Introduction
The following research paper is a discussion on how a healthcare administrator can use the Swiss cheese theory developed by James Reason to come up with strategies, which minimize risks and promote efficiency in a healthcare facility. The risks involved in health matters have a great bearing because an error will result in the loss of human lives.
Swiss cheese theory
This theory is based on the model of Swiss cheese, which has a block of cheese that is sliced. The sliced cheese has holes in the block as representations of errors, which exist or are likely to be done by professionals in a particular field. The slices of cheese represent organizational levels that can prohibit the error from occurring. The model demonstrates how small errors result in grave mistakes when not acted upon by relevant authorities. This paper will examine how to control the errors and who is responsible for controlling the errors that are likely to occur in a health facility where Pone is an administrator.
Identifying errors
The first step as a health administrator is to deal with errors that will jeopardize the patient’s safety in the clinic. The identification of the errors is critical in dealing with these errors. There are two types of errors for identification according to Swiss cheese theory, represented by the holes. Latent errors are those errors in existence for a long period such that they seem common and at times, not attended to when they occur (Reason, 2000).
For healthcare administrators, it is imperative to take note of errors some of which are common in the medical field. For example, negligence, poor supervision of patients, inadequate drugs, and poor sanitation facilities as well as poor ventilation in the health facility. In addition, there exist active errors or unprecedented errors, which occur unexpectedly. These types of errors or circumstances usually result in accidents when they are combined with the preexisting mistakes (Reason, 2000). For instance, if there is an unprecedented cholera outbreak and the health facility has poor sanitation, the treatment will not have any effect and it is likely to result in the death of patients.
For the health administrator to be in control of these likely accidents one must identify the latent holes in the health facility that allow the penetration of active holes or mistakes in the organization. The first error to look at is that of inadequate drugs or even lack of drugs. The administrator must work closely with the pharmacist to ensure that all types of drugs are available to deal with all kinds of illnesses. This will curb the problem of having untreated patients in the facility due to a lack of drugs (Jason, 2009).
The other latent problem in the healthcare facility, which the healthcare administrator has to deal with, is that of unattended patients or poor supervision of patients by the nurses (Reason, 1997). The administrator needs to ensure that there are enough nurses capable of giving patients the necessary attention. Attention is imperative because if they are suffering from blood pressure or heart attack they need constant reexamination to assess their health. If there is no one to examine them, their health is likely to deteriorate and may result in loss of life. For the administrator, the remedy to this risk is to ensure strict adherence to the duty roster and the distribution should cover all hours of the day.
The health administrator should be effective by ensuring that the health facility is in good condition with adequate sanitation facilities. Cleanliness in those facilities requires constant maintenance. The administrator must ensure that the rooms have proper ventilation so that they are aerated. The administrator has to ensure that waste is dumped in areas where it is not hazardous to human beings. The water check at all times is necessary to ensure there is no contamination with anything that can endanger the patients’ life (Jason, 2009).
The administrator must also work to ensure that there is cohesion between the workers in the health facility to enhance communication between the departments. This is because communication is critical to the performance of the health facility. When communication is not clear it results in errors both latent and active. Communication in the health facility involves the proper flow of information from the patients to the staff and from the staff to the patients. The medical records are part of this communication and keeping them well is an added advantage. Communication also involves the flow of information between the staff members to alert one another in case of a problem (Reason, 1997).
Conclusion
The administrator should ensure that minor errors are corrected immediately. When an active error occurs, it certainly leads to accidents and the accident has great consequences in the field of healthcare due to loss of lives. In conclusion, the Swiss cheese theory has had wide acclaim all over the world in its exploration of the cause of accidents. It is also applicable in fields other than healthcare such as aviation.
References
Jason, H. (2009). The impact of facility design on patient safety. Cambridge: Cambridge University Press.
Reason, J. (2000). Human errors: Models and management. London: British Medical Journal.
Reason, J. (1997). Managing the risks of organizational accidents. Aldershot: Ash Gate Publishing.