22:
154:
cheese slices are dubbed defensive layers to describe their role and function as the system location outfitted with features capable of intercepting and deflecting hazards. The layers represent discrete locations or organizational levels potentially populated with errors permitting error progression. The four layers include: 1) organizational leadership, 2) risky supervision, 3) situations for unsafe practices, and 4) unsafe performance.
162:
McDaniel & Driebe, 2001) and co-evolve with the environment (Casti, 1997). Healthcare professionals function in the system as diverse actors within the complex environment utilizing different methods to process information (Coleman, 1999) and solve systemic problems within and across organizational layers (McDaniel & Driebe, 2001).
158:
accidents might be revealed (Leape et al., 1995). Experts have discussed the importance of examining these layers within the context of the complex adaptive healthcare system (Kohn et al., 2000; Wiegmann & Shappell, 2003) and considering the psychological safety of clinicians. Hence, this model expands Reason’s seminal work.
558:
Leape, L. L., Bates, D. W., Cullen, D. J., Cooper, J., Demonaco, H. J., Gallivan, T., R., H., Ives, J., Laird, N., Laffel, G., Nemeskal, R., Peterson, L. A., Porter, K., Servi, D., Shea, B. F., Small, S. D., Sweitzer, B. J., Thompson, B. T., & van der Vliet, M. (1995). Systems analysis of adverse
170:
A complex adaptive healthcare system (CAHS) is a care delivery enterprise with diverse clinical and administrative agents acting spontaneously, interacting in nonlinear networks where agents and patients are information processors, and actively co-evolve with their environment with the purposed to
161:
The model incorporates the complex adaptive healthcare system as a key characteristic. Complex adaptive systems characteristically demonstrate self-organization as diverse agents interact spontaneously in nonlinear relationships where professionals act as information processors (Cilliers, 1998;
153:
The healthcare error proliferation model (HEPM) adapts the Swiss Cheese Model to the complexity of healthcare delivery systems and integrated organizations. The Swiss Cheese Model, likens the complex adaptive system to multiple hole infested slices of Swiss cheese positioned side-by-side. The
106:. The healthcare error proliferation model explains the etiology of error and the sequence of events typically leading to adverse outcomes. This model emphasizes the role organizational and external cultures contribute to error identification, prevention, mitigation, and defense construction.
157:
The HEPM portrays hospitals as having multiple operational defensive layers outfitted with essential elements necessary to maintain key defensive barricades (Cook & O'Connor, 2005; Reason, 2000). By examining the defensive layers attributes, prospective locales of failure, the etiology of
118:
in that they are diverse in both structure (e.g. nursing units, pharmacies, emergency departments, operating rooms) and professional mix (e.g. nurses, physicians, pharmacists, administrators, therapists) and made up of multiple interconnected elements with
574:
Rasmussen, J. (1999). The concept of human error: Is it useful for the design of safe systems in health care? In C. Vincent & B. deMoll (Eds.), Risk and safety in medicine: 31-47. London: Elsevier.
543:
Anderson, R. A., Issel, M. L., & McDaniel, R. R. (2003). Nursing homes as complex adaptive systems: Relationship between management practice and resident outcomes. Nursing
Research, 52(1): 12-21.
592:
Reason, J. T., Carthey, J., & de Leval, M. R. (2001). Diagnosing vulnerable system syndrome: An essential prerequisite to effective risk management. Quality in Health Care, 10(S2): 21-25.
276:
Palmieri, P. A., DeLucia, P. R., Ott, T. E., Peterson, L. T., & Green, A. (2008). "The anatomy and physiology of error in averse healthcare events". In E. Ford; G. Savage (eds.).
546:
Berta, W. B. & Baker, R. (2004). Factors that impact the transfer and retention of best practices for reducing error in hospitals. Health Care
Management Review, 29(2): 90-97.
51:
521:
449:
309:
562:
Leape, L. L. & Berwick, D. M. (2005). Five years after "To err is human": What have we learned? Journal of the
American Medical Association, 293(19): 2384-2390.
568:
Leonard, M. L., Frankel, A., & Simmonds, T. (2004). Achieving safe and reliable healthcare: Strategies and solutions. Chicago: Health
Administration Press.
555:
Cook, R. I., Render, M., & Woods, D. D. (2000). Gaps in the continuity of care and progress on patient safety. British
Medical Journal, 320(7237): 791-794.
488:
Palmieri, P. A., DeLucia, P. R., Ott, T. E., Peterson, L. T., & Green, A. (2008). "The anatomy and physiology of error in adverse health care events".
601:
Roberts, K. H. (2002). High reliability systems. Report on the institute of medicine committee on data standards for patient safety on
September 23, 2003.
577:
Reason, J. T. & Mycielska, K. (1982). Absent-minded? The psychology of mental lapses and everyday errors. Englewood Cliffs, NJ: Prentice-Hall Inc.
565:
Leduc, P. A., Rash, C. E., & Manning, M. S. (2005). Human factors in UAV accidents, Special
Operations Technology, Online edition ed., Vol. 3.
215:
505:
472:
293:
674:
663:
652:
641:
617:
335:
73:
711:
669:
Waldrop, M. M. (1990). Complexity: The emerging science at the edge of order and chaos. New York: Simon & Schuster (
598:
Roberts, K. (1990). Some characteristics of one type of high reliability organization. Organization
Science, 1(2): 160-176.
701:
34:
235:
44:
38:
30:
595:
Reason, J. T. & Hobbs, A. (2003). Managing maintenance error: A practical guide. Aldershot, England: Ashgate.
549:
Chiles, J. R. (2002). Inviting disaster: Lessons from the edge of technology. New York: HarperCollins
Publishers.
185:
172:
55:
706:
195:
125:
402:"Nursing Homes as Complex Adaptive Systems: Relationship between Management Practice and Resident Outcomes"
696:
200:
612:
Cilliers, P. (1998) Complexity and post modernism: Understanding complex systems. New York: Routledge. (
443:
250:
647:
Holland, J. H. (1995). Hidden order: How adaptation builds complexity. Reading, MA: Helix Books. (
583:
Reason, J. T. (1997). Managing the risks of organizational accidents. Aldershot: Ashgate
Publishing.
559:
drug events. ADE prevention study group. Journal of the American Medical Association, 274(1): 35-43.
245:
210:
636:
Holland, J. H. (1992). Adaptation in natural and artificial systems. Cambridge, MA: MIT Press. (
586:
Reason, J. T. (1998). Managing the risks of organizational accidents. Aldershot, England: Ashgate.
552:
Coleman, H. J. (1999). What enables self-organizing behavior in business. Emergence, 1(1): 33-48.
515:
303:
255:
220:
134:
130:
91:
589:
Reason, J. T. (2000). Human error: Models and management. British Medical Journal, 320, 768-770.
145:
have extended CAS theory and research to the social sciences such as education and healthcare.
670:
659:
648:
637:
613:
501:
468:
431:
382:
331:
289:
493:
421:
413:
372:
364:
281:
138:
571:
Rasmussen, J. (1990). The role of error in organizing behavior. Ergonomics, 33: 1185-1199.
240:
658:
Holland, J. H. (1998). Emergence: From chaos to order. Reading, MA: Addison-Wesley. (
123:
tendencies in that they have the capacity to change and learn from experience. The term
691:
426:
401:
377:
352:
497:
285:
685:
417:
225:
190:
142:
230:
205:
99:
95:
368:
435:
386:
141:. Subsequently, scholars such as Ruth A. Anderson, Rubin McDaniels, and
580:
Reason, J. T. (1990). Human error. New York: Cambridge University Press.
103:
492:. Advances in Health Care Management. Vol. 7. pp. 33–68.
102:
delivery system and the attribution of human error within these
490:
The anatomy and physiology of error in averse healthcare events
15:
400:
Anderson, R. A., Issel, M. L., & McDaniel, R. R. (2003).
465:
Complexity and post modernism: Understanding complex systems
280:. Vol. 7. Emerald Publishing Group. pp. 33–68.
43:but its sources remain unclear because it lacks
8:
520:: CS1 maint: multiple names: authors list (
448:: CS1 maint: multiple names: authors list (
321:
319:
308:: CS1 maint: multiple names: authors list (
129:(CAS) was coined at the interdisciplinary
425:
376:
74:Learn how and when to remove this message
268:
513:
441:
301:
258:of accident causation in human systems
216:International healthcare accreditation
7:
353:"Human error: models and management"
88:healthcare error proliferation model
90:is an adaptation of James Reason’s
278:Advances in Health Care Management
14:
418:10.1097/00006199-200301000-00003
20:
330:. Cambridge University Press.
1:
498:10.1016/S1474-8231(08)07003-1
286:10.1016/S1474-8231(08)07003-1
98:inherent in the contemporary
236:Patient safety organization
94:designed to illustrate the
728:
171:produce safe and reliable
186:Adverse effect (medicine)
173:patient-centered outcomes
467:. New York: Routledgel.
369:10.1136/bmj.320.7237.768
126:complex adaptive systems
29:This article includes a
712:Evidence-based medicine
357:British Medical Journal
196:Evidence-based medicine
114:Healthcare systems are
58:more precise citations.
351:Reason, J. T. (2000).
326:Reason, J. T. (1990).
201:Hospital accreditation
463:Cilliers, P. (1998).
251:Serious adverse event
702:Medical terminology
246:Root cause analysis
211:Iatrogenic disorder
256:Swiss Cheese model
221:Latent human error
131:Santa Fe Institute
92:Swiss Cheese Model
31:list of references
630:Complexity theory
507:978-1-84663-954-8
474:978-0-415-15286-0
295:978-1-84663-954-8
84:
83:
76:
719:
625:Other literature
526:
525:
519:
511:
485:
479:
478:
460:
454:
453:
447:
439:
429:
406:Nursing Research
397:
391:
390:
380:
363:(7237): 768–70.
348:
342:
341:
323:
314:
313:
307:
299:
273:
139:Murray Gell-Mann
79:
72:
68:
65:
59:
54:this article by
45:inline citations
24:
23:
16:
727:
726:
722:
721:
720:
718:
717:
716:
682:
681:
680:
632:
627:
622:
609:
604:
539:
534:
529:
512:
508:
487:
486:
482:
475:
462:
461:
457:
440:
399:
398:
394:
350:
349:
345:
338:
325:
324:
317:
300:
296:
275:
274:
270:
266:
261:
241:Peter Pronovost
181:
168:
151:
135:John H. Holland
112:
80:
69:
63:
60:
49:
35:related reading
25:
21:
12:
11:
5:
725:
723:
715:
714:
709:
707:Medical ethics
704:
699:
694:
684:
683:
679:
678:
675:978-0671767891
667:
664:978-0738201429
656:
653:978-0201442304
645:
642:978-0262581110
633:
631:
628:
626:
623:
618:978-0415152860
610:
608:
605:
603:
602:
599:
596:
593:
590:
587:
584:
581:
578:
575:
572:
569:
566:
563:
560:
556:
553:
550:
547:
544:
540:
538:
535:
533:
530:
528:
527:
506:
480:
473:
455:
392:
343:
336:
315:
294:
267:
265:
262:
260:
259:
253:
248:
243:
238:
233:
228:
223:
218:
213:
208:
203:
198:
193:
188:
182:
180:
177:
167:
164:
150:
149:Model overview
147:
111:
108:
82:
81:
39:external links
28:
26:
19:
13:
10:
9:
6:
4:
3:
2:
724:
713:
710:
708:
705:
703:
700:
698:
697:Medical error
695:
693:
690:
689:
687:
676:
672:
668:
665:
661:
657:
654:
650:
646:
643:
639:
635:
634:
629:
624:
621:
619:
615:
606:
600:
597:
594:
591:
588:
585:
582:
579:
576:
573:
570:
567:
564:
561:
557:
554:
551:
548:
545:
542:
541:
536:
531:
523:
517:
509:
503:
499:
495:
491:
484:
481:
476:
470:
466:
459:
456:
451:
445:
437:
433:
428:
423:
419:
415:
411:
407:
403:
396:
393:
388:
384:
379:
374:
370:
366:
362:
358:
354:
347:
344:
339:
337:0-521-31419-4
333:
329:
322:
320:
316:
311:
305:
297:
291:
287:
283:
279:
272:
269:
263:
257:
254:
252:
249:
247:
244:
242:
239:
237:
234:
232:
229:
227:
226:Medical error
224:
222:
219:
217:
214:
212:
209:
207:
204:
202:
199:
197:
194:
192:
191:Adverse event
189:
187:
184:
183:
178:
176:
174:
165:
163:
159:
155:
148:
146:
144:
143:Paul Cilliers
140:
136:
132:
128:
127:
122:
117:
109:
107:
105:
101:
97:
93:
89:
78:
75:
67:
57:
53:
47:
46:
40:
36:
32:
27:
18:
17:
611:
489:
483:
464:
458:
444:cite journal
412:(1): 12–21.
409:
405:
395:
360:
356:
346:
327:
277:
271:
231:Nursing care
206:Iatrogenesis
169:
160:
156:
152:
124:
120:
115:
113:
110:Introduction
87:
85:
70:
61:
50:Please help
42:
328:Human Error
166:Definitions
56:introducing
686:Categories
532:References
133:(SFI), by
100:healthcare
96:complexity
516:cite book
304:cite book
264:Citations
537:Articles
436:12552171
387:10720363
179:See also
121:adaptive
64:May 2023
427:1993902
378:1117770
116:complex
104:systems
52:improve
673:
662:
651:
640:
616:
504:
471:
434:
424:
385:
375:
334:
292:
137:, and
692:Error
607:Books
37:, or
671:ISBN
660:ISBN
649:ISBN
638:ISBN
614:ISBN
522:link
502:ISBN
469:ISBN
450:link
432:PMID
383:PMID
332:ISBN
310:link
290:ISBN
86:The
494:doi
422:PMC
414:doi
373:PMC
365:doi
361:320
282:doi
688::
620:)
518:}}
514:{{
500:.
446:}}
442:{{
430:.
420:.
410:52
408:.
404:.
381:.
371:.
359:.
355:.
318:^
306:}}
302:{{
288:.
175:.
41:,
33:,
677:)
666:)
655:)
644:)
524:)
510:.
496::
477:.
452:)
438:.
416::
389:.
367::
340:.
312:)
298:.
284::
77:)
71:(
66:)
62:(
48:.
Text is available under the Creative Commons Attribution-ShareAlike License. Additional terms may apply.