James Reason's Swiss Cheese Theory

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James Reason's Swiss cheese Theory

James Reason's Swiss cheese TheoryIntroduction

The model of Swiss cheese is a model of accident causation which is used risk management and its analysis in system of healthcare, aviation, and engineering. Swiss Cheeses Model compares human system to Swiss cheese slices. The slices are piled together with one another. Basically it was founded in 1990, by James T. Reason, a British psychologist of University of Manchester. The model gained wide acceptance and has been used by healthcare industry, emergency services organizations, aviation industry, and safety industry since it was developed. It is also known as cumulative act effect.

According to a survey, in most of the cases, there can be four levels of failure for an accident: unsafe supervision, unsafe act of themselves, organizational influence, and preconditions for unsafe acts. James T. Reason, in his Swiss Cheese Model developed defenses of organization against the failure and represented barriers as slices of Swiss cheese. And individual weaknesses are shown by the holes in the slices as part of the system, and all holes are different in position and sizes in those slices. The failure of the system occurs when holes in slices simultaneously align in aggregate, giving permission, as James Reason's said “a trajectory of accident opportunity", so that in all the defenses, jeopardy passes through all holes, which causes failure.


The theory of James T. Reason involves mathematical analysis and is complicated and also involves underlying and active failures. Swiss cheese model applies here in the way that I can do to prevent the Swiss cheese presenting on training floor. It means as a healthcare administrator I have to prevent mishaps to be happened. The model has become the standard for assessing patient security and medical mistakes.

James T. Reason explained the model of Swiss cheese in order to expose the failure of system like medical mishap (Reason JT, et al. 2001). In a complicated system prevention of hazards is done through losses of human through a chain of barriers. All barriers contain unplanned holes, or weaknesses; thus the likeness with Swiss cheese. The holes in the Swiss cheese model randomly close and open due to inconsistent weaknesses. The hazard reaches to patient only when all the holes simultaneously align. Attention is drawn to healthcare system by Reason's model, and conflicting to randomness, and to the individual, as conflicting to planned action, in happening of mistakes in healthcare system. Reason's Swiss cheese model is broadly accepted and commonly referred to professionals of patient's safety. The analysis proposed several interpretations of components of the Swiss cheese model: a) slice of cheese, b) hole, c) arrow, d) active error, e) how to make the system safer.

Reason's Swiss cheese model has become the dominant paradigm for analyzing medical errors and patient safety incidents. The aim of this study was to determine if the components of the model are understood in the same way by clinical professionals and do they encourage physician's leadership to enhance patient's ...
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