The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.
Approach to Improving Safety
- Root Cause Analysis
- Morbidity and Mortality Conferences
- Human Factors Engineering
- Residents and Fellows
Setting of Care
Academic medical centers are working to increase resident engagement in patient safety work. Building on Reason's system failure investigation model, this commentary describes the integration of monthly educational opportunities into actual improvement efforts. Core elements of the program rely on effective case selection, root cause analysis, and resident-led discussion.