Reason’s Swiss Cheese Model of organizational accidents highlights the fact that a single error at the “sharp end” of the system is rarely enough to cause an accident. Instead, errors have to break through the multiple but inadequate safety barriers or “layers of Swiss cheese” in order to cause harm. Understanding the complexities of accident causation is fundamental to perform meaningful root cause analysis and develop effective patient safety and quality improvement strategies. Instead of trying to achieve perfect human behavior at the “sharp end” it is necessary to create multiple overlapping safety barriers or system defenses to reduce the likelihood of the “Swiss cheese holes” being aligned and letting an error slip through.
