{"id":23898,"date":"2025-03-13T13:33:26","date_gmt":"2025-03-13T14:33:26","guid":{"rendered":"http:\/\/medexperts.pro\/?p=23898"},"modified":"2025-03-13T15:25:07","modified_gmt":"2025-03-13T15:25:07","slug":"james-reason-who-used-swiss-cheese-to-explain-human-error-dies-at-86","status":"publish","type":"post","link":"https:\/\/medexperts.pro\/?p=23898","title":{"rendered":"James Reason, Who Used Swiss Cheese to Explain Human Error, Dies at 86"},"content":{"rendered":"
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Mistakes happen, he theorized, because multiple vulnerabilities in a system align \u2014 like the holes in cheese \u2014 to create a recipe for disaster.<\/p>\n

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The story of how James Reason became an authority on the psychology of human error begins with a teapot.<\/p>\n

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

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

After swearing at Rusky, Professor Reason berated himself: How could he have done something so stupid?<\/p>\n<\/div>\n<\/div>\n

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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

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

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Mistakes happen, he theorized, because multiple vulnerabilities in a system align \u2014 like the holes in cheese \u2014 to create a recipe for disaster.The story of how James Reason became an authority on the psychology of human error begins with a teapot.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.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.\u201dAfter swearing at Rusky, Professor Reason berated himself: How could he have done something so stupid?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.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.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and\u00a0log into\u00a0your Times account, or\u00a0subscribe\u00a0for all of The Times.Thank you for your patience while we verify access.Already a subscriber?\u00a0Log in.Want all of The Times?\u00a0Subscribe.<\/p>\n","protected":false},"author":1,"featured_media":23900,"comment_status":"close","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[34],"tags":[],"class_list":["post-23898","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-science"],"_links":{"self":[{"href":"https:\/\/medexperts.pro\/index.php?rest_route=\/wp\/v2\/posts\/23898","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medexperts.pro\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medexperts.pro\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medexperts.pro\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/medexperts.pro\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=23898"}],"version-history":[{"count":2,"href":"https:\/\/medexperts.pro\/index.php?rest_route=\/wp\/v2\/posts\/23898\/revisions"}],"predecessor-version":[{"id":23901,"href":"https:\/\/medexperts.pro\/index.php?rest_route=\/wp\/v2\/posts\/23898\/revisions\/23901"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medexperts.pro\/index.php?rest_route=\/wp\/v2\/media\/23900"}],"wp:attachment":[{"href":"https:\/\/medexperts.pro\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=23898"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medexperts.pro\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=23898"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medexperts.pro\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=23898"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}