Reason's Swiss Cheese Theory

Reason's Swiss Cheese Theory is a representation of a model that was developed to analyze accidents or a failure in an organization's setting. This theory presents the argument that; failure within an organization is usually as result of a series of events occurring in particular manner (Perneger, 2005). Reason equates the slices of Swiss cheese to opportunity to stop the events while the holes at the center of the cheese represent opportunity for failure. When the cheese is arranged in layers, the holes are aligned allowing the problem to pass (Reason, 2000).

This model expresses the idea that, the small errors that are overlooked within an organization setting are the ones that accumulate and when aligned they result in accidents and failures. These accidents and failures in the health care organization can lead to serious results in detrimental effects like death of the patients.

Reason's Swiss cheese theory has widely been applied in the health care setting to eliminate the proliferation of errors that may result in failures such as loss of life. This model shows how small organizational errors can contribute to adverse outcome when not addressed in time (Gluck, 2008). Health care industry is a very sensitive industry where failures may result in loss of life or a lot of suffering to individuals. Therefore, failures should be avoided by any means possible. It has become vital for a health care organization to anticipate and prevent problems before they take place. James Reason's Swiss Cheese Theory supports this goal. The slices of cheese which are opportunities to prevent events that leads to failure. These events may be or refer to as:

1. good health care management practices (Reiling, Hughes & Murphy, 2009)

2. better facility design to suit the patient's needs (Reiling, Hughes & Murphy, 2009)

3. having the right personal and ensuring collaboration between professionals and patients (Reiling, Hughes & Murphy, 2009)

When the health care organization is fully equipped, has qualified practitioners, has been maintained in a good condition and there is effective communication errors are minimized which is corresponding to sealing the holes in the cheese. When the problematic events arise, the cheese slices becomes more effective in stopping the problem because there are steps that has been put in place previously to solve that issue.

According to reason there are two types of holes, these are opportunities for failures; active holes and latent holes (Reason, 2000). Latent holes are opportunities for failures that are always in existence with the organization. Examples of latent holes are unavailability of drugs and equipment, poor sanitation and negligence.

Active holes refer to opportunities for failures that occur leading to an accident when combined with the