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James Reason's Swiss Cheese Theory

Examine James Reasons' Swiss Cheese Theory and its application to quality and risk management, including patient safety, in a healthcare setting. What organizational influences would predispose an organization to the Swiss Cheese Theory? What strategies, or system approaches, would benefit an organization in preventing active and latent failures?

Solution Preview

The Swiss cheese model is frequently referred to and widely accepted by patient safety professionals in explaining the essence of safety culture of an organization and risk management. It explains the occurrence of system failures, such as medical mishaps. According to this theory, in a complex system, hazards are prevented from causing harm to patients by a series of barriers. Each barrier has unintended weaknesses, or holes similar to Swiss cheese. These weaknesses are inconstant, i.e., the holes open and close at random. When by chance all holes are aligned, the hazard reaches the patient and causes harm.

According to this theory every accident is the result of multiple and sometimes seemingly small and unrelated system failures. By themselves, none of ...

Solution Summary

This solution explains how James Reasons' Swiss Cheese Theory applies to quality and risk management in healthcare setting. In addition it discusses organizational influences and strategies effecting prevention of active and latent failures.

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