Swiss Cheese Model
Between 44,000 and 98,000 people die each year in U.S. hospitals because of medical errors.
According to an article by Johns Hopkins Nursing, there is usually a string of errors in a number of different systems.
They call it the “Swiss Cheese Model.”
“For example, the intern writes an order that is incomplete; the pharmacy fills it in error; and the nurse administers the wrong drug or dose to the patient. There was a hole in each of three systems—ordering, dispensing, and administering. When the holes line up, the original error travels through the systems and reaches the patient.”
Nurses are now taking on a new role as patient safety officers in hopes to bring recognition and leadership to the evolving safety programs in hospitals. After all, nurses are the “primary sentinels” of patient care, “providing the first warning and rapid intervention for those too sick to help themselves.”
Date: April 20, 2014