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. 2015 Dec;24(6):278-82.
doi: 10.1053/j.sempedsurg.2015.08.003.

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

James E Stein  1 , Kurt Heiss  2
Affiliations

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

James E Stein et al. Semin Pediatr Surg. 2015 Dec.

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.

Keywords: Crew resource management; Human factors; Medical error; Patient safety; Pediatric surgery.

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