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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 ...
James T. Reason CBE (1 May 1938 – 5 Feb 2025) [1] [2] was a professor of psychology at the University of Manchester, from where he graduated in 1962 and where he was a tenured professor from 1977 until 2001.
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 ...
James Reason: Human Error, Cambridge University Press; 1st edition (October 26, 1990) ...
James Reason extended this approach with human reliability [6] and the Swiss cheese model, now widely accepted in aviation safety and healthcare. These accidents often resemble Rube Goldberg devices in the way that small errors of judgment, flaws in technology, and insignificant damages combine to form an emergent disaster. Langewiesche writes ...
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A complex adaptive healthcare system (CAHS) is a care delivery enterprise with diverse clinical and administrative agents acting spontaneously, interacting in nonlinear networks where agents and patients are information processors, and actively co-evolve with their environment with the purposed to produce safe and reliable patient-centered outcomes.
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