Human Error¶
Reason, J. (2000). Human Error: Models and Management. BMJ, 320(7237), 768-770.
Cited by¶
5 citations across 5 artifacts.
Each citation links to the sentence it supports in the citing article.
Primes¶
- Conjunctive Path Activation
- The Swiss-cheese model from aviation is now standard vocabulary in software incident post-mortems, the layered-defence-plus- alignment-of-holes diagnostic porting without re-derivation.
This sourceRestates the Swiss-cheese model of layered defenses and aligned holes, now standard vocabulary in incident analysis across aviation, medicine, and software.
- The Swiss-cheese model from aviation is now standard vocabulary in software incident post-mortems, the layered-defence-plus- alignment-of-holes diagnostic porting without re-derivation.
- Knowledge-Action Gap
- A hospital risk register carries a hazard everyone agrees is high priority — the knowledge subsystem is intact, with universal agreement on the right action — yet the item sits open for eighteen months: the action subsystem diverges.
This sourceDevelops the latent-conditions / Swiss-cheese account in which known organizational weaknesses lie dormant in a system (e.g., on risk registers) long before they precipitate harm, supporting the claim that recognized hazards persist unremediated despite agreement on their priority.
- A hospital risk register carries a hazard everyone agrees is high priority — the knowledge subsystem is intact, with universal agreement on the right action — yet the item sits open for eighteen months: the action subsystem diverges.
- Swiss Cheese Model (Layered Defense with Aligning Holes)
- In patient safety, adverse events are traced through prescription review, dispensing check, nurse double-check, and monitoring; preventable harm is the rare hole-alignment.
This sourceThe Swiss cheese model of system accidents and its application to patient safety, with holes aligning to allow a hazard trajectory.
- In patient safety, adverse events are traced through prescription review, dispensing check, nurse double-check, and monitoring; preventable harm is the rare hole-alignment.
Domain-specific¶
- Latent-Path Activation
- In Reason's Swiss-cheese imagery this is the alignment of holes across all defensive layers simultaneously
This sourceThe Swiss-cheese model itself — defences as layers whose holes continually open, shut and shift, with an accident occurring only when the holes in successive layers momentarily line up into a trajectory that brings hazards into damaging contact with victims.
- In Reason's Swiss-cheese imagery this is the alignment of holes across all defensive layers simultaneously
Mechanisms¶
- No-Response Escalation Protocol
- Its strength is turning a fraught, high-adrenaline judgment ("do I sound the alarm or keep waiting?") into a calm, pre-decided sequence that scales the response to the evidence — the layered-barrier logic of the Swiss cheese model, where each independent rung catches what the previous one missed.
This sourcePresents the Swiss cheese model as successive defensive layers whose holes can align to permit failure.
- Its strength is turning a fraught, high-adrenaline judgment ("do I sound the alarm or keep waiting?") into a calm, pre-decided sequence that scales the response to the evidence — the layered-barrier logic of the Swiss cheese model, where each independent rung catches what the previous one missed.
Verification¶
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