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Wednesday / June 19.
HomemilastwordThe Last Word: The Swiss Cheese Model

The Last Word: The Swiss Cheese Model

At mivision we have strict editorial procedures to ensure mistakes don’t happen (well, as few as possible) but when they do, we discover it has more to do with human error and not sticking to our processes, than ‘the gremlins getting into the works’.

Have you heard of the Swiss Cheese model?

The Swiss Cheese model is a study of human processes and systems and used in the risk analysis and risk management of human systems in accidents. It was mooted by British psychologist James T. Reason in 1990 and has gained worldwide acceptance in healthcare, aviation safety, emergency organisations and now, in optical publishing.

The Swiss cheese model (or the Cumulative Act Effect as it’s sometimes called) studies individual weaknesses represented as holes in slices of Swiss cheese. The holes in the cheese represent the imperfections in individual safeguards or defences, which in the real world rarely approach the ideal of being completely foolproof against failure.

Our editorial processes, or our Swiss cheese slices are the reason why, after 44 issues, we have had to print very few corrections in mivision…

Sometimes the holes in the Swiss cheese line up and an error slips through the aligned holes.

Such was the case for us, with our Feb issue, the first issue of the New Year.

We were just about to print 7,500 copies of the magazine. It was 10pm, a time when we should be drifting off on the lounge in front of the telly, not looking at layouts. But there we were, scanning through layouts to upload to our new website, when we spotted an absolute clanger.

At the beginning of an article, right at the start, instead of the opening first few pars of copy; we reproduced our editorial instructions to the designer.

This error slipped past us all. It went through every slice of Swiss cheese in our system: our designer, our sub-editor, editor, all our staff – we all missed it. It was only sheer luck (or God) that saved us from monumental embarrassment!

The cost for us to fix that error was small compared to the embarrassment it would have caused for the writer, the organisation they represent and the mivision team. But we fixed it quick smart and were still able to come out on time.

Our editorial processes, or our Swiss cheese slices, are the reason why, after 44 issues, we have had to print very few corrections in mivision. We resource ourselves to ensure mistakes are reduced, however occasionally things go awry. And when they do, we know we need to tighten up our processes, or better still add additional layers of cheese.

Whether you’re a publisher, flying a plane or running an optometric or ophthalmic practice, it’s important to remember that the small holes in each slice of Swiss cheese can line up and this is how mistakes happen.

No matter how foolproof your quality procedures are, mistakes occur. By testing and updating your processes you will stand a better chance of the holes in the Swiss cheese not lining up.