The ‘Swiss-Cheese Effect’ in health care mistakes: When your patient almost becomes a statistic.

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Almost every journal article, news paper article, and student paper discussing mistakes made in health care refers to the Institute of Medicine report, “To Err Is Human: Building a Safer Health System.” The report caused a media frenzy that panicked many patients and health care providers alike. Although the number of deaths caused by medical errors is enough to scare the most experienced nurse, the statistics haven’t always translated into bedside improvements.

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What happens when it is your patient on the cusp of becoming part of this number?

I have pondered this question through many 12 hour shifts and during hours of formal classes. It wasn’t until I was required, during a hospital orientation, to watch a video on medical errors that the pieces fell into place for me. I have no doubt that many of you have seen the same video. In this production, the fairly decent actors portrayed a post-event meeting between members of a hospital team comprised of both the medical staff and hospital administration.

The main point of the video was to explain a phenomenon they referred to as the ‘Swiss-Cheese Model.’ (James Reason’s Swiss Cheese Model explained) The summarized explanation is that mistakes do not happen as isolated events. Instead, mistakes occur due to a series of events. When these events are taken individually, they may be very benign. They are either harmless or the system is such that they will automatically corrected. If you picture each mistake as a hole in a piece of Swiss Cheese and stack many slices together, the random holes won’t go all of the way through the stack. Mistakes occur when all of those holes do happen to line up and the error is allowed to ‘fall through.’

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Just yesterday, an event occurred in my area of practice is a classic example of the holes lining up and a mistake occurring. By sharing this event as well as another that occurred when I was the nurse providing the care, I hope to convince a few more providers that mistakes should be approached, not from a perspective of blame, but from a perspective of process improvement.

Incident #1

45 y/o male POD #3, s/p ex-fix removal with subsequent ORIF of right Tib/Fib. The patient presented in pre-op with a Groshong® Catheter which was placed at an outside hospital. I was called to the bedside to complete the discharge paperwork for a transfer back to the LTC facility he was a resident of. He was to be discharged with long term antibiotics for MRSA of his wound. He had a 20+ year history of CHI as a result of a dune buggy accident which left him with residual effects to include slurred speech, and unable to be completely independent.