The Swiss cheese model of adverse event occurrence—closing the holes.

James E. Stein; Kurt Heiss

Commentary

The Swiss cheese model of adverse event occurrence—closing the holes.

January 13, 2016

Stein JE, Heiss K. Semin Pediatr Surg. 2015;24(6):278-82.

View more articles from the same authors.

Shifting the focus from individual failures to system problems has produced new ways to reduce adverse events. This commentary discusses how human factors research has improved understanding about medical error and the role of teamwork training and safety culture in identifying and addressing safety problems in surgical practice.

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Operating Room

Health Care Executives and Administrators

Surgery

Epidemiology of Errors and Adverse Events

Human Factors Engineering

The Swiss cheese model of adverse event occurrence—closing the holes.

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