Human error is an issue of concern in most fields, but in the health care field human error can be tragic. In 2000, James Reason’s Swiss Cheese Theory was published as a model of accident causation in risk analysis and risk management. The Swiss Cheese Theory was formed to focus on accidents in complex systems where many elements interact with each other. Each element is guided by its own set of rules and policies, but interacts with other elements to create a whole system. The Swiss Cheese Theory was developed to track accident causation in distinct levels of an organization without placing blame on individuals.
In Reason’s theory, each slice of Swiss cheese represents the safeguards of the system and the holes represent unsafe acts and latent conditions. One of the benefits of using this model is that it forces investigators to take into account latent failures within the causal sequence of events (Raheja & Escano, 2011). Reason’s theory proposes that the holes in each layer are not static and for an accident to occur each hole must line up through every defensive layer for an adverse event to take place.
A 2011 study was conducted by Taylor et al. to determine what factors were important determinants of the effectiveness of patient safety practice interventions. The panel determined that four features were important in determining the success of a patient safety practice: safety culture, teamwork and leadership involvement; structural organisational characteristics; external factors, and availabili