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Understanding the Swiss Cheese Model and Its Application to Patient Safety

期刊

JOURNAL OF PATIENT SAFETY
卷 18, 期 2, 页码 119-123

出版社

LIPPINCOTT WILLIAMS & WILKINS
DOI: 10.1097/PTS.0000000000000810

关键词

patient safety; system analysis; root cause analysis; human error; human factors

资金

  1. Clinical and Translational Science Award program, through the National Institutes of Health National Center for Advancing Translational Sciences [UL1TR002373]
  2. University of Wisconsin School of Medicine and Public Health's Wisconsin Partnership Program

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This article reviews the Theory of Active and Latent Failures, also known as the Swiss cheese model, and aims to provide a better understanding of its underlying theory. The goal is to help patient safety professionals leverage the model and its tools for root cause analysis and other patient safety activities.
This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident causation. Although the Swiss cheese model has become well known in most safety circles, there are several aspects of its underlying theory that are often misunderstood. Some authors have dismissed the Swiss cheese model as an oversimplification of how accidents occur, whereas others have attempted to modify the model to make it better equipped to deal with the complexity of human error in health care. This narrative review aims to provide readers with a better understanding and greater appreciation of the Theory of Active and Latent Failures upon which the Swiss cheese model is based. The goal is to help patient safety professionals fully leverage the model and its associated tools when performing a root cause analysis as well as other patient safety activities.

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