Preventing Harm In the language of human factors, complex organizations such as those providing medical and behavioral healthcare have insufficient layers of protection and therefore allow the mistakes made by human beings to continue on their way to cause harm. According to Bates and Singh (2018), it is commonly the cumulative effect of multiple small mistakes—each unlikely to create an accident alone, but potentially deadly when combined—that can result in a catastrophe. It follows that harm to patients can be prevented only when environmental conditions, especially broken work processes, are identified and redesigned to produce a safer system of care. Healthcare leadership will need to pave the way for durable change, changing cultural attitudes within systems of care. Leadership can inspire change to move toward preventing harm (Bates & Singh, 2018). The Swiss Cheese Model The Swiss Cheese Model (Jedick, 2022) provides a visual depiction of the ways that multiple weaknesses, both individual and organizational, can align to cause an accident. The model also shows the different points at which failures occur within an organizational system. Figure 1 illustrates the model and will be used to discuss the concepts necessary for understanding the human factors approach. Figure 1. The Swiss Cheese Model
constraints within an organization. Budgetary constraints lead to inadequate resource allocation. Inadequate resource allocation, in turn, creates a number of vulnerabilities at the delivery level of the organization, such as understaffing, unwieldy caseloads, less time spent with clients to understand their issues, reduced in-service training, and inadequate supervision for inexperienced clinicians. It is the cumulative effects of these organizational weaknesses that come together and produce catastrophe at the delivery level of the organization. Sharp End and Blunt End In the language of human factors, the delivery level of the organization is referred to as the sharp end. It is the point at which active failures occur, and it is called the sharp end because it is the point where system vulnerabilities come together to produce a mishap. It is also that point in the organization where the clinician and client come together. In contrast, the blunt end describes latent (hidden) weaknesses. Latent factors range from external forces, such as state and federal legislation, to policy and management decisions within an organization. Legislation related to guns, lack of parity in reimbursement for mental illness relative to medical illness, and deinstitutionalization of people with mental illness without adequate funding to support them in the community are examples of external blunt end factors. An example of a blunt end weakness at the organizational level is the failure to develop policies around working overtime—a failure that can contribute to worker fatigue and compromise patient safety. Another example at the organizational level is the decision by management to cut staff positions without redesigning work processes so that remaining staff are not overburdened. Blunt end weaknesses emerge, sooner or later, at the sharp end. A faulty decision made at the blunt end can lay the groundwork for a disastrous encounter at the sharp end (Smith & Plunkett, 2019). Seshia and colleagues (2018) sought to expand the Swiss Cheese Model and found factors contributing to human and systems error, namely unhealthy cultures, poor communication between one or more levels of care, inadequate resources such as staffing and equipment, and the of difficulty accessing resources. Their report went on to identify other negative factors: Failure to promote and practice person- and family- centered care, insufficient shared decision making, unpredictable situations, time and concentration factors, and failure to seek an independent reliable opinion (outside view) when the situation is critical. On the individual level, Seshia and colleagues (2018) found both provider and patient cognitive-affective states can catalyze error. Importantly, they note that cognitive-affective states influence human error, yet generally remain overlooked in patient safety research. These provider states can include: ● Biases in judgment and decision making (these can relate to the professional’s biases related to a patient’s social status, history, medical status [e.g., obesity], age, gender, and so on) ● Sleep deprivation/fatigue ● Psychological state, including dysphoria, personal life stressors, and burnout ● Cognitive overload that impairs the individual professional Patient-related factors that impact human error include: ● Communication challenges (e.g., language barrier and cognitive dysfunction) ● Adherence (compliance and concordance with medical advice) ● Cognitive-affective biases of patients that influence personal healthcare decisions (same as biases listed above)
Note . Modified from Jedick, R. (2022). Human factors in medicine: A medical error model that isn't full of holes. Emergency Medicine News, 44(11), 24. Active and Latent Failure The Swiss Cheese Model describes two types of failures: Active and latent. An active failure is defined as an operational error at the delivery level of the organization, such as a clinician’s diagnostic error. An active failure may result from action (such as a misdiagnosis), inaction (such as failure to report abuse), or faulty decision making (following an order without questioning its appropriateness). In contrast, a latent failure is defined as an environmental factor. An environmental factor can lie dormant in an organization for days, weeks, or months, until it finally lines up with other system weaknesses and contributes to a disaster. One example of a latent failure is reduced state and federal funding for mental health services. Decreased funding produces budgetary
UNDERSTANDING ORGANIZATIONAL CULTURE
The difficulty of culture is that it an abstraction, culled and created—at minimum-- from the milieu of subjective attitudes and behaviors of people, both individuals and groups. Moreover, there are varying definitions of what culture exactly is. It is real,
but it is veiled, somewhat invisible. The visible effects are seen within the patterns of thought and behavior that the group demonstrates most often. Because of these characteristics, culture can often be unquestioningly accepted, followed, and
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