The Swiss Cheese Model is a widely used framework for understanding and analyzing how errors can occur in complex systems, such as healthcare. The model was first proposed by James Reason, a British psychologist, and it has been used in many industries to identify and manage risks.
The Swiss Cheese Model consists of multiple layers of defense, each represented by a slice of Swiss cheese. Each layer has holes (potential weaknesses or errors), and the layers are not perfect, which means that some errors may pass through the holes in one or more layers, resulting in an adverse event.
In the context of healthcare, the Swiss Cheese Model can be used to illustrate how errors can occur at various stages of patient care, from diagnosis to treatment to follow-up. For example, a healthcare provider may make an error in prescribing medication (hole in one slice of cheese), which may not be caught by the pharmacist (hole in another slice of cheese), leading to the patient receiving the wrong medication and suffering harm.
Dr. Khalid Abulmajd
Healthcare Quality Consultant