The Swiss Cheese Model is commonly used to guide root cause analyses (RCAs) and safety efforts across a variety of industries, including healthcare. [ 4 – 12 ] Various safety and RCA frameworks that define the holes in the cheese and their relationships have also been developed, such as the Human Factors Analysis and Classification System ...

The Swiss cheese model of accident causation is a model used in risk analysis and risk management. It likens human systems to multiple slices of Swiss cheese , which has randomly placed and sized holes in each slice, stacked side by side, in which the risk of a threat becoming a reality is mitigated by the differing layers and types of defenses ...

“瑞士奶酪模型”，又名“Reason模型”，是英国曼彻斯特大学教授James Reason于1990年在其著名的心理学专著《Human Error》中提出的。 该模型认为，组织活动中发生的事故与环境影响、不安全的监督、不安全行为的前兆、不安全的操作行为四个层面的因素有关，每个层面代表一重防御体系，层面上所存在的空洞代表防御体系中存在的 漏洞，这些空洞的位置、大小不是固定不变的，不安全因素就像一个不间断的光源，每个层面上的空洞同时处于一条直线上时，危险就会像光源 …

2022年3月1日 · This article reviews several key aspects of the Theory of Active and Latent Failures, typically referred to as the Swiss cheese model of human error and accident causation. Although the Swiss cheese model has become well known in most safety circles, there are several aspects of its underlying theor …

2020年6月1日 · The Swiss Cheese Model (SCM) is a product of specific historical circumstances, and a collaboration process. The graphical choices while drawing the SCM may be understood as key success factors. The SCM’s critics must be understood from two …

The Swiss Cheese model of accident causation, originally proposed by James Reason, likens human system defences to a series of slices of randomly-holed Swiss Cheese arranged vertically and parallel to each other with gaps in-between each slice.

2024年5月13日 · What is the Swiss Cheese Model? Developed by James Reason as a tool for preventing risks and errors in the 1990s, the Swiss Cheese Model is now one of the most basic concepts on which safety rests within various domains including healthcare aviation …

瑞士奶酪理论 （英語： Swiss Cheese Model），又稱 乳酪理論 或 瑞士起司理論，是英國 曼徹斯特大學 教授 詹姆斯·瑞森 （James Reason）於1990年提出的關於意外發生的風險分析與控管的模型 [1]。 主要是講， 瑞士起司 在製造與 發酵 過程當中，很自然的會產生小孔洞。 如果把許多片起司重疊在一起，正常情況下，每片起司的空洞位置不同，光線透不過。 只有在很極端的情況下，空洞剛好連成一直線，才會讓光線透過去。 導致嚴重事故發生的從來都不是因為某個單獨的原 …

2024年9月19日 · The Swiss Cheese Model suggests that human systems are like slices of Swiss cheese, with layers of defence (like the slices of cheese) having holes (representing potential failures or weaknesses). An accident occurs when the holes in these layers momentarily align, allowing a trajectory of failure to pass through all the defenses — resulting ...

Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular hazard.