The CHI+MED team who are researching the computer-human interactions with medical devices actually came up with a new version of the Swiss cheese model, which I’m quite partial to: the hot-cheese model of accident causation. This turns the Swiss cheese on its side: imagine that the slices of cheese are horizontal and mistakes are raining down from the top. Only mistakes that fall down through holes in every layer make it out the bottom to become accidents. The new element is that the cheese slices themselves are hot and parts of them are liable to drip down, causing new problems. Working with
...more
