Invisible Gaps, Visible Harm: The Swiss Cheese Model in Dental Patient Safety- A Scoping Review.

Author

Dr. B. LakshmanaRao, Dr. M. Vaishnavi Devi , Dr. V. Dal Singh, Dr. D. Srikanth, Dr. Vikas Punia


Abstract

 Background: Patient safety has not been as systematically addressed in dentistry as it has in medicine, even though dental care involves many invasive procedures. James Reason's Swiss Cheese Model, originally developed to explain how organizational and human errors can lead to adverse events, is now widely used in healthcare to illustrate how mistakes can reach patients.

Objective: This review explains the theory behind the Swiss Cheese Model and connects its general 'layers of defence' to specific safety measures in dental and prosthodontic practice. It uses wrong-site tooth extraction as a practical example.

Discussion: The model describes active failures, which are unsafe actions during care, and latent conditions, which are weaknesses in systems like protocols and training, as 'holes' in protective layers. Harm happens only when these holes line up. In dentistry, these layers include steps like patient identification, consent, radiographic checks, site verification, safety checklists, clinical skills and supervision, sterilization, infection control, and post-operative review. The model's focus on looking back at errors and the different interpretations of them among safety experts is seen as limitations. 

Conclusion: The Swiss Cheese Model is still a useful tool for teaching and reflecting on dental patient safety. It works best when used as part of a broader approach focused on systems and resilience, not just as a simple checklist.



Keywords

Patient safety; Swiss cheese model; Human factors; Dental errors; Wrong-site tooth extraction; Systems approach.



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References


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