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 A Life in Error: From Little Slips to Big Disasters. 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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
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
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
Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'. May 18, 2022
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
Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals. January 20, 2016
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
A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals. October 14, 2020
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
What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization. October 21, 2020
"At home, with care": lessons from New York City home-based primary care practices managing COVID-19. December 16, 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
Tiered daily huddles: the power of teamwork in managing large healthcare organisations. October 7, 2020
The role of organizational and professional cultures in medication safety: a scoping review of the literature. January 15, 2020
Lessons learned from a systems approach to engaging patients and families in patient safety transformation. February 12, 2020
The effect of the fit between organizational culture and structure on medication errors in medical group practices. February 7, 2007
Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being. June 8, 2022
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
The use of a standard design medication room to promote medication safety: organizational implications. February 13, 2013
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 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
An Organisation Losing its Memory? Patient Safety Alerts: Implementation, Monitoring and Regulation in England February 19, 2020
Seniors managing multiple medications: using mixed methods to view the home care safety lens. March 2, 2016
Family involvement in managing medications of older patients across transitions of care: a systematic review. June 26, 2019
Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy. November 25, 2020
The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England. August 18, 2021
Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid. April 2, 2014
Patient and consumer safety risks when using conversational assistants for medical information: an observational study of Siri, Alexa, and Google Assistant. September 19, 2018
The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study. August 24, 2022
Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation. July 20, 2022
Assessing the dangers of a hospital stay for patients with developmental disability In England, 2017–19. October 19, 2022
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
Safety checklists for emergency response driving and patient transport: experiences from emergency medical services. July 7, 2021
Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports. November 3, 2021
Shaping systems for better behavioral choices: lessons learned from a fatal medication error. March 24, 2010
Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence. August 17, 2022
Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database. December 1, 2021
'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors. November 24, 2021
"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses. March 22, 2023
The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy. April 27, 2022
The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review. January 11, 2023
The work of nurses to provide good and safe services to children receiving hospital-at-home: a qualitative interview study from the perspectives of hospital nurses and physicians. October 20, 2021
Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs. April 5, 2017
Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care. June 16, 2021
Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. March 1, 2023
COVID-19 increased the risk of ICU-acquired bloodstream infections: a case-cohort study from the multicentric OUTCOMEREA network. March 17, 2021
Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study. September 15, 2021
The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study. July 28, 2021
A systematic review of trauma crew resource management training: what can the United States and the United Kingdom learn from each other? September 2, 2020
COVID-19 can last for several months. The disease’s “long-haulers” have endured relentless waves of debilitating symptoms—and disbelief from doctors and friends. July 1, 2020
Chronicle of a pandemic foretold: learning from the COVID-19 failure—before the next outbreak arrives. July 1, 2020
Early prognostic value of the medical emergency team calling criteria in patients admitted to intensive care from the emergency department. February 6, 2008
The value from investments in health information technology at the U.S. Department of Veterans Affairs. May 5, 2010
Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. May 5, 2010
Does one size fit all? Assessing the need for organizational second victim support programs. April 7, 2021
Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient surgical units. February 3, 2021
Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams. March 16, 2022
Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals. June 29, 2022
What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. May 18, 2022
NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. July 21, 2021
Resilience from a stakeholder perspective: the role of next of kin in cancer care. September 23, 2020
Restructuring of a general surgery residency program in an epicenter of the coronavirus disease 2019 pandemic: lessons from New York City. July 29, 2020
Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA. June 24, 2020
Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care. August 24, 2022
Variation in the reporting of elective surgeries and its influence on patient safety indicators. July 6, 2022
Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system. February 2, 2022
Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. December 8, 2021
Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors. October 12, 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
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
A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors. September 24, 2014