Dr reason swiss cheese
- •
Swiss cheese model
Model used in risk analysis
The Swiss cheese model of accident causation is a model used in risk analysis and risk management. It likens human systems to multiple slices of Swiss cheese, which has randomly placed and sized holes in each slice, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses which are "layered" behind each other. Therefore, in theory, lapses and weaknesses in one defense do not allow a risk to materialize (e.g. a hole in each slice in the stack aligning with holes in all other slices), since other defenses also exist (e.g. other slices of cheese), to prevent a single point of failure.
The model was originally formally propounded by James T. Reason of the University of Manchester,[1] and has since gained widespread acceptance. It is sometimes called the "cumulative act effect". Applications include aviation safety, engineering, healthcare, emergency service organizations, and as the principle behind layered security, as used in computer security a
- •
James Reason
Professor on Human Error
Ingredients of heroic recovery
Professor James Reason is recognised as a world leading expert on human error, with a distinguished career spanning industry, healthcare and academia. He is a graduate of the University of Manchester and held the position of Professor of Psychology from 1977 to 2001. He has written books on absent- mindedness, human error, aviation human factors and managing the risks of organisational accidents. His book, Human Error, is one of the pre-eminent books on the subject. He is Fellow of the British Psychological Society, the Royal Aeronautical Society, the British Academy and an Honorary Fellow of the Royal College of General Practitioners. He was a member of the Chief Medical Officer's expert group 'An Organisation with a Memory' and is a recipient of the Distinguished Foreign Colleague Award from the United States Human Factors and Ergonomics Society. In 2003, he was appointed Commander of the British Empire for services toward reducing risk in healthcare.Professor James Reason is recognised as
- •
Human Error
The book starts with some history. In the early twentieth century Freud was pondering on apparent slips and “accidents” having a basis in the subconscious. I suppose according to Freud, if someone made a slip in dispensing medication it would be because they had some deep seated dislike of a patient, or harboured unconscious opinions about their treatment! Thankfully, other views from the early twentieth century have aged better. In 1905 Ernst Mach wrote that “knowledge and error flow from the same mental sources, only success can tell one from the other.” Mach is referring to the fact that certain helpful types of behaviour, can also cause problems. For example, people have the ability to learn skills which involve a high level of automatic facility, allowing musicians to play musical instruments, typists to type, drivers to drive cars - all without thinking about the mechanics of every string plucke
Copyright ©bandtide.pages.dev 2025