Benefiting from the "Gift of Failure": Essentials for an event reporting system

Journal of Legal Medicine

Volumn 24, Issue 1, 2003, Pages 29-35

  Kaplan, Harold S ^a  

^a Columbia University ^*  (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ATTITUDE; CONFERENCE PAPER; ERROR; HEALTH CARE POLICY; HEALTH CARE QUALITY; HUMAN; MEDICAL DOCUMENTATION; PATIENT CARE;

HUMANS; MEDICAL ERRORS; MODELS, ORGANIZATIONAL; ORGANIZATIONAL CULTURE; RISK MANAGEMENT; UNITED STATES;

EID: 0037360896     PISSN: 01947648     EISSN: 1521057X     Source Type: Journal    
DOI: 10.1080/713832121     Document Type: Article

References (11)

1. Committee on Quality of Health Care in America, Institute of Medicine, To Err Is Human: Building a Safer Health System (Linda Kohn et al. eds. 1999).
2. James T. Reason, Managing the Risks of Organizational Accidents 118-19 (1997).
3. David Marx, PatientSafety and the "Just Culture”: A Primer for Heath Care Executives (2001), at www.mers-tm.net.
4. T. W. VAN DER SCHAAF ET AL., NEAR MlSS REPORTING AS A SAFETY TOOL 51-56 (1991).
5. Karl E. Weick & Kathleen M. Sutcliffe, Managing the Unexpected: Assuring High Performance in an Age of Complexity 46-49 (2001).
6. Associated Press, Hospital Lists Safety Lapses in MRIDeath, Newsday, Aug. 22, 2001, at A45.
7. John Gosbee & Joe DeRosier, MR Hazard Summary (VA National Center for Patient Safety Jan. 2001), available at http://www.patientsafety.gov/alerts/MRI.doc (working document).
8. Associated Press, Number of MRI Accidents May Be Increasing, Experts Fear, Aug. 1, 2001, available at
9. Jens Rasmussen, Cognitive Control andHumanErrorMechanisms, in New Technology and Human Error 53 (1987).
10. Jens Rasmussen, Reasons, Causes, and Human Error, in NewTechnology, supra note 18, at 193,294-95.
11. Jacques Leplan & Jens Rasmussen, Analysis of HumanErrors inIndustrial Incidents and Accidents for Improvement of Work Safety, in New Technology, supra note 18, at 157.