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

Human Error.

March 27, 2005

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

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

November 4, 2015

Resilient Health Care Series.

September 16, 2015

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

March 27, 2005

Man-Made Disasters. 2nd ed.

March 6, 2005

Score Your Safety Culture.

March 27, 2005

Patient Safety in Anesthetic Practice.

March 27, 2005

One group of doctors changes its ways.

July 6, 2005

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

March 27, 2005

Patient Safety Incident Response Framework.

August 31, 2022

Saying Sorry.

March 26, 2014

Raising and Responding to Concerns.

February 25, 2015

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

December 4, 2013

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

August 21, 2013

Healthcare Safety for Nursing Personnel: An Organizational Guide to Achieving Results.

February 4, 2015

Safety First: One Year On.

January 9, 2008

Digital Clinical Safety Strategy

October 20, 2021

Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method.

August 30, 2006

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

December 9, 2020

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

June 14, 2023

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

November 7, 2018

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

October 6, 2021

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

March 28, 2018

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

Risk mitigation in large scale systems: lessons from high reliability organizations.

March 6, 2005

Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review.

July 25, 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

State of Healthcare 2008.

January 7, 2009

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

May 18, 2022

Solutions from Professional Regulation and Beyond.

October 5, 2022

Learning Not Blaming.

September 9, 2015

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005.

January 2, 2008

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

Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.

October 24, 2007

The Safety of Maternity Services in England.

August 25, 2021

Complaints and Raising Concerns.

February 4, 2015

Patient Safety.

July 15, 2009

CRICO Patient Safety Updates: Medical and Legal Perspectives.

March 6, 2005

Investigating Clinical Incidents in the NHS.

May 6, 2015

When Things Go Wrong: Voices of Patients and Families.

January 1, 2011

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

PHSO Review: Quality of NHS Complaints Investigations.

June 22, 2016

Disclosure: what works now and what can work even better (part 3 of 3).

March 6, 2005

Analysis of patient safety risk management call data during the COVID‐19 pandemic.

January 27, 2021

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory.

December 22, 2021

Risk Management Pearls for Medication Safety: Part I and Part II.

February 19, 2014

2015 Patient Safety Core Topics and Tips.

March 27, 2013

Root Cause Analysis Playbook.

February 17, 2016

Patient Safety Risk Management Playbook.

February 10, 2016

The growing role of the Patient Safety Officer: implications for risk managers.

March 6, 2005

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

A Socio-cultural Perspective on Patient Safety.

February 22, 2012

Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting.

June 24, 2020

Incentives for patient safety: holding healthcare executives accountable.

September 3, 2008

First, Do No Harm Part 1: A Case Study of Systems Failure.

March 27, 2005

Opportunities to mine EHRs for malpractice risk management and patient safety.

September 7, 2022

A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.

September 22, 2021

Moving towards a Safety II approach.

August 7, 2019

Risk Management Pearls on Disclosure of Adverse Events.

July 26, 2006

Social risk, health inequity, and patient safety.

October 5, 2022

Cybersecurity in health is an urgent patient safety concern: we can learn from existing patient safety improvement strategies to address it.

April 7, 2021

Nurses' experiences of organizational learning.

August 19, 2020

Safety Climate: New Developments in Conceptualization, Theory, and Research.

October 6, 2010

Serious Safety Events: Getting to Zero. Second Edition.

October 17, 2012

Organizational factors that promote error reporting in healthcare: a scoping review.

September 14, 2022

Opioid dependence and overdose after surgery: rate, risk factors, and reasons.

September 21, 2022

10 Facts on Patient Safety.

June 27, 2018

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

Safety Culture: Theory, Method and Improvement.

March 31, 2010

Who killed patient safety?

July 20, 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

Measuring shared mental models in healthcare.

November 7, 2018

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

Patient Safety Culture: Theory, Methods and Application.

January 21, 2015

Risk perception on the labour ward: a mixed methods study.

April 28, 2021

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

Organizational and cultural changes for providing safe patient care.

August 3, 2005

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

Health Literacy Toolkit.

January 31, 2018

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

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

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

August 24, 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

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

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

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

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

See More About The Topic

Quality and Safety Professionals

Organizational Behaviorists

Safety Scientists

Latent Errors

Error Analysis