Systematic Analysis of Medication Errors in an Indian Context Using the Swiss Cheese Model

Document Type : Review Article

Authors

Vrashal Verma ¹

Dipti Singh ²

Manish Kumar Asthana ²

¹ Department of Design, Indian Institute of Technology Roorkee, Roorkee, India.

² Department of Humanities and Social Sciences, Indian Institute of Technology Roorkee, Roorkee, India.

10.22067/jstinp.2025.93764.1155

Abstract

In the past two decades, medication error have grown in India. During the recent time the work on medication error in Indian context focusing the Swiss cheese model is limited. The medication error interventions should be explored using the systems thinking approach. The systems thinking approach might help us to understand its necessity as a precautionary and preventive measure for medication error.

Objective: To perform a systematic analysis of medication error in the Indian healthcare setting using Swiss cheese model.

Methods: To understand the holistic thought in medication errors system thinking is used. We analyzed the outcomes of the system mapping with the help of Swiss cheese model. The current work is made with latest paper in the medication error with Indian perspective. Interconnections and dependencies of medication errors from the systems perspective are addressed by common errors in phases of medication errors.

Results: The results highlights the importance of Swiss cheese model in the precaution and prevention of medication error. Before the implementation of the causal loop diagram consideration of the layer model of the swiss cheese model certainly implemented.

Conclusion: By applying the Swiss cheese model, the study demonstrates the criticality of multiple system layers where error can occur. The dynamic behaviour of the medication error system is understood with the cluster diagram and causal loop diagram. Medication error rate and medication error capacity are critical factors in system behaviour. The Swiss cheese model predicts the critical factors of the system's behaviour and provides preventive and precautionary measures in detail. The understanding of these attributes helps in the identification of medication errors in the healthcare system. Cross-functional findings of the theories, models and principles of the medication error system thinking can be utilised for understanding the holistic view.

Keywords

Medication error

Swiss cheese model

Systems Thinking

Causal loop diagram

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