The Swiss Cheese of Aged Care Safety; a case study

Reason's Swiss cheese model has become the dominant paradigm for analysing medical errors and patient safety incidents. It can be as easily applied to aged care as it can to tertiary care, primary care, community care and aviation safety (see article on Air NZ here).

The problem is, however, that the model is grossly misunderstood.

Common understanding – the holes in the cheese (“bad stuff”) line up, the holes go right through, and adverse events (“even worse stuff”) occurs as an outcome.

The model rather works like this

You slice the cheese medially (think cheese singles your mum put in your lunch), and you give each slice a purpose. In aged care we could slice the block into eight singles and say each slice is a quality standard. The “bad stuff” is actually a hole (or gap) in the governance, operation, or customer service of that standard.

Let’s assume a consumer has a fall in the shower and as a result dies from their injuries, and examine the holes in the operation and governance of the Aged Care Quality Standards that "lined up".

Standard 1 – The organisation has a culture of rushing. Quicker, faster, time is money. No culture of respect = Hole in slice one.

Standard 2 – The consumer was never consulted for how they would like to be showered in the care planning phase. A stock standard approach from unguided staff to showering everyone the same way = Our second hole in the cheese.

Standard 3 – The organisation has nonclinical staff (care coordinators) completing care plan reviews. A deterioration in the consumers physical and/or cognitive function goes unrecognised and bingo bongo, a third hole appears.

Standard 4 – This hole, the one where a physio was never consulted about the consumer’s change in physical function, happened because there was no recognition of the change. So, no referral was ever made. We now have 50% of our governance slices with a dirty great hole in them.

Standard 5 - The organisation provides a safe and comfortable service environment that promotes the consumer’s independence, function, and enjoyment. Except because the physical function deterioration wasn’t noted, the physio wasn’t referred, the was no OT referral and no shower stool was implemented. You can almost guess at this point, with another hole in the slice, bad stuff is more likely.

Standard 6 – “I don’t want to have a shower” says consumer (aka gives immediate feedback). “Don’t be silly” says organisation, “You HAVE to keep clean”. And because the consumer isn’t given the opportunity to engage and express their fear of falling due to feeling unsafe, another hole appears in standard 6.

Standard 7 – The aged care workforce has unsustainable attrition rates made worse by covid. Graduate nurses are running the floor and care staff are either new, exhausted, underpaid, undertrained or all of the above. Irrespective of the reason, they are not supported in effectively performing their roles. Hole number 7 is a human resources responsibility and might be the biggest one so far.

Standard 8 – The organisation does not promote a culture of safe, inclusive and quality care and services and they’ve failed to be accountable. Slice 8 has the final hole which gives us the Swiss cheese effect – an adverse event.

An elderly consumer who has deteriorated physically and cognitively lives in an environment where their care provider has a culture that fails to plan, rushes cares, ignores and fails to respond to deterioration, leading to the resident trying desperately to advocate for themselves where they are ignored and placated, forced to shower unsafely and they slip, and they die.

The layers of governance (the cheese slices) were designed to protect the consumer. The system is sufficient. The laws are enough. The onus is on the organisational governance and the directors of that provider.?

We at Aged and Home Care Quality Consultants are experts in quality and patient safety. We examine more than your compliance, we actively reduce risk, improve consumer satisfaction and increase revenue. Call us today

www.agedandhomecarequalityconsultants.com.au