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

Provide Feedback |

Register

Commentary

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.

View more articles from the same authors.

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.

PubMed citation

Related Resources From the Same Author(s)

The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers.

June 21, 2023

Supporting recovery after adverse events: an essential component of surgeon well-being.

February 10, 2021

The unmeasured quality metric: burn out and the second victim syndrome in healthcare.

August 7, 2019

Peer support to promote surgeon well-being: the APSA program experience.

September 25, 2024

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

March 1, 2011

Designing and implementing a comprehensive quality and patient safety management model: a paradigm for perioperative improvement.

February 15, 2011

Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims.

January 25, 2017

Surgeon and surgical trainee experiences after adverse patient events.

June 19, 2024

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

April 5, 2013

View More

Related Resources

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

Medically-necessary, time-sensitive procedures: a scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic.

May 6, 2020

What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.

June 12, 2019

Applying human-centered design thinking to enhance safety in the OR.

May 24, 2017

Instrument count sheets and set reviews as patient safety tools.

January 11, 2017

Perioperative safety: learning, not taking, from aviation.

July 27, 2016

An innovative approach to the surgical time out: a patient-focused model.

June 29, 2016

Speaking up to reduce noise in the OR.

July 22, 2015

Human factors engineering: its place and potential in OR safety.

May 20, 2015

Briefings, checklists, geese, and surgical safety.

January 28, 2010

View More

See More About The Topic

Health Care Executives and Administrators

Epidemiology of Errors and Adverse Events

Human Factors Engineering

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364