Table 1 |
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Interpretation of the Swiss cheese model of medical error by 85 professionals who claimed to be fairly or very familiar with the model. |
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Compatibility with Swiss cheese model |
N (%) endorsing statement |
Percent "correct" answers |
|
|
|
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In your opinion, what does a slice of cheese represent? |
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A health care professional |
Sometimes3 |
14 (16.5) |
- |
|
A barrier that protects patients from harm |
yes |
61 (71.8) |
71.8 |
|
A root cause of an error |
no |
9 (10.6) |
89.4 |
|
A procedure that alleviates the consequences of an error |
yes |
14 (16.5) |
16.5 |
|
A defence that prevents the occurrence of an error |
yes |
52 (61.2) |
61.2 |
|
|
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In your opinion, what does a hole represent? |
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|
A latent error1 |
yes |
28 (32.9) |
32.9 |
|
A loss (in terms of health or money) due to an error |
no |
5 (5.9) |
94.1 |
|
An opportunity for error |
yes |
53 (62.4) |
62.4 |
|
A weakness in defences against error |
yes |
54 (63.5) |
63.5 |
|
An unsafe act |
yes |
17 (20.0) |
20.0 |
|
|
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What does the arrow represent? |
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The patient's trajectory through the health care system |
no |
29 (34.1) |
65.9 |
|
A transfer of energy that injures a patient |
no |
2 (2.4) |
97.6 |
|
The transformation of a latent error1 into an active error2 |
no |
24 (28.2) |
71.8 |
|
The series of events leading to a medical error |
Sometimes4 |
51 (60.0) |
- |
|
The path from hazard to patient harm |
yes |
41 (48.2) |
48.2 |
|
|
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How or where is an active error represented on this figure? |
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|
At the base (origin) of the arrow |
no |
10 (11.8) |
88.2 |
|
At the tip of the arrow |
no |
24 (28.2) |
71.8 |
|
As one of the holes |
yes |
26 (30.6) |
30.6 |
|
As the arrow itself |
no |
24 (28.2) |
71.8 |
|
As the alignment of holes |
no |
28 (32.9) |
67.1 |
|
|
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How can we make the health care system safer, using the "Swiss cheese" metaphor? |
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|
By adding a slice of cheese |
yes |
27 (31.8) |
31.8 |
|
By removing a slice of cheese |
no |
6 (7.1) |
92.9 |
|
By plugging a hole |
yes |
76 (89.4) |
89.4 |
|
By adding a hole |
no |
1 (1.2) |
98.8 |
|
By making all slices thinner |
no |
6 (7.1) |
92.9 |
|
|
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1 Latent error: Failure of system design that increases the probability of harmful events. Loosely equivalent to causal factor or contributing factor. 2 Active error: Error (of commission or omission) committed at the interface between a human and a complex system. 3 A professional whose role is to make the process of care safer may be thought of as a protective barrier 4 This would be true if the error equates with patient harm, as in the case of wrong site surgery |
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Perneger BMC Health Services Research 2005 5:71 doi:10.1186/1472-6963-5-71 |
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