An ICU conducts a root cause analysis (RCA) of an incident where a patient received a 10-fold antibiotic overdose. The investigation identifies system...

Question

An ICU conducts a root cause analysis (RCA) of an incident where a patient received a 10-fold antibiotic overdose. The investigation identifies system-level contributing factors. According to the Swiss cheese model of accident causation (James Reason), what does this model illustrate?

Accepted Answer

That system failures occur when multiple layers of defence (like slices of Swiss cheese) each have weaknesses (holes) that temporarily align, allowing an error to pass through all barriers and reach the patient - preventing recurrence requires strengthening multiple barriers, not just blaming individuals

Answer

That all errors are caused by individual negligence

Answer

That errors are always random and unpredictable

Answer

That only one barrier failure is ever responsible for an incident

Answer

The Swiss cheese model is not applicable to healthcare

uk-fficm MCQ (SBA): Swiss Cheese Model

An ICU conducts a root cause analysis (RCA) of an incident where a patient received a 10-fold antibiotic overdose. The investigation identifies system-level contributing factors. According to the Swiss cheese model of accident causation (James Reason), what does this model illustrate?