Accendo Reliability

Your Reliability Engineering Professional Development Site

  • About
    • Adam Bahret
    • Alex Williams
    • Andre Kleyner
    • Anne Meixner
    • Arthur Hart
    • Ash Norton
    • Carl Carlson
    • Chris Jackson
    • Chris Stapelmann
    • Dennis Craggs
    • Dev Raheja
    • Doug Lehr
    • Doug Plucknette
    • Fred Schenkelberg
    • George Williams
    • Gina Tabasso
    • Greg Hutchins
    • James Kovacevic
    • James Reyes-Picknell
    • Joe Anderson
    • John Paschkewitz
    • Katie Switzer
    • Kevin Stewart
    • Kirk Gray
    • Les Warrington
    • Mike Konrad
    • Mike Sondalini
    • Nancy Regan
    • Perry Parendo
    • Philip Sage
    • Ray Harkins
    • Rob Allen
    • Robert (Bob) J. Latino
    • Robert Kalwarowsky
    • Ryan Chan
    • Shane Turcott
    • Steven Wachs
    • Tim Rodgers
    • Usman Mustafa Syed
  • Reliability.fm
    • Dare to Know
    • Speaking Of Reliability
    • Rooted in Reliability: The Plant Performance Podcast
    • Maintenance Disrupted
    • Practical Reliability Podcast
    • Reliability Matters
    • Masterminds in Maintenance
    • Accendo Reliability Webinar Series
    • Asset Reliability @ Work
  • Articles
    • CRE Preparation Notes
    • on Leadership & Career
      • Advanced Engineering Culture
      • Engineering Leadership
      • Managing in the 2000s
      • Product Development and Process Improvement
    • on Maintenance Reliability
      • Aasan Asset Management
      • CMMS and Reliability
      • Conscious Asset
      • EAM & CMMS
      • Everyday RCM
      • Maintenance and Reliability
      • Plant Maintenance
      • ReliabilityXperience
      • RCM Blitz®
      • Rob’s Reliability Project
      • The Intelligent Transformer Blog
      • The RCA
    • on Product Reliability
      • Accelerated Reliability
      • Achieving the Benefits of Reliability
      • Apex Ridge
      • Musings on Reliability and Maintenance Topics
      • Reliability Engineering Insights
      • Reliability in Emerging Technology
    • on Risk & Safety
      • CERM® Risk Insights
      • Equipment Risk and Reliability in Downhole Applications
    • on Tools & Techniques
      • Big Data & Analytics
      • Experimental Design for NPD
      • Innovative Thinking in Reliability and Durability
      • Inside FMEA
      • Testing 1 2 3
      • The Manufacturing Academy
      • Reliability Reflections
  • eBooks
    • Reliability Engineering Management DRAFT
  • Resources
    • Accendo Authors
    • FMEA Resources
    • Feed Forward Publications
    • Openings
    • Books
    • Webinars
    • Journals
    • Higher Education
    • Podcasts
  • Groups
    • Reliability Integration
    • Mastermind
    • Study Groups
  • Courses
    • 14 Ways to Acquire Reliability Engineering Knowledge
    • Reliability Analysis Methods online course
    • SPC-Process Capability Course
    • Reliability Centered Maintenance (RCM) Online Course
    • Process Capability Analysis course
    • Root Cause Analysis and the 8D Corrective Action Process course
    • Return on Investment online course
    • 5-day Reliability Green Belt ® Live Course
    • 5-day Reliability Black Belt ® Live Course
    • CRE Preparation Online Course
  • Webinars
    • Upcoming Live Events
  • Calendar
    • Call for Papers Listing
    • Upcoming Webinars
    • Webinar Calendar
  • Login
    • Member Home
Don’t show this message again.

Cookies

This site uses cookies to give you a better experience, analyze site traffic, and gain insight to products or offers that may interest you. By continuing, you consent to the use of cookies. Learn how we use cookies, how they work, and how to set your browser preferences by reading our Cookies Policy.

by Robert (Bob) J. Latino Leave a Comment

Swiss Cheese and Our Healthcare

Swiss Cheese and Our Healthcare

Swiss Cheese and Our Healthcare

The graphic of the Swiss Cheese Model (attached is an expression from AHRQ) is a good one and one that many will remember and relate to.

However, I would like to expand on that model and express that more commonly, there is a not a singular or linear path to failure. There are typically multiple paths of failure that converge together at some point in time to cause an undesirable outcome.

The reality is that we are human and therefore prone to error. Recognizing that, we will have ‘Swiss Cheese’ with holes, as opposed to solid ‘American Cheese’:-). No slice of cheese will be failsafe. The best we can do is:

1. to reduce the number of holes in the cheese (number of vulnerabilities),

2. minimize the diameter of the holes that remain (reduce magnitude of consequence) and

3. ensure the holes that remain, do not line up to provide a pathway to failure

Our ‘systems’ are intended to help accomplish this but they are created by humans, so flaws exist. Ultimately we are responsible for our own decisions and actions, even if well-intended with a bad outcome. I refer to this as ‘consequential thinking’. If we were all well-versed in the principles of proactive RCA, human factors engineering, reliability engineering, human performance and the like, we would be much more aware of the potential consequences of our decisions. When this occurs, the entire work environment is safer. This is because we recognize the potential flaws in our system and don’t hang our hat on the fact that we followed an inadequate or insufficient procedure (or non-existent in many cases) to protect ourselves legally. Too often procedures are written to protect ourselves legally just to say we had them in place and could pass a regulatory audit. Often, they are only enforced when something goes wrong, and then we discipline people for not following them (hypocritical). When obsolete procedures are in place, the workforce knows this but they do not have the time or energy to cut through the red tape to get it fixed. This is when the ‘workarounds’ pop up. We should ask ourselves why there is a need for a workaround, when we see one?

Unfortunately, compliance does not necessarily equate to patient safety.

To me, the solution is providing all our people education in understanding the human decision making process and its contribution to failure. We should teach people to proact (identify unacceptable risk) instead of react (respond to consequences) and support that behavior instead of demonizing it with a paradigm that ‘failure is inevitable, the best we can do is respond faster’. What patient wants to hear that!

Secondly, doctors should willingly and actively participate on in-depth RCA’s. True RCA is all about understanding the human decision. Why did the person making the bad decision, think it was the right decision at the time? When we accurately answer these questions, we are doing RCA. If we indiscriminately blame people for bad decisions and levy discipline, we effectively cannot do RCA (we will not know why they made the decision they did). Without the doctor’s input as to their reasoning, we cannot under the resulting sequence of consequences. Oftentimes doctors see themselves above the activity of an RCA and do not elect to participate. I will add caveat in defense of some doctors, that what some organizations call RCA is a farce and merely an attempt to go through the motions to pass regulatory scrutiny. If doctors have participated on such RCA teams, I don’t blame them for not returning.

The attached image is an example of this. ‘Poor Communication’ is not an adequate root cause because it is not actionable. We need to drill further down to understand what about the communication system was poor and why people were not following systems in place designed to aid proper communication (poor systems that were followed, or good systems that were not).

Stepping off my soapbox:-).

Filed Under: Articles, on Maintenance Reliability, The RCA

« Now You Understand Your Risks: What’s Next?
Design Assurance Reduces Equipment Risk »

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Article by Robert (Bob) J. Latino
CEO of Reliability Center, Inc.

in the The RCA article series

Join Accendo

Receive information and updates about articles and many other resources offered by Accendo Reliability by becoming a member. It’s free and only takes a minute.

Join Today

Recent Posts

  • 5 Ways To Reduce Your Overall Maintenance Workload
  • Infrastructure Is Not a One Time Investment
  • What’s Wrong With A Questioning Attitude?
  • Maximizing Oilfield Equipment Reliability
  • Living With The 6 Failure Patterns

© 2021 FMS Reliability · Privacy Policy · Terms of Service · Cookies Policy