PATIENT SAFETY
August 25, 2025

A Physics Tribute to James Reason

​​​Author Biography
Mohammad Bakhtiari, PhD, WellSpan Health
Mohammad Bakhtiari (mbakhtiari@wellspan.org) is a senior medical physicist at WellSpan Radiation Oncology in Chambersburg, Pennsylvania. His expertise includes radiation oncology, healthcare quality, patient safety, AI applications, and systems improvement. His research surrounds practical solutions for complex healthcare systems.

​Abstact

​In memory of James Reason (1938–2025), the influential psychologist behind the Swiss cheese model (SCM),1–3 who passed away on February 5, 2025, we honor his legacy by acknowledging how his work has shaped patient safety. Reason’s pioneering insights have profoundly advanced our understanding of human error and systemic safety management across high-risk domains,2–5 including radiation therapy.6 This brief tribute highlights the continued relevance and application of Reason’s concepts by examining their critical role in analyzing radiation therapy incidents.6

References

  1. Reason J, Hollnagel E, Paries J. Revisiting the Swiss Cheese Model of Accidents. J Clin Eng. 2006;27(4):110-115. Google Scholar 
  2. Reason J. Human Error. Cambridge University Press; 1990. doi:10.1017/​CBO9781139062367 Google Scholar 
  3. Reason J. Human Error: Models and Management. BML. 2000;320(7237):768-770. doi:10.1136/​bmj.320.7237.768. PMID:10720363 Google ScholarPubMed CentralPubMed 
  4. Reason J. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. CRC Press; 2017. doi:10.1201/​9781315239125 Google Scholar 
  5. Reason J. Managing the Risks of Organizational Accidents. Routledge; 2016. doi:10.4324/​9781315543543 Google Scholar 
  6. Reason J. Understanding Adverse Events: Human Factors. BMJ Qual Saf. 1995;4(2):80-89. doi:10.1136/​qshc.4.2.80. PMID:10151618 Google ScholarPubMed CentralPubMed 
  7. Gurevich AV, Zybin KP. Runaway Breakdown and the Mysteries of Lightning. Phys Today. 2005;58(5):37-43. doi:10.1063/​1.1995746 Google Scholar 
  8. Wiegmann DA, Wood LJ, Cohen TN, Shappell SA. Understanding the “Swiss Cheese Model” and Its Application to Patient Safety. J Patient Saf. 2022;18(2):119-123. doi:10.1097/​PTS.0000000000000810. PMID:33852542 Google ScholarPubMed CentralPubMed 
  9. Weintraub SM, Salter BJ, Chevalier CL, Ransdell S. Human Factor Associations With Safety Events in Radiation Therapy. J Appl Clin Med Phys. 2021;22(10):288-294. doi:10.1002/​acm2.13420. PMID:34505353 Google ScholarPubMed CentralPubMed​
Three slices of Swiss cheese hanging on a piece of rope by wooden clothespins in front of a barnwood wall.