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The Swiss cheese model of adverse event occurrence--Closing the holes
1Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 100, Los Angeles, California 90027.
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.
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