BMJ 2011; 343 doi: (Published 31 October 2011) Cite this as: BMJ 2011;343:d6812
  1. James A Heathcote, general practitioner, South View Lodge Surgery, South View, Bromley, UK
  1. jheathcote{at}

Late last year, I missed a message in our day book and failed to telephone a patient in trouble. Later that afternoon, he was admitted to hospital and two days later he died.

At one level this is a system failure and a classic example of James Reason’s “Swiss cheese model,” which suggests that a series of events must occur in a specific order and manner for an accident to occur. Reason describes individual failures as being like the holes in several unique pieces of Swiss cheese and the system as being like a stack of cheese slices. Each hole is an opportunity for a failure or accident to …

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