condition of discharge. Another example of a constraining function is a team meeting in which all professionals involved in a client’s care provide input into readiness for discharge. Understanding human error—its frequency, type, and prevention—was important early in the patient safety movement, in part because of medicine’s longstanding and widespread tradition of focusing on people as the perpetrators of unsafe acts. Early on, such discussion was useful in that it helped professionals begin to grasp the pervasiveness of human error in the workplace. This 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
knowledge was a beginning step toward accepting the inevitability of human error and moving away from blame. However, this narrow understanding, important as it is, fails to improve patient safety on its own because it is when human error occurs in a poorly designed system that tragedy results. To achieve safer care, the focus must be broadened beyond the individual worker to include an examination of flaws in the system of work. Safer care cannot be achieved simply by preventing error; it can be achieved only by preventing harm (Reason, 1990). 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 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.
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).
Page 51
Book Code: PCUS1525
EliteLearning.com/Counselor
Powered by FlippingBook