**3. Problems with RCA and the "Swiss Cheese" model: why are hospitals different from other industries?**

There are three fundamental problems with the application of the "Swiss Cheese" model to adverse events in hospitals. First, in the hospital, the distinction between individual and organisational accidents is not clear. The entire premise of the "Swiss Cheese" model was the investigation of causation factors of large industrial accidents as opposed to individual accidents. In the hospital we do not have large scale accidents but, instead, multiple little accidents or adverse events daily, if not hourly, and in almost every setting. The literature on causation of adverse events in hospitals overwhelmingly points to failures at the sharp end of care delivery to the patient by frontline staff. Analysis of the causative factors associated with the adverse events in The Quality in Australian Health Care Study found that cognitive failure was a factor in 57% of these adverse events [14]. In this analysis, cognitive failure included such errors as: failure to synthesise, decide and act on available information; failure to request or arrange an investigation, procedure or consultation; lack of care or attention; failure to attend; misapplication of, or failure to apply, a rule, or use of a bad or inadequate rule [14]. In a two-hospital study from the United Kingdom that looked at 100 sequential admissions to the intensive care unit (ICU) from ward areas, it was found that 54 had sub-optimal care on the ward prior to transfer [15]. This group of patients had a mortality rate of 56%. Some of the sub-optimal treatment factors included failure to seek advice, lack of knowledge, failure to appreciate clinical urgency, and lack of supervision [15].

Adoption of the Reason "Swiss Cheese" model for organisational accidents has led the whole Quality and Safety industry, and in particular hospitals, looking for system solutions to what can be explained by individual competency and micro environment cultural issues at the patient interface. In particular, a major rationale of Reason's philosophy is to avoid individual accountability for errors and the culture of blame and shame. Nearly 20 years ago Reason himself noted the folly of this approach in medicine when he stated, "*It is curious that such a bastion of discretionary action as medicine should be moving towards a 'Feed Forward' mode of control when many other hitherto rule dominated domains – notably railways and oil exploration and production – are shifting towards performance-based controls and away from prescriptive ones*" [9]. When Reason talks about human contribution to organisational accidents, he describes two schemas of control [9]. A "Feed Forward" control system is one where human performance is determined by rules and procedures as determined by an organisational standards and objectives. In this schema occasional accidents and incidents are analysed and then fed back into either an alteration of an existing rule or procedure or the creation of a new one (**Figure 3**). At the other end of the control spectrum there is the model where organisational output is largely determined by individual human performance. The basis for this model is that, in the first instance, the humans are generally highly trained and that performance is controlled by continual performance reinforcement against a known or standard comparator (**Figure 4**). The best example of this, in hospitals, is specialist medical practice. To even start specialist training there have been many years of training and experience (medical school, house officer jobs, and pre specialty registrar placements) followed by a period of mentoring

**Figure 3.**

*The Reason Feedforward process control system [22].*

**Figure 4.**

*The Reason feedback process control system [22].*

and in essence apprenticeship to learn the specialty to the known standard of the comparator, the standard of practice as maintained by the specialty colleges. Taking these two schemata one can immediately see the trouble with health care in hospitals. It is a large industry with community and political expectations that are more congruent with the "Feed Forward" schema, but yet with most of the actual clinical activity being undertaken by the "Human Performance" schema.

What we have seen in the construction of hospital adverse event defences is an over reliance on the administrative blunt end of the organisation, in terms of policy and procedures, with the assumption that the health care professionals at the patient end are competent and will be compliant. The shift to looking for hospital wide problems has come at the cost of avoiding the issue of individual professional accountability and associated issues, most notably the education and certification of health care professionals. In Australia and the United Kingdom, several studies indicate that the medical undergraduate syllabus does not provide graduates with the basic knowledge, skills, and judgement to manage acute life-threatening emergencies [16–18]. These studies identified deficiencies in cognitive abilities, procedural skills,

#### *Clinical Futile Cycles: Systematic Microeconomic Reform of Health Care by Reform… DOI: http://dx.doi.org/10.5772/intechopen.106034*

and communication. Despite this, undergraduate and postgraduate curricula have been slow to embrace a patient safety culture [19–21].

The second fundamental problem with the "Swiss Cheese" model and the Palmieri variation of this are, that they are overly simplistic and do not take into account the complexity of the patient and the hospital system. When a patient enters a hospital system, they enter a system where they will be exposed to a variety of hazards which, in turn, have numerous defences in place to prevent an adverse patient outcome. Operations, anaesthesia, medical interventions and procedures, drugs and fluids and even oxygen therapy constitute the hazards. Most defences in health care are reliant on the competence of the health care professional and as such are "soft." "Hard" defences are those that are impossible to overcome, for example in anaesthesia where the administration of hypoxic gas mixtures is physically prevented. The soft defences, in health care include treatment policies and procedures, manual alarm systems, and ad hoc hierarchical and lateral human checking systems. Soft defences are very reliant on the training and education that healthcare workers receive and the culture of compliance. Superimposed on these layers of hazards and defences that confront a patient, there are the latent conditions that exist, most obviously within the patient, but more insidiously within the hospital as an organisation. A patient's past medical history, family history, social history, associated co-morbidities, drug regimen and allergies largely constitute their latent conditions. These conditions and their relation to the current presenting complaint that brings the patient into the hospital system, is territory that individual healthcare workers are usually extremely well trained in and familiar with. Hospital latent conditions are not so explicit, particularly to the patient or the frontline healthcare worker. They are made up of a complex matrix of production and cultural imperatives such as the financial operating environment, political and societal imperatives, medico-legal and insurance concerns, compliance issues imposed by various regulatory bodies (often with associated financial incentives or disincentives) and workforce and work-practice issues. Thus, in the hospital system, unlike any other industry we have a high degree of ever-changing complexity; complex patients and a complex system where adverse events are essentially prevented by a whole host of predominantly soft defences [22]. The "Swiss Cheese" model is a static model with fixed defences in terms of the layers and the size of holes in each layer. This translates well into most industries, but in health care, the complexity is dynamic and ever changing, the number of holes and layers change with every patient and each and every different healthcare professional.

The third problem with the "Swiss Cheese" model is that adverse events in hospitals occur so insidiously that they become normalised into the operating behaviour and practice of the organisation. This is distinct from large scale industrial accidents, where the impact of the event has a high degree of face validity, primarily due to the immediacy and scale of the event. Therefore, in terms of numbers, patient adverse events may constitute a crisis. However, to the individual practitioner or even hospital these events may not appear to be a problem. On the whole, such events are infrequent and occur, over a long-time frame. For example, The Quality in Australian Healthcare Study looked at a random sample of 14,179 admissions to 28 hospitals in two states of Australia in 1992 and documented 112 deaths (0.79%) and 109 cases where the adverse event caused greater than 50% disability (0.77%) [14]. Seventy percent of the deaths and 58% of the cases of significant disability were considered to have had a high degree of preventability [14]. Thus, for the individual clinicians, treating departments and units, and even the 28 study hospitals themselves, their actual experience of these outcomes, over the year would be minimal (one or two cases) [14].

The "Swiss Cheese" model and RCA gives a poor explanation of the multitude of insidious individual accidents that occur in hospitals and is too simplistic for the complexity of most patients and the complex matrix of healthcare that is provided in a hospital. Most importantly, the focus on system issues whilst valid and important, has detracted from what is really needed; focussed attention on clinical competence and accountability at the patient interface.
