{"id":12641,"date":"2025-03-13T15:57:17","date_gmt":"2025-03-13T15:57:17","guid":{"rendered":"https:\/\/site.itshrt.com\/worldnews\/james-reason-who-used-swiss-cheese-to-explain-human-error-dies-at-86\/"},"modified":"2025-03-13T15:57:17","modified_gmt":"2025-03-13T15:57:17","slug":"james-reason-who-used-swiss-cheese-to-explain-human-error-dies-at-86","status":"publish","type":"post","link":"https:\/\/site.itshrt.com\/worldnews\/james-reason-who-used-swiss-cheese-to-explain-human-error-dies-at-86\/","title":{"rendered":"James Reason, Who Used Swiss Cheese to Explain Human Error, Dies at 86"},"content":{"rendered":"<p> <script async src=\"https:\/\/pagead2.googlesyndication.com\/pagead\/js\/adsbygoogle.js?client=ca-pub-6606220950177433\"\r\n     crossorigin=\"anonymous\"><\/script>\r\n<!-- ItShrt World News -->\r\n<ins class=\"adsbygoogle\"\r\n     style=\"display:block\"\r\n     data-ad-client=\"ca-pub-6606220950177433\"\r\n     data-ad-slot=\"1882483372\"\r\n     data-ad-format=\"auto\"\r\n     data-full-width-responsive=\"true\"><\/ins>\r\n<script>\r\n     (adsbygoogle = window.adsbygoogle || []).push({});\r\n<\/script>\r\n<br \/>\n<\/p>\n<div data-testid=\"companionColumn-0\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">The story of how James Reason became an authority on the psychology of human error begins with a teapot.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">It was the early 1970s. He was a professor at the University of Leicester, in England, studying motion sickness, a process that involved spinning his subjects round and round, and occasionally revealing what they had eaten for breakfast.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">One afternoon, as he was boiling water in his kitchen to make tea, his cat, a brown Burmese named Rusky, sauntered in meowing for food. \u201cI opened a tin of cat food,\u201d he later recalled, \u201cdug in a spoon and dolloped a large spoonful of cat food into the teapot.\u201d<\/p>\n<p class=\"css-at9mc1 evys1bk0\">After swearing at Rusky, Professor Reason berated himself: How could he have done something so stupid?<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-1\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">The question seemed more intellectually engaging than making people dizzy, so he ditched motion sickness to study why humans make mistakes, particularly in high-risk settings.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">By analyzing hundreds of accidents in aviation, railway travel, medicine and nuclear power, Professor Reason concluded that human errors were usually the byproduct of circumstances \u2014 in his case, the cat food was stored near the tea leaves, and the cat had walked in just as he was boiling water \u2014 rather than being caused by careless or malicious behavior.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">That was how he arrived at his Swiss cheese model of failure, a metaphor for analyzing and preventing accidents that envisions situations in which multiple vulnerabilities in safety measures \u2014 the holes in the cheese \u2014 align to create a recipe for tragedy.<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-2\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">\u201cSome scholars play a critical role in founding a whole field of study: Sigmund Freud, in psychology. Noam Chomsky, in linguistics. Albert Einstein, in modern physics,\u201d Robert L. Sumwalt, the former chairman of National Transportation Safety Board, wrote in a 2018 <a class=\"css-yywogo\" href=\"https:\/\/safetycompass.wordpress.com\/2018\/05\/01\/the-age-of-reason\/\" title=\"\" rel=\"noopener noreferrer\" target=\"_blank\">blog post<\/a>. \u201cIn the field of safety, Dr. James Reason has played such a role.\u201d<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-3\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">Professor Reason died on Feb. 5 in Slough, a town about 20 miles west of London. He was 86.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">His death, in a hospital, was caused by pneumonia, his family said.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">A gifted storyteller, Professor Reason found vivid and witty ways to explain complicated ideas. At conferences, on TV news programs and in consultation with government safety officials around the world, he would sometimes deploy slices of cheese as props.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">In one instructional <a class=\"css-yywogo\" href=\"https:\/\/www.youtube.com\/watch?v=KND5py-z8yI\" title=\"\" rel=\"noopener noreferrer\" target=\"_blank\">video<\/a>, he sat at his dining room table, which was set for a romantic dinner, with a bottle of wine, two glasses and a cutting board layered with cheese.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">\u201cIn an ideal world, each defense would look like this,\u201d he said, holding up a slice of cheese without holes. \u201cIt would be solid and intact.\u201d<\/p>\n<p class=\"css-at9mc1 evys1bk0\">Then he reached for another slice, one with quarter-size cutouts. \u201cBut in reality, each defense is like this,\u201d he said. \u201cIt has holes in it.\u201d<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-4\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">The metaphor was easy to understand.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">\u201cAll defenses have holes in them,\u201d Professor Reason continued. \u201cEvery now and again, the holes line up so that there can be some trajectory of accident opportunity.\u201d<\/p>\n<p class=\"css-at9mc1 evys1bk0\">To explain how the holes develop, he put them in two categories: active failures, or mistakes typically made by people who, for example, grab the cat food instead of the tea leaves; and latent conditions, or mistakes made in construction, written instructions or system design, like storing two scoopable substances near each other in a cabinet.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">\u201cNearly all organizational accidents involve a complex interaction between these two sets of factors,\u201d he wrote in his autobiography, <a class=\"css-yywogo\" href=\"https:\/\/www.routledge.com\/A-Life-in-Error-From-Little-Slips-to-Big-Disasters\/Reason\/p\/book\/9781472418418?srsltid=AfmBOor7ihT1XfKmbWdRrlEuFI0Go0KLh0qrlglS-7M3MCYQjOqU_wg8\" title=\"\" rel=\"noopener noreferrer\" target=\"_blank\">\u201cA Life in Error: From Little Slips to Big Disasters\u201d<\/a> (2013).<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-5\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">In the Chernobyl nuclear accident, he identified latent conditions that had been in existence for years: a poorly designed reactor; organizational mismanagement; and inadequate training procedures and supervision for frontline operators, who triggered the catastrophic explosion by making the error of turning off several safety systems at once.<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-6\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">\u201cRather than being the main instigators of an accident, operators tend to be the inheritors of system defects,\u201d he wrote in \u201cHuman Error\u201d (1990). \u201cTheir part is that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking.\u201d<\/p>\n<p class=\"css-at9mc1 evys1bk0\">Professor Reason\u2019s model has been widely used in health care.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">\u201cWhen I was in medical school, an error meant you screwed up, and you should just try harder to not screw up,\u201d <a class=\"css-yywogo\" href=\"https:\/\/medicine.ucsf.edu\/people\/robert-wachter\" title=\"\" rel=\"noopener noreferrer\" target=\"_blank\">Robert Wachter<\/a>, the chairman of the department of medicine at the University of California San Francisco, said in an interview. \u201cAnd if it was really bad, you would probably get sued.\u201d<\/p>\n<p class=\"css-at9mc1 evys1bk0\">In 1998, a doctor he had recently hired for a fellowship said he wanted to specialize in patient-safety strategy, to which Dr. Wachter replied, \u201cWhat\u2019s that?\u201d There were no formal systems or methods in his hospital (or most others) to analyze and prevent errors, but there was plenty of blame to go around, most of it aimed at doctors and nurses.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">This particular doctor had trained at Harvard Medical School, where they were incorporating Professor Reason\u2019s ideas into patient-safety programs. Dr. Wachter, who began reading Professor Reason\u2019s journal articles and books, said the Swiss cheese model was \u201can epiphany,\u201d almost \u201clike putting on a new pair of glasses.\u201d<\/p>\n<p class=\"css-at9mc1 evys1bk0\">Someone given the wrong dose of medicine, he realized, could have been the victim of poor syringe design rather than a careless nurse. Another patient could have died of cardiac arrest because a defibrillator that was usually stored in the hallway had been taken to a different floor to replace one that had malfunctioned \u2014 and there was no system to alert anyone that it had been moved.<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-7\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">\u201cWhen an error happens, our instinct can\u2019t be to look at this at the final stage,\u201d Dr. Wachter said, \u201cbut to look at the entirety of the system.\u201d<\/p>\n<p class=\"css-at9mc1 evys1bk0\">When you do, he added, you realize that \u201cthese layers of protection are pretty porous in ways that you just didn\u2019t understand until we opened our eyes to all of it.\u201d<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-8\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">James Tootle was born on May 1, 1938, in Garston, a village in Hertfordshire, northwest of London. His father, Stanley Tootle, died in 1940, during World War II, when he was struck by shrapnel while playing cards in the bay window of his house. His mother, Hilda (Reason) Tootle, died when he was a teenager.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">His grandfather, Thomas Augustus Reason, raised James, who took his surname.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">In 1962, he graduated from the University of Manchester with a degree in psychology. He received his doctorate in 1967 from the University of Leicester, where he taught and conducted research before joining the faculty at the University of Manchester in 1977.<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<div data-testid=\"companionColumn-9\">\n<div class=\"css-53u6y8\">\n<p class=\"css-at9mc1 evys1bk0\">He married Rea Jaari, a professor of psychology, in 1964. She survives him, along with their daughters, Paula Reason and Helen Moss, and three grandchildren.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">Throughout his career, Professor Reason\u2019s surname was a reliable source of levity.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">\u201cThe word \u2018reason\u2019 is, of course, widely used in the English language, but it does not describe what Jim is rightly famous for, namely \u2018error,\u2019\u201d Erik Hollnagel, the founding editor of the International Journal of Cognition, Technology and Work, wrote in the preface to Professor Reason\u2019s autobiography. \u201cIndeed, \u2018error\u2019 is almost the opposite of \u2018reason.\u2019\u201d<\/p>\n<p class=\"css-at9mc1 evys1bk0\">Still, it made sense.<\/p>\n<p class=\"css-at9mc1 evys1bk0\">\u201cJim has certainly brought reason to the study of error,\u201d he wrote.<\/p>\n<\/div>\n<aside class=\"css-ew4tgv\" aria-label=\"companion column\"\/><\/div>\n<p><script async src=\"https:\/\/pagead2.googlesyndication.com\/pagead\/js\/adsbygoogle.js?client=ca-pub-6606220950177433\"\r\n     crossorigin=\"anonymous\"><\/script>\r\n<!-- ItShrt World News -->\r\n<ins class=\"adsbygoogle\"\r\n     style=\"display:block\"\r\n     data-ad-client=\"ca-pub-6606220950177433\"\r\n     data-ad-slot=\"1882483372\"\r\n     data-ad-format=\"auto\"\r\n     data-full-width-responsive=\"true\"><\/ins>\r\n<script>\r\n     (adsbygoogle = window.adsbygoogle || []).push({});\r\n<\/script>\r\n<br \/>\n<br \/><a href=\"https:\/\/www.nytimes.com\/2025\/03\/13\/science\/james-reason-dead.html\">Source link <\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>The story of how James Reason became an authority on the psychology of human error begins with a teapot. It<\/p>\n","protected":false},"author":1,"featured_media":12642,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[38],"tags":[441,4103,1539,4102,4106,4105,4104],"class_list":["post-12641","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-science","tag-deaths-obituaries","tag-james-1938-2025","tag-psychology-and-psychologists","tag-reason","tag-robert-l","tag-sumwalt","tag-university-of-leicester"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>James Reason, Who Used Swiss Cheese to Explain Human Error, Dies at 86 - World News<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/site.itshrt.com\/worldnews\/james-reason-who-used-swiss-cheese-to-explain-human-error-dies-at-86\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"James Reason, Who Used Swiss Cheese to Explain Human Error, Dies at 86 - World News\" \/>\n<meta property=\"og:description\" content=\"The story of how James Reason became an authority on the psychology of human error begins with a teapot. 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