‘Surely we all have the right to save our own lives?’ Yes, even in hospital.

When things go bad in hospital - how can patients get help? Experts agreed this week that patients should be able to call a Rapid Response / Critical Care Outreach / Medical Emergency Team directly.

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Not enough seats on the plane from Dubrovnik

Coming back from the mediterranean we witness an interesting dilemma: the plane can't take all passengers. Volunteers are needed to stay behind.

Is 70 a bit late for learning how to read ?

Just in case you missed it between the headlines about beating Panama and ghosts of penalties past: The NHS is finally reached its 70th birthday. There is a lot of noise on achievements and some notes on the roots in a philosophy originating from miners working in Wales. The Tredegar Medical Aid Society became the... Continue Reading →

The James Reason Swiss Cheese Failure Model in 300 Seconds

And a great summary about systems approach to failure.

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James Reason Swiss Cheese Model. BMJ, 2000 Mar 18:320(7237): 768-770
James Reason Swiss Cheese Model. Source: BMJ, 2000 Mar 18:320(7237): 768-770

This week I’m at the Cardiff pilot of Practical Strategies for Learning from Failure (#LFFdigital), explaining the Swiss Cheese Failure Model in 300 seconds (5 minutes).

In the event of failure (ha ha ha, I couldn’t resist that), this is what I’m aiming to cover….

The Swiss Cheese Model of Accident Causation (to give it the full name), was developed by Professor James T. Reason at the University of Manchester about 25 years ago. The original 1990 paper,“The Contribution of Latent Human Failures to the Breakdown of Complex Systems”, published in the transactions of The Royal Society of London, clearly identifies these are complex human systems, which is important.

Well worth reading is the British Medical Journal (BMJ), March 2000 paper, ‘Human error: models and management’. This paper gives an excellent explanation of the model, along with…

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