Journal Article
Commentary

Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature.

Thonon H; Espeel F; Frederic F; Thys F.

The Swiss cheese model illustrates how independent weaknesses can combine to result in failure. This commentary examines factors that contribute to central venous catheterization mistakes and applies the Fishbone diagram to show areas requiring process improvement. The authors suggest steps before, during, and after central venous catheter placement to support safe practice.