Swiss Cheese Model

Errors in n institution are considered losses; the role of risk management is to prevent losses from occurring. The Swiss Cheese Model explains that every institution/organization is made up of defense layers to prevent losses. These defense layers could include, procedures, policies, alarms, control room operators, automatic shutdowns, and so on (Reason, 2000). In a perfect world, all of these defense layers are intact, looking like a single slice of cheddar cheese. But the reality is that these defense layers are full of holes, errors, or faults, causing it to look more like a lice of Swiss cheese, full of holes. The holes in the defenses arise for two reasons: active failures and latent conditions” (Reason, 2000). Active failures refer to the mistakes that people who are in direct contact with the patient make (Reason, 2000). These are simple mistakes, or procedural violations that have a short lived impact on the integrity of the defenses of the organization, such as an overworked nurse forgetting to add a note to a patient file (Reason, 2000). Latent conditions come from decisions made by management, such as understanding or inadequate equipment (Reason, 000).

These conditions can create lasting holes in the defense systems, and when these holes line up, a major error is made. The role of risk management is to prevent these latent conditions from occurring, in turn preventing losses to the organization. Health care organizations main concern is patient care, their secondary concern is to maximize profits of the organization (University, 2007). Mistakes can be costly to an organization, risk Managers are responsible for the policies and procedures which reduce injury to patients, staff members, and suitors within an organization (University, 2007).

Risk management in a healthcare organization can either be proactive, or reactive (Hall, 2015). Proactive risk management works hard at collecting data and developing plans, to prevent a major incident from occurring (Hall, 2015). They survey the hospital, meet with senior leadership, research new developments in the industry, to keep up on how to keep the organization safe (Hall, 2015). Keeping up with new developments in the industry allows for risk mangers to update the practices within the organization.

Surveying the hospital, or “doing mounds”, gives risk managers a first-hand view on how policies and procedures are being implemented. It also allows them to see where the mistakes are being made. Meeting with Senior Leadership gives the risk managers an opportunity to discuss new policies and the mistakes that are being made, as well as get ideas on where policies and procedures can be improved. Risk managers examine all of the defense layers of the organization, and evaluate where the mistakes are being made.

Using this information they develop plans, policies, and procedures, to attempt to crease the chances of the occurrence of a major error (Hall, 2015). Reactive risk management is basically damage control. This type of risk management attempts to minimize losses to the organization once an incident has occurred (Mind, 1996). Reactive risk management does not plan for ahead for problems, instead it attempts to deal with them as they come along (Mind, 1996). The issue with organizations that have this type of risk management is that they tend to deliver a lower quality, inconsistent work (Mind, 1996).

The reason behind this is that if a mistake occurs, the organization does not have back-up plan and is then forced to pull workers away from their regular duties to deal with the problem at hand (Mind, 1996). In conclusion, risk managers have the tough job of keeping a healthcare organization safe from errors and profit losses. They work hand-in-hand with the leadership and the staff of a hospital to make is a safe place for both patients and staff. There are two types of risk management styles, proactive and reactive.