Medication Errors And Patient Safety

Question 1

The systems-based model/approach

Answer 1

Individual factors - related to either the patient/family or health professional;
Team factors - related to the interprofessional team;
Task factors - related to the ways in which certain tasks are performed;
Environmental – related to the environmental surroundings and workforce structures;
Systems or organisational – related to the broader organisation and policies

Question 2

The Swiss cheese model/approach

Answer 2

The Swiss cheese model recognisees that every step in a process has the potential for failure:

Active failures “are unsafe acts committed by people who are in direct contact with the patient or system” (Reasons, 2000, p. 769). These includes slips, lapses, fumbles, mistakes and procedural violations.
Latent conditions “lie dormant within the system for many years before they combine with active failures and local triggers to create an accident opportunity” (Reason, 2000, p. 769). Latent conditions can create two situations:
Error provoking conditions within the local workplace such as understaffing, fatigue, inexperience, inadequate training and time pressures; or
Long-lasting holes or weaknesses in the defences such as untrustworthy alarms and indicators, poor or unworkable procedures