Layers of Safety: Reason’s Swiss Cheese Model

How to talk to your patients about COVID-19 safety precuations

Throughout the COVID-19 pandemic, governments around the world have issued stay-at-home orders and mask mandates, and health organizations have launched communication campaigns in an attempt to increase compliance with preventive measures. Their success has been limited and variable. This is no surprise to physicians and other healthcare providers, many of whom have spent their careers trying to motivate their patients to adopt healthy behavior change.

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Navigating the sea of misinformation

“As healthcare providers, we take our role as educators and community partners very seriously,” says James Merlino, MD, Chief Clinical Transformation Officer at Cleveland Clinic. “There is a sea of information out there about COVID-19, and that the information can be difficult to interpret. Sometimes it’s just wrong.”

For this reason, Dr. Merlino and his Cleveland Clinic team of medical, safety, legal and communications experts have launched a new COVID-19 platform with guides for staying safe during COVID-19. Their work includes webinars with health and infectious disease experts, as well as more than a dozen playbooks (including some in Spanish and several UK-specific editions). Dr. Merlino believes this messaging can be helpful as healthcare providers speak with patients about the importance of precautions, such as mask wearing, hand hygiene and physical distancing.

Our message: Layers of safety

When messaging COVID-19 safety precautions to the public, Dr. Merlino’s team finds it helpful to refer to the Swiss Cheese Model posited by James Reason, PhD, in the 1990s. The model acknowledges that there are inherent risks in any communal setting. Most of the time these risks are never realized because safeguards are in place to prevent them. In Reason’s model, these safeguards are represented as multiple layers of Swiss cheese. Every process has “holes” that, under the right circumstances, can line up and lead to an error, accident or “hazard.”

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The COVID-19 pandemic requires multiple layers of prevention. Per Reason’s model, the more layers of effective interventions that are implemented, the less likely your patient will be to contribute to the spread of COVID-19.

For example, wearing face masks slows the spread of COVID-19; however, no mask is 100% effective. Physical distancing from non-household members is an effective way to reduce transmission of the virus, but may not always be possible. Cleaning and disinfection are extremely important, but it is impossible to keep a surface completely disinfected between cleanings. Frequent handwashing is essential to prevent the spread of the virus, but handwashing alone will not prevent transmission. While any one of these interventions is imperfect, when used in conjunction with a broader range of safety practices, the risk of COVID-19 transmission is significantly reduced.


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Reason’s model applied to COVID-19 precautions.


“There’s a lot of confusion out there about which practices are best. The reality is: every safety practice has pros and cons, and the evidence of their efficacy is sometimes weak. The Swiss Cheese Model has taught people in the military, airlines, healthcare and other industries that safety is not just about one thing. Safety is achieved by aligning many tactics for enhanced protection,” says Dr. Merlino.

“Now, more than ever, we need to maintain vigilance and find new ways to share the safety message. These safety practices need to be the new ‘normal’ until there’s an approved vaccine, with adequate supply and a solid distribution plan. As physicians, we need to be communicating these practices clearly and often,” Dr. Merlino concludes.