Reason's Swiss Cheese Model - Health

From  Perneger, T.V (2005). The Swiss cheese model of safety accidents: Are there holes in this metaphor? BMC Health Sciences Research, 5: 71 online here

Reason's Swiss Cheese model is often used to help organisations manage risk and errors in their operations.

All service organisations are to some extent managing risk. Service managers can learn from disasters and mistakes that occur in other businesses and organisations. Service organisations can also learn how important it is to have a culture of trust as an essential part of any safety culture.

The most common industry to hear about Reason's model is the airline industry as airlines understand safety culture and have highly developed techniques and processes for investigating air accidents so they can continuously improve safety in the airline industry more generally. They derived Reason's Swiss Cheese Model to explain accidents, and Reason's model is now widely used in other industries like health. Arguably all service industries need to have a safety culture in place and so can learn from the Swiss Cheese Model.

The Swiss Cheese analogy is pictured graphically above. Imagine a series of Swiss cheese slices lined up on top of each other. Each slice has a few holes in it. Each of the layers of the cheese represents some aspect of organisational practice. So for example, in a service industry like medicine (let's use the example of a hip replacement operation) where an error can cause catastrophic impact (death) then layers might represent screening patients, personnel factors, facility factors, and process factors. For a surgery screening factors could include checking patients are not allergic to medication and are healthy enough to cope with the operation, personnel factors would include aspects like proper staff training, facility factors might include appropriate equipment and cleanliness, and process factors would include triple checks that the person going into theater is, in fact, the correct person and is getting a hip operation. If the holes line up, then you may get an error. The aim of the service manager (or risk manager) is to ensure that the holes are as small as possible and that there are enough layers in the cheese that the holes have less likelihood of lining up.

It's really important to develop 'no blame' cultures in service organisations. Most airlines have a 'No blame' culture attached to any error that involves a safety issue. What this means is that if for example, a mechanic drops a screw into an engine, he or she should immediately report their mistake even if it means holding up a flight at the cost of hundreds of thousands of dollars. The mechanic has done the right thing and should not be punished or castigated for his or her error. In fact, this staff member should be celebrated as a 'Safety Champion' because his or her actions are to be encouraged, not discouraged (note the word 'courage' in encourage because this does take bravery).

The model represents the actual existence of unavoidable mistakes/errors in any process. Equipment will malfunction. People do make mistakes. Patients lie about their health. Surgeons have bad days. The idea is to manage and mitigate risk.