Image/Poster Swiss Cheese Model. Citation Text: Adapted from: Reason JT. Managing the Risks of Organizational Accidents. Aldershot, Hants, England: Ashgate: 1997. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Adapted from: Reason JT. Managing the Risks of Organizational Accidents. Aldershot, Hants, England: Ashgate: 1997. View more articles from the same authors. The "Swiss cheese" model illustrates how a particular hazard must penetrate multiple barriers and safeguards in order to cause harm. Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Adapted from: Reason JT. Managing the Risks of Organizational Accidents. Aldershot, Hants, England: Ashgate: 1997. Copy Citation Related Resources From the Same Author(s) Managing the Risks of Organizational Accidents. March 27, 2005 Safety-I and Safety-II: The Past and Future of Safety Management. August 20, 2014 Human Error. 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September 24, 2014 View More See More About The Topic Quality and Safety Professionals Organizational Behaviorists Safety Scientists Latent Errors Error Analysis
Influencing the Quality, Risk and Safety Movement in Healthcare: In Conversation with International Leaders. November 4, 2015
Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer. December 4, 2013
Healthcare Safety for Nursing Personnel: An Organizational Guide to Achieving Results. February 4, 2015
Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method. August 30, 2006
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995. April 25, 2007
Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'. May 18, 2022
'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation. November 16, 2022
Heatwaves, hospitals and health system resilience in England: a qualitative assessment of frontline perspectives from the hot summer of 2019. March 22, 2023
An Organisation Losing its Memory? Patient Safety Alerts: Implementation, Monitoring and Regulation in England February 19, 2020
JCAHO proposal for patient-centered care brings concept to mainstream healthcare settings. June 29, 2005
Disclosure of unanticipated events: creating an effective patient communication policy (part 2 of 3). March 6, 2005
Using simulation to teach nursing students and licensed clinicians obstetric emergencies. November 7, 2012
Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory. December 22, 2021
Disclosure of unanticipated events: the next step in better communication with patients (part 1 of 3). March 27, 2005
Strategies and tips for maximizing failure mode and effect analysis in your organization. March 27, 2005
The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. August 15, 2007
Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting. June 24, 2020
A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency. September 22, 2021
Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it. April 7, 2021
Organizational factors that promote error reporting in healthcare: a scoping review. September 14, 2022
Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. December 16, 2020
The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study. August 24, 2022
Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities. October 19, 2022
Responding to health information technology reported safety events: insights from patient safety event reports. June 12, 2019
Rethinking high reliability in healthcare: the role of error management theory towards advancing high reliability organizing. February 13, 2019
Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit. August 8, 2018
Lessons learned from implementing a principled approach to resolution following patient harm. January 9, 2019
Learning from safety incidents in high reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare. March 31, 2021
From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme. June 15, 2022
The influence of organizational culture, climate and commitment on speaking up about medical errors. December 18, 2019
Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. June 25, 2008
Culture at Work in Aviation and Medicine: National, Organizational, and Professional Influences. March 6, 2005
Ethical leadership supports safety voice by increasing risk perception and reducing ethical ambiguity: evidence from the COVID-19 pandemic. November 9, 2022
Leveraging a safety event management system to improve organizational learning and safety culture. March 30, 2022
Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care. June 29, 2022
Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023
Classification of health information technology safety events in a pediatric tertiary care hospital. June 7, 2023
Patient Safety Innovations Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023
Crisis recovery in surgery: error management and problem solving in safety-critical situations. September 14, 2022
First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality. March 3, 2021
Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis. February 3, 2021
An in situ simulation program: a quantitative and qualitative prospective study identifying latent safety threats and examining participant experiences. January 20, 2021
Relationship between operating room teamwork, contextual factors, and safety checklist performance. August 31, 2016
Giving voice to quality and safety matters at board level: a qualitative study of the experiences of executive nurses working in England and Wales. August 24, 2016
Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability. July 20, 2016
Information transfer in multidisciplinary operating room teams: a simulation-based observational study. May 18, 2016
Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. December 17, 2014
Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. December 17, 2014
Effectiveness of facilitated introduction of a standard operating procedure into routine processes in the operating theatre: a controlled interrupted time series. November 19, 2014
Learning from failure: the need for independent safety investigation in healthcare. November 19, 2014
Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. October 29, 2014
A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors. September 24, 2014
The friends and family test: a qualitative study of concerns that influence the willingness of English National Health Service staff to recommend their organisation. September 24, 2014