ABSTRACT
James Reason’s “Swiss cheese” model of accident causation and system failures has, indeed, become the dominate paradigm for incident investigation and accident reconstruction [1]. It not only provides a tremendously useful way of metaphorically looking at how accidents happen but also how the intrinsic hazards particularly within high-tech, high-risk enterprises, for example, hospitals, can be further identied, eliminated, or their eects minimized. Since this model is focused on systems and the organization rather than on blaming the individual, its appeal and acceptance has been further enhanced.
