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PSNet: Patient Safety Network

Managing the Risks of Organizational Accidents.

Reason JT. Aldershot, Hants, England: Ashgate: 1997. ISBN: 9781840141047

Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest and illustrates many of the key concepts that ultimately formed the core of the patient safety movement. Much of Lucian Leape's work in Error in Medicine involved translating Reason's concepts into health care applications. In this seminal book, readers are introduced to the now-famous "Swiss cheese model" of errors in high-risk enterprises, the difference between active and latent errors, the difference between "slips" and "mistakes," the importance of a safety culture, the role of regulation, training and incentives, and much more. This book provides a good introduction to safety and systems theory.