Continuous Quality Improvement (CQI) Practice Exam

What example best illustrates the Swiss cheese theory?

1. Patient receiving a medication they have taken before

2. Patient being prescribed medication they are allergic to

3. A patient experiencing a minor allergic reaction

4. Patient undergoing successful treatment without complications

The correct answer is: Patient being prescribed medication they are allergic to

The Swiss cheese theory is a model used in risk management and safety, illustrating how layers of defense can help prevent errors. In this theory, each layer of defense may have holes (or weaknesses), but when stacked together, they provide a greater overall protection against failure. The holes in the cheese represent potential risks or failures, and while one layer might fail, the subsequent layers can still catch the error before it reaches the patient. The scenario of a patient being prescribed medication they are allergic to vividly demonstrates this concept. It highlights a significant failure in the safety layers that should be in place to prevent such an error. In well-designed healthcare systems, multiple checks should exist – such as allergy alerts in medical records, pharmacist reviews, and physician consultations – that should ideally flag this kind of situation. The presence of these "holes" in the system, where the allergy information was not properly considered or communicated, illustrates the vulnerability of safety systems. Therefore, this example effectively showcases how individual failures in safety layers can lead to harmful outcomes when they go unchecked, which is the essence of the Swiss cheese model. The other examples do not effectively represent this concept. For instance, a patient receiving a medication they have taken before does not indicate any breach of safety, as