title: The Swiss cheese model of adverse event occurrence--Closing the holes.
abstract: Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability.
authors.affiliation: Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, California 90027. Electronic address: jstein@chla.usc.edu.
authors.forename: James E
authors.initials: JE
authors.lastname: Stein
authors.affiliation: Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, California 90027.
authors.forename: Kurt
authors.initials: K
authors.lastname: Heiss
mesh_terms: D006804:Ergonomics; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D008962:Models, Theoretical; D015279:Organizational Culture; D010348:Patient Care Team / Q000458:organization & administration; D061214:Patient Safety / Q000592:standards*; D010372:Pediatrics / Q000458:organization & administration / Q000592:standards*; D012941:Social Responsibility; D013043:Specialties, Surgical / Q000458:organization & administration / Q000592:standards*
keywords: Crew resource management; Human factors; Medical error; Patient safety; Pediatric surgery