Duke University Case Study Links

The case study will require a one to two-page paper which summarizes the case and answers the questions which were asked.  Spelling and grammar count as well for these assignments.

Please review the following links which will provide you some background on what happened within the Duke University Health System and how it impacted the 3,800 patients.  Also look at Reason’s Swiss Cheese Model which this is an example of how when things line up how things can go bad.







Swiss Cheese Model Link



The questions for the case study are. 

  1. How would you feel if you or one of your family members was one of those surgical patients?
  2. Who do you find to be at fault the most in this case?
  3. Describe Reason’s Swiss Cheese Model and how it pertains to this issue.
  4. If you were the CEO of Duke Health System what would have done differently?




  • Provided a detail summary of the case.
  • Provided in depth responses to the assigned questions