Fig. 2From: Errors in IVF laboratories: risks assessments and mitigationsReason’s Swiss Cheese Theory of Error [27]. The bars represent an organization’s defences against failures and the holes represent weaknesses in the defences. A patient experiences an adverse event only when all the holes in the defensive layers align to allow these errors trajectory to eventually reach the patient. These weaknesses in the clinic’s policy, planning, building design, and inter-departmental communication are responsible for the adverse event experienced by the patient.Back to article page