James Reason Swiss Cheese Model. Source: BMJ, 2000 Mar 18:320(7237): 768-770 A while ago I was part of the Cardiff pilot of Practical Strategies for Learning from Failure (#LFFdigital). My job was to explain the James Reason Swiss Cheese Failure Model in 300 seconds (5 minutes). This is what I did. The Swiss Cheese Model of […]
Do we need a Public Services, ‘Museum of Failed Products?’
Most commercial products new to the market fail. Fact. Most change programmes fail. Fact. Most initiatives in public services work perfectly. It’s completely different here….. Really? I may have upset some people, with those assertions, so I’d better explain myself. Most Commercial Products Fail – The Museum of Failed Products. I’ve mentioned this before. Basically […]
Failure Models and NUMB3RS. How do you get from backwards look to real time learning?
If you’ve seen the television show NUMB3RS you may have the impression that it is possible to mathematically predict complex situations. Gather some NUMB3RS (data, information etc), apply a relevant mathematical model, calculate the next occurrence of the event and catch the perpetuator in the act. All you need is the application of some fiendishly […]