Professor James Reason was the originator of the Swiss Cheese model which has been an important model in developing ways to improve patient safety and reduce adverse events in healthcare.  

Reason J. Human error: models and management. BMJ. 2000 Mar 18;320(7237):768-70. doi: 10.1136/bmj.320.7237.768. PMID: 10720363; PMCID: PMC1117770. Link to paper

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