients/family members, and many others. By making small changes, the holes can be shrunk to prevent alignment as long as everyone takes responsibility for their part.