The Swiss Cheese Model

What is James Reason’s Swiss Cheese Model showing layered defences with holes to explain human error and accident causation with a covid coronavirus pandemic example. A core safety model used in healthcare, NHS patient safety, and aviation, illustrating how aligned weaknesses can lead to failure.

Prints
Copied!

👇 Get new sketches each week

The Swiss Cheese Model helps explain why, despite all our best intentions, accidents happen.

Analysis of accidents in large complex systems such as power stations or plane crashes led to an understanding that "no one failure, human or technical, is sufficient to cause an accident. Rather, it involves the unlikely and often unforeseeable conjunction of several contributing factors arising from different levels of the system."

James Reason's Swiss Cheese Model is a memorable visual metaphor that illustrates how each safeguard may contain a latent flaw or hole and that an unfortunate circumstance may result in these holes lining up to disastrous effect. It's also a nice reminder that multiple layers of defence will be more effective, but even with our best efforts, there's still potential for something to go wrong.

Excerpt from Revisiting the "Swiss Cheese" Model of Accidents (pdf), Reason, Hollnagel and Paries, 2006.

Coronavirus example from the Cleveland Clinic .

I learned recently that it's sometimes called the "cumulative act effect".

This sketch, updated and polished, features with a number of others in my book Big Ideas Little Pictures.

Also see:

Published 3 Oct 2020

Get the book!

Big Ideas Little Pictures

Prefer to listen?

Try the podcast

🎉 Help keep Sketchplanations ad-free 🎉 Keep this ad-free 🎉 Help keep Sketchplanations ad-free by supporting me

Keep exploring

Detecting prostate cancer summary - how screening for prostate cancer has changed DRA, PSA blood test and MRI screening compared in the old way and new way

Detecting prostate cancer: old way, new way

Catch drilling dust with a Post it

Normalisation of deviance: A person looks dubiously on at a building site which seems to be ignoring all the safety signs.
(Normalization of deviance)

The Normalisation of Deviance

Don't Think of an Elephant

Anamorphosis

Yak shaving

1 in 8 men in the UK get prostate cancer, according to the charity Prostate Cancer UK, and the risk of prostate cancer doubles if you're black. It's also the second most common cause of death from cancer for men in the UK, after lung cancer. Prostate cancer is not always life-threatening, but an early diagnosis can be life-saving. So, for Men's Health Week 2024, I worked with experts at Prostate Cancer UK to visualise how screening for and diagnosing prostate cancer has changed. In short, it's more accurate and safer than before and needn't rely on a chance conversation to trigger a discussion—you can do a 30s online check for your prostate cancer risk on the Prostate Cancer UK website right now. The new way has reduced reliance on the imperfect DRE (digital rectal examination—the test that might come to mind for many). After a suspicious PSA blood test result, you can be referred for a pre-biopsy MRI scan. Clinical trials show that pre-biopsy MRI triage can rule out 27% of men from having an unnecessary biopsy (a biopsy is when a doctor removes some cells for analysis). Biopsies have also improved and can now be guided by imaging, allowing doctors to identify the areas of the prostate they need to biopsy. It makes it safer and has fewer side effects. These changes, together, mean fewer unnecessary biopsies and diagnoses that find a higher proportion of clinically significant cancers over clinically insignificant cancers (which may not require treatment), meaning fewer men are at risk of harm from the screening. Rob Bell, host of the Sketchplanations podcast among many other talents, is an ambassador for Prostate Cancer UK, which supports our "dads, brothers, partners and friends by raising awareness, funding life-changing research, campaigning for change and providing much-needed support." Rob made the connection (this isn't a paid promotion), and you'll hear our discussion with Amy Rylance, Assistant Director of Health Improvement, on how screening has changed in this week's podcast. Medical research and knowledge is always changing. This sketch has been checked by the team at Prostate Cancer UK based on research. See, for example, the article Fewer Men Face Harm in Prostate Cancer Diagnosis. It's intended to raise awareness, help early diagnosis now or in the future for men reading this, and maybe even save a life. If you have feedback or comments on it, please do write to me: jono.hey@gmail.com Didn't know when Men's Health Week was? I learned that International Men's Health Week is the week preceding and including Father's Day. Don't forget, you (or someone you know or love) can do a 30s online prostate cancer risk check online now. Aside from helping your father avoid prostate cancer, he might like a copy of Big Ideas Little Pictures. Also see: The Swiss Cheese model Dracula sneeze Reference: Most common causes of cancer death1 in 8 men in the UK get prostate cancer, according to the charity Prostate Cancer UK, and the risk of prostate cancer doubles if you're black. It's also the second most common cause of death from cancer for men in the UK, after lung cancer. Prostate cancer is not always life-threatening, but an early diagnosis can be life-saving. So, for Men's Health Week 2024, I worked with experts at Prostate Cancer UK to visualise how screening for and diagnosing prostate cancer has changed. In short, it's more accurate and safer than before and needn't rely on a chance conversation to trigger a discussion—you can do a 30s online check for your prostate cancer risk on the Prostate Cancer UK website right now. The new way has reduced reliance on the imperfect DRE (digital rectal examination—the test that might come to mind for many). After a suspicious PSA blood test result, you can be referred for a pre-biopsy MRI scan. Clinical trials show that pre-biopsy MRI triage can rule out 27% of men from having an unnecessary biopsy (a biopsy is when a doctor removes some cells for analysis). Biopsies have also improved and can now be guided by imaging, allowing doctors to identify the areas of the prostate they need to biopsy. It makes it safer and has fewer side effects. These changes, together, mean fewer unnecessary biopsies and diagnoses that find a higher proportion of clinically significant cancers over clinically insignificant cancers (which may not require treatment), meaning fewer men are at risk of harm from the screening. Rob Bell, host of the Sketchplanations podcast among many other talents, is an ambassador for Prostate Cancer UK, which supports our "dads, brothers, partners and friends by raising awareness, funding life-changing research, campaigning for change and providing much-needed support." Rob made the connection (this isn't a paid promotion), and you'll hear our discussion with Amy Rylance, Assistant Director of Health Improvement, on how screening has changed in this week's podcast. Medical research and knowledge is always changing. This sketch has been checked by the team at Prostate Cancer UK based on research. See, for example, the article Fewer Men Face Harm in Prostate Cancer Diagnosis. It's intended to raise awareness, help early diagnosis now or in the future for men reading this, and maybe even save a life. If you have feedback or comments on it, please do write to me: jono.hey@gmail.com Didn't know when Men's Health Week was? I learned that International Men's Health Week is the week preceding and including Father's Day. Don't forget, you (or someone you know or love) can do a 30s online prostate cancer risk check online now. Aside from helping your father avoid prostate cancer, he might like a copy of Big Ideas Little Pictures. Also see: The Swiss Cheese model Dracula sneeze Reference: Most common causes of cancer death

Newer

RRandom

Older

As an Amazon Associate I earn from qualifying purchases.