Tuesday, September 04, 2007

The "Swiss cheese effect"

From the HeraldTribune.com article:
Two major advances that have improved health care -- abundant, specialized medications and powerful new technology -- also create new possibility for errors.

"The likelihood of error goes up with the more steps there are," said Frances Griffin, a director of the Institute for Healthcare Improvement.

The nonprofit group, known as IHI, won acclaim for its "100,000 Lives Campaign" in 2005 to reduce medical errors.

To all that, add in that doctors are susceptible to the same "classic human factors," Griffin said: "If we have to rely on memory for something, if we're distracted by something, if we have to do several things at once."

She and Krumholz both cited the "Swiss cheese effect."

The concept arose from studying aviation errors, and in recent years has been applied to health care. The thinking goes: A block of Swiss cheese has a lot of holes. But only rarely do they line up so you can see all the way through. When they do, a mistake makes its way through to the patient.
This article also discusses one physician who is very transparent about a surgical error that he made. Click here to check it out.

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