James Reason Medical Errors

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Systems Approach | PSNet

https://psnet.ahrq.gov/primer/systems-approach

The work of James Reason and Dr. Charles Vincent, another pioneer in the field of error analysis, has established a commonly used classification scheme for latent errors that includes causes ranging from institutional factors (e.g., regulatory pressures) to work environmental factors (e.g., staffing issues) and te… See more

Human error: models and management | The BMJ

https://www.bmj.com/content/320/7237/768

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The Swiss cheese model of safety incidents: are there …

https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-5-71

James Reason proposed the image of "Swiss cheese" to explain the occurrence of system failures, such as medical mishaps [ 1 – 5 ]. According to this …

Why Do Errors Happen? - To Err is Human - NCBI …

https://www.ncbi.nlm.nih.gov/books/NBK225171/

Factors can intervene between the design of a system and the production process that creates conditions in which errors are more likely to happen. …

Case 34-2010 — A 65-Year-Old Woman with an …

https://www.nejm.org/doi/full/10.1056/NEJMcpc1007085

Causes of Human Error How could this have happened to Dr. Ring and his patient? The question is more complex than it initially appears. …

The Incident Decision Tree: Guidelines for Action …

https://www.ahrq.gov/downloads/pub/advances/vol4/Meadows.pdf

Use of the tool was not mandatory during the pilot, and there were situations where managers chose not to apply it. The most common reason was forgetfulness. Use was …

Swiss cheese model - Wikipedia

https://en.wikipedia.org/wiki/Swiss_cheese_model

Latent failures span the first three domains of failure in Reason's model. In the early days of the Swiss Cheese model, late 1980 to about 1992, attempts were made to combine two theories: James Reason's multi …

James Reason and the foundation of patient safety

https://www.kevinmd.com/2012/06/james-reason-foundation-patient-safety.html

Reason’s “Swiss cheese” model, in particular – which holds that most errors in complex organizations are caused not so much by the inevitable human …

James Reason: patient safety, human error, and Swiss …

https://pubmed.ncbi.nlm.nih.gov/22207020/

James Reason: patient safety, human error, and Swiss cheese. Interview by Karolina Peltomaa and Duncan Neuhauser Qual Manag Health Care. 2012 Jan-Mar;21 (1):59-63. …

James Reason’s 12 Principles of Error Management

https://aerossurance.com/safety-management/james-reasons-12-principles-error-management/

James Reason’s 12 Principles of Error Management. James Reason, Professor Emeritus, University of Manchester , set out 12 systemic human factors centric principles of error management in his book …

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