ArticleJournal of evaluation in clinical practice2018
Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety.
Article in Journal of evaluation in clinical practice, 2018. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 17 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
17 citing papers in PubMed, 45 citations in OpenAlex.
- Implementation of Simulation-Based Technology to Promote Safety in the Nursing Handover in the Intensive Care Unit.Journal of clinical nursing · 2026Article
- Florence Nightingale's Contemporary Legacy for Patient Safety: Implications for Nursing and Public Health.Nursing inquiry · 2026Article
- Supporting Sound Reasoning in Patient Safety: Mental Models.Journal of general internal medicine · 2026Article
- Leveraging community engagement and human-centered design to develop multilevel implementation strategies to enhance adoption of a health equity intervention.Implementation science communications · 2025Article
- Biosecurity perceptions among Ontario horse owners during the COVID-19 pandemic.Equine veterinary journal · 2025Article
- Fall risk factors and mitigation strategies for hematological malignancy patients: insights from a qualitative study using the reason model.Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer · 2025Article
- Influencing factors of sports tourism safety accidents in Tibet, China: fsQCA analysis based on the SCM.PloS one · 2025Article
- Mapping Strategies for Strengthening Safety Culture: A Scoping Review.Healthcare (Basel, Switzerland) · 2024Article
- Experiences and perceptions of final-year nursing students of using a chatbot in a simulated emergency situation: A qualitative study.Journal of nursing management · 2022Article
- Sustaining University Operations During the COVID-19 Pandemic.Disaster medicine and public health preparedness · 2022Article
- Clinical reasoning in dire times. Analysis of cognitive biases in clinical cases during the COVID-19 pandemic.Internal and emergency medicine · 2022Article
- Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines.World journal of surgery · 2022Article
- Nurses' perceptions of fall risk factors and fall prevention strategies in acute care settings in Saudi Arabia.Nursing open · 2022Article
- Implicit bias in healthcare: clinical practice, research and decision making.Future healthcare journal · 2021Article
- "Incident Teaching (IT)" Lecture Series - Incorporating Education Surrounding Clinical Incidents and Complaints into Foundation Year 1 (FY1) Doctors' Induction.Journal of European CME · 2021Article
- The Delicate Dance of Teaching Rounds.Medical science educator · 2019Article
- Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety.Journal of evaluation in clinical practice · 2018Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
6 authors at 5 institutions in 2 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
introductionAlthough patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement. HYPOTHESIS: A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care.
methodsThematic analysis, qualitative information from several sources being used to support argumentation. DISCUSSION: Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions. LIMITATIONS: The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect.
conclusionsThe proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.