• Shashi S Seshia, Bryan Young G G Clinical Neurological Sciences and Medicine (Critical Care), Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada, Gr, Michael Makhinson, Preston A Smith, Kent Stobart, and Pat Croskerry.
• Department of Pediatrics, University of Saskatchewan, Saskatoon, Canada.
• J Eval Clin Pract. 2018 Feb 1; 24 (1): 187-197.

IntroductionAlthough patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement.HypothesisA model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care.MethodsThematic analysis, qualitative information from several sources being used to support argumentation.DiscussionComplex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions.LimitationsThe concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect.ConclusionsThe proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.© 2017 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons, Ltd.

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