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Figure 3. The GEMS Framework (Adapted from Reason, 1990)

 

The GEMS framework facilitates the linkage of an error/violation to an individual's level performance at the time the failure occurred.

 

1) Unintentional or intentional action

First it is necessary to determine whether the error or violation was an unintentional or intentional action. "Did the person intend the action?" If the answer to that question is no, then it is an unintentional action. Unintentional actions are actions that do not go as planned; these are errors in execution.

If the answer to the question "Did the person intend the action?" is yes, then the action is intentional. Intentional actions are actions that are carried out as planned but the actions are inappropriate; these are errors in planning.

 

 

 

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