Human Error¶
Reason, J. (2000). Human Error: Models and Management. BMJ, 320(7237), 768-770.
Cited by¶
11 citations across 11 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.
Supported in partVerified against the work's full text
Reason presents the Swiss-cheese model of layered defences with holes lining up, but nothing here shows it is standard vocabulary in software post-mortems or that it was ported without re-derivation.
“Usually, this can happen only when the holes in many layers momentarily line up to permit a trajectory of accident opportunity”
- 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.
Supported in partVerified against the work's full text
Reason states the general Swiss cheese model for health care (layered defences whose holes rarely line up), but does not name the medication-safety layers listed.
“In reality, however, they are more like slices of Swiss cheese, having many 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.
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.
SupportedVerified against the source
- In Reason's Swiss-cheese imagery this is the alignment of holes across all defensive layers simultaneously
- Medication Error
- The shared frame is Reason's Swiss-cheese model, a general model of layered defences in high-technology systems (its layers include pilots and control-room operators as well as surgeons and anaesthetists) that Reason applied to medicine himself and that medication error realizes; on top of it aviation has checklists and crew resource management, finance has separation of duties, and industrial safety has its own barrier analysis
This sourceReason's Swiss-cheese model of layered, imperfect defences in high-technology systems, which Reason applied to medical error.
Supported in partVerified against the source
- The shared frame is Reason's Swiss-cheese model, a general model of layered defences in high-technology systems (its layers include pilots and control-room operators as well as surgeons and anaesthetists) that Reason applied to medicine himself and that medication error realizes; on top of it aviation has checklists and crew resource management, finance has separation of duties, and industrial safety has its own barrier analysis
Mechanisms¶
- Layered Control Matrix
- This is the failure the Swiss cheese model warns of: protection fails when the holes in successive layers line up.
This sourceModels organizational accidents as occurring when weaknesses in successive defensive layers momentarily align and permit a hazard through.
- This is the failure the Swiss cheese model warns of: protection fails when the holes in successive layers line up.
- Multi-Barrier Verification Drill
- 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.
- Safety Case Review
- Treating defenses as layered and asking where the holes line up is the discipline the Swiss cheese model of accident causation formalizes.
This sourceModels safeguards as multiple imperfect defense layers whose holes can align to permit an accident trajectory.
- Treating defenses as layered and asking where the holes line up is the discipline the Swiss cheese model of accident causation formalizes.
- Structural Audit
- Its strength is making an organization's own harmful arrangements visible from the inside and attributable to design rather than to individuals — surfacing the latent conditions that sit dormant until circumstances line up, in the sense James Reason gave the term.
This sourceDefines latent conditions as systemic weaknesses that can remain dormant until they combine with active failures and local triggers.
- Its strength is making an organization's own harmful arrangements visible from the inside and attributable to design rather than to individuals — surfacing the latent conditions that sit dormant until circumstances line up, in the sense James Reason gave the term.
- Swiss-Cheese Barrier Review
- It is the natural entry point to the whole archetype, and it directly attacks the layer-counting fallacy — the comfort of many slices when the holes sit in the same place
This sourceShows that multiple defensive layers can still fail when their weaknesses align into a path for an accident.
- It is the natural entry point to the whole archetype, and it directly attacks the layer-counting fallacy — the comfort of many slices when the holes sit in the same place
Verification¶
Does it exist? Confirmed. This work's DOI resolves to a registered record, which fixes its identity. That is all it fixes.
Does it back the claim? Read against the text for 4 of 11 citations: 1 supported, 3 supported in part. Each verdict is shown under its citation below, with what in the work backs the sentence.
Was it audited? Yes. A second, independent pass read the citation against the article text and recorded a verdict.
Support is checked per citation rather than per work — the same source can be cited soundly in one article and wrongly in another. Per-citation recording began recently, so a citation with no recorded check is a gap in the record rather than evidence it went unchecked.
See how references were verified.
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