The Field Guide › Paper

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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