What Causes Errors
Swiss Cheese Model
Quality Improvement/Patient Safety SBMR
Tuesday, Jan. 26th, 7:30-8am
UMMCH 6th floor conference room
All Pediatric residents and fellows are encouraged to attend!
Morning report calendar can be found here:
Swiss Cheese Model
2 types of failures
For more information:
· Reason, James. "Human error: models and management." Bmj 320.7237 (2000): 768-770.
· Perneger, Thomas V. "The Swiss cheese model of safety incidents: are there holes in the metaphor?." BMC health services research 5.1 (2005): 71.
· Jeffs, Lianne, et al. "Learning from near misses: from quick fixes to closing off the Swiss-cheese holes." BMJ quality & safety (2012): bmjqs-2011.
· Li Y, Thumbleby J. "Hot cheese: a processed Swiss cheese model." JR Coll Physicians Edinb44 (2014): 116-21. [This is a critique of SCM, proposing a modification called Hot Cheese Model J]
· Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999:1.
· Warrick, Catherine, et al. "Diagnostic error in children presenting with acute medical illness to a community hospital." International Journal for Quality in Health Care 26.5 (2014): 538-546. [Application of SCM in a UK community hospital]
· Veazie, Peter J. "An individual-based framework for the study of medical error."International Journal for Quality in Health Care 18.4 (2006): 314-319.
· Moloney, J. "Error modelling in anaesthesia: slices of Swiss cheese or shavings of Parmesan." British journal of anaesthesia (2014): aeu223.
· Vioque, Sandra M., et al. "Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology."The American Journal of Surgery (2014).
· This article applied the SCM to analysis in an adult patient: Offredy, Maxine, Martin Rhodes, and Yvonne Doyle. "The anatomy, physiology and pathogenesis of a significant untoward incident." Quality in primary care 17.6 (2009): 415-421.
· Reinertsen, James L. "Let's talk about error." Bmj 320.7237 (2000): 730.
IHI Open School Academy Patient Safety 100: Introduction to Patient Safety.
www.ihi.org, go to IHI Open School under the education tab
**Free to trainees**
[i] Runciman, William, et al. "Towards an International Classification for Patient Safety: key concepts and terms." International Journal for Quality in Health Care 21.1 (2009): 18-26.
[ii] Reason, James. "Human error: models and management." Bmj 320.7237 (2000): 768-770.
[iii] Moloney, J. "Error modelling in anaesthesia: slices of Swiss cheese or shavings of Parmesan." British journal of anaesthesia (2014): aeu223.
[iv] Chang, Andrew, et al. "The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events." International Journal for Quality in Health Care 17.2 (2005): 95-105.