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Common Cause Analysis: Focus on Institutional Change
mistakes, etc. “Latent conditions” are the inevitable systems failures, that relate to design—such as alarms that are not Figure 1. The “Swiss Cheese Model” depicting the way systems place barriers designed to prevent harm and create safe processes. Source: Adapted from Reason 2002 and US Department of Veterans’ Affairs
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Improving Patient Safety Through Provider …
www.ahrq.govAnalysis of 421 communication events in the operating room found communication failures in approximately 30 percent of team exchanges; one-third of these jeopardized patient safety by
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