How Swiss Cheese Can Save Our School Children

Now that Congress is back to work in Washington, it’s time to stop all the BS over what to do about school shootings and get down to business.

I’m talking about Swiss cheese.

My colleague at Innovative Decisions, Inc., Dr. Robin Dillon-Merrill, introduced me to the Swiss cheese model of risk management several years ago. The Swiss cheese model is used many places, including aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security and military defense in depth. It likens human systems to multiple slices of Swiss cheese, stacked side by side, in which the risk of a hazard becoming a reality is mitigated by the differing types of defenses which are “layered” behind each other.

Therefore, in theory, lapses and weaknesses in one layer do not allow a risk to materialize, since other defenses also exist to prevent a single point of failure. But on rare occasions, a threat will make it through most of the layers — a near-miss — or through all the layers —a catastrophic loss. The model was developed by James T. Reason of the University of Manchester and has since gained widespread acceptance. It is sometimes called the cumulative act effect. (Source: Wikipedia)

Robin explains that the cheese slices are the safety systems that we build to block potential bad outcomes, and the holes are the inherent weaknesses caused by design flaws, human error, and adaptive adversaries. “No barrier is perfect, and sometimes a hazard can thread a needle through the holes in the cheese slices.” System failure usually occurs when holes in the layers line up due to unexpected interaction or some enabling condition (and generally bad luck).

Robin Dillon-Merrill is a professor and senior policy scholar at the Center for Business and Public Policy at Georgetown University in Washington, D.C. She has studied risk and resiliency for several decades, seeking to understand and explain how and why people make the decisions that they do under conditions of uncertainty and risk. This research specifically examines critical decisions that people make following near-miss events in situations with severe outcomes, such as hurricane evacuation, terrorism, cybersecurity, space launches, and nuclear power accidents.

The power of the Swiss cheese model is that it shows us how we can reduce the chance of a catastrophic event by improving an individual slice whenever a near-miss warns us of a problem. Think of the chances that we would come up with four heads in a row (a catastrophic loss) if we flipped a coin four times. The product of .5 x .5 x .5 x .5 is only about 6%. But if lives were at stake and we could improve one layer to be 90% effective, we could reduce our risk to about 1%. If each of the four layers could be made 90% effective, the chances of a catastrophic event are less than one in ten thousand. The problem is that we ignore the holes in our cheese until it is too late.

So why don’t we take action more often before catastrophe strikes? In Robin’s work, she finds that people judge near-misses and successful outcomes pretty much the same. We say, “Whew, that was a close call!” and go about our business. We don’t learn from our near-misses, yet these are the indicators, the canary in the coal mine, screaming that we need to take corrective action. Instead, when catastrophe happens, we go thrashing about for unobtainable “fix it” solutions.

Learning from our near-misses is possible. Recently the Pennsylvania Patient Safety Authority took a close look at near-miss data they were already collecting. Since 2005, Pennsylvania hospitals had increasingly reported patient safety events associated with barcode medication administration (BCMA), a technology used to prevent errors such as overdosing.

The Safety Authority found 453 near-miss events related to BCMA processes that might have caused harm but did not reach the patient because of chance or active effort by attentive caregivers. The BCMA events occurred during all points of the medication-management process. The majority of events involved administering the medication, while the remaining events involved dispensing, prescribing, and transcribing errors.

The three hospitals of Blue Mountain Health System quickly took on the challenge of improving their reliability on high-risk processes such as medication management, including BCMA.

Working with the Safety Authority, Blue Mountain found that the growth in near-miss BCMA events was attributable in part to the health system’s specific efforts to identify and report such events. Administration issues were found, as well, including what appeared to be intentional barcode scans of the wrong patient. In its direct observations of the health system’s workflow, the Safety Authority identified the perceived wrong-patient scans were a matter of workarounds that staff employed to pursue better efficiency. Other problems identified were variations in access to records, resulting in potential wrong-patient selections, and lack of internet connectivity in certain areas, leading to additional staff workarounds.

With this information, the Safety Authority and Blue Mountain collaborated to improve Blue Mountain’s BCMA process. Between 2014 and 2016, the health system reduced its BCMA-workflow near-miss events by 53%.

“As demonstrated by Blue Mountain Health System’s efforts, near-miss event analysis provides valuable information that can identify patient safety
hazards and be used to fix system weaknesses,” said Dr. Ellen S. Deutsch, medical director for the Safety Authority. “Identifying hazards even before patients are harmed is an important component of event reporting. Near-misses can warn healthcare facilities about hazards before patient harm, much as a lighthouse warns ships about high-risk areas.” (Source: Dec. 20, 2017 /PRNewswire-USNewswire)

Can we look at data from our schools and identify near-miss events? If so, we might be able to build our own Swiss cheese model and find out where to make the best improvements to the system to impact the school shooting problem.

Four common layers in Swiss cheese models are avoidance, prevention, protection and mitigation. We can illustrate how modest improvements to each layer could add up to a big impact on improving school safety.

1. Avoidance — Restricting (not banning) ownership of military-style assault weapons.
2. Prevention — Increasing access to mental health counseling and intervention for school students.
3. Protection — Enhancing school security with metal detectors, vehicle barriers, and visitor badges.
4. Mitigation — Improving rapid response, equipment, and training of school resource officers.

We also need to continue to collect and use near-miss data to reduce the risks to our school kids over time. Robin Dillon-Merrill’s research led her to offer seven suggestions for recognizing and preventing near-misses.

1. Pay careful attention to high pressure. Often, enormous political and financial pressure lead us to ignore clear warning signs. If we had more time and more resources would we make the same decision?
2. Learn from deviations. Sometimes, we can repeatedly “get away” with a deviance from an established safety standard until it becomes the new norm. Have we always been comfortable with this level of risk? Has our policy toward this risk changed over time?
3. Uncover root causes. Why did this near-miss happen? What was required to produce this effect? What do we need to do to address the root cause?
4. Demand accountability. When we are accountable for our behavior, we will become more self-critical and take multiple perspectives on issues. Does the corporate culture make us feel accountable for our decisions?
5. Consider the worst-case scenarios. Play the Devil’s Advocate. Rather than focusing on success, could we have seen other outcomes? How bad could the outcome have been?
6. Evaluate performance at every stage. Organizations need the same degree of rigor whether things are going well or badly. Can we “pause and learn” something from this past year?703-967-3324
7. Reward public officials and school administrators for owning up. Create an organizational culture that recognizes and rewards uncovering near-misses and taking corrective action. How can we create an organizational culture that Trevor recognizes and rewards uncovering near-misses?

Finally, we must take personal responsibility to change the tone of our public conversations. The solution to mass shootings in our schools is not going to be an “Either or” answer, but a “Yes, and” answer.