Final answer:
A common error in healthcare delivery is medication errors. The Reason's Swiss Cheese model explains that errors occur through active failures, such as stress-induced mistakes, and latent conditions, like system design flaws. To prevent these errors, multiple layers of defense, including thorough checks and standardized protocols, should be in place.
Step-by-step explanation:
A common error in healthcare delivery is medication errors, such as prescribing or administering the wrong dosage of a drug. According to Reason's Swiss Cheese model, errors in healthcare can occur when there are sequential failures in the line of defense. This model envisions healthcare safety as multiple layers of protection (like slices of Swiss cheese), where each layer has potential holes due to latent conditions or active failures. The holes in the layers represent weaknesses or failures such as miscommunication, poor hand-offs, or latent system flaws.
For instance, a doctor might prescribe the wrong medication if they are under stress or misinformed about a patient's history, which is an example of an active failure. A latent condition could be a poorly designed electronic health record system that allows for easy mistakes in medication ordering.
To prevent medication errors, multiple layers of defense should be implemented. These include:
Thorough patient history and medication reconciliation processes to check for potential drug interactions and allergies.
Clear and standardized prescribing protocols.
Pharmacist review of prescriptions before dispensing.
Double-checks at the point of administering medications to patients.
Each of these steps acts as a barrier to prevent the error from reaching the patient and causing harm. By addressing both active and latent failures, healthcare providers can improve the safety and effectiveness of healthcare delivery.