Into the abyss: Seven principles for identifying the causes of and preventing human error in complex systems

American Journal of Health-System Pharmacy

Volumn 57, Issue 6, 2000, Pages 554-564

  Grasha, Anthony F ^a  

^a UNIVERSITY OF CINCINNATI   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CONFERENCE PAPER; DRUG USE; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; PRIORITY JOURNAL; SAFETY; WORKPLACE;

EID: 0034654648     PISSN: 10792082     EISSN: None     Source Type: Journal    
DOI: 10.1093/ajhp/57.6.554     Document Type: Conference Paper

References (49)

1. Grasha AF. Practical applications of psychology. Englewood Cliffs, NJ: Prentice-Hall; 1995.
2. Dember WN, Martin SH, Hummer MK et al. The measurement of optimism and pessimism. Curr Psychol Res Rev. 1989; 8:102-19.
3. McConnell AR, Bill CM, Dember WN et al. Personality through metaphor: optimism, pessimism, locus of control, and sensation seeking. Curr Psychol. 1993; 12:195-215.
4. Peterson C, Bassio L. Health and optimism. New York: Free Press; 1992.
5. Seligman MEP. Learned optimism. New York: Knopf; 1991.
6. Seligman MEP. What you can change and what you can't. New York: Knopf; 1994.
7. Nutt P. Managing planned change. New York: Macmillan; 1991.
8. Peters T. Thriving on chaos. New York: Knopf; 1988.
9. Gleick J. Chaos: making a new science. New York: Penguin; 1987.
10. Gilbert DT. Thinking lightly about others: automatic components of the social inference process. In: Uleman JS, Bargh JA, eds. Unintended thought: limits of awareness, intention, and control. New York: Guilford; 1989.
11. Gilbert DT, McNulty SE, Giuliano TA et al. Blurry words and fuzzy deeds: the attribution of obscure behavior. J Personal Soc Psychol. 1992; 62:18-25.
12. Grasha AF, O'Neill M. Cognitive processes in medication errors. US Pharm. 1996; 21:96-109.
13. Miller JG. Culture and the development of everyday social explanation. J Personal Soc Psychol. 1984; 46:961-78.
14. Triandis H. Culture and social behavior. New York: McGraw-Hill; 1994.
15. Menon T, Morris MW, Chiu C et al. Culture and the construal of agency: attribution to individual versus group dispositions. J Personal Soc Psychol. 1999; 76:701-17.
16. Peng K, Nisbett RE. Culture, dialectics, and reasoning about contradiction. Am Psychol. 1999; 54:741-54.
17. Gardner WL, Gabriel S, Lee AY. "I" value freedom, but "we" value relationships: self-construal priming mirrors cultural differences in judgment. Psychol Sci. 1999; 10:4, 321-26.
18. Beaudin BP, Jacoby L, Quick D. Selecting safe employees: a behavioral science perspective. Prof Saf. 1997; 42:24-8.
19. Geller ES. The psychology of safety: how to improve behaviors and attitudes on the job. Radnor, PA: Chilton; 1996.
20. Geller ES. The truth about safety incentives. Prof Saf. 1996; 41:34-9.
21. Weinstein MB. Total quality approach to safety management. Prof Saf. 1996; 41:23-5.
22. Guastello SJ. Do we really know how well our occupational accident prevention programs work? Saf Sci. 1993; 16:445-6.
23. Casey S. Set phasers on stun: and other true tales of design, technology, and human error. Santa Barbara, CA: Aegean; 1998.
24. Abood RR. Errors in pharmacy practice. US Pharm. 1996; 21:2-11.
25. Kamp J, Krause TR. Selecting safe employees: a behavioral science perspective. Prof Saf. 1997; 42:18-24.
26. Grasha AF. The role of cognitive processes in dispensing errors: a conceptual analysis. Cincinnati, OH: University of Cincinnati; 1995. Technical report 1-0495.
27. Grasha AF. Workload and pharmacy dispensing errors. Cincinnati, OH: University of Cincinnati, 1998; research update report no. 1-1198.
28. Flynn EA, Barker KN, Gibson JT et al. Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy. Am J Health-Syst Pharm. 1999; 56:1319-23.
29. Lambert BL. Predicting look-alike and sound-alike medication errors. Am J Health-Syst Pharm. 1997; 54:1161-71.
30. Buchanan TL, Barker KN. Illumination and errors in dispensing. Am J Hosp Pharm. 1991; 48:2137-45.
31. Flynn EA, Barker KN, Gibson JT. Relationships between ambient sounds and the accuracy of pharmacists' prescription-filling performance. Hum Factors. 1996; 38:614-22.
32. Grasha AF, Schell KG, Reilley S et al. Correcting human error in the prescription process. San Diego, CA; Paper presented at National Association of Chain Drug Stores Annual Meeting; 1999 Aug 29-Sept 1.
33. Allan EL. Relationships among facility design variables and medication errors in a pharmacy. Auburn, AL: Auburn University; 1994. Dissertation.
34. Allan-Flynn E, Barker KN, Malloy MJ et al. Dispensing errors and counseling in community practice. Am Pharm. 1995; 12:25-33.
35. Spader TJ. Dispensing errors and detection at an outpatient pharmacy. Chapel Hill, NC: University of North Carolina; 1994. Thesis.
36. Grasha AF, Schell KG. Psychosocial factors and time-accuracy functions in a simulated pharmacy. Boston, MA; Paper presented at American Psychological Association Annual Meeting; 1999 Aug 20-24.
37. Hart SG, Staveland LE. Development of NASA-TLX (Task Load Index): results of empirical and theoretical research. In: Hancock PA, Meskkati N, eds. Human mental workload. Amsterdam, Netherlands: North-Holland; 1988.
38. Grasha AF. Practical poetry: using metaphors to evaluate academic programs. J Staff Program Organ Dev. 1990; 1:23-32.
39. Grasha AF, Schell KG. Effects of intrapersonal, interpersonal, and task factors on human performance and error in a simulated pharmacy dispensing task. Cincinnati, OH: University of Cincinnati; 1999. Technical report 2-0699.
40. Schell KG, Grasha AF. Anxiety and speedaccuracy functions in a simulated pharmacy task. Percept Mot Skills. In press.
41. Crowe L, Grasha AF. Work stress and coping styles: comparisons across occupational groups. Paper presented at First Annual Conference on Stress in the Workplace. Washington, DC: American Psychological Association; 1993 Oct 14-17.
42. Belkin L. How can we save the next victim? N Y Times Mag. 1997; Jun 15:19-30.
43. Edmundson AC. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. J Appl Behav Sci. 1996; 32:5-28.
44. Reason J. Human error. Cambridge, England: Cambridge Univ. Press; 1990.
45. Doughety DM. Is human failure a stochastic process? Reliab Eng Syst Saf. 1997; 55:209-15.
46. Lakoff G, Johnson M. Metaphors we live by. Chicago, IL: Univ. of Chicago Press; 1980.
47. Sontag S. AIDS and its metaphors. New York: Farrar, Straus & Giroux; 1989.
48. Sontag S. Illness and metaphor. New York: Doubleday; 1990.
49. Fountain R. The relationship of error-based experiential learning to organizational change: how and why what we learn may or may not change how we behave. Cleveland, OH: Case-Western Reserve University; 1999. Dissertation.