Patient Safety and Quality Improvement
 Modules  Module 3: The “Science” of Human Error
1. Introduction to Course
2. History of Patient Safety
3. The Science of Human Error
4. The Analysis of Medical Error
5. Evidence-Based Medical Practice
6. Communication and Information Transfer
7. Adverse Patient Outcomes
8. The Role of the Patient and Family
9. Environmental Safety in the Medical Setting
10. Safe Medical Practice In Ambulatory Settings

The “Swiss Cheese” Model of Error (Reason, 1990)

  • In any “process” there are multiple levels of “defense against error”, but at each level the defenses are not perfect (e.g., “holes” in a slice of Swiss cheese)
  • Usually, with multiple layers, e.g. multiple slices of Swiss cheese, the “holes” usually do not line up, and thus the error does not pass through
  • Occasionally (unique circumstances) the “holes” DO line up, and the error gets through
 
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