Exercise 13.1

Objective: To practice identifying different types of errors described in Reason's swiss cheese model.

Instructions:

Consider the following scenario: In Florida, Clara, an active 94-year-old great-grandmother who still worked as a hospital volunteer two days a week, was admitted to the hospital for a bowel obstruction. She and her family, along with nurses from the hospital, said that there were too few nurses to check on her during the night when her eldest son went home to sleep for a couple of hours. Clara called the nurses to help her use the bathroom but when no one came, she climbed over the bed railing. Still groggy from surgery 20 hours earlier, Clara fell to the floor and broke her left hip. She died two days later during surgery to repair the hip fracture. "It was just too much for her," said her grandson. "For want of one nurse, she died" (Gibson and Singh 2003, 101).

Review the following list of latent errors, active errors, and preconditions that could have contributed to the event described in this scenario.

- Absence of one nurse and one nurse aide because of illness that night

- Clara's advanced age not taken into consideration by caregivers

- Unavailability of staff to fill in for the two people calling in sick

- Falls risk assessment not complete on patient's chart

- Decision to upgrade computed tomography scanner over purchasing safer patient beds

- Lack of training for nurses about specialized needs of elderly patients, especially related to their responses to medications

- The departure of Clara's son

- Consistent scheduling of the night shift with minimum staff needed on the unit

- Bioengineering's skipping of last month's preventive maintenance check on the call light system (because the department was six weeks behind on its work)

- Admission of three new patients to this unit from the emergency department between 7:00 pm and 10:00 pm

- Falls precautions not implemented for this patient Write the errors and risk factors in column 2 beside the appropriate category.

Note: Write 6 points for every category.

Category/Type of Failure Error Latent errors at the level of senior decision makers Latent failures at the level of frontline management Circumstances or conditions present when the patient's accident occurred Active errors associated with this event