tag:blogger.com,1999:blog-23445755.post5744654366325340589..comments2008-07-21T21:27:25.605+08:00Edwardhttp://www.blogger.com/profile/16020445581810054798noreply@blogger.comBlogger2125tag:blogger.com,1999:blog-23445755.post-33928103332196364952008-07-21T21:27:00.000+08:002008-07-21T21:27:00.000+08:00Grant,<BR/><BR/>Thanks for the swiss cheese analogy. I think I've heard it before, and I think it takes a little too much emphasis off the individual making decisions.<BR/><BR/>Quite often (if you read the medical defense magazines) there is a narrative / litany of cascading events. Though perhaps it is in their interest to make it seem this way, so the paranoid medico happily pays his / her ever increasing subscriptions on time. . .Edwardhttp://www.blogger.com/profile/16020445581810054798noreply@blogger.comtag:blogger.com,1999:blog-23445755.post-16071035443255108512008-07-21T09:48:00.000+08:002008-07-21T09:48:00.000+08:00perhaps a more foodie analogy is known as "The Swiss Cheese Phenomenon" ... it's actually a pretty poor analogy as i've never been able to see through a block of swiss cheese!<BR/><BR/>quote:<BR/><BR/>James Reason proposed the image of "Swiss cheese" to explain the occurrence of system failures, such as medical mishaps [1-5]. According to this metaphor, in a complex system, hazards are prevented from causing human losses by a series of barriers. Each barrier has unintended weaknesses, or holes – hence the similarity with 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 ). This model draws attention to the health care system, as opposed to the individual, and to randomness, as opposed to deliberate action, in the occurrence of medical errors.<BR/><BR/>full text: http://www.biomedcentral.com/1472-6963/5/71Shlog Bloggerhttp://www.blogger.com/profile/09638453568902227581noreply@blogger.com