Adverse Events in Hospitals: “Swiss Cheese” Versus the “Hierarchal Referral Model of Care and Clinical Futile Cycles”

Abstract

The James Reason ‘Swiss Cheese’ model of adverse event causation has been the predom- inant 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. later found widespread bowel and hepatic ischaemia, and Mrs. M died the next day of multi-organ failure (Day-6).