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. 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Influencing the Quality, Risk and Safety Movement in Healthcare: In Conversation with International Leaders. November 4, 2015
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
An Organisation Losing its Memory? Patient Safety Alerts: Implementation, Monitoring and Regulation in England February 19, 2020
Reporting of health information technology system-related patient safety incidents: the effects of organizational justice. October 6, 2021
Speaking up during the COVID-19 pandemic: nurses' experiences of organizational disregard and silence. February 1, 2023
The influence of organizational culture, climate and commitment on speaking up about medical errors. December 18, 2019
Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units. September 1, 2021
The role of organizational and professional cultures in medication safety: a scoping review of the literature. January 15, 2020
The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. November 10, 2010
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
Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals. January 20, 2016
"At home, with care": lessons from New York City home-based primary care practices managing COVID-19. December 16, 2020
Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'. May 18, 2022
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
Safety Ethics: Cases from Aviation, Healthcare and Occupational and Environmental Health. May 4, 2005
Heatwaves, hospitals and health system resilience in England: a qualitative assessment of frontline perspectives from the hot summer of 2019. March 22, 2023
Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020. February 22, 2023
Safety checklists for emergency response driving and patient transport: experiences from emergency medical services. July 7, 2021
National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020. March 1, 2023
Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement. August 25, 2021
Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports. November 3, 2021
Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems. December 14, 2022
Improving handoff by deliberate cognitive processing: results from a randomized controlled experimental study. April 28, 2021
Stakeholder safety communication: patient and family reports on safety risks in hospitals. October 12, 2022
Shaping systems for better behavioral choices: lessons learned from a fatal medication error. March 24, 2010
Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer. December 4, 2013
Tiered daily huddles: the power of teamwork in managing large healthcare organisations. October 7, 2020
A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals. October 14, 2020
Organizational learning: health care leaders need to design structures and processes that enhance collective learning. March 27, 2005
First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review. July 22, 2020
Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease. September 9, 2009
Systems thinking for managing COVID-19 in health care systems: seven key messages. September 23, 2020
What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization. October 21, 2020
Lessons learned from a systems approach to engaging patients and families in patient safety transformation. February 12, 2020
A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period. July 17, 2013
Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey. March 22, 2023
Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda. March 29, 2023
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995. April 25, 2007
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Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023
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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
Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis of the literature. May 13, 2020
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
Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. December 17, 2014
Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. December 17, 2014
Learning from failure: the need for independent safety investigation in healthcare. November 19, 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
Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. October 29, 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