Andy Montoya
The Swiss Cheese Model is a model used in risk analysis and management. It likens human systems to multiple slices of Swiss cheese, with holes representing potential failure points. When the holes align, a failure occurs. The model illustrates how failures are usually the result of multiple factors, rather than a single root cause. These factors can include latent errors within a system, which can be considered as holes in the cheese.
| Characteristics | Values |
|---|---|
| What the holes represent | Shortcomings, failure points, weaknesses in defences |
| Latent errors, unsafe acts, or conditions | |
| Active failures, immediate causes | |
| Underlying causes | |
| What the slices represent | Organisation's defence against risk as a whole |
| Barriers, defences | |
| Alignment of holes | Failure occurs when holes align |
| Holes may not always align, preventing catastrophe |
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What You'll Learn
Holes represent areas of potential failure
The Swiss Cheese Model is a model used in risk analysis and management. It likens human systems to multiple slices of Swiss cheese, with holes of varying sizes and placements. These holes represent areas of potential failure.
The model illustrates how failures are usually the result of multiple factors, rather than a single cause. These factors can include latent errors, which are inherent in a procedure, machine, or system. Latent errors are present before an accident occurs and can lie dormant for long periods. They are designed or built into the system and can be difficult to detect until an adverse event occurs. For example, in a healthcare setting, a latent failure could be the similar packaging of two different drugs stored near each other, contributing to the administration of the wrong drug. This model has helped to show that medical errors can result from system flaws, rather than individual character flaws.
Active failures, on the other hand, are "unsafe" acts often directly linked to an incident. They tend to receive the most attention during investigations. An example of an active failure is texting while driving. When active failures and latent conditions align, a failure occurs.
In the model, each slice of cheese represents a different defence or barrier against risk. Each slice has its own unique set of holes, representing potential failure points or weaknesses. When stacked, these slices represent an organisation's defence against risk as a whole. Sometimes, the holes in one slice will be covered by the slice above it, demonstrating how some areas of an organisation can compensate for the shortcomings of others. However, if the holes in each slice align, it creates a pathway for a hazard to pass through, resulting in a failure.
The Swiss Cheese Model is used in various fields, including aviation, engineering, healthcare, and emergency services. It has been criticised for its broad application and lack of supporting models. Despite this, it is a respected and useful tool for relating concepts and understanding accidents and patient safety incidents.
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Holes represent weaknesses in defences
The Swiss Cheese Model is a model used in risk analysis and management. It likens human systems to multiple slices of Swiss cheese, with holes of varying sizes and placements. These holes represent weaknesses in defences or areas where there is potential for failure. For example, a nurse mis-programming an infusion pump or an anaesthesia resident failing to provide an adequate briefing when handing off a patient to the ICU. These incidents threaten the overall safety integrity of the system.
The model illustrates how failures usually result from a combination of factors, rather than a single root cause. These factors often include latent errors inherent in a procedure, machine, or system. Latent failures include contributory factors that may lie dormant for days, weeks, or months until they contribute to an accident. They can be considered underlying causes. For example, in the case of aviation accidents, a latent failure could be a navigation error.
Active failures, on the other hand, are immediate causes or unsafe acts that are often directly linked to an incident. They tend to garner the most intense focus during investigations. Texting while driving is an example of an active failure.
When the holes in the slices of cheese align, a failure occurs. This alignment creates a "trajectory of accident opportunity", allowing a hazard to pass through the holes and leading to a failure. However, if the holes do not align, the series of events leading to a catastrophe can be changed or prevented.
The Swiss Cheese Model has been applied in various fields, including aviation safety, engineering, healthcare, and emergency service organizations. It is used to assess risk and improve safety by identifying weaknesses in defences, or "holes", and implementing measures to address them.
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Holes represent latent errors
The Swiss Cheese Model is a model used in risk analysis and management. It is used to illustrate that failures are usually the result of a combination of factors, rather than a single root cause. The holes in the Swiss cheese model represent the potential failure points in a system. These holes represent latent errors or weaknesses in a system, procedure, machine, or organisation.
Latent errors are those that lie dormant or are present in a system before an accident occurs. They can be designed or built into a system and may go undetected until an adverse event occurs. For example, in a healthcare context, a latent failure could be the similar packaging of two different drugs that are stored close to each other in a pharmacy. This could contribute to the administration of the wrong drug to a patient. Latent errors can also be found in aviation safety, engineering, and emergency service organisations.
In the Swiss Cheese Model, each slice of cheese represents a different defence mechanism or safety barrier within a system. The holes in each slice represent potential failure points or weaknesses in that particular defence. These holes can be the result of latent errors, which are failures that threaten the overall safety integrity of the system. If these latent errors did not exist, the cheese would not have any holes, and the system would be represented by solid slices of cheese.
The model demonstrates that a failure occurs when the holes in each slice align, creating a trajectory of accident opportunity. This alignment of holes represents a weak point that is common across multiple areas of an organisation, where the potential for failure is greatest. However, it is important to note that not all holes in a system will lead to an accident. Some holes may be inconsequential, while others may be detected and corrected before any harm occurs.
The Swiss Cheese Model has been criticised for its broad application and lack of supporting models. Additionally, there is some variability in the interpretation of the model, particularly in understanding the representation of medical errors. Despite these criticisms, the model is widely accepted and provides a powerful approach to accident investigation and prevention.
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Holes represent unsafe acts
The Swiss Cheese Model is a model used in risk analysis and management. It likens human systems to multiple slices of Swiss cheese, with holes of varying sizes and placements. These holes represent potential failure points or areas of weakness in an organization's defence against risk.
However, it is important to note that accidents are typically the result of a combination of factors, including latent conditions or "latent failures". These are factors that are present before an accident occurs and can lie dormant within a system for a long period of time. An example of a latent failure is the similar packaging of two different drugs in a pharmacy, which could contribute to the administration of the wrong drug to a patient.
The Swiss Cheese Model illustrates how these active and latent failures interact to produce an incident. When the holes in the slices of cheese align, it creates a "trajectory of accident opportunity", and a failure occurs. This model highlights the importance of addressing both active and latent failures to prevent incidents.
While the Swiss Cheese Model has gained widespread acceptance and is commonly used in industries such as aviation, engineering, and healthcare, it has also faced criticism. One criticism is that it may be too simplistic and does not effectively represent the complex interrelationships among the causes of incidents.
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Holes represent accident opportunities
The Swiss Cheese Model is a model used in risk analysis and management. It likens human systems to multiple slices of Swiss cheese, with holes of varying sizes and placements. These holes represent accident opportunities, or areas where there is potential for failure. The model illustrates how failures usually result from a combination of factors, rather than a single root cause.
Each slice of cheese represents a different defence mechanism, or safety barrier, within a system. The holes in each slice are the absence of, or failure in, these safety barriers. For example, in a healthcare context, a hole could be a nurse mis-programming an infusion pump, or an anaesthetic resident not providing an adequate briefing when handing a patient over to the ICU. These failures threaten the overall safety integrity of the system.
When the holes in the slices align, a failure occurs, as the hazard passes through the holes, creating a "trajectory of accident opportunity". This is because, when the holes align, there are no defences in place to prevent an accident. However, if the holes do not align, the accident is prevented, as there are other slices of cheese (defences) in place to prevent the accident from occurring.
The Swiss Cheese Model is useful in understanding that accidents are often the result of multiple factors, rather than a single cause. This is particularly relevant in industries such as aviation, healthcare, and engineering, where the model is often applied.
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Frequently asked questions
The holes in the Swiss Cheese Model represent areas where there is potential for failure, or "shortcomings".
Each slice of cheese represents a different defence or barrier against risk.
A latent failure is a contributory factor that may lie dormant for days, weeks or months until it contributes to an accident.
An active failure is an "unsafe act" that can be directly linked to an accident.
