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PSNet: Patient Safety Network
Journal Article

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

Stein JE, Heiss K. Seminars in pediatric surgery. 2015;24:278-82.

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.