The Swiss cheese model of adverse event occurrence—closing the holes. | PSNet

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The Swiss cheese model of adverse event occurrence—closing the holes.

January 13, 2016

Stein JE, Heiss K. Semin Pediatr Surg. 2015;24(6):278-82.

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Shifting the focus from individual failures to system problems has produced new ways to reduce adverse events. This commentary discusses how human factors research has improved understanding about medical error and the role of teamwork training and safety culture in identifying and addressing safety problems in surgical practice.

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Health Care Executives and Administrators

Epidemiology of Errors and Adverse Events

Human Factors Engineering

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