Swiss Cheese Model to Assess Medical Errors and Patient Safety

Patient safety and risk management are major aspects of healthcare that should be intertwined in any healthcare organisation (Fisher and Scott 2013). Patient safety is where the patient does not experience unnecessary suffering or harm during treatment while risk management is described to be any activity, processor policies that are taken up to reduce liability exposure (World Health Organisation (WHO), 2017). Medical malpractice claims demonstrate the significance of potential hazards that can occur in healthcare organisations (Spath 2011). Medical malpractice tends to cover a wide range of conditions and severity. Example of some of these claims includes administering medication without a diagnosis, improper prescription of medication, mishandling of patients and lack of ethics among healthcare professionals (Spath, 2011).

In this account, human factors and key issues will be discussed as they were identified using the Swiss Cheese Model of error in part one of this portfolio and from the Risk Assessment Tool (see appendix —–); however, the focus will mainly be on the medication errors of the junior sister in the acute medical ward.

The Swiss Cheese Model has developed to be a dominant paradigm used for analysing medical errors and patient safety incidents (Reason 2000). This model is often referred to and generally accepted by patient safety healthcare professionals. They use the model to explain the occurrence of system failures such as medication error (Reason 2000). According to Morath and Turnbull (2005) the Swiss Cheese Model, in any complex systems, risks and hazards with the potential of causing harm are prevented by a series of barriers. However, each barrier has its weaknesses (Holes) which are inconstant. This means that these holes are continuously opening, shutting and shifting their location. By chance, if all holes align the risks and hazards are able to reach the patient and cause harm (Morath and Turnbull 2005).

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The Swiss Cheese model shows that most accidents do not occur from one mistake or error. However, it happens because of multiple small causes, each insufficient to generate an accident, although possibly deadly when all merged (Morath and Turnbull, 2010). Thus, the implementation of the Swiss Cheese model in patient safety is used for defences, barriers, and safeguarding the potential victims and resources from hazards (Reason 2000).

A risk is a term that is commonly used to refer to a chance or likelihood of an undesirable event occurring. Based on Fisher and Scot (2013), risk typically refers to a possibility that an act or activity may occur and that has the potential to cause harm. A risk in healthcare is considered to be a sensitive issue as it has the potential of causing significant damage to the caregiving process and ultimately the patients or even to the healthcare professionals (Holden et al. 2011). A risk in healthcare compromises patient safety and reduces the quality of care given to a patient by a healthcare practitioner (Fisher and Scot 2013). Health care risk has grown to be very prevalent in many healthcare organisations. Some of the causes of risks in healthcare include lack of enough healthcare professionals and ignorance of healthcare practitioners whilst offering healthcare services (RCN, 2010).

 In this case, it shows that Sarah’s attitude towards the staff and the patient in the acute medical ward was out of control (NMC 2018). As a junior sister, she should be familiar with the environment of the ward and aware of how to approach confused older people. Sarah looks like that she lost her temper to one of the confused patients who talk loudly during the night. She also failed to deliver a safe and effective practice in the administration of medication (NICE Guidelines, 2015).

 It was incumbent upon Sarah to show compassion to her patients and avoid mishandling them. Sarah’s did not demonstrate competence to her role as a junior sister as it seems like that, she failed to carry out a risk assessment before giving the care to the patient and administered un-prescribed sedative to the confused older patient, which could have been the cause of unconsciousness, cognitive impairment and death as the side effect of the sedative (REFERENCE). Alzheimer’s Society (2015) stated that it can be challenging for healthcare professionals to precisely assess cognitive function in older persons. However, this is one of the most significant assessments of the healthcare professionals make, especially those working in older people in psychiatry and geriatric medicine. Mental Capacity Act (MCA) (2005) highlighted that, it is always requirement to make an assessment of capacity prior to undertaking any care or treatment for the individuals.

Risk assessment is defined as the overall method or process that is followed to identify hazards or threats that have the potential of causing harm (HSE 2014). The process analyses and evaluates the risk factors that are associated with the risk or hazard and also determines the best suitable ways to implement to eliminate or reduce the potential of the risk occurring (Vincent 2010). According to Health and Safety Executive (HSE) (2014), there exists a variety of steps that need to be followed when carrying out risk assessment this includes: Step one is identifying of hazards, thus, refers to anything within the healthcare organisation that has the potential of causing harm. Hazards can be classified into physical, mental, chemical or biological. Step two is identifying who is at risk of falling victim of the hazard in this case-patients were more likely to fall victim of the risks. Step three involves analysing and assessing risk and take relevant action, this includes the health practitioners identifying the risk factors and identify the best approach that can be used to mitigate or reduce the likelihood of the risk from occurring. Step four includes making a record of the findings this will help in proof of assessment and finally, regularly reviewing the risk assessment.

Sarah’s level of knowledge, skills, and expertise was in question here, as it does not show that she was competent to handle this group of patients (NMC, 2018 and MCA 2005). As a junior sister, she should be aware with her working practices, policies, procedures and protocol of the trust (NMC 2018, Fisher and Scott 2013). The Francis Report (2013) highlighted that patients must come first at all times and should be protected from unnecessary harm.

The risk factors that was mentioned were probably caused by a variety of factors which include long working hours, as the role of nurses especially in acute wards continually expands from the bedside to the boardroom and waiting room (Royal College of Nursing (RCN) 2010). Also, there exist a shortage of healthcare professionals mostly in acute wards in hospitals, thus there is an increased workload on the shoulders of the few healthcare practitioners (Cloete, 2015). This causes fatigue and reduces the level of efficiency in terms of care delivery to patients, it decreases the objectivity of the healthcare practitioner and reduces their performance, and thus it is possible for the nurse to administer wrong medication to patients (Fisher and Scott 2013).

According to the study of Policy Research Unit in Economic Evaluation of Health & Care Interventions (EEPRU) (2018), an estimated two hundred and thirty-seven million medication errors occur in the medication process in the National Health Services (NHS) in England per year. However, seventy-two per cent have little or no potential of causing harm. It is probably that many errors are picked up prior in reaching the patient.

Medication error can be defined as a failure in the treatment process that brings about or has the potential lead to harm of a patient (Fisher and Scott 2013). It includes dispensing of inappropriate medicine, administering medication without prescription to mention a few (NICE Guidelines 2015).

When nursing patients in the hospital, it is one of the duties and responsibilities of a registered nurse to follow the medication guidelines of the trust for the safety of the patient, especially to those patients who were taking more than one medicine (NICE Guidelines 2015). Nursing and Midwifery Council (NMC) code of conduct (2018) highlighted that all registered nurses should always follow the recommendation of the National Institute for Health and Care Excellence (NICE) Guidelines with regards to administration in medication. The actions of Sarah as a junior sister violated the NMC (2018) code of conduct, NICE Guidelines in medication administration (2015) and the six fundamental values that nurses are bound to operate in (Department of Health (DH) England 2012). They include Care which is any healthcare organisation’s core business. Compassion which is how care is given through relationships based on empathy. Competence which means that those in caring roles need to be able to understand a patient’s needs and be able to deliver adequate care. Communication which is central to a successful, caring relationship. Courage which enables the care provider to do the right thing and finally commitment which is fundamental to the care process so as to improve care. These are known as the 6 C’s (DH England 2012). The 6C’s which underpin the compassion in practice strategy, they were implemented as a way of articulating the values that are needed to underpin the practice and culture of healthcare organisations.

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However, Sarah’s actions could have been because of her burnout caused by the workload in the ward and with the very challenging patient cases that she had when on duty (Waddill-Goad 2016). In her intent to provide the best care to her patients, she did it in an unsafe and unacceptable way where she could put the staff, the organisation and the older patients at risk of harm. Fisher and Scot (2013) specified that error or mistake normally happens when the individual is trying to do the right thing, yet in fact does the wrong thing.

Research has shown that nurses in hospitals show a very high burnout rate and most are likely not to be satisfied with their jobs, it revealed that large scale of nurses reported physical, mental and emotional exhaustion (RCN, 2010). These risk factors have adverse effects on patient safety and quality of care as it will reflect in the care that he or she is giving and reflects in the attitude towards colleagues and the patients (Yoder-Wise, 2015). Nurses who are feeling burned out and stressed, cannot focus in the same way or treating people in the same way (Bolton et al. 2012). In this case, Sarah looks like she was working to get the job done and was losing compassion to her patients, and this will give a negative impact on patient satisfaction or experience (NMC 2018).

As Sarah failed to work within the legal and professional codes, she was then suspended and at the end was jailed for two years. NMC (2017) lack of competence specified that nurses could make mistakes or error of their judgement from time to time, yet if this extremely serious and involve an undesirable below standards of professional act, which could compromise the safety of the patient. This will then demonstrate that the nurse has lack of knowledge, clinical skills and clinical judgement, the registered nurse is then not safe in practice (NMC, 2017).

Based on the above discussion, all nurses and other healthcare professionals must adhere in the NMC (2018) code of conduct, NICE Guidelines (2015) safe medication administration, HSE (2014) risk assessment and with trust policies and procedures that clearly define the procedures and operations necessary to improve patient safety and quality of care. It is important to always carrying out risk assessment to enable the healthcare organisation and professionals take necessary measures for the purpose of patient safety and health protection. Nurse managers should regularly organise a medication management training and regularly remind all the nurses about the safe medication guidelines for nurses to avoid or reduce medication error.

In conclusion, patient safety is among the major objectives of healthcare. Patient safety is the base that guides the actions and operations of any healthcare organisation. However, there are various risks that are associated with the care operations like medication error. Some of the risk factors include burnout, stress and fatigue of healthcare practitioners. However, it is essential that healthcare organisations and practitioners take up risk assessment and management seriously as it helps identify the root cause, effects and management strategies of the hazards posing a threat to patient safety.

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