Understanding the ‘Swiss Cheese Model’ of Error


The human lapses that occurred after the computerized ordering system and pill-dispensing robots did their jobs perfectly well is a textbook case of English psychologist James Reason’s “Swiss cheese model” of error. Reason’s model holds that all complex organizations harbor many “latent errors,” unsafe conditions that are, in essence, mistakes waiting to happen. They’re like a forest carpeted with dry underbrush, just waiting for a match or a lightning strike.

Still, there are legions of errors every day in complex organizations that don’t lead to major accidents. Why? Reason found that these organizations have built-in protections that block glitches from causing nuclear meltdowns, or plane crashes, or train derailments. Unfortunately, all these protective layers have holes, which he likened to the holes in slices of Swiss cheese.

On most days, errors are caught in time, much as you remember to grab your house keys right before you lock yourself out…

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