Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.
Jeffs L, Berta W, Lingard LA, et al. Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. BMJ Qual Saf. 2012;21(4):287-94. doi:10.1136/bmjqs-2011-000256.
This study identified three different scenarios associated with organizational responses to near misses.