Message accountability and miscommunication are the main reasons for the creation of the holes. It is necessary to understand that the importance of all messages is not the same in healthcare. According to a report by CRICO Strategies National Comparative Benchmarking System, the healthcare industry suffers almost 1.7 billion dollars lost due to 1700 malpractices and taking 1700 precious lives of the patients. The main aim of any reliable and safe communication procedure is to terminate the errors or the holes in the Swiss Cheese Model.
Message responsibility is the transmission of a reliable block of text that needs to be transferred from one person to another. It comprises of 4 components which are:
- The message includes the urgency of the situation for the recipient and should consider the context.
- The recipient should acknowledge the responsibility of the information
- The sender knows that the recipient has considered the message.
- If initially the message is not delivered due to technical faults or has been accidentally sent to a wrong recipient, then there should be a system that will automatically rectify the mistake and will send the message to the appropriate person.
There are several circumstances in the healthcare industry whose negligence might lead to the holes of the Swiss Cheese Model and ultimately leading to unavoidable accidents. They are:
Coding Situations: When a patient with an acute ST-elevation myocardial disorder enters the emergency, code STEMI is sent to the cardiac catheterization team urgently. The health system must be confirmed that the message has been sent to the required personnel and is seen for the intervention. Otherwise, a delay in the treatment may cost the life of the patient also.
Test Reports: A patient with a subdural hematoma goes for a test. If a radiologist does not intervene in the diagnosed reports to the neurosurgeon, then this can create a hole in the total healthcare system of a hospital.
Alarms for Patient Care: When a patient clicks the alarm for calling the nurse, the request can be simply to drink water or of sudden chest pain. A responsible nurse will see the message and will ensure that appropriate action is taken quickly. The patient should be assisted according to the contexts of the alarm.
Most of the holes of the Swiss Cheese Model in the healthcare segment are created due to miscommunication. Absence in message accountability can result in adverse effects. When the message is not delivered by a system, it is in the duty of the sender to convey that message face to face to the recipient. Technologies including interoperability of the source systems, escalation and tracking procedures and secure messaging will close all the potential holes in the Swiss Cheese Model for the patient safety errors.