Overview
Definitions of Error
Basic Tenets of Human Error
Human Factors Engineering
Human Performance
Vocabulary
Types of Errors
Systems to Reduce Errors
Stroop Test
Swiss Cheese Model
Toxic Cascades
Lessons from Other Industries
Basic Safety Principles
Summary

Toxic Cascades

Current thinking about patient safety is primarily focused on the immediate consequences of mistakes that affect care, such as medication errors. Some mistakes become apparent only after a lapse of time from when they were committed.

The toxic cascade model presents an approach to patient safety that locates “upstream sources and downstream consequences of errors” (AFP 2001). It is conceptualized as a tiered diagram, presenting four levels that are potential threats to patients’ safety. Click on each of the boxes for an explanation. If the diagram seems counter-intuitive, think of rapids in a river: as the river narrows, the water goes faster and the flow becomes more powerful.


 

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