Swiss cheese model

Definition

The Swiss cheese model is a risk management framework used to analyze the causes of systemic failures or errors. It visualizes multiple layers of defense, each with potential weaknesses (holes), aligning to permit a hazard to pass through unchecked.

5 Must Know Facts For Your Next Test

1. Each layer in the Swiss cheese model represents a barrier or safeguard against error.
2. Holes in the 'cheese' symbolize weaknesses or gaps in each layer that can lead to failure if aligned.
3. In healthcare, this model helps identify how individual and systemic factors contribute to drug errors.
4. Effective risk management involves closing these 'holes' through improved protocols and safety measures.
5. The alignment of holes in all layers can result in a critical event or adverse outcome.

Review Questions

• What do the holes represent in the Swiss cheese model?
• How does the Swiss cheese model apply to preventing drug errors?
• Why is it important to have multiple layers of defense in risk management?

Related terms

Root Cause Analysis:

A method used to identify underlying reasons for errors or adverse events.

Human Factors Engineering: A field focused on designing systems that accommodate human limitations and strengths.

Adverse Event: An incident that results in harm to a patient, often preventable through effective safeguards.