A Slice of Safety: What National Sandwich Month Can Teach Us About Patient Care

August is National Sandwich Month, a time to celebrate all things layered, flavorful, and well-constructed. According to Nationaltoday.com, in 1762, the first sandwich was popularized in England by John Montagu, the 4th Earl of Sandwich. He wanted something he could eat with one hand while playing in a major gambling match with the other. 

But did you know that the humble sandwich—especially one stacked with Swiss cheese—can serve as a powerful metaphor for safety in healthcare? 

The Swiss Cheese Model, widely used in healthcare quality improvement, uses the image of slices of Swiss cheese stacked together to represent the layers of defense that exist to prevent harm to patients. Each slice is a barrier represented by policies, procedures, teamwork, or training. But as we know, Swiss cheese has holes. When those holes align, whether due to system weaknesses, human error, or environmental factors, errors can slip through, sometimes with serious consequences (Reason, 2000; Agency for Healthcare Research and Quality [AHRQ], n.d.).

So, while you’re enjoying your favorite sandwich this month, let’s explore how this “cheesy” model can help nurses improve safety, recognize near misses, and respond proactively to sentinel events.

Swiss Cheese

Understanding the Swiss Cheese Model in Healthcare

Developed by psychologist James Reason, the Swiss Cheese Model illustrates how adverse events occur not from a single failure, but from a series of minor missteps or system weaknesses (Reason, 2000). Each barrier to harm has potential flaws—holes—and when those holes line up, it allows a hazard to pass through all layers and cause harm.

In nursing, these layers might include:

• Standard protocols (e.g., medication administration policies)

• Technology safeguards (e.g., barcode scanning)

• Communication practices (e.g., SBAR handoffs)

• Staff education and training (e.g., new equipment training)

• Team collaboration and leadership oversight (e.g., Blame Culture)

Nurses are on the frontlines of all these layers. When systems function correctly, errors are identified and corrected before they reach the patient. But when systems fail—when the holes align—harm can occur (AHRQ, n.d.).

From Near Misses to Sentinel Events: Why Evaluation Matters

A near miss is like almost taking a bite of a sandwich with something spoiled inside; thankfully, someone caught it just in time. These events are critical learning opportunities. They demonstrate where a layer of safety was effective, but also reveal where another layer may have failed (AHRQ, 2024).

On the other hand, sentinel events are the worst-case scenarios, the errors that made it through all the layers. These moments demand urgent, thoughtful analysis, not blame, but systems thinking (Joint Commission, 2025).

Nurses can use the Swiss Cheese Model to:

• Reflect on system weaknesses when something goes wrong.

• Ask critical questions about where the process broke down.

• Work collaboratively with interdisciplinary teams to strengthen barriers.

• Participate in root cause analyses with a mindset of learning, not punishment (Institute for Healthcare Improvement [IHI], n.d.).

• Contribute to continuous quality improvement (CQI) efforts that make care safer for everyone (Hughes, 2008).

How Nurses Can Strengthen the Layers

Just like every sandwich is built slice by slice, strong healthcare systems are built one layer at a time, and nurses are central to every step.

Here’s how nurses can contribute to a “well-layered” system:

• Report near misses without fear: These are golden opportunities for learning and improvement.

• Engage in safety huddles and CQI initiatives: Your voice matters.

• Double-check processes and follow protocols: Redundancy is not inefficiency—it’s a matter of safety.

• Support a culture of transparency and teamwork: Psychological safety strengthens every layer of the organization.

• Educate new nurses and students: Passing on safety knowledge helps build resilient teams.

Closing Bite: Your Role in Making Healthcare Safer

So, as you enjoy your sandwich this month—perhaps one with Swiss cheese—take a moment to reflect on the layers you help hold together every day in your nursing practice. You are a vital piece of the safety puzzle. Each time you speak up, double-check, or advocate for a patient, you’re helping to keep the holes from lining up.

Let’s continue to build a healthcare system where the layers are solid, the gaps are closed, and safety is always the first ingredient.

What are your thoughts on the Swiss Cheese Model? Have you witnessed a near miss or an improvement that made your unit safer? Share your experience in the comments—we learn best when we learn together.

References

Agency for Healthcare Research and Quality. (n.d.). Swiss cheese model. Patient Safety Network. Retrieved July 16, 2025. https://psnet.ahrq.gov/glossary-0#glossary-heading-term-73837

Agency for Healthcare Research and Quality. (2024). Adverse events, near misses, and errors. Patient Safety Network. https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors

Hughes, R.G., editor. Patient safety and quality: An evidence-based handbook for nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2651/

Institute for Healthcare Improvement. (n.d.). RCA2: Improving root cause analyses and actions to prevent harm. Retrieved July 16, 2025, from https://www.ihi.org/library/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm

Joint Commission. (2025). Sentinel event. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768–770. https://doi.org/10.1136/bmj.320.7237.768