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Introduction to Patient Safety and Improvement Knowledge
Published in Michael Ljungberg, Handbook of Nuclear Medicine and Molecular Imaging for Physicists, 2022
Another well-known model is the Swiss cheese model described by Reason [5], which is built up like a number of slices of Swiss cheese, each of which represents a barrier to preventing threats from reaching the patient (Figure 24.2). The barriers are created by, or represent, different “actors,” all the way from legislation, organizational structures on different levels, technical resources, routines and protocols, and finally the healthcare personnel standing next to the patient. Like the slices of a Swiss cheese, the barriers have inherent holes at different locations. Some of the holes are well known, while others, referred to as latent errors, are unknown. Some holes are always present, while others show up only on certain occasions. The accident occurs when the holes in all the barriers happen to line up, allowing the hazard to slip through all slices, or barriers, and finally expose the patient. The last barrier, the medical personnel in “direct contact” with the patient, is often the rescuer, who manages to identify the potential risk of an error and prevents the results of that error from reaching the patient. However, as a natural part of being human, we sometimes fail, or, as the title says in in the earlier-mentioned report, “to err is human.” For this reason, it is important to observe and secure the barriers located behind the personal, as being as safe, as free from holes as possible.
Managing human error
Published in Paul Bowie, Carl de Wet, Aneez Esmail, Philip Cachia, Safety and Improvement in Primary Care: The Essential Guide, 2020
Professor James Reason illustrated this concept through his well-known ‘Swiss cheese model’ (seeFigure 25.1).4 In this model, the slices of cheese represent the various system defences between hazards and adverse events and the holes represent active and latent errors. The slices of cheese are in constant motion. The holes generally do not form a straight line, with at least one slice blocking hazards from reaching patients. Most incidents of harm occur when the holes in the slices of cheese (the active and latent errors) temporarily align, allowing hazards to reach patients. The model’s key principles and their implications are shown in Table 25.1.
Patient Safety and Quality Improvement
Published in Eric Ford, Primer on Radiation Oncology Physics, 2020
Related to the above example is the Swiss cheese model of accidents (Figure 27.1.2) due to James Reasons, Professor of Psychology from Manchester University. Here an error happens (left), but before it reaches the patient it may be interrupted by one of the many safety barriers in place, e.g. review by a physicist or therapist or imaging. These barriers are the slices of cheese. However, the barriers do not operate perfectly. There are holes, and the holes may line up in such a way as to let the error through.
Why the government should be blamed for road safety
Published in International Journal of Occupational Safety and Ergonomics, 2022
Linlin Jing, Wei Shan, Yingyu Zhang
The human factors analysis and classification system (HFACS) [31], drawing on the Swiss cheese model [51,52], has become one of the most popular systems approaches that integrates multiple levels of human and organizational factors into a unified framework. The HFACS has been applied in many domains, such as the mining industry [44], maritime industry [43] and railway industry [53]. The HFACS represents four levels of human and organizational errors, i.e., unsafe behaviors (active failures), preconditions for unsafe behaviors (latent failures), unsafe supervision (latent failures) and organizational influences (latent failures). Unsafe behaviors are the center of most accident investigations, while preconditions for unsafe behaviors, unsafe supervision and organizational influences constitute latent failures that are often ignored by investigators. Reinach and Viale [54] modified the primordial HFACS by adding the top-most level (i.e., outside factors).
The development and validation of a human factors analysis and classification system for the construction industry
Published in International Journal of Occupational Safety and Ergonomics, 2022
Actually, these 12 theories are able to cover an effective spectrum of existing accident theories. The majority of researchers consider that accident theories should be classified into three groups, including sequential, epidemiological and systemic [31]. Sequential models view an accident as the outcome of events occurring sequentially. In the 11 theories, the former seven models can be categorized as sequential models. Epidemiological models consider that accidents result from the combination of co-occurring causes. The Swiss cheese model is widely viewed as the most classic epidemiological model. Systemic accident models endeavor to regard the factors related to accidents as a whole and accidents will occur when some factors happen in a specific time and space. From such a perspective, the hierarchy of causal influences can be considered one of them. Therefore, the work by Hosseinian and Torghabeh [24] was built upon a solid theoretical foundation.
Application and modification of the Tripod Beta method for analyzing the causes of oil and gas industry accidents
Published in International Journal of Occupational Safety and Ergonomics, 2021
Omran Ahmadi, Seyyed Bagher Mortazavi, Hasan Asilian Mahabadi
The Tripod Beta analysis method is derived from the Tripod method, which is in turn based on the Swiss cheese model (Figure 1) [16]. This model, which was developed by Reason in 1990, suggests that an accident occurs as a result of a combination of errors and negligence at various levels of the organization. It is titled the Swiss cheese model because it represents failures as holes in slices of Swiss cheese. Some of these factors include failure in human activities in the workplace and other failures relating to management organizational factors. Organizational failures are the main factors in an accident that remain as latent factors in the system for a long time. These latent factors are always followed by technical and human errors (active error), which contribute to an accident [16]. In this model, there are several layers of barrier designed to minimize or prevent an error. This model is similar to the layers of the system, where each of these layers has holes indicating a failure in safety. The presence of a hole in a layer may cause a mishap because the other layers act as a protector. In contrast, if the holes of each layer are aligned together, an error occurs – indicating the absence of barriers for the prevention of error occurrence. Based on this model (Figure 1), accident causes are categorized into four levels: (a) organizational influences; (b) unsafe supervision; (c) preconditions for unsafe acts; (d) unsafe acts.