Reason's accident causation model: application to adverse events in acute care.

Adverse events are unintended harm to a patient caused by the health care provided; more than half of all these events have been deemed avoidable. Adverse events are a common problem in acute care and represent a breach in care quality and safety. They are generally not caused by a single mistake or error and although safety barriers exist in health care, patients today are still harmed. Using an accident causation model is a constructive way of identifying the underlying causes of adverse events and to strengthen a study's theoretical underpinnings. Reason's model is recommended as a useful framework for adverse event analysis as it promotes a focus on the conditions or situation in which the clinician was trying to perform, rather than apportioning blame.