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The Swiss cheese model of adverse event occurrence—closing the holes.
Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003.
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January 13, 2016
Stein JE, Heiss K. Semin Pediatr Surg. 2015;24(6):278-82.
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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