Professor James Reason is the intellectual father of the patient safety field. I remember reading his book Managing the Risks of Organizational Accidents in 1999 and having the same feeling that I had when I first donned eyeglasses: I saw my world anew, in sharper focus.
Reason’s “Swiss cheese” model, in particular – which holds that most errors in complex organizations are caused not so much by the inevitable human mistakes but rather by the organization’s incomplete layers of protection, which allow the errors to pass through on their way to causing terrible harm – was an epiphany. It is the fundamental mental model for patient safety, as central to our field as the double helix is to genetics.
Last month, I returned to England to give a couple of talks, one at a conference called “Risky Business,” the other at the UK’s National Patient Safety Congress. The former brings together many of the leading thinkers in a variety of risk-heavy fields, including aviation, nuclear power, space travel, the financial system … and healthcare. At the latter, I was asked to give the 2012 James Reason Lecture, a singular honor.