Running Head: JAMES REASON'S SWISS CHEESE THEORY

James Reason's Swiss Cheese Theory
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James Reason's Swiss Cheese Theory

Introduction The model of Swiss cheese is a model of accident causation which is used risk management and its analysis in system of healthcare, aviation, and engineering. Swiss Cheeses Model compares human system to Swiss cheese slices. The slices are piled together with one another. Basically it was founded in 1990, by James T. Reason, a British psychologist of University of Manchester. The model gained wide acceptance and has been used by healthcare industry, emergency services organizations, aviation industry, and safety industry since it was developed. It is also known as cumulative act effect. According to a survey, in most of the cases, there can be four levels of failure for an accident: unsafe supervision, unsafe act of themselves, organizational influence, and preconditions for unsafe acts. James T. Reason, in his Swiss Cheese Model developed defenses of organization against the failure and represented barriers as slices of Swiss cheese. And individual weaknesses are shown by the holes in the slices as part of the system, and all holes are different in position and sizes in those slices. The failure of the system occurs when holes in slices simultaneously align in aggregate, giving permission, as James Reason's said “a trajectory of accident opportunity", so that in all the defenses, jeopardy passes through all holes, which causes failure.

Discussion The theory of James T. Reason involves mathematical analysis and is complicated and also involves underlying and active failures. Swiss cheese model applies here in the way that I can do to prevent the Swiss cheese presenting on training floor. It means as a healthcare administrator I have to prevent mishaps to be happened. The model has become the standard for assessing patient security and medical mistakes. James T. Reason explained the model of Swiss cheese in order to expose the failure of system like medical mishap (Reason JT, et al. 2001). In a complicated system prevention of hazards is done through losses of human through a chain of barriers. All barriers contain unplanned holes, or weaknesses; thus the likeness with Swiss cheese. The holes in the Swiss cheese model randomly close and open due to inconsistent weaknesses. The hazard reaches to patient only when all the holes simultaneously align. Attention is drawn to healthcare system by Reason’s model, and conflicting to randomness, and to the individual, as conflicting to planned action, in happening of mistakes in healthcare system. Reason’s Swiss cheese model is broadly accepted and commonly referred to professionals of patient’s safety. The analysis proposed several interpretations of components of the Swiss cheese model: a) slice of cheese, b) hole, c) arrow, d) active error, e) how to make the system safer. Reason's Swiss cheese model has become the dominant paradigm for analyzing medical errors and patient safety incidents. The aim of this study was to determine if the components of the model are understood in the same way by clinical professionals and do they encourage physician’s leadership to enhance patient’s safety. Because the model gives understanding of system safety, complicated incidents can be analyzed through Swiss cheese model. Being a healthcare administrator patient safety can be improved through increasing collaboration among clinical professionals and by motivating physician leadership with the help of application of Reason’s Swiss cheese model. A cognitive psychologist has helped frame and articulate the new paradigm related to patient safety. James Reason added clarity by specifying the differences between slips and lapses and those of mistakes (Reason, 1997; Reason, 1990). Central to [pic]the system[pic] approach is the idea that all hazardous technologies (e.g., airline industry, nuclear plants, space program) employ barriers and safeguards (i.e., system defenses) against en-or. When an adverse event occurs, it is important to determine how and why the defenses failed, not who blundered. Reason illustrated system accidents using a Swiss cheese model where slices of cheese are lined up on a trajectory and represent barriers and safeguards. In addition, Reason (1997) articulated the difference between active and latent errors, an important distinction that is referenced by those who espouse a systems approach to safety. Active errors are those [pic]at the[pic]"sharp end"[pic]of the system[pic] and [pic]are[pic] the result of actions or violations that have a direct effect and usually in an immediate but short-lived manner. These active errors occur at the human-system interface and [pic]tend to be unique to a specific event.

Furthermore, [pic]latent conditions[pic] may [pic]lie dormant for a long time until[pic] conditions are such that the interaction with local circumstances defeats the organization's defenses and generates errors. Finally, unlike the sharp-end interface with active errors, latent conditions generally arise from the upper echelons and infrastructure of organizations. The paradigm and mantra of systems thinking now pervade the medical and nursing (Leape & Fromson, 2006; Pape, 2003; Pape, 2001 ). Researchers built numerous descriptive summaries, poignant anecdotes, and analytical discussions on Reason's work to emphasize those systems failures usually precede medical errors. For example, if two drugs are packaged in an almost identical manner and are placed close to each other, a health care professional will, no doubt, eventually get confused and administer the wrong drug. Such packaging and placement are systems problems. These researchers all advanced the understanding of error in health care from 1990 to the early 200Os. There is broad recognition that errors are an inevitable component of human activities, including health care, and can be managed appropriately even if never eliminated. Learning how to manage errors more appropriately requires acknowledging that medical errors are not the result of ignorance, malice, laziness, or greed on the part of individuals or organizations. If meaningful medical cultural change is to occur, it must be based on the realization that error is a matter of "system flaws, not character flaws" (Leape, 1994).

Conclusion The interpretations of specific features of the Swiss cheese model varied considerably among quality and safety professionals. Reaching consensus about concepts of patient safety requires further work. In summary, the gravity of adverse drug event has been firmly established in the medical and patient’s care literature since the early 1990s, and a more sophisticated framework in terms of systems has been implanted. A basic, fundamental groundwork has been laid in the patient’s care research, even if the designs are not impressive in their rigor. The model of Reason Swiss cheese provides big room in the patient safety and care if it is implemented with its true essence with proper collaboration of clinical professionals and leadership motivation for patient’s safety and risk mitigation. The one study that is quasi-experimental in design is a step forward from the descriptive level of research to identify management interventions that have the potential for improving patient outcomes and safety (Pape, 2001). As always, more information is needed.
References

Reason, J. (1997) “Managing the Risks of Organizational Accidents”, Burlington, VT: Ashgate.
Reason, J. (1990) “Human Reason”, Cambridge University Press.
Leape, L. L. &, Fromson, J. A. (2006) “Problem Doctors: Is There A System-Level Solution?”, Annals of Internal Medicine.
Pape, T. M. (2001) “Searching For The Final Answer: Factors Contributing To Medication Administration Errors”, Journal of Continuing Education in Nursing.
Pape, T. M. (2003) “Applying Airline Safety Practices to Medication Administration”, Medsurg Nursing.
Leape, L. L. (1994) “Error in Medicine”, Journal of the American Medical Association