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The Swiss Cheese Model – Ways to Avoid Mistakes in Hospitals

Submitted by on August 2, 2012 – 6:57 AM

Human nature is to make errors and doctors are no exceptions. In fact, hospitals are probably the only places, where slip-ups are frequently common. But, it is again in hospitals only, where even a slightest mistake, can lead to a hazardous result. Patients, doctors and the staff- Indispensible elements of this triangle, when once tilt from either angle can disrupt the normal function of the entire system.

A doctor is always actively involved in all the aspects of management and in case of a mishap, the patient bears the burnt. Hence, it is our ethical responsibility that we must assure the safety of our patients first. We should always stay forefront to learn and improve ourselves and ensure the well being of the system.

Forgetting to check the blood glucose level of a post-op patient after being transferred from the recovery room is fairly common. Missing to send the daily morning blood sample of a patient on dialysis is also well known to doctor. Such minor errors occur across the hospitals worldwide. The problem is that it’s not just a matter of good or bad memory, but it signifies the erroneous ways of running the system. This eventually leads to a series of false interpretations and decisions which are taken at some instances later on.


This pattern is representative of The Swiss cheese model. It is described as a working environment where one accidental mistake made by someone leads to another error. It leads to malfunctioning of the entire working chain leaving the patient to suffer in the end.


Reasons and Recommendations:  

Doctors are required to work tirelessly and their performance affects the staff and the rest of the medical team. So, it is of utmost importance to know that being in a medical profession is not just merely a business. It comes with immense responsibility, and requires traits of honesty. My emphasis is on the doctors since I am one of them. I accept that many a times I have made mistakes but thankfully, it has never led to any disastrous outcome.


Based on the above mentioned experiences, I have realized now, that practicing medicine ought not to be taken casually and expectedly in spite of the long working shifts and tiring duty hours. There is always that one nagging patient’s relative who irritates. It happens regularly in the daily practice in hospitals, particularly in the state run hospitals. But our one slack can actually be responsible for some one’s death. Individually, we all must strive to do our job as earnestly as possible and same holds true for any other working member of the hospital. Here are few tips that we should learn by heart:

1. When transferring your responsibilities to another physician, complete all your tasks before handing over to the incoming doctor.

2. Never ever skip a full history and examination of a patient. Clerking a patient is a skill that every doctor must master. Never just assume a visibly well appearing patient to be completely healthy. Sometimes, an abdomen exam only reveals the diagnosis on its own.

3. If slightly unsure about anything- never hesitate to ask a senior, however, how late it may be. It’s an error which is almost inexcusable. Of course, no one knows everything, so it helps a wonder, if you just make that call to your senior and confirm it.



4. Always pay heed to what your staff has to say about the patient. Since they are the ones in constant touch with your patient most of the times and know them better than you do. Therefore, you will be surprised how helpful it is to ask just about anything from the dosage to diagnosis from them.

5. Since, our workplace is intricate and decisions about patients’ treatment are intimate. As a team we share this unsaid trust, that helps us work better and rather without any fear. It is thus, imperative to be cordial to each other and treat your juniors, seniors and your staff with due respect. It helps to also bring in a box of chocolates too, grab a cup of coffee sometimes, at work. Or just greet with a smile!

6. Never ignore any complaint from the patient, as trivial as it seems. Nothing is unimportant when they are admitted under your care. Explain, reassure and comfort them. Work on your interacting skills with them. They are not just your patients or bed numbers. They like to be addressed with warmth, like they matter to you. It is amazing, how kind words can psychologically heal them and improve their well being. Besides, they are always the ones to praise you in front of your consultants. Being friendly with them is a very good idea.


7. Last but not the least, always be ready to learn and improve yourselves. Mistakes are inevitable, but rectifying them is our duty and learning from your experiences is in our hands. To have a humble and adaptive approach to education and work, helps create a healthy mind and not just a healthy body.




To sum up, it is okay to be make mistakes but it is important to rectify them. Open up and do your best. Relax on when you are off and return to work with fresh mind.  Enjoy your work. It is only then, a healthy working ambiance shall produce an effective and efficient working bodies.


About the Author: Dr. Quratulain Qureshi is a graduate from Dow University of Health Sciences, Karachi, Pakistan and currently working in the United Kingdom (UK). She aspires to be a surgeon. She has been actively involved in various medical relief camps in the various parts of Pakistan during unrest and natural disasters. She  has also led vaccination teams for polio vaccine campaigns and blood donation camps. She can be reached at: [email protected]


About this article: This article is competing for the JPMS International Medical Writing Contest 2012 for the theme: Learning from medical errors. To learn more about the contest and to participate in it, follow this link:


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