Swiss Cheese Model

Swiss Cheese Model

The Swiss Cheese Model is a risk management and accident analysis model used in various industries, including aviation, engineering, and healthcare. It was developed by James Reason, a British psychologist, and has been widely adopted due to its simplicity and effectiveness in illustrating how accidents can occur in systems.

Overview

The Swiss Cheese Model is based on the idea that while many layers of defense (the "cheese") exist in most systems to prevent accidents, these defenses are not perfect and contain "holes" (errors or failures). These holes are constantly opening, closing, and shifting their location. The system as a whole produces failures when holes in all of the slices momentarily align, permitting "a trajectory of accident opportunity," so that a hazard passes through holes in all of the defenses, leading to an accident.

Application in Healthcare

In healthcare, the Swiss Cheese Model is used to analyze medical errors and patient safety incidents. The layers of defense in healthcare can include protocols, checklists, double-check systems, training, and automated systems. The holes in these defenses can be due to human error, system failures, or unexpected situations.

Criticisms

While the Swiss Cheese Model is widely used, it has also been criticized. Some argue that it oversimplifies complex systems and does not adequately account for systemic issues or the dynamic nature of many systems. Others argue that it places too much emphasis on individual errors and not enough on system failures.

See Also

• Risk management
• Patient safety
• Human error
• James Reason

Swiss Cheese Model Resources
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