Patient safety and quality
Introduced| English | Meaning |
|---|---|
| Swiss cheese model | The idea that harm happens when gaps in several layers of defence line up. |
| near-miss | An error caught before it reached or harmed the patient. |
| SBAR handover | A structured handover: Situation, Background, Assessment, Recommendation. |
Ten times the dose
- (Fictional) A nurse at the bedside notices that a syringe holds ten times the prescribed dose and stops. Nobody is harmed. Whose fault was it?
- Patient safety asks a better question: which parts of the system let the error travel that far? This lesson is about errors as system failures.
The Swiss cheese model
- In Reason's Swiss cheese model 瑞士奶酪模型, a hazard meets several layers of defence: design, barriers, procedures, people. Every layer has holes.
- Harm happens only when the holes in all the layers line up. So the question after an incident is what made the holes, not who was standing in one.
In the Swiss cheese model, harm reaches the patient when —
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Every layer has holes; harm passes only when they line up, so defences in depth matter.
Analysing an incident
- After an incident, memory builds a tidy story with one person to blame. A structured method searches every layer instead.
- The London Protocol checks seven groups of contributing factors: patient, task and technology, individual staff, team, work environment, organisation and management, and institutional context.
- (Fictional) The tenfold dose: two drugs with similar names were prescribed, there was no independent check when the dose was made up, and the nurse was interrupted at the bedside. Three holes lined up.
- The fixes change the design: "tall-man" lettering for look-alike names, separate storage, an independent check, and no-interruption zones. Nobody is blamed.
Once the person who made the error is identified, the incident analysis is complete.
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"Human error" is the start. The analysis asks what allowed the error and what will stop it next time.
Which are system fixes for a look-alike drug-name error? Select all that apply.
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Design changes close holes for everyone. "Be more careful" changes nothing in the system.
Near-misses are free lessons
- A near-miss 未遂事件 is an error caught before it causes harm. It shows exactly where the holes are, at no cost to a patient.
- Reporting near-misses keeps the holes visible. A culture where staff can speak up without fear is itself a layer of defence.
A wrong dose is drawn up but caught before it is given. This is —
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A near-miss shows where the holes are at no cost to a patient, so it should be reported.
SBAR for handovers
- Information gets lost when care passes between people. The SBAR handover SBAR 交接 fixes the order: Situation, Background, Assessment, Recommendation.
- At the bedside, the same idea gives the "five rights" check: right patient, drug, dose, route and time.
Put the parts of an SBAR handover in order.
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A fixed order means nothing is forgotten under pressure.
Measuring quality
- Judge a service on three levels: structure (staff, equipment), process (were the right steps done, such as checklists and handovers) and outcome (results for patients, adjusted for risk).
- Process measures respond quickly to improvement work; outcome measures show whether patients actually benefit. Quality work tracks both.
Match each quality measure to its level.
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Structure is what the service has, process is what it does, outcome is what happens to patients.
Common slips
- Stopping at "human error". That is where the analysis starts, not where it ends.
- Blaming instead of redesigning. The same holes will line up again for the next person.
- Treating a checklist as safety. It is one layer; a culture of speaking up is another.
Recap
- Swiss cheese: harm needs holes lined up across every layer; fix the system, not the person.
- The London Protocol's seven factor groups; near-misses are free lessons.
- SBAR for handovers, five rights at the bedside; quality = structure + process + outcome.