Patient safety and Swiss cheese – How many layers do you have?

Reason's Swiss cheese model has become the dominant paradigm for analyzing medical errors and patient safety incidents. Reason has written extensively about how humans and organizations commit errors and how such incidents can be prevented once their causes are understood. In particular, he has developed what he calls the "Swiss Cheese" model of incident occurrence.

Here is what it looks like applied in one area where vulnerabilities can have dire consequences, the hospital setting:

ARDS is Acute Respiratory Distress Syndrome which can result from a number of preventable circumstances. In the illustration above, each slice of cheese, starting from the right, represents an obstacle or defense to ARDS development in a patient admitted to the hospital. But the holes in the cheese slice represent something different - a latent error or system failure waiting to happen. These could be human error, equipment failure, and so on. Each of these can be handled and prevented by proper training, supervision, maintenance and so on. But when these methods break down, the likelihood of a serious event increases.

To bring the message home, try and develop a model for your operation theater. How many slices of cheese exist to help you prevent an accident, or recover from it? How big are the holes, and how often do you refine your procedures to improve the chances of not being in an accident, or surviving one?

The Operation Theater module of H.I.S can reduce such risks in patient safety. With features like

• Pre-operative checklist.

• Pre-define list of instruments and consumables.

• Equipment and consumable sterilization tracking.

• Exception handling for emergency surgery cases.

• Surgery related anesthesia information.

The operation theater module helps you add additional layers of cheese to prevent accidents and ensure patient safety, besides saving you money and increasing process efficiency.

• Optimal utilization of theater resources.

• Just in time inventory savings on theater consumables.

• Surgery scheduling for multiple theaters.

• Scheduling based on average time for a class of surgery.

• Measure surgeon's performance.

• OT performance analysis (Weekly, monthly, yearly).

• And increased accountability through integrated in patient billing.

So why wait? Increase patient safety and save money at the same time.