Reasons, James

James Reason offered another useful model, often referred to as the Swiss cheese model, that explains how the many factors can converge, resulting in an incident (Figure 6-5). A company tries to promote safety and prevent catastrophic incidents hy putting into place layers of system defenses, depicted in Figure 6-5 as slices of Swiss cheese. Essentially, the term system defenses refers to the safety-related decisions and actions of the entire company top management, the line supervisors, and the workers. This model recognizes that each defense layer has weaknesses or holes. 

Dr. William Cannell Dr. David Embrey Dr, Deborah Lucas Prof. James Reason Mr. Roger Taylor... 

Chapter 2, the committee examines the more significant of the chemical events at JACADS and TOCDF to determine their characteristics with respect to facility performance and human performance. How these events are related to safety performance is not a simple question. In his widely referenced book (Reason, 1997), in a chapter devoted to the relationship between frequent, low-consequence events and the risk of high-consequence events, James Reason concludes that ... 

Human error is defined by James Reason as the failure of planned actions to achieve their desired ends - without the interveution of some unforeseeable event [1]. Depending on the mode in which we are performing, different types of errors might occur. These are often referred to as slips, lapses and mistakes. 

Cooper and Leape are not the only authors to understand the importance of human factors and psychology to medical harm and medical error at an early stage. For instance, Marilyn Bogner s 1994 book Human error in medicine contained many insightful and important chapters by David Woods, Richard Cook, NevUle Moray and others James Reason articulated his theory of accidents and discussed its apphcation in medicine in Medical Accidents (Vincent, Ennis and Audley, 1993). Cooper and Leape were, however, particularly important influences and they Ulustrate the more general point that some of the defining characteristics of patient safety are its acceptance of the importance of psychology and the lessons to be learnt from other safety critical industries. 

The immediate causes described above are the result of actions, or omissions, by people at the scene. However, other factors further back in the causal chain can also play a part in the genesis of an accident. These latent conditions, as they are often termed, lay the foundations for accidents in the sense that they create the conditions in which errors and failures can occur (Reason, 1997). This places the operators at the sharp end in an invidious position, as James Reason eloquently explains ... 

As must now be clear, error has many different facets and the subject of error, and how to reduce error, can be approached in different ways. While there are a multitude of different taxonomies and error reduction systems, we can discern some broad general perspectives or error paradigms as they are sometimes called. Following Deborah Lucas (1997) and James Reason (1997)... 

In daily life, errors are frequently attributed to stupidity, carelessness, forgetfulness, recklessness and other personal defects. The implication is that the person who makes an error has certain characteristics which produce the error and, furthermore, that these characteristics are under their control and they are therefore to blame for the errors they make. This is error seen from the individual perspective when applied to understanding accidents James Reason refers to this as the person model (Reason, 2000). 

THE JAMES REASON S THEORY-THE EFFECT OF A HUMAN ERROR UPON CAUSES OF AIR ACCIDENTS... 

The effect of a human factor upon causes of air accidents is perfectly well explained with the James Reason s theory, who claims that safety within any system depends on the following factors (Reason 1990) ... 

Figure 1. A model of how an air accident arises, according to James Reason. 

First, we make a general acknowledgment to major contributors to the field of patient safety whose work we have drawn on for this book. Among them are James Reason, Karl Weick, Jens Rasmussen, Richard Cook, David Woods, and Karlene Roberts. Special thanks to Lucian Leape for writing the Foreword he has been not only a pioneer in the field but also a mentor. Don Berwick, president of the Center for Healthcare Improvement, and Jim Conway, chief operating officer of the Dana-Farber Cancer Institute, both in Boston, have made substantial contributions through their work, which appears in this book. 

Others lose their concentration due to job or task interruption. Healthcare workers and professionals should deal with stress, lack of sleep, and fatigue on the job. Workplace environmental factors, personal or home distractions, and substance abuse can also impair performance. James Reason in his studies developed some questions to address errors committed on the job. Consider the following questions when investigating an error or other adverse event ... 

In Managing Maintenance Error A Practical Guide, James Reason and Alan Hobbs comment appropriately on the need to inquire into the systemic causal factors that shape human error ... 

Another author has written similarly. James Reason, in Managing the Risks of Organizational Accidents, observes that occupational safety approaches directed largely on the unsafe acts of persons have limited value with respect to the prevention of accidents having severe consequences. 

James Reason s Human Error, which was previously mentioned, is also a highly recommended resource. First published in 1990, it has since had 12 reprintings. Reason discusses The Nature of error Studies of human error Performance levels and error types Cognitive underspecification and error forms A design for a fallible machine The detection of errors Latent errors and system disasters and Assessing and reducing the human error risk. 

Another of James Reason s books—Managing the Risks of Organizational Accidents—is a must read for safety professionals who want an education in human error reduction. It was published in 1997 and has been reprinted five times. Reason writes about how the effects of decisions accumulate over time and become the causal factors for incidents resulting in serious injuries or damage when all the circumstances necessary for the occurrence of a major event come together. This book was referenced in Chapter 3, Serious Injury Prevention, because it stresses the need to focus on decision making above the worker level to prevent major accidents. Reason writes this ... 

Incidents that result in serious injuries are often low-probability events that result from what James Reason refers to as an accumulation of latent technical conditions and operating practices that are built into a system and shape an organization s culture. He discusses the long-term impact of a continuum of less-than-adequate management leadership and decision making in Managing the Risks of Organizational Accidents ... 

An analysis of the incident by the Bureau of Air Safety Investigation (BASI, 1993) draws specifically on the accident analysis model developed by James Reasons in which he distinguishes between active and latent factors, which correspond broadly to the victim- and system-blaming explanations discussed above. (The following quotations from Reasons are found in the BASI report, p 31.)... 

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