Question-   Leadership for Quality & Patient Safety



PS 102

Lesson 1: The Swiss Cheese Model

In this lesson, we learn that tragedy has happened to Nora. She died before her fourth birthday due to an infection that no one has known. The Swiss Cheese Model created an after-effect that can be from a small hazard because hazards are everywhere in the healthcare setting, such as medication, surgery, and receiving radiation. These can be beneficial as we treat the patient correctly; however, they can also create harm. It starts from the top-level, like the leader to line manager, then points of care. When the holes in the cheese align, then it turned the managerial deficiency into an adverse outcome. For example, a small mistake such as not washing hands before and after contact with each patient and misplace of a hand sanitizer can be harmful. Mainly, it is the failure of the system that causes detrimental ways. However, this error can be preventable by the new way of thinking: the deeper appreciation of error causation and the deeper appreciation of error prevention.

Lesson 2: Understanding Unsafe Acts

            In 2001, Peter Pronovost, a critical care specialist, created a checklist with steps to help prevent infection that many health care systems are widely adopted today.

An unsafe act believed to be the cause of human error by people bad practice and habits that become their normality in life. For instance, the unproperly wear protective gears at home to not proper wear protective gears at works. According to James Reason, unsafe acts may be categorized:

    • Violation, if a person acts against known rules.
    • Errors is when the act is not violated.

Individuals still need to be accountable for their actions even if blaming and punishing are not appropriate responses. Moreover, their organization should handle individuals for errors and unintended events appropriately when blameworthy occurs ().

            To minimize the risk from unsafe acts practice, many steps should take in the form of a checklist to help the staffs follow each of the procedures every time they are dealing with CLABSIs.

Lesson 3: A Closer Look at Harm

Harm is defined as an unintentional injury to the patient that results in death, including medical care, additional care, and physical or psychological. However, harm can be preventable. For example, changing the way of practice in antibiotic use by not overusing it in every situation like viral infection could make more resistance. After learning about the harm and error, the healthcare systems should modify a new or better treatment in prevention. Sometimes, it is better to have a new method to combat harm.

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