Chapters authored
Adverse Events in Hospitals: “Swiss Cheese” Versus the “Hierarchal Referral Model of Care and Clinical Futile Cycles”
The James Reason ‘Swiss Cheese’ model of adverse event causation has been the predominant principle in the determination and prevention of health-care-associated adverse events for the last 20 years. This model was developed to understand the causation of large-scale organisational and industrial accidents. In principle, it looks for holes in the defence layers of a large organisation that are largely administrative and not the fault of individuals that may be directly involved with the accident. This model has limitations when applied to health care, where most of the errors or accidents are individual technical or competency deficiencies within a background of an ever-changing micro socio-cultural environment. As such, using ‘Swiss Cheese’ methodology, there has been an over reliance on looking for system issues in health care that has led to a decreased focus on the individual performance of the health-care professional and avoidance of difficult cultural workplace issues. Clinical futile cycles (CFCs) are a model of adverse event causation that primarily focuses on the interaction between the immediate health-care professionals and patients and between health-care professionals. This focus allows for interventions that address issues such as clinical competency and the culture of the health-care environment.
Part of the book: Vignettes in Patient Safety
Clinical Futile Cycles: Systematic Microeconomic Reform of Health Care by Reform of the Traditional Hierarchical Referral Model of Care
The incidence of adverse patient events in hospitals has not improved over the last two decades despite enormous efforts in the area of Quality and Safety. Notably, the same errors are often repeated, even though previous reviews of these events have resulted in learnings, guidelines and policy. The traditional review of a Hospital Adverse Event (HAE) is most commonly a Root Cause Analysis (RCA) to find factors and conditions that caused or contributed to the HAE. The basis for the RCA is the James Reason Swiss Cheese model of adverse events developed from analysis of large- scale industrial accidents. In this model the HAE occurs when a patient deteriorating clinical trajectory broaches the hospital’s organisational and professional defences. The learnings from the RCA typically result in new or changed policies and procedures, and occasionally professional disciplinary review of the involved health care workers. Clinical Futile Cycles (CFC) is clinical action or intervention (or lack thereof) that has no patient benefit. Analysis of HAE by looking for CFC creates learnings that focus on the human factors of the involved health care workers, and more importantly the socio, politico, and fiscal cultural hospital environment at the time of the HAE. As such, the learnings focus not on limitations of the individual practitioners but rather, the greater environment that has them often ignoring, broaching or being oblivious to professional standards, and the already existent policy procedure and guidelines.
Part of the book: Contemporary Topics in Patient Safety