Organisational sources of safety and danger: Sociological contributions to the study of adverse events

Quality in Health Care

Volumn 9, Issue 2, 2000, Pages 120-126

  West, Elizabeth ^a  

^a ROYAL COLLEGE OF NURSING   (United Kingdom)

Author keywords

Adverse events; Errors; Organisation; Safety

Indexed keywords

HEALTH CARE ORGANIZATION; HEALTH HAZARD; HOSPITAL MANAGEMENT; HUMAN; INTERPERSONAL COMMUNICATION; MEDICAL ETHICS; MOTIVATION; NATIONAL HEALTH SERVICE; PATIENT CARE; RESPONSIBILITY; REVIEW; RISK ASSESSMENT; SAFETY; SOCIAL ASPECT;

COMMUNICATION BARRIERS; DECISION MAKING, ORGANIZATIONAL; GREAT BRITAIN; HEALTH SERVICES RESEARCH; HUMANS; MEDICAL ERRORS; MODELS, ORGANIZATIONAL; ORGANIZATIONAL CULTURE; ORGANIZATIONAL INNOVATION; ORGANIZATIONAL OBJECTIVES; QUALITY ASSURANCE, HEALTH CARE; SAFETY MANAGEMENT; SOCIOLOGY, MEDICAL; STATE MEDICINE;

EID: 0347164816     PISSN: 09638172     EISSN: None     Source Type: Journal    
DOI: 10.1136/qhc.9.2.120     Document Type: Review

References (38)

1. Hughes EC Mistakes at work. Can J Econ Political Sci 1951;17:320-7.
2. Vincent C Risk, safety and the dark side of quality BMJ 1997;314 1775
3. Leape LL. A systems analysis approach to medical error. J Eval Clin Pract 1997;3:213-22
4. Department of Health. Clinical governance: quality in the new NHS. London. The Stationen Office, 1999
5. Vaughan D. The Challenger launch decision. Chicago: Chicago University Press, 1996.
6. Boisjoly R, Curtis EF, Mellican E. The Challenger disaster: organisational demands and personal ethics. In: Ermann DM, Lundman RJ, eds. Corporate and governmental deviance: problems of organisational behaviour in contemporary society. 5th edn. Oxford: Oxford University Press, 1996.
7. MacPherson M. The black box: cockpit voice recorder accounts of in-flight accidents. London Harper Collins, 1998.
8. Weick K. The vulnerable system: an analysis of the Tenerife air disaster. In: Frost P, Moore L, Louis M, et al, eds. Reframing organisational culture. Newbury Park, California: Sage, 1991: 117-30.
9. Perrow C. The accident at Three Mile Island: the human dimension. Boulder, Colorado: Westview Press, 1981
10. Clarke L. The wreck of the Exxon Valdez. In: Nelkin D, ed. Controversies: Politics of technical decisions. Beverley Hills: Sage, 1992:80-96.
11. Shrivastava P. Bhopal: anatomy of a crisis. Cambridge, Massachusetts: Balinger, 1987.
12. Hohenemser C. The accident at Chernobyl: health and environmental consequences and the implications for risk management. Ann Rev Energy Environ 1988;13:383-428.
13. Vaughan D. The dark side of organisations: mistake, misconduct and disaster. Ann Rev Social 1999;25:271.
14. Roberts KH. Some characteristics of one type of high reliability organisation. Organisation Sci 1990;1:160-76.
15. LaPorte TR The United States air traffic system: increasing reliability in the midst of rapid growth. In: Hughes T, Mayntz R, eds. The development of large scale technical systems. Boulder, Colorado: Westview Press, 1988: 215-44.
16. Scott WR. Organizations: rational, natural and open systems. 3rd edn. Englewood Cliffs, New Jersey: Prentice Hall, 1992.
17. Brennan TA, Leape LL, Laird NM, et al. The nature of adverse events in hospitalised patients results from the Harvard medical practice study. 1. N Engl J Med 1991;324: 2377-84.
18. Walshe K. Adverse events in health care: issues in measurement Quality in Health Care 2000,9:47-52
19. West E. The salience of social boundaries in the informal networks of health care professionals. Paper presented at the Organizations and Occupations section of the American Sociological Association Annual Meeting, Chicago, 1999.
20. Berwick DM, Improving patient safety: the need and the opportunity. Paper presented at the Fourth Annual European Forum on Quality Improvement in Health Care, Stockholm, Sweden, 1999.
21. West E, Barron D, Newton J, et al. Hierarchies and cliques in the social networks of health care professionals. Soc Sci Med 1999;48:633-46.
22. Drife J Reducing risks in obstetrics. Quality in Health Care 1995;4:108-14.
23. Latane B, Rodin R. A lady in distress: inhibiting effects of friends and strangers on bystander intervention. J Exp Soc Psychol 1969;5:189-202.
24. Latane B, Williams K, Harkins S. Many hands make light work the causes and consequences of social loafing. J Personality Soc Psychol 1979;37:822-32.
25. Williams K, Harkins S, Latane B. Identifiability as a deterrent to social loafing J Personality Soc Psychol 1981,40 303-11.
26. Thompson DF. Moral responsibility of public officials: the problem of many hands. Am Political Sci Rev 1980;74:905-16.
27. Bovens B. The quest for responsibility: accountability and citizenship in complex organisations. Cambridge. Cambridge University Press, 1998.
28. Braithwaite J. The allocation of responsibility for corporate crime: individualism, collectivism and accountability. Sidney Law Review 1988,12:468-513.
29. West E, Kirson A, Savage J, et al. Who decides: centralisation and decentralisation in acute NHS trusts. Interim report to NHS R&D Programme on the Organisation and Management of Services, 2000.
30. Reason J. Understanding adverse events: human factors. Quality in Health Care 1995,4:80-9.
31. West E, McDonnell J. The buck stops - where, exactly? Decision-making and clinical governance in NHS trusts. Paper to be given at the Fourth International Conference on Strategic Issues in Health Care Management, University of St Andrews, April 2000
32. Wilson RM, Harrison BT, Gibberd RW, et al. An analysis of the causes of adverse events from the Quality in Australian Health Care Study, Med J Aust 1999;170:411-5.
33. Selznick P. TVA and the grass roots Berkeley: University of California Press, 1949.
34. West E. Clinical effectiveness. Report prepared for the Clinical Standards Advisory Group. London: Department of Health, 1995.
35. West E. Clinicians in management Report prepared for the Clinical Standards Advisory Group. London: Department of Health, 1996.
36. McKee M, Black N. Does the current use of junior doctors in the United Kingdom affect the quality of medical care. Soc Sci Med 1992;34: 549-58.
37. Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in US hospitals. Image J Nurs Sch 1998; 30:315-21.
38. Sagan SD. The limits of safety organizations, accidents and nuclear weapons Princeton: Princeton University Press, 1993.