What do Swiss cheese and malpractice litigation have in common? Neither exist without the holes in them. In a clinical care setting, as depicted by the image to the right, the probability for error increases as your gaps in care increase. The more ‘holes’ you have, the better chances of those holes aligning, making way for adverse events that could result in a malpractice suit.
Areas of particular concern (1) include:
- Patient history and physical
- Provider collaboration
- Pain management
- Staff training
We’ll explore each of these clinical elements in more depth in future blogs.
Generally speaking, errors and adverse events are often a combination of human, electronic, and technical errors. The goal shouldn’t be to assign blame, but rather to mitigate the issues (2) so that they don’t happen in the first place, or in the very least, so that they don’t recur. Usually, this is best accomplished by recognizing and addressing systems issues. What systemic changes can be made to better support the clinician at the point of care and to prevent similar mistakes or adverse outcomes? No one truly benefits from a malpractice suit, not even the plaintiff if they win. They incurred some sort of loss to become a plaintiff in the first place, and would surely rather choose not to, if they could do it all over again.
Not all adverse events result in death, disability, or other major/chronic issues. However, the goal of risk mitigation is to reduce the overall trend of adverse events in total. Even issues deemed to be minor or insignificant (3).
The Swiss cheese model (4) is not germane to the healthcare industry. It can be applied to any industry where singular issues, when compounded with other seemingly singular issues, create a sum (adverse event) greater than their parts. Picture it as slicing a block of Swiss cheese, and laying the slices atop each other. It’s practically inevitable – something will eventually slip through every slice.
Be assured that the partnership between CARE and OmniSure provides you with a plethora of knowledge, experience, and expertise to help your practice identify potential holes, if you will, in your risk management plan. Contact us today for more information.