CRIM 2653 Lecture Notes - Lecture 20: Swiss Cheese Model, Human Factors And Ergonomics, Suxamethonium Chloride
3 May 2020
School
Department
Course
Professor
Document Summary
So much of safety is just looking at things from different perspective. We have many human factor engineers that look into issues like this at uoft. Need to check bottle three times: a) off shelf, b) when filling, and c) when putting it back. Nurses are told same thing, right room, right strength, right time, etc. But it could still be wrong if doctor writes it down wrong or nurse makes a mistake or w/e. Although system approach is necessary, it"s not enough. Swiss cheese model, there"s holes in the system. We put barriers in place and those barriers have holes, and when holes line up, those things that get right through. When we want to make systems safer we need to have them working in safe and well designed systems. Humans are not capable of perfect performance and multitask too often.
