The Swiss Cheese Model for the Self

I’ve been through maybe a dozen hospital onboarding orientations over the years, and every single one spent a significant amount of time explaining something called The Swiss Cheese Model.

Hospitals care deeply about this and it’s not because they’re enlightened (trust me). It’s because complex systems become dangerous when people are afraid to report mistakes.

So they encourage reporting without punishment whenever possible. Near misses matter. Mistakes that never made it to the patient matter. Because if people feel safe enough to say, “Hey, this process sucks over here,” the system can improve before something catastrophic happens, and it does happen.

And honestly, if even today’s liability-driven, bottom-line-focused healthcare systems understand that punitive reporting leads to worse outcomes, why am I still running my inner world that way?

Because I do it all the time.

Instead, I just keep snapping at people while remaining strangely unconscious to the pattern.

If I snap at people when I’m rushed, maybe the actual solution is incredibly simple: get up ten minutes earlier, or stop attaching so much meaning to being late, or communicate differently…

But when every mistake becomes an indictment of my character, I stop examining the problem honestly. I avoid looking too closely because looking hurts.

And then nothing improves.

Have you ever avoided a chore for six months only to finally do it and realize it took five minutes? The suffering came less from the task itself and more from the mental resistance surrounding it. That’s what a lack of resilience often looks like.

Not the absence of pain.
The inability to look directly at the pain without turning it into self-destruction.

But it speaks more clearly in environments that feel safe enough to hear it.

Amy Dinaburg, Philosopher, Retired ER RN