Structural and organizational issues in patient safety: A comparison of health care to other high-hazard industries

California Management Review

Volumn , Issue 1, 2000, Pages 83-102

  Gaba, David M ^a  

^a NONE

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[No Author keywords available]

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EID: 0034557582     PISSN: 00081256     EISSN: None     Source Type: Journal    
DOI: 10.2307/41166067     Document Type: Article

References (117)

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8. Kohn et al., op. cit.; T. Brennan, A. Localio, L. Leape, N. Laird, L. Peterson, H. Hiatt, and B. Barnes, "Identification of Adverse Events Occurring during Hospitalization," Annals of Internal Medicine, 112 (1990): 221-226; T. Brennan, L. Leape, N. Laird, A. Localio, A. Lawthers, J. Newhouse, P. Weiler, and H. Hiatt, "Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I," New England Journal of Medicine, 324 (1991): 370-376; L. Leape, T. Brennan, N. Laird, A. Lawthers, A. Localio, B. Barnes, L. Herbert, J. Newhouse, P. Weiler, and H. Hiatt, "The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II," New England Journal of Medicine, 324 (1991): 377-384.
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10. T.A. Brennan, "The Institute of Medicine Report on Medical Errors - Could It Do Harm?" New England Journal of Medicine, 342 (2000): 1123-5; L. Leape, "Institute of Medicine Medical Error Figures Are Not Exaggerated," JAMA, 284 (2000): 95-97;
11. C. McDonald, M. Weiner, and S. Hui, "Deaths Due to Medical Errors Are Exaggerated in the Institute of Medicine Report," JAMA, 284 (2000): 93-95.
12. National Transportation Safety Board, "Accidents, Fatalities, and Rates, 1982 through 1999 for U.S. Air Carriers," 〈http://www.ntsb.gov/aviation/Table6.htm〉, June 6, 2000.
13. National Highway Traffic Safety Administration, "Traffic Safety Facts 1996," 〈http://www.nhtsa.dot.gov/people/ncsa〉, May 25, 2000.
14. American Hospital Association, "Fast Facts on U.S. Hospitals from Hospital Statistics," 〈http://www.aha.org/resource/Newpage.html〉, June 5, 2000.
15. C. Paul, "Back from the Brink: Making Chemotherapy Safer," in S. Findlay, Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine (Washington, D.C.: National Coalition on Health Care, 2000), pp. 4-8.
16. C. Perin and J. Carroll, "Organizational Analysis in High-Hazard Production Systems: An Academy-Industry diaLogue," National Science Foundation Report #9510883-SBR, 1997, 〈http://stsfac.mit.edu/projects/risk/reports/sts.pdf〉.
17. B. Turner, Man-Made Disasters (Oxford: Butterworth-Heinemann, 1978); C. Perrow, Normal Accidents (New York, NY: Basic Books, 1984); J. Reason, Human Error (Cambridge: Cambridge University Press, 1990); J. Reason, Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate Publishing Limited, 1997); J. Rasmussen, "Cognitive Control and Human Error Mechanisms," in J. Rasmussen, K. Duncan, and J. Leplat, New Technology and Human Error (Chichester: John Wiley Sons, Ltd., 1987), pp. 53-61; J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, 27 (1997): 183-213; G. Rochlin, T. La Porte, and K. Roberts, "The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea," Naval War College Review, 42 (Autumn 1987): 76-90; K. Roberts, "New Challenges in Organizational Research: High Reliability Organizations," Industrial Crisis Quarterly, 3 (1989): 111-125.
18. B. Turner, Man-Made Disasters (Oxford: Butterworth-Heinemann, 1978); C. Perrow, Normal Accidents (New York, NY: Basic Books, 1984); J. Reason, Human Error (Cambridge: Cambridge University Press, 1990); J. Reason, Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate Publishing Limited, 1997); J. Rasmussen, "Cognitive Control and Human Error Mechanisms," in J. Rasmussen, K. Duncan, and J. Leplat, New Technology and Human Error (Chichester: John Wiley Sons, Ltd., 1987), pp. 53-61; J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, 27 (1997): 183-213; G. Rochlin, T. La Porte, and K. Roberts, "The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea," Naval War College Review, 42 (Autumn 1987): 76-90; K. Roberts, "New Challenges in Organizational Research: High Reliability Organizations," Industrial Crisis Quarterly, 3 (1989): 111-125.
19. B. Turner, Man-Made Disasters (Oxford: Butterworth-Heinemann, 1978); C. Perrow, Normal Accidents (New York, NY: Basic Books, 1984); J. Reason, Human Error (Cambridge: Cambridge University Press, 1990); J. Reason, Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate Publishing Limited, 1997); J. Rasmussen, "Cognitive Control and Human Error Mechanisms," in J. Rasmussen, K. Duncan, and J. Leplat, New Technology and Human Error (Chichester: John Wiley Sons, Ltd., 1987), pp. 53-61; J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, 27 (1997): 183-213; G. Rochlin, T. La Porte, and K. Roberts, "The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea," Naval War College Review, 42 (Autumn 1987): 76-90; K. Roberts, "New Challenges in Organizational Research: High Reliability Organizations," Industrial Crisis Quarterly, 3 (1989): 111-125.
20. B. Turner, Man-Made Disasters (Oxford: Butterworth-Heinemann, 1978); C. Perrow, Normal Accidents (New York, NY: Basic Books, 1984); J. Reason, Human Error (Cambridge: Cambridge University Press, 1990); J. Reason, Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate Publishing Limited, 1997); J. Rasmussen, "Cognitive Control and Human Error Mechanisms," in J. Rasmussen, K. Duncan, and J. Leplat, New Technology and Human Error (Chichester: John Wiley Sons, Ltd., 1987), pp. 53-61; J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, 27 (1997): 183-213; G. Rochlin, T. La Porte, and K. Roberts, "The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea," Naval War College Review, 42 (Autumn 1987): 76-90; K. Roberts, "New Challenges in Organizational Research: High Reliability Organizations," Industrial Crisis Quarterly, 3 (1989): 111-125.
21. B. Turner, Man-Made Disasters (Oxford: Butterworth-Heinemann, 1978); C. Perrow, Normal Accidents (New York, NY: Basic Books, 1984); J. Reason, Human Error (Cambridge: Cambridge University Press, 1990); J. Reason, Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate Publishing Limited, 1997); J. Rasmussen, "Cognitive Control and Human Error Mechanisms," in J. Rasmussen, K. Duncan, and J. Leplat, New Technology and Human Error (Chichester: John Wiley Sons, Ltd., 1987), pp. 53-61; J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, 27 (1997): 183-213; G. Rochlin, T. La Porte, and K. Roberts, "The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea," Naval War College Review, 42 (Autumn 1987): 76-90; K. Roberts, "New Challenges in Organizational Research: High Reliability Organizations," Industrial Crisis Quarterly, 3 (1989): 111-125.
22. B. Turner, Man-Made Disasters (Oxford: Butterworth-Heinemann, 1978); C. Perrow, Normal Accidents (New York, NY: Basic Books, 1984); J. Reason, Human Error (Cambridge: Cambridge University Press, 1990); J. Reason, Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate Publishing Limited, 1997); J. Rasmussen, "Cognitive Control and Human Error Mechanisms," in J. Rasmussen, K. Duncan, and J. Leplat, New Technology and Human Error (Chichester: John Wiley Sons, Ltd., 1987), pp. 53-61; J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, 27 (1997): 183-213; G. Rochlin, T. La Porte, and K. Roberts, "The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea," Naval War College Review, 42 (Autumn 1987): 76-90; K. Roberts, "New Challenges in Organizational Research: High Reliability Organizations," Industrial Crisis Quarterly, 3 (1989): 111-125.
23. B. Turner, Man-Made Disasters (Oxford: Butterworth-Heinemann, 1978); C. Perrow, Normal Accidents (New York, NY: Basic Books, 1984); J. Reason, Human Error (Cambridge: Cambridge University Press, 1990); J. Reason, Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate Publishing Limited, 1997); J. Rasmussen, "Cognitive Control and Human Error Mechanisms," in J. Rasmussen, K. Duncan, and J. Leplat, New Technology and Human Error (Chichester: John Wiley Sons, Ltd., 1987), pp. 53-61; J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, 27 (1997): 183-213; G. Rochlin, T. La Porte, and K. Roberts, "The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea," Naval War College Review, 42 (Autumn 1987): 76-90; K. Roberts, "New Challenges in Organizational Research: High Reliability Organizations," Industrial Crisis Quarterly, 3 (1989): 111-125.
24. B. Turner, Man-Made Disasters (Oxford: Butterworth-Heinemann, 1978); C. Perrow, Normal Accidents (New York, NY: Basic Books, 1984); J. Reason, Human Error (Cambridge: Cambridge University Press, 1990); J. Reason, Managing the Risks of Organizational Accidents (Aldershot, England: Ashgate Publishing Limited, 1997); J. Rasmussen, "Cognitive Control and Human Error Mechanisms," in J. Rasmussen, K. Duncan, and J. Leplat, New Technology and Human Error (Chichester: John Wiley Sons, Ltd., 1987), pp. 53-61; J. Rasmussen, "Risk Management in a Dynamic Society: A Modelling Problem," Safety Science, 27 (1997): 183-213; G. Rochlin, T. La Porte, and K. Roberts, "The Self-Designing High Reliability Organization: Aircraft Carrier Flight Operations at Sea," Naval War College Review, 42 (Autumn 1987): 76-90; K. Roberts, "New Challenges in Organizational Research: High Reliability Organizations," Industrial Crisis Quarterly, 3 (1989): 111-125.
25. D. Gaba, M. Maxwell, and A. DeAnda, "Anesthetic Mishaps: Breaking the Chain of Accident Evolution," Anesthesiology, 66 (1987): 670-676; D. Gaba, K. Fish, and S. Howard, Crisis Management in Anesthesiology (New York, NY: Churchill-Livingstone, 1994); D. Galletly and N. Mushet, "Anaesthesia System Errors," Anesthesia and Intensive Care, 19 (1991): 66-73; C. Eagle and J. Davies, "Accident Analysis of Large-Scale Technological Disasters Applied to an Anaesthetic Complication," Canadian Journal of Anaesthesia, 39 (1992): 118-122; J. Reason, "Human Error: Models and Management," British Medical Journal, 320 (2000): 768-770.
26. D. Gaba, M. Maxwell, and A. DeAnda, "Anesthetic Mishaps: Breaking the Chain of Accident Evolution," Anesthesiology, 66 (1987): 670-676; D. Gaba, K. Fish, and S. Howard, Crisis Management in Anesthesiology (New York, NY: Churchill-Livingstone, 1994); D. Galletly and N. Mushet, "Anaesthesia System Errors," Anesthesia and Intensive Care, 19 (1991): 66-73; C. Eagle and J. Davies, "Accident Analysis of Large-Scale Technological Disasters Applied to an Anaesthetic Complication," Canadian Journal of Anaesthesia, 39 (1992): 118-122; J. Reason, "Human Error: Models and Management," British Medical Journal, 320 (2000): 768-770.
27. D. Gaba, M. Maxwell, and A. DeAnda, "Anesthetic Mishaps: Breaking the Chain of Accident Evolution," Anesthesiology, 66 (1987): 670-676; D. Gaba, K. Fish, and S. Howard, Crisis Management in Anesthesiology (New York, NY: Churchill-Livingstone, 1994); D. Galletly and N. Mushet, "Anaesthesia System Errors," Anesthesia and Intensive Care, 19 (1991): 66-73; C. Eagle and J. Davies, "Accident Analysis of Large-Scale Technological Disasters Applied to an Anaesthetic Complication," Canadian Journal of Anaesthesia, 39 (1992): 118-122; J. Reason, "Human Error: Models and Management," British Medical Journal, 320 (2000): 768-770.
28. D. Gaba, M. Maxwell, and A. DeAnda, "Anesthetic Mishaps: Breaking the Chain of Accident Evolution," Anesthesiology, 66 (1987): 670-676; D. Gaba, K. Fish, and S. Howard, Crisis Management in Anesthesiology (New York, NY: Churchill-Livingstone, 1994); D. Galletly and N. Mushet, "Anaesthesia System Errors," Anesthesia and Intensive Care, 19 (1991): 66-73; C. Eagle and J. Davies, "Accident Analysis of Large-Scale Technological Disasters Applied to an Anaesthetic Complication," Canadian Journal of Anaesthesia, 39 (1992): 118-122; J. Reason, "Human Error: Models and Management," British Medical Journal, 320 (2000): 768-770.
29. D. Gaba, M. Maxwell, and A. DeAnda, "Anesthetic Mishaps: Breaking the Chain of Accident Evolution," Anesthesiology, 66 (1987): 670-676; D. Gaba, K. Fish, and S. Howard, Crisis Management in Anesthesiology (New York, NY: Churchill-Livingstone, 1994); D. Galletly and N. Mushet, "Anaesthesia System Errors," Anesthesia and Intensive Care, 19 (1991): 66-73; C. Eagle and J. Davies, "Accident Analysis of Large-Scale Technological Disasters Applied to an Anaesthetic Complication," Canadian Journal of Anaesthesia, 39 (1992): 118-122; J. Reason, "Human Error: Models and Management," British Medical Journal, 320 (2000): 768-770.
30. Perrow (1984), op. cit.; C. Perrow, "The Limits of Safety: The Enhancement of a Theory of Accidents," Journal of Contingencies and Crisis Management, 2 (1994): 212-220.
31. Perrow (1984), op. cit.; C. Perrow, "The Limits of Safety: The Enhancement of a Theory of Accidents," Journal of Contingencies and Crisis Management, 2 (1994): 212-220.
32. S. Sagan, The Limits of Safety (Princeton, NJ: Princeton University Press, 1993).
33. Rochlin et al., op. cit.; K. Roberts, "Some Characteristics of High Reliability Organizations," Organization Science, 1 (1990): 160-177; K. Roberts, D. Rousseau, and T. La Porte, "The Culture of High Reliability: Quantitative and Qualitative Assessment aboard Nuclear Powered Aircraft Carriers," Journal of High Technology Management Research, 5 (1994): 141-161; T. La Porte, "A Strawman Speaks Up: Comments on The Limits of Safety: Organizations, Accidents, and Nuclear Weapons,'" Journal of Contingencies and Crisis Management, 2 (1994): 207-211; T. La Porte and G. Rochlin, "A Rejoinder to Perrow," Journal of Contingencies and Crisis Management, 2 (1994): 221-227.
34. Rochlin et al., op. cit.; K. Roberts, "Some Characteristics of High Reliability Organizations," Organization Science, 1 (1990): 160-177; K. Roberts, D. Rousseau, and T. La Porte, "The Culture of High Reliability: Quantitative and Qualitative Assessment aboard Nuclear Powered Aircraft Carriers," Journal of High Technology Management Research, 5 (1994): 141-161; T. La Porte, "A Strawman Speaks Up: Comments on The Limits of Safety: Organizations, Accidents, and Nuclear Weapons,'" Journal of Contingencies and Crisis Management, 2 (1994): 207-211; T. La Porte and G. Rochlin, "A Rejoinder to Perrow," Journal of Contingencies and Crisis Management, 2 (1994): 221-227.
35. Rochlin et al., op. cit.; K. Roberts, "Some Characteristics of High Reliability Organizations," Organization Science, 1 (1990): 160-177; K. Roberts, D. Rousseau, and T. La Porte, "The Culture of High Reliability: Quantitative and Qualitative Assessment aboard Nuclear Powered Aircraft Carriers," Journal of High Technology Management Research, 5 (1994): 141-161; T. La Porte, "A Strawman Speaks Up: Comments on The Limits of Safety: Organizations, Accidents, and Nuclear Weapons,'" Journal of Contingencies and Crisis Management, 2 (1994): 207-211; T. La Porte and G. Rochlin, "A Rejoinder to Perrow," Journal of Contingencies and Crisis Management, 2 (1994): 221-227.
36. Rochlin et al., op. cit.; K. Roberts, "Some Characteristics of High Reliability Organizations," Organization Science, 1 (1990): 160-177; K. Roberts, D. Rousseau, and T. La Porte, "The Culture of High Reliability: Quantitative and Qualitative Assessment aboard Nuclear Powered Aircraft Carriers," Journal of High Technology Management Research, 5 (1994): 141-161; T. La Porte, "A Strawman Speaks Up: Comments on The Limits of Safety: Organizations, Accidents, and Nuclear Weapons,'" Journal of Contingencies and Crisis Management, 2 (1994): 207-211; T. La Porte and G. Rochlin, "A Rejoinder to Perrow," Journal of Contingencies and Crisis Management, 2 (1994): 221-227.
37. Rochlin et al., op. cit.; K. Roberts, "Some Characteristics of High Reliability Organizations," Organization Science, 1 (1990): 160-177; K. Roberts, D. Rousseau, and T. La Porte, "The Culture of High Reliability: Quantitative and Qualitative Assessment aboard Nuclear Powered Aircraft Carriers," Journal of High Technology Management Research, 5 (1994): 141-161; T. La Porte, "A Strawman Speaks Up: Comments on The Limits of Safety: Organizations, Accidents, and Nuclear Weapons,'" Journal of Contingencies and Crisis Management, 2 (1994): 207-211; T. La Porte and G. Rochlin, "A Rejoinder to Perrow," Journal of Contingencies and Crisis Management, 2 (1994): 221-227.
38. K. Weick, K. Sutcliffe, and D. Obstfeld, "Organizing for High Reliability: Processes of Collective Mindfulness," Research in Organizational Behavior, 21 (1999): 81-123.
39. R. Bea, "Human and Organization Factors: Engineering Operating Safety into Offshore Structures," Reliability Engineering and System Safety, 61 (1998): 109-126.
40. P. Schulman, "The Analysis of High Reliability Organizations: A Comparative Framework," in K. Roberts, New Challenges to Understanding Organizations (New York, NY: Macmillan Publishing Company, 1993); R. Klein, G. Bigley, and K. Roberts, "Organizational Culture in High Reliability Organizations: An Extension," Human Relations, 48 (1995): 1-23.
41. P. Schulman, "The Analysis of High Reliability Organizations: A Comparative Framework," in K. Roberts, New Challenges to Understanding Organizations (New York, NY: Macmillan Publishing Company, 1993); R. Klein, G. Bigley, and K. Roberts, "Organizational Culture in High Reliability Organizations: An Extension," Human Relations, 48 (1995): 1-23.
42. Personal communication, Karlene Roberts.
43. Sagan, op. cit.
44. Reason (1990), op. cit.
45. Ibid.
46. Gaba et al. (1987), op. cit.; Galletly and Mushet, op. cit.; Eagle and Davies, op. cit.; L. Leape, "Error in Medicine," JAMA, 272 (1994): 1851-1857.
47. Gaba et al. (1987), op. cit.; Galletly and Mushet, op. cit.; Eagle and Davies, op. cit.; L. Leape, "Error in Medicine," JAMA, 272 (1994): 1851-1857.
48. Gaba et al. (1987), op. cit.; Galletly and Mushet, op. cit.; Eagle and Davies, op. cit.; L. Leape, "Error in Medicine," JAMA, 272 (1994): 1851-1857.
49. Gaba et al. (1987), op. cit.; Galletly and Mushet, op. cit.; Eagle and Davies, op. cit.; L. Leape, "Error in Medicine," JAMA, 272 (1994): 1851-1857.
50. Gaba et al. (1987), op. cit.
51. Ibid.
52. Ibid.
53. M. Weinger and C. Englund, "Ergonomie and Human Factors Affecting Anesthetic Vigilance and Monitoring Performance in the Operating Room Environment," Anesthesiology, 73 (1990): 995-1021; M. Weinger and N. Smith, "Vigilance, Alarms, and Integrated Monitoring Systems," in J. Ehrenwerth and J. Eisenkraft, Anesthesia Equipment: Principles and Applications (St. Louis, MO: Mosby-Year Book, Inc., 1993), pp. 351-384; R. Botney and D. Gaba, "Human Factors Issues in Monitoring," in C. Blitt, Monitoring in Anesthesia and Intensive Care (New York, NY: Churchill Livingstone, 1994), pp. 23-54.
54. M. Weinger and C. Englund, "Ergonomie and Human Factors Affecting Anesthetic Vigilance and Monitoring Performance in the Operating Room Environment," Anesthesiology, 73 (1990): 995-1021; M. Weinger and N. Smith, "Vigilance, Alarms, and Integrated Monitoring Systems," in J. Ehrenwerth and J. Eisenkraft, Anesthesia Equipment: Principles and Applications (St. Louis, MO: Mosby-Year Book, Inc., 1993), pp. 351-384; R. Botney and D. Gaba, "Human Factors Issues in Monitoring," in C. Blitt, Monitoring in Anesthesia and Intensive Care (New York, NY: Churchill Livingstone, 1994), pp. 23-54.
55. M. Weinger and C. Englund, "Ergonomie and Human Factors Affecting Anesthetic Vigilance and Monitoring Performance in the Operating Room Environment," Anesthesiology, 73 (1990): 995-1021; M. Weinger and N. Smith, "Vigilance, Alarms, and Integrated Monitoring Systems," in J. Ehrenwerth and J. Eisenkraft, Anesthesia Equipment: Principles and Applications (St. Louis, MO: Mosby-Year Book, Inc., 1993), pp. 351-384; R. Botney and D. Gaba, "Human Factors Issues in Monitoring," in C. Blitt, Monitoring in Anesthesia and Intensive Care (New York, NY: Churchill Livingstone, 1994), pp. 23-54.
56. R. Cook, M. Render, and D. Woods, "Gaps in the Continuity of Care and Progress on Patient Safety," British Medical Journal, 320 (2000): 791-794.
57. Rochlin et al., op. cit.; K. Roberts and D. Rousseau, "Research in Nearly Failure-Free, High Reliability Organizations: Having the Bubble," IEEE Transactions on Engineering Management, 36 (1989): 132-139.
58. Rochlin et al., op. cit.; K. Roberts and D. Rousseau, "Research in Nearly Failure-Free, High Reliability Organizations: Having the Bubble," IEEE Transactions on Engineering Management, 36 (1989): 132-139.
59. Leape, op. cit.
60. D. Gaba, S. K. Howard, and B. Jump, "Production Pressure in the Work Environment: California Anesthesiologists' Attitudes and Experiences," Anesthesiology, 81 (1994): 488-500; J. M. Healzer, S. K. Howard, and D. M. Gaba, "Attitudes toward Production Pressure and Patient Safety: A Survey of Anesthesia Residents," Journal of Clinical Monitoring and Computing, 14(1998): 145-146.
61. D. Gaba, S. K. Howard, and B. Jump, "Production Pressure in the Work Environment: California Anesthesiologists' Attitudes and Experiences," Anesthesiology, 81 (1994): 488-500; J. M. Healzer, S. K. Howard, and D. M. Gaba, "Attitudes toward Production Pressure and Patient Safety: A Survey of Anesthesia Residents," Journal of Clinical Monitoring and Computing, 14(1998): 145-146.
62. Reason (1990), op. cit.
63. D. Vaughan, The Challenger Launch Decision (Chicago, IL: University of Chicago Press, 1996).
64. J. Green, Risk and Misfortune: The Social Construction Of Accidents (London: UCL Press, 1997).
65. Leape, op. cit.
66. Rochlin et al., op. cit.
67. Nuclear Regulatory Commission, "Nuclear reactors," 〈http://www.nrc.gov/NRC/reactors.html〉, June 6, 2000.
68. National Transportation Safety Board (2000), op. cit.; Air Transport Association, "ATA Airline Statistics - 1997," 〈http://www.air-transport.org/public/industry/41.asp〉, June 6, 2000.
69. National Transportation Safety Board (2000), op. cit.; Air Transport Association, "ATA Airline Statistics - 1997," 〈http://www.air-transport.org/public/industry/41.asp〉, June 6, 2000.
70. American Medical Association, "Nonfederal Physicians in the United States and Possessions by Selected Characteristics," 〈http://www.ama-assn.org/physdata/physnow/nowgraf1.htm〉, June 6, 2000.
71. R. Morell, "OBA Questions, Problems Just Now Being Recognized, Being Defined," Anesthesia Patient Safety Foundation Newsletter, 15 (2000): 1-3.
72. American Hospital Association, op. cit.
73. K. Weick, "Organizational Culture as a Source of High Reliability," California Management Review, 29/2 (Winter 1987): 112-127.
74. P. Starr, The Social Transformation of American Medicine (New York, NY: Basic Books, Inc., 1982).
75. L. A. Bero, R. Grilli, J. M. Grimshaw, E. Harvey, A. D. Oxman, and M. A. Thomson, "Closing the Gap between Research and Practice: An Overview of Systematic Reviews of Interventions to Promote the Implementation of Research Findings: The Cochrane Effective Practice and Organization of Care Review Group," British Medical Journal, 317 (1998): 465-468.
76. Starr, op. cit.
77. Bero et al., op. cit.
78. B.A. Liang, "Error in Medicine: Legal Impediments to U.S. Reform," Journal of Health Politics Policy and Law, 24 (1999): 27-58.
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