incident causation model

James Reason’s classic Swiss cheese model is a vivid and memorable way to visualise how patient harm happens only when all system defences fail. Although Reason’s model has been criticised for its simplicity and static portrait of complex systems, its use has been growing, largely because of the direct clarity of its simple and memorable metaphor. A more general, more flexible and equally memorable model of accident causation in complex systems is needed. We present the hot cheese model, which is more realistic, particularly in portraying defence layers as