Annals of Family Medicine :- ()
© Annals of Family Medicine, Inc.
Click on image to view larger version.
Figure 5. Analytic construct to incorporate Reason’s model of organizational accidents into the notion of cascades.
Note: The construct recognizes that each error in the cascade can arise from error-producing conditions, which exist because of latent failures, and that the errors occur in the absence of adequate defenses (safeguards). The predisposing factors that contribute to each error are not necessarily distinct, eg, fatigue may cause error A and error B, nor does injury only occur as a result of distal errors.
