How Holey is Your Cheese?

This week has been a very cheesy one. Unfortunately, not of an edible nature, but one grappling with the now infamous Swiss Cheese model. In 2000 in the book “Human Error” James Reason postulated that accidents happen due to failures, or 'holes' in many layers of an organisation and wider society - hence Swiss cheese

This model was further expanded in 2014 by Li and Thimbleby who suggested that the cheese was ‘hot’, thus introducing the concept of feedback loops into the model, with one layer affecting the other, and visa versa.

However, while both models go so far to define the nature of accidents in a system, they are both very simplified and do not fully articulate the very complex systems and connections that make up an NHS organisation. Arguably the complex nature of any organisation, its interactions and failure points are much more akin to a bubbling mass of fondue than any neatly ordered slice of Swiss cheese – melted or not.

In my research I will be employing Systems Dynamics mapping to try and untangle the cheesy, stringy mess that is the complex nature of the NHS to understand whether the built environment is having a significant impact on the number of accidents and incidents that are happening all to frequently.