HLST 3400 Lecture 5: IHI PS102 Summary

• School: York University
• Department: Health Studies
• Course: HLST 3400
• Professor: Liane Ginsburg

Document Summary

Ps 102: from error to harm (visit www. ihi. org/education/ihiopenschool/courses to learn more. ) The swiss cheese model, from james reason, is a useful way to think about errors in complex organizations: the stack of cheese represents your organization"s safety system. Slices of cheese prevent hazards from resulting in harm, but every now and then, the. Holes line up and cause harm: the holes represent both latent conditions (so-called accidents waiting to happen) and active failures (errors and violations by front-line providers). The tenerife plane crash in 1977 is an example of how multiple unsafe conditions allowed the pilot to make an error, which the system then failed to stop from causing harm. Unsafe acts are categorized as either errors or violations: an error is lapse, slip, or mistake. When an action fails to go as intended, the error is called either a slip (if it is observable) or a lapse (if it is unobservable).