Swiss Cheese Model.

Image/Poster

Swiss Cheese Model.

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

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

The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries.

May 5, 2010

A Life in Error: From Little Slips to Big Disasters.

November 13, 2013

Human Error.

March 27, 2005

The risks of the prescribing cascade.

September 16, 2020

Score Your Safety Culture.

March 27, 2005

Operating room to intensive care unit handoffs and the risks of patient harm.

July 22, 2015

Influencing the Quality, Risk and Safety Movement in Healthcare: In Conversation with International Leaders.

November 4, 2015

Resilient Health Care Series.

September 16, 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

Nurses' experiences of organizational learning.

August 19, 2020

A review of organizational culture instruments for nurse executives.

February 21, 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

Beyond Blame: Solutions to America's Other Drug Problem [DVD].

March 27, 2005

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

Man-Made Disasters. 2nd ed.

March 6, 2005

Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'.

May 18, 2022

Patient Safety in Anesthetic Practice.

March 27, 2005

A Tale of Two Stories: Contrasting Views of Patient Safety.

March 27, 2005

Safety Culture: Theory, Method and Improvement.

March 31, 2010

Patient Safety Incident Response Framework.

August 31, 2022

Identification of common themes from never events data published by NHS England.

April 14, 2021

Patient Safety Culture: Theory, Methods and Application.

January 21, 2015

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

Health Literacy Toolkit.

January 31, 2018

Raising and Responding to Concerns.

February 25, 2015

Lessons from walking the medical distancing tightrope.

July 22, 2020

Safety Ethics: Cases from Aviation, Healthcare and Occupational and Environmental Health.

May 4, 2005

Standardise, Educate, Harmonise: Commissioning the Conditions for Safer Surgery.

April 23, 2014

Heatwaves, hospitals and health system resilience in England: a qualitative assessment of frontline perspectives from the hot summer of 2019.

March 22, 2023

Digital Clinical Safety Strategy

October 20, 2021

Resilience Engineering: Concepts and Precepts.

September 13, 2006

NHS Improvement.

May 18, 2019

A Socio-cultural Perspective on Patient Safety.

February 22, 2012

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

A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England.

August 21, 2013

Human error and the problem of causality in analysis of accidents.

March 6, 2005

Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare.

March 14, 2012

Resilience Engineering in Practice: a Guidebook.

January 12, 2011

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

National Patient Safety Alerting System.

February 19, 2014

A system safety approach to assessing risks in the sepsis treatment process.

September 22, 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

Saying Sorry.

March 26, 2014

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

Safely Home: What Happens When People Leave Hospital Care Settings?

August 26, 2015

Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer.

December 4, 2013

Improving Patient Safety Culture – A Practical Guide.

August 2, 2023

Safety First: One Year On.

January 9, 2008

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

Targeting zero harm: a stretch goal that risks breaking the spring.

August 12, 2020

Managing safety in perioperative settings: strategies of meso-level nurse leaders.

March 15, 2023

Digital health technology-specific risks for medical malpractice liability.

December 7, 2022

Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.

July 1, 2020

LeDeR - Learning from Lives and Deaths.

January 19, 2022

Graded autonomy in medical education—managing things that go bump in the night.

March 26, 2014

Including the reason for use on prescriptions sent to pharmacists: scoping review.

January 26, 2022

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

December 9, 2020

First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review.

July 22, 2020

Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice.

May 29, 2019

Learning From Invited Reviews.

April 10, 2019

Avoiding Unconscious Bias: a Guide for Surgeons.

August 24, 2016

Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease.

September 9, 2009

Good for You, Good for Us, Good for Everybody.

October 6, 2021

Gosport War Memorial Hospital. The Report of the Gosport Independent Panel.

November 7, 2018

Systems thinking for managing COVID-19 in health care systems: seven key messages.

September 23, 2020

Managing teamwork in the face of pandemic: evidence-based tips.

June 24, 2020

One group of doctors changes its ways.

July 6, 2005

Hard Truths: the Journey to Putting Patients First.

November 27, 2013

Culture Change in the NHS: Applying the Lessons of the Francis Inquiries.

March 11, 2015

Government Response to the Investigation into the Death of Elizabeth Dixon.

June 14, 2023

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

Reducing risks in complex care transitions in rural areas: a grounded theory.

March 22, 2023

The Report of the Short Life Working Group on Reducing Medication-related Harm.

March 28, 2018

Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995.

April 25, 2007

Barriers and enablers affecting patient engagement in managing medications within specialty hospital settings.

October 22, 2014

Seniors managing multiple medications: using mixed methods to view the home care safety lens.

March 2, 2016

Safety risks and workflow implications associated with nursing-related free-text communication orders.

March 15, 2023

Mitigating patient and consumer safety risks when using conversational assistants for medical information: exploratory mixed methods experiment.

December 15, 2021

Related Resources

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

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Improving Quality and Safety in Healthcare.

October 26, 2022

Crisis recovery in surgery: error management and problem solving in safety-critical situations.

September 14, 2022

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

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

Never Events Analysis of HSIB's National Investigations Report.

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

Behind Human Error, Second Edition.

November 10, 2017

The Field Guide to Human Error Investigations, Third Edition.

August 24, 2017

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

Healthcare staff wellbeing, burnout, and patient safety: a systematic review.

August 24, 2016

Hospital at night: an organizational design that provides safer care at night.

August 10, 2016

Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability.

July 20, 2016

Understanding models of error and how they apply in clinical practice.

July 20, 2016

Human factors in healthcare: welcome progress, but still scratching the surface.

June 29, 2016

Information transfer in multidisciplinary operating room teams: a simulation-based observational study.

May 18, 2016

Aviation and healthcare: a comparative review with implications for patient safety.

February 3, 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

Systematic biases in group decision-making: implications for patient safety.

November 5, 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

See More About The Topic

Quality and Safety Professionals

Organizational Behaviorists

Safety Scientists

Latent Errors

Error Analysis