Swiss Cheese Model (SCM)

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Swiss Cheese Model (James Reason)

- used for analyzing medical errors and patient safety incidents 

(how harmful events occurred and how they can be prevented)

- visualize incidents that happen as the result of the accumulation of multiple failures in defenses

- Blame cannot be placed on problems involving just one slice of cheese rather " a system design" flaw

                 Taken from Clinical Leadership Solution Ltd (2019). Available on https://www.youtube.com/watch?v=MfWpMrEOlJ8. Accessed: 25/02/2022.


Components:

1. Slice of cheese - barrier

2. Hole - weakness, which is inconstant as it could be like a hole that opens and close at random cheese

3. Arrow - If by chance all holes are aligned, the hazard reaches the patient and can cause harm. 

4. Active error/ Latent error

    Active failures: generally committed by persons who perform their duty at the so-called sharp end of the system

    eg: administering the wrong drug

    Latent Conditions: potential contributing factors that lie dormant in the system and occur upstream at the more remote layers, called blunt end

    eg: confusingly similar names of two different drugs

5. How to make the system safer



References

INTeReSTS, DeClARATION Of. "Hot cheese: a processed Swiss cheese model." JR Coll Physicians Edinb 44 (2014), 116-21.

Perneger, T.V. The Swiss cheese model of safety incidents: are there holes in the metaphor?. BMC Health Serv Res 5, 71 (2005), https://doi.org/10.1186/1472-6963-5-71

Reason J: Human error: models and management. BMJ (2000), 320: 768-70. 10.1136/bmj.320.7237.768.

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