PS 102 Lesson 1: The Swiss Cheese Model
Serious adverse events are almost always the result of multiple failed opportunities to stop a hazard from causing harm. James Reason, a psychology professor and one of the seminal thinkers in the field of human error, has called this idea the Swiss cheese model of accident causation. This lesson will describe the Swiss cheese model and how it should inform your thinking about error and harm in health care.
Estimated Time of Completion: 25 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Summarize the relationship between error and harm.
2. Describe the Swiss cheese model of accident causation.
3. Define latent error and its role in causing harm.
Contributors
Author(s):
Doug Bonacum, MBA, CSP, Vice President for Safety Management, Kaiser Permanente View Profile
Fran Griffin, RRT, MPA, RRT, MPA, Institute for Healthcare Improvement View Profile
Editor(s):
Laura Fink, Director, Editorial and Online Learning, Institute for Healthcare Improvement View Profile
Reviewer(s):
Frank Federico, RPh, Vice President, Senior Patient Safety Expert, Institute for Healthcare Improvement View Profile
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health View Profile
Requirements
You must be a registered IHI.org user to take this lesson.
You must achieve a minimum score of 75% to successfully complete this lesson.