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The Swiss Cheese Model of Patient Safety Errors: Closing the Holes with Message Accountability

September 12, 2017

How many times in history has disaster struck due the “Swiss Cheese model of accident causation? From plane crashes and engineering errors to patient safety events, this model defines how a series of small errors can lead to a major event. Miscommunication often plays a significant role in these errors—costing $1.7 billion and attributing to 30 percent of malpractice cases, or more than 1,700 lives, according to a 2015 CRICO Strategies National Comparative Benchmarking System (CBS) Report. The primary goal of any safe, reliable communication process is to eliminate errors, or the “holes” in the Swiss cheese.

Exploring how miscommunication and message accountability create “holes”, it is important to recognize that all messages in healthcare are not created equal. “The family is in the room and would like to talk to you when you are free,” is different than “The CT scan shows a new, acute subdural hematoma with midline shift.” The first message is important, but will not likely have a major change in the patient’s outcome if missed or not seen urgently. The second message is critical—if that important change in the patient condition is not acted on urgently, the patient will certainly have a bad outcome.

As I work with health systems and providers, I consider message accountability as a way of closing the “holes” or errors in healthcare communications. For Spok, message accountability is not simply the reliable transmission of a block of text from one person to another. Rather it consists of four components:

1) The message contains information for the recipient to understand the urgency and context to take action.

2) The recipient explicitly acknowledges taking ownership and responsibility for the information in the message.

3) The sender knows when the recipient has taken accountability for the message.

4) If the initial transfer of accountability fails due to lack of acknowledgment after a pre-defined time or because the message was sent to a person not responsible for acting on the information — the system is designed to automatically escalate the message to the next appropriate individual or notify the sender.
There are numerous instances when message accountability is critical:

Code Situations
When a patient rolls into the ED with an acute ST-elevation myocardial infarction (Code STEMI), the health system must call the cardiac catheterization team urgently into the hospital. The health system must know the interventional cardiologist has received the message and is on their way—otherwise, the intervention cannot happen.


Critical Test Results
The subdural hematoma example above is considered a medical emergency. The radiologist diagnoses the problem but does not perform the intervention—the accountability must be transferred to the patient’s provider and ultimately, the neurosurgeon. In this case, the information must be sent immediately from the radiology system with a rapid escalation path if the initial recipient does not accept accountability to ensure the patient receives the appropriate intervention quickly.

Patient Care Alarms
When a patient clicks the nurse call button, the request could simply be for water or help with the sudden onset of severe chest pain. The concept of message accountability ensures a responsible nurse sees the message quickly and can take the appropriate action—assisting the patient as needed depending on the context of the message.


As a physician, I’m certainly aware of near misses, adverse events that occur due to miscommunication, and lack of message accountability. When messages cannot be conveyed in reliable, face-to-face conversation – technologies including secure messaging, interoperability with source systems, and escalation and tracking processes go a long way toward closing potential “holes” in the Swiss cheese model of patient safety errors.


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By Dr. Andrew Mellin, Chief Medical Officer
Dr. Mellin has almost 20 years of experience as both a practicing physician and healthcare executive. He brings an extensive background in health information technology including leading physician adoption programs for new technologies and developing innovative clinical solutions. Previous to joining Spok he was VP, Medical Director at RedBrick Health, where he helped health systems drive employee engagement of consumer-oriented population health and well-being solutions. Prior to RedBrick Health, Dr. Mellin spent 15 years at McKesson in various positions where he served as Medical Director for McKesson’s population health analytics solutions, developed a novel real-time quality solution for hospitals, and led physician strategy and product management for the electronic health record. He previously served as Medical Director for Allina Health’s Davies Award-winning implementation of an electronic health record at nine hospitals and 60 clinics across Minnesota. Dr. Mellin received his M.D. from Duke University in Durham, N.C., and his MBA from the University of Minnesota, Carlson School of Management. He trained in Internal Medicine at Barnes Hospital in St. Louis, Mo., and is board certified in Internal Medicine.