The Swiss cheese model of adverse event occurrence--Closing the holes.

Semin Pediatr Surg

Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, California 90027.

Published: December 2015

AI Article Synopsis

  • The traditional view in surgery tends to blame individual mistakes for errors and complications, rather than looking at the bigger picture.
  • Recent research in human factors has revealed that many errors in healthcare come from systemic issues, which can help us improve patient safety.
  • This article discusses how human factors science can be applied to enhance teamwork, improve surgical culture, reduce medical errors, and promote accountability among healthcare professionals.

Article Abstract

Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability.

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Source
http://dx.doi.org/10.1053/j.sempedsurg.2015.08.003DOI Listing

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