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James T. Reason CBE ... He wrote books on human error, [2] ... etc. [2] Reason also described the first fully developed theory of a just culture in his 1997 book, ...
Latent failures span the first three domains of failure in Reason's model. [9] 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-layer defence model and Willem Albert Wagenaar's tripod theory of accident causation. This resulted in a period in which the Swiss ...
The first fully developed theory of a just culture was in James Reason's 1997 book, Managing the Risks of Organizational Accidents. [2] In Reason's theory, a just culture is postulated to be one of the components of a safety culture. A just culture is required to build trust so that a reporting culture will occur.
Healthcare systems are complex in that they are diverse in both structure (e.g. nursing units, pharmacies, emergency departments, operating rooms) and professional mix (e.g. nurses, physicians, pharmacists, administrators, therapists) and made up of multiple interconnected elements with adaptive tendencies in that they have the capacity to change and learn from experience.
It has been described as a phenomenon in the psychology of human error, such that a person may inadvertently perform one action while intending to do another. The term "slips and capture" became more widely known in the early 21st century in the United States, after being referred to by law enforcement in two prominent fatal police shooting ...
That's a real toughie - and one that director James Marsh was eager to take on with The Theory of Everything. The thing you as a viewer have to remember is that this movie isn't so much a story ...
Human error: models and management – James Reason British Medical Journal 2000;320:768–70 (Internet Archive) Human factors view of accident causation References
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