This paper provides a structured chronology of an investigation into a significant untoward incident in an elderly care ward. Using Reason’s Swiss Cheese Model, which has become one of the dominant paradigms for analysing clinical and patient safety incidents, it charts the interplay of national and local policies resulting in unsafe practice.A qualitative approach was used in this multidimensional investigation. This approach aimed to discover what actually happened in the specific and related incidents and the underlying causes. Thus, the anatomy of the incident refers to the structure of staffing, the physiology includes the process in place at the time of the incident and the pathogenesis alludes to the development of the incident.The findings report on the patients involved in the incident. The investigation also explores how strategic financial directions from the Department of Health impact on staffing levels and training. These are contextualised using the concepts of the Swiss Cheese Model to assist understanding of how and why the incident occurred.Key points emanating from a learning event are captured to aid understanding and the importance of being cognisant of the ever present risks in clinical practice. The impact of the investigation on staff and the primary care trust are also presented.
Maxine Offredy, Martin Rhodes, Yvonne Doyle
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