The Swiss Cheese Chronicles promotes a shift from blaming individuals to understanding systemic causes of healthcare errors. Through a real pediatric medication near-miss, CAHO demonstrates how multiple vulnerabilities align to cause harm. Using RCA tools, Just Culture, and practical safety improvements, the initiative encourages healthcare teams to identify risks and strengthen patient safety.
Unpeeling the Layers: Inside the “SwissCheese Chronicles” and Healthcare’s Questfor Systemic Truth
