Andy Montoya
The Swiss Cheese Model is a model used in risk analysis and management. It was proposed by James Reason in his book, 'Human Error'. The model illustrates that accidents within complex systems, such as healthcare, are caused by a breakdown or absence of safety barriers across four levels within a system. These levels are Unsafe Acts, Preconditions for Unsafe Acts, Supervisory Factors, and Organisational Influences. The 'holes' in the cheese represent the absence of safety barriers within a system. Latent conditions are things that can go wrong in a system due to the way it is designed or managed. For example, understaffing or inadequate equipment. Latent conditions can promote unsafe acts and weaken defensive mechanisms.
| Characteristics | Values |
|---|---|
| Latent conditions | Things that can go wrong in a system due to the way it is designed or managed |
| Understaffing or inadequate equipment | |
| Conflicting policies and procedures | |
| Poorly-maintained and out-of-date technology | |
| Counterproductive incentive systems | |
| Lack of leadership engagement | |
| Workload and competing priorities | |
| Lax oversight and accountability | |
| Poor teamwork and communication | |
| Excessive interruptions | |
| Similar packaging of two drugs that are then stored close to each other in a pharmacy |
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What You'll Learn
- Latent conditions are caused by system design or management
- They can be triggered by active errors, which are unsafe behaviours
- Latent failures include conflicting policies, outdated technology, and counterproductive incentive systems
- Latent failures can be identified and remedied by near-miss reporting and risk management
- Latent conditions can promote unsafe acts and weaken defensive mechanisms or be triggered by other factors
Latent conditions are caused by system design or management
The Swiss Cheese Model is a model used in risk analysis and management. It is based on James Reason's Theory of Active and Latent Failures, which states that accidents within complex systems, such as healthcare, are caused by a breakdown or absence of safety barriers across four levels within a system. These levels are Unsafe Acts, Preconditions for Unsafe Acts, Supervisory Factors, and Organisational Influences.
Latent conditions, according to the Swiss Cheese Model, are things that can go wrong in a system due to the way it is designed or managed. These are considered latent failures, which are inherent in a procedure, machine, or system and can lie dormant for days, weeks, or months until they contribute to an accident. Latent failures are unsafe conditions higher up in the system, which can promote unsafe acts and weaken defensive mechanisms.
In the context of system design, latent conditions can be caused by conflicting policies and procedures, poorly maintained and out-of-date technology, counterproductive incentive systems, and excessive interruptions, among other factors. For example, in healthcare, a latent failure could be similar packaging and close storage of two different drugs in a pharmacy, which could lead to the administration of the wrong drug to a patient. This demonstrates how latent failures are not due to individual mistakes but are rather "system flaws, not character flaws".
In terms of management, latent conditions can be caused by a lack of leadership engagement, workload and competing priorities, lax oversight and accountability, poor teamwork and communication, and inadequate equipment, including understaffing. For instance, in the context of marine accidents, latent conditions were found to be caused by the inadequate condition of equipment.
Overall, latent conditions caused by system design or management can create weaknesses in a system's defences, increasing the potential for accidents to occur.
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They can be triggered by active errors, which are unsafe behaviours
The Swiss Cheese Model is a model used in risk analysis and management. It is based on James Reason's Theory of Active and Latent Failures. In this model, an organisation's defences against failure are modelled as slices of Swiss cheese, with holes of varying sizes and in different positions across the slices. The holes represent weaknesses or potential failure points in individual parts of the system.
Latent conditions are things that can go wrong in a system due to the way it is designed or managed. They are dormant factors that may lie latent for days, weeks, or months until they contribute to an accident. Examples include understaffing, inadequate equipment, conflicting policies and procedures, poorly maintained technology, and counterproductive incentive systems. Latent conditions can be triggered by active errors, which are unsafe behaviours carried out by individuals.
For instance, in healthcare, a latent failure could be similar packaging and storage of two different drugs in a pharmacy. This latent failure becomes a contributory factor in the administration of the wrong drug to a patient when triggered by an active error, such as a nurse mis-programming an infusion pump.
Another example is in the context of aircraft accidents, where a latent failure could be inadequate equipment or poor maintenance. An active error, such as a navigation error, could then trigger an accident by causing the aircraft to deviate from its planned route.
By understanding the relationship between latent conditions and active errors, organisations can strengthen their defences and reduce the likelihood of accidents occurring. This involves identifying and addressing weaknesses in the system and implementing measures to prevent active errors from occurring or escalating into accidents.
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Latent failures include conflicting policies, outdated technology, and counterproductive incentive systems
The Swiss Cheese Model is a powerful approach to accident investigation and prevention. It is based on the Theory of Active and Latent Failures, where the holes in the cheese represent the failure or absence of safety barriers within a system. Latent failures are inherent in a procedure, machine, or system and are triggered by active errors or unsafe behaviours carried out by individuals.
Latent failures include conflicting policies and procedures, outdated technology, and counterproductive incentive systems. Conflicting policies arise when different areas or departments within an organization have inconsistent or incompatible rules and guidelines. This can create confusion, inefficiency, and even legal issues if not properly addressed. For example, in the healthcare industry, conflicting policies between different departments could lead to communication breakdowns and potentially harm patients.
Outdated technology refers to equipment or systems that are no longer effective or efficient due to age or advancements in technology. This can include computers, software, machinery, or any other tools or systems used within an organization. For instance, a manufacturing company that fails to update its machinery may experience decreased productivity and competitiveness in the market due to the rapid pace of technological development.
Counterproductive incentive systems refer to situations where incentives or rewards motivate unintended or negative behaviours. These incentives can be monetary, recognition-based, or performance-based. For example, Volkswagen's focus on performance incentives led to the publication of false information about vehicle emissions, as employees prioritised short-term goals over ethical behaviour. Similarly, an organization with incentives solely focused on revenue growth may inadvertently discourage employees from speaking up about ethical concerns or hinder progress in areas like diversity, equity, and inclusion.
By addressing these latent failures, organizations can improve their overall safety and performance. This involves reviewing and aligning policies, investing in technology upgrades, and carefully designing incentive systems that promote ethical behaviour and long-term sustainability.
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Latent failures can be identified and remedied by near-miss reporting and risk management
The Swiss Cheese Model is a model used in risk analysis and management. It was developed by James T. Reason and likens human systems to slices of Swiss cheese, with holes of varying sizes and positions representing weaknesses or potential failure points in the system. When the holes align, a failure occurs.
Latent failures are those that lie dormant for extended periods before contributing to an accident. They are often triggered by active errors or unsafe behaviours by individuals. Latent failures can be identified and addressed through near-miss reporting and risk management strategies. For example, near-miss reporting can identify unsafe behaviours that may trigger latent failures, while risk management can help identify and address weaknesses in the system that could lead to accidents.
In healthcare, a latent failure could be similar packaging and storage of two different drugs in close proximity in a pharmacy, which could contribute to the administration of the wrong drug. This realisation led to the understanding that medical errors are often due to "system flaws, not character flaws". Latent failures can also include conflicting policies and procedures, outdated technology, counterproductive incentive systems, excessive interruptions, and poor teamwork and communication.
By understanding the Swiss Cheese Model and Reason's Theory of Active and Latent Failures, organisations can strengthen their problem-solving approaches and develop strategies to address weaknesses. This model is particularly useful for identifying weak points and developing strategies to prevent accidents, even when organisations have made their best efforts to prevent them.
In summary, latent failures are an important aspect of the Swiss Cheese Model, and by utilising near-miss reporting and risk management, these failures can be identified and addressed to improve overall system safety and reduce accidents.
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Latent conditions can promote unsafe acts and weaken defensive mechanisms or be triggered by other factors
The Swiss Cheese Model is a model used in risk analysis and management. It was proposed by James Reason in his book, 'Human Error'. The model illustrates how failures typically result from a combination of factors rather than a single root cause. These factors often include latent errors inherent in a procedure, machine, or system.
The model is visualized as multiple layers of Swiss cheese, where the holes in each layer represent potential failure points. When these holes align, a failure occurs. Each slice of cheese can be thought of as a line of defence against accidents. These slices represent different areas within an organization, such as management, allocation of resources, and safety programs.
Latent conditions are things that can go wrong in a system due to the way it is designed or managed. Examples include understaffing, inadequate equipment, conflicting policies and procedures, poorly maintained technology, and counterproductive incentive systems. Latent conditions can promote unsafe acts and weaken defensive mechanisms in several ways:
Firstly, they can create an environment where unsafe acts are more likely to occur. For example, understaffing or excessive workload can increase stress and fatigue among employees, making them more prone to making mistakes or engaging in unsafe behaviours.
Secondly, latent conditions can directly contribute to unsafe acts. For example, poorly maintained equipment or inadequate safety procedures can increase the risk of accidents or errors.
Thirdly, latent conditions can weaken defensive mechanisms by compromising the effectiveness of safety measures. For instance, if an organization has poorly designed emergency response plans or inadequate training programs, their ability to mitigate or respond to incidents is diminished.
Additionally, latent conditions can interact with other factors to trigger accidents. In the Swiss Cheese Model, holes in the defensive layers (representing latent conditions) can align with holes in other layers (such as active failures or unsafe acts), allowing hazards to come into direct contact with potential losses, resulting in an accident.
Furthermore, latent conditions can remain dormant for extended periods before contributing to an accident. They may lie dormant for days, weeks, or months, making them challenging to identify and address proactively.
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Frequently asked questions
The Swiss Cheese Model is a model used in risk analysis and risk management. It likens human systems to multiple slices of Swiss cheese, which have randomly placed and sized holes. Each slice of cheese can be thought of as a line of defence against accidents.
Latent conditions are things that can go wrong in a system due to the way it is designed or managed. They are also known as latent failures and can be triggered by active errors or unsafe behaviours carried out by individuals. Examples of latent conditions include conflicting policies and procedures, poorly maintained and out-of-date technology, understaffing, and inadequate equipment.
The Swiss Cheese Model can be used to understand why accidents occur in healthcare settings despite efforts to prevent them. It helps to identify weak points and develop strategies to combat them. For example, a latent failure could be similar packaging and storage of two different drugs in a pharmacy, which could contribute to the administration of the wrong drug to a patient.
