Medical errors are among the well known contributors of morbidity and mortality. Efforts have been going on for very long time to understand, explain and reduce the possibility or incidence of the errors.
Error has been variously defined as “something incorrectly done through ignorance”, “transgression of law or duty”, “acting differently from how he/she should have” etc. Ultimately it implies something that should not be or should not have been done, has been done with either by “omission or commission”. At the common level, human errors have resulted in the development of “shame and blame” culture. Unfortunately, this approach has not been found to be useful in either properly understanding the “anatomy of error” or in developing mechanisms for reducing them.
Swiss Cheese model was developed by Dr James Reason.
Swiss cheese is made up of layers of cheese. Imagine the effects of holes
a) in the corresponding points in all of them and
b)in non corresponding points.
In the former example it is easy to pass an object, say an arrow, as shown in the picture where as it is more difficult in the latter situations.
Similarly a health care delivery system is considered as multilayered, each provided by different subunits or people. Each system, or subsystem is naturally prone to have its own set of weak areas, of varying degrees.