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Latent errors are hidden problems within health care systems that contribute to adverse events (Agency for Healthcare Research and Quality [AHRQ], 2018a, 2018b). For example, policies and procedures within an organization may be inaccessible, difficult to understand, or inaccurate. Work processes might be confusing and patient handoffs may be rushed and inadequate. The environment may be cramped and noisy, making it difficult to concentrate. Technology may fail or be cumbersome to use. Individuals may blame others rather than taking personal responsibility. The culture of the hospital might hinder a nurse's ability to speak up about safety concerns. All of these “blunt end” factors may contribute to an error at the “sharp end,” where clinicians interact with the patient.

James Reason (1997) proposed the Swiss Cheese model, shown in Figure 4.1, to illustrate how errors occur. The model suggests that every step in a process has the potential for error. The holes in the Swiss cheese represent opportunities for a process to fail, and each slice is a defensive layer to prevent an error in the process. An error may pass through a hole in one layer but in the next layer, the hole is in a different spot and the layer catches the error before it reaches the patient. More layers of cheese and smaller holes allow more errors to be stopped or caught. When the holes in the Swiss cheese line up, an error occurs.

FIGURE 4.1 Swiss cheese model.

Source: © Used with permission granted from Patti Ludwig‐Beymer.