# Human Error: Models and Management

*Reason · Safety & Error · BMJ · 2000 · Open access*

The BMJ paper that brought the Swiss Cheese model and the person vs system approach to a clinical audience. Argues that the person approach — blaming individuals for forgetfulness, carelessness, or moral weakness — is emotionally satisfying but practically counterproductive. The system approach, by contrast, treats errors as consequences of upstream conditions and focuses on building defences. Introduced the concept of a 'just culture' as the precondition for an effective reporting culture.

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## Connected concepts (27)

- [Behind Human Error: Cognitive Systems, Computers, and Hindsight](https://explore.psychsafety.com/n/woods-et-al-1994.md) (paper)
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- [Risk Management in a Dynamic Society: A Modelling Problem](https://explore.psychsafety.com/n/rasmussen-1997.md) (paper)
- [Working in Practice But Not in Theory: Theoretical Challenges of "High-Reliability Organizations"](https://explore.psychsafety.com/n/laporte-consolini-1991.md) (paper)
- [A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population](https://explore.psychsafety.com/n/haynes-et-al-2009.md) (paper)
- [From Safety-I to Safety-II: A White Paper](https://explore.psychsafety.com/n/hollnagel-wears-braithwaite-2015.md) (paper)
- [From Titanic to Costa Concordia — a Century of Lessons Not Learned](https://explore.psychsafety.com/n/schroder-hinrichs-et-al-2012.md) (paper)
- [Independent Review on the Care Given to Mrs Elaine Bromiley](https://explore.psychsafety.com/n/harmer-bromiley-2005.md) (paper)
- [Learning from Mistakes Is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error](https://explore.psychsafety.com/n/edmondson-1996.md) (paper)
- [Learning from the Piper Alpha Accident: A Postmortem Analysis of Technical and Organizational Factors](https://explore.psychsafety.com/n/pate-cornell-1993.md) (paper)
- [The Criminalization of Human Error in Aviation and Healthcare: A Review](https://explore.psychsafety.com/n/dekker-2011-criminalisation.md) (paper)
- [The Evolution of Crew Resource Management Training in Commercial Aviation](https://explore.psychsafety.com/n/helmreich-merritt-wilhelm-1999.md) (paper)
- [The Intuitive Psychologist and His Shortcomings: Distortions in the Attribution Process](https://explore.psychsafety.com/n/ross-1977.md) (paper)
- [Why Hospitals Don't Learn from Failures: Organizational and Dynamics That Inhibit System Change](https://explore.psychsafety.com/n/tucker-edmondson-2003.md) (paper)
- [Airline Pilots' Perceptions of and Experiences in Crew Resource Management (CRM) Training](https://explore.psychsafety.com/n/beaubien-baker-2002.md) (paper)
- [Blametropism](https://explore.psychsafety.com/n/blametropism.md)
- [Collective Mind in Organizations: Heedful Interrelating on Flight Decks](https://explore.psychsafety.com/n/weick-roberts-1993.md) (paper)
- [Just Culture](https://explore.psychsafety.com/n/just-culture.md)
- [State of Science: Evolving Perspectives on 'Human Error'](https://explore.psychsafety.com/n/read-et-al-2021.md) (paper)
- [The Cost of Silence: Normalization of Deviance and Groupthink](https://explore.psychsafety.com/n/nasa-normalization-deviance-2014.md) (paper)
- [The Unintended Consequences of No Blame Ideology for Incident Investigation in the US Construction Industry](https://explore.psychsafety.com/n/sherratt-et-al-2023.md) (paper)
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- [Human Error & PS](https://explore.psychsafety.com/n/psychological-safety-human-error.md)
- [Swiss Cheese Model](https://explore.psychsafety.com/n/the-swiss-cheese-model.md)
- [You Can't Fix a Secret](https://explore.psychsafety.com/n/you-cant-fix-a-secret.md)