Human error: models and management.
Reason J. BMJ. 2000;320:768-770.
The author discusses concepts of human error, contrasting the person approach with a system approach in understanding the differing philosophies of error management. The person approach focuses on blaming individuals, whereas the system approach concentrates on the conditions under which individuals work. The author further explains several background concepts, including the
“Swiss cheese” model
of system accidents, the components of error management, and the principles of becoming a high-reliability organization. He explains the benefits of making the transition from a person approach to a system approach in the context of a high-reliability organization. This article is from a
British Medical Journal
special issue on patient safety.
Free full text
National Patient Safety Agency, the Medical Defence Union and Medical Protection Society. London, England: NPSA; 2005
Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families.
Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway.
Dean J, Hutchinson A, Hamilton Escoto K, Lawson R. BMC Health Serv Res. 2007;7:89.
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