THE SWISS CHEESE MODEL

HOW MISTAKES HAPPEN

Everyone makes mistakes some people learn from them, but others repeat them. Here is what you need to know about mistakes. There are different types of mistakes:

Real mistakes- occur  when the wrong process is carried out. 

Blackouts- occur when part of the processes is forgotten 

Slip ups- occur when the right process is carried out incorrectly. 

There are various levels on which mistakes occur. 

Skill based level

Rule base level 

knowledge base level

And there are various factors that contribute to mistakes occurring. 

People involved- boss team colleagues friends

Technical provisions -Equipment workplace

Globalization- all elements

Toss to be filled timing. 

Outside influences time economic, climate, weather. 

The most impressive illustration of the causes and effects of mistakes is the human error or swiss cheese model by James Reason (1990) The model compares different levels on which mistakes occur which slices of emmental cheese. In a mistake 

free world the cheese would have no holes. But in the real world the cheese is cut into thin slices, and every slice has many holes. They different in different places and in different slices. Imagine the holes are conduits fir mistakes. A mistake remains a  irrelevant if it penetrates only one hole in one of the slices. That it can lead to catastrophe if the holes in different slices align and the mistake passes through all the holes in defence since. The model can be used in the fields of medicine and air traffic for example -And anywhere the stakes have fatal consequences. 

Experience is in the name everyone gives to mistakes Oscar Wilde