This article reflects the conversations in the breakout group on this topic at the Recently Appointed Consultants symposium on Friday 13 March 2015.


When a critical incident occurs it is very easy to try to attribute the blame to one person and this is often the tendency, rather than addressing the composite factors involved. Try to see the bigger picture, as there may be a wide range of human factors interwoven in each incident. It can be complex to understand these factors and to address the key elements involved.

Draw up a timeline of events and use a model to help break down the multiple factors. Using a model can help identify the right aspects to address.

Suggested models include:

SHELL model
Software: Look at protocols. Are the correct systems in place?
Hardware: Are adequate instruments and resources available?
Environment: What was the context of the occurrence?
Liveware: Look at the team as a whole and whether sufficient communication was in play.
Liveware: Look at the individual people involved. This may involve looking at the responsibilities of the leader in the situation. Realising human fallibility in an objective way from a personal point of view is important.

Swiss cheese model
This model looks at the layers of defence that are available against incidents occurring. It likens each involved facet to a series to multiple slices of Swiss cheese stacked together. Each layer relates to different factor. The holes relate to different areas of weakness in each defence layer. The aim is to learn ways to block any holes that may align in the Swiss cheese, allowing the possibility of a critical incident.  

Debrief sessions should follow after examination of critical incidents, in order to discuss the situation and optimise modifiable factors.

Do not underestimate the need to emotionally offload or debrief also, even in a situation where you think this is not a factor. Choose a trusted friend, mentor, or your own GP.  It is very important that you keep the emotional aspect separate from the fact-finding efforts outlined above.  See also “Looking after ourselves and our colleagues” and “Listening and learning from feedback and complaints”

Further resources:
Criticism, Concerns and Complaints during COVID. RCPE Education Portal (login and access codes required)

Breakout group leader: Dr Michael Moneypenny, Centre Director, Scottish Centre for Simulation and Clinical Human Factors

Reviewed January 2018, final paragraph & links added September 2021.