Swiss cheese model
Patient Safety
Definition. The Swiss cheese model describes accidents as the result of holes in several layers of defence lining up, so that a hazard passes through all barriers and causes harm.
Explanation
Reason proposed that each defensive layer, such as training, procedures, technology and supervision, has weaknesses created by active failures and latent conditions (Reason, 2000). Harm occurs only when these weaknesses coincide.
The model remains one of the most cited frameworks in patient safety and risk management, although reviews note that it is often used as a metaphor rather than an analytical method (Shabani et al., 2024). Systems approaches such as STAMP were developed partly to capture interactions that the linear layer image misses.
Related concepts
Medical error Human factors Root cause analysis (RCA) STAMP and STPA Adverse event
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References
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768–770. https://doi.org/10.1136/bmj.320.7237.768
Shabani, T., Jerie, S., & Shabani, T. (2024). A comprehensive review of the Swiss cheese model in risk management. Safety in Extreme Environments, 6 (1), 43–57. https://doi.org/10.1007/s42797-023-00091-7
Cite this entry: Kurutkan, M. N. (2026). Swiss cheese model. In The Health Topics glossary. https://healthtopic.org/glossary/swiss-cheese-model/
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