Andy Montoya
The Swiss Cheese model, developed by psychologist James Reason and published in 2000, is a model of safety incidents that illustrates how accidents in complex systems are rarely caused by a single failure. Instead, they occur when multiple minor lapses (symbolized by holes in slices of Swiss cheese) line up across different layers of defence. The model is widely accepted and used by patient safety professionals and in other fields such as aviation safety and warehouse safety. However, some consider the model to be obsolete due to the evolving complexity of systems and the emergence of new technologies.
| Characteristics | Values |
|---|---|
| Creator | James Reason |
| Year of Publication | 1997, 2000, 2001 |
| Type of Model | Risk Management |
| Application | Analysing medical errors, patient safety incidents, accidents and catastrophes |
| Holes | System vulnerabilities/weaknesses |
| Slices | Defense mechanisms and barriers |
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What You'll Learn
- The Swiss cheese model is a dominant paradigm for analysing medical errors and patient safety incidents
- It was developed by psychologist James Reason in the 1990s
- The model illustrates how accidents in complex systems are rarely caused by a single failure
- It is widely accepted and used by patient safety professionals
- The model is used for accident causation analysis and risk management
The Swiss cheese model is a dominant paradigm for analysing medical errors and patient safety incidents
The Swiss Cheese Model, developed by psychologist James Reason in the 1990s, is a dominant paradigm for analysing medical errors and patient safety incidents. It is a widely accepted model in patient safety and is used to understand complex accidents. The model is based on the idea that accidents in complex systems are rarely caused by a single failure. Instead, they occur when multiple minor lapses (symbolized by holes in slices of Swiss cheese) line up across different layers of defence.
In Reason's model, each slice of cheese represents a system of defence, and the holes represent potential points of failure. When the holes in the slices line up, a failure occurs. This can be applied to medical errors and patient safety incidents, where multiple weaknesses in a system align, allowing a hazard to slip through every layer of defence. For example, in the case of wrong-site surgery, a healthcare professional whose role is to ensure patient safety may be thought of as a protective barrier. However, if an error occurs that results in patient harm, then this would be considered an active error.
The Swiss Cheese Model has been applied to various industries, including healthcare, aviation, and warehousing. In healthcare, it is used to analyse medical errors and patient safety incidents, and it has been proposed as a framework for improving patient safety culture. However, there is some criticism of the model, with some arguing that it oversimplifies how accidents occur and does not adequately account for the complexity of human error in healthcare.
Despite this criticism, the Swiss Cheese Model remains a popular and widely accepted framework for understanding and preventing accidents in complex systems. It provides a common language and a foundation for building methods to identify and analyse failures, contributing to the development of robust safety protocols and procedures.
Overall, the Swiss Cheese Model is a valuable tool for analysing medical errors and patient safety incidents, helping to identify weaknesses in systems and improve overall safety.
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It was developed by psychologist James Reason in the 1990s
The Swiss Cheese model was developed by psychologist James Reason in the 1990s. Reason's model has become the dominant paradigm for analysing medical errors and patient safety incidents. It is commonly used to guide root cause analyses (RCAs) and safety efforts across a variety of industries, including healthcare.
Reason's Swiss Cheese model of accident causation likens human system defences to a series of slices of randomly holed Swiss cheese arranged vertically and parallel to each other with gaps in between each slice. The holes in the cheese slices represent individual weaknesses in individual parts of the system and are continually varying in size and position in all slices. The system as a whole produces failures when holes in all the slices momentarily align, permitting "a trajectory of accident opportunity", so that a hazard passes through holes in all the defences, leading to an accident.
Reason hypothesises that most accidents can be traced to one or more of four levels of failure: organisational influences, unsafe supervision, preconditions for unsafe acts, and the unsafe acts themselves. The Swiss Cheese model, therefore, models an organisation's defences against failure as a series of barriers, represented as slices of cheese.
In the early days of the Swiss Cheese model, from the late 1980s to about 1992, attempts were made to combine James Reason's multi-layer defence model and Willem Albert Wagenaar's tripod theory of accident causation. This resulted in a period in which the Swiss cheese diagram was represented with the slices of cheese labelled 'active failures', 'preconditions', and 'latent failures'.
In 1990, James Reason published a book called 'Human Error', in which he described the Swiss Cheese Model.
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The model illustrates how accidents in complex systems are rarely caused by a single failure
The Swiss Cheese Model, developed by psychologist James Reason in the 1990s, is a powerful metaphor for understanding how accidents and failures occur in complex systems. The model illustrates that accidents in complex systems are rarely caused by a single failure, but rather by a combination of multiple small failures. Each slice of cheese represents a defensive layer in the system, such as procedures, training, or equipment, and the holes in the cheese represent weaknesses or vulnerabilities in these defences.
This perspective shifts the focus from blaming individuals to understanding and improving the system as a whole. By addressing both active failures and latent conditions, organisations can reduce the likelihood of accidents. Active failures are unsafe acts committed by people who are in direct contact with the system, such as errors, violations of procedures, or mistakes. Latent conditions, on the other hand, are the less obvious systemic weaknesses that may lie dormant in the system for years before they combine with other failures to cause an accident.
The Swiss Cheese Model is widely accepted and used by patient safety professionals to analyse medical errors and patient safety incidents. It is also applied in other industries, such as aviation and warehousing, to improve safety and prevent accidents. In a warehouse setting, for example, multiple safety layers such as regular inspections, engineered repairs, data tracking, protective equipment, and employee training can be integrated to reduce the chances of accidents occurring.
The model also encourages a proactive approach to safety, where organisations continuously work to identify and address potential vulnerabilities across all levels of their operations. This helps to create safer, more reliable systems and prevent catastrophic failures.
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It is widely accepted and used by patient safety professionals
The Swiss Cheese Model, developed by psychologist James Reason in the 1990s, is a widely accepted concept in patient safety and safety science. It is used to analyse medical errors and patient safety incidents, and is considered the dominant paradigm in these fields. The model illustrates how accidents in complex systems are rarely caused by a single failure. Instead, accidents occur when multiple minor lapses (symbolised by holes in slices of Swiss cheese) line up across different layers of defence.
The model is frequently referred to and applied by patient safety professionals. Safety expert Ronald Westrum summarised the model's popularity and effectiveness in a 2000 testimony:
> "Reason's model has become the common language through which complex accidents can be understood. I remember being at one conference where six speakers in a row got up and showed Swiss cheese diagrams as a kind of academic overkill. The popularity of this model obviously comes from its wide application. It's generally felt, as I said, this provides a common ground for discussing system safety."
The Swiss Cheese Model is used as a framework for risk management, demonstrating that accidents happen when multiple safety lapses (or "holes") align. By implementing multiple safety layers, such as regular inspections, engineered repairs, data tracking, protective equipment, and employee training, the chances of these "holes" aligning are significantly reduced.
While the model is widely accepted and applied, there are varying interpretations of its components. A survey of professionals familiar with the model found that while most interpreted a "hole" as a weakness in defences, only a few understood it as a latent error or an unsafe act. Similarly, only half of the respondents chose the most obvious interpretation of the "arrow" as the path from hazard to harm. These varying interpretations highlight the need for a unified understanding of the model's components to ensure effective communication and application.
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The model is used for accident causation analysis and risk management
The Swiss Cheese Model, developed by psychologist James Reason in the 1990s, is a model used for accident causation analysis and risk management. The model illustrates how accidents in complex systems are rarely caused by a single failure, but rather by multiple minor lapses or "holes" in defences. Each slice of Swiss cheese represents a different safety-critical system, and the holes in the cheese represent potential points of failure. When the holes in the cheese line up, it allows a hazard to slip through every layer of defence, resulting in an accident.
The model is particularly useful for understanding why accidents occur even when organisations have taken steps to prevent them. By identifying the weak points in a system, organisations can develop strategies to address them and improve overall safety. The Swiss Cheese Model has been applied in a variety of industries, including aviation, healthcare, engineering, and warehouse safety.
In the context of accident causation analysis, the Swiss Cheese Model distinguishes between active and latent failures. Active failures are unsafe acts directly linked to an accident, such as an employee choosing not to follow safety procedures. Latent failures, on the other hand, are built into procedures, systems, or machines and lie dormant until they are triggered by an active failure. For example, a faulty fire alarm system is a latent condition that becomes a failure when it is needed but fails to function.
The Swiss Cheese Model is also a valuable tool for risk management. By treating each slice of cheese as a line of defence, organisations can implement multiple, overlapping safety measures. This reduces the chances of holes aligning and creating a single point of failure. Regular inspections, engineered repairs, data tracking, protective equipment, and employee training are some examples of how organisations can create these additional layers of defence.
Overall, the Swiss Cheese Model provides a comprehensive framework for understanding and managing risk and accidents. By acknowledging the complex interplay of factors that contribute to accidents, organisations can strengthen their defences and improve safety across a range of industries.
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Frequently asked questions
The Swiss Cheese model is a concept in safety science that illustrates how accidents in complex systems are rarely caused by a single failure. Instead, they occur when multiple minor lapses (symbolized by holes in slices of Swiss cheese) line up across different layers of defence.
The Swiss Cheese model was developed by psychologist James Reason in the 1990s.
The Swiss Cheese model is used to analyse medical errors and patient safety incidents. It is also used for accident causation analysis and risk management.
The holes in the Swiss Cheese model represent system vulnerabilities, weaknesses, or potential points of failure. When the holes line up, a failure occurs.
Some people consider the Swiss Cheese model to be obsolete due to the evolving complexity of systems and the emergence of new technologies. The model assumes a linearity of failure, which may not be applicable in modern complex systems with multiple paths to failure.
