Table 1 Interpretation of the Swiss cheese model of medical error by 85 professionals who claimed to be fairly or very familiar with the model.
From: The Swiss cheese model of safety incidents: are there holes in the metaphor?
Compatibility with Swiss cheese model | N (%) endorsing statement | Percent "correct" answers | |
|---|---|---|---|
In your opinion, what does a slice of cheese represent? | |||
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 |
In your opinion, what does a hole represent? | |||
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 |
What does the arrow represent? | |||
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 |
How or where is an active error represented on this figure? | |||
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 |
How can we make the health care system safer, using the "Swiss cheese" metaphor? | |||
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 |