Transcription of From Safety-I to Safety-II: A White Paper
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From Safety-I to Safety-II: A White Paper
From Safety-I to safety -II: A White Paper Professor Erik Hollnagel University of Southern Denmark, Institute for Regional Health Research (IRS), Denmark Center for Quality, Region of Southern Denmark Professor Robert L Wears University of Florida Health Science Center Jacksonville, United States of America Professor Jeffrey Braithwaite Australian Institute of Health Innovation, Macquarie University, Australia First published in 2015 by The Authors Printed and bound by: Erik Hollnagel, Robert L Wears, Jeffrey Braithwaite This report is published by the authors for information purposes.
models, such as Heinrich’s (1931) Domino Model that is at the heart of Root Cause Analysis, later supplemented by composite linear models such as Reason’s Swiss Cheese Model, were soon adopted as the basic safety tools in health care. Few people noticed that the very same models were being
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