From cognition to the system: Developing a multilevel taxonomy of patient safety in general practice

Ergonomics

Volumn 49, Issue 5-6, 2006, Pages 486-502

  Kostopoulou, O ^a  

^a UNIVERSITY OF BIRMINGHAM   (United Kingdom)

Author keywords

General practice; Human error; Information processing; Patient safety; Performance shaping factors; Taxonomy

Indexed keywords

ACCIDENT PREVENTION; DATA PROCESSING; MATHEMATICAL MODELS; PATIENT MONITORING;

INFORMATION-PROCESSING MODEL; PATIENT SAFETY; TASK ANALYSIS;

ERGONOMICS;

ARTICLE; CLINICAL PRACTICE; COGNITION; COMPREHENSION; CONFIDENTIALITY; GENERAL PRACTICE; HEALTH CARE DELIVERY; HEALTH CARE SYSTEM; INFORMATION PROCESSING; JOB PERFORMANCE; MEDICAL ERROR; METHODOLOGY; PATIENT SAFETY; RELIABILITY; THEORETICAL MODEL; VALIDITY; WORK ENVIRONMENT;

CLASSIFICATION; COGNITION; FAMILY PRACTICE; GREAT BRITAIN; HUMAN ENGINEERING; HUMANS; MEDICAL ERRORS; PRIMARY HEALTH CARE; SAFETY MANAGEMENT; SYSTEMS ANALYSIS;

EID: 33744787654     PISSN: 00140139     EISSN: 13665847     Source Type: Journal    
DOI: 10.1080/00140130600569038     Document Type: Article

References (42)

1. Annett, J. and Duncan, K. (1967) Task analysis and training design Occupational Psychology, 41, pp. 211-221.
2. Audit Commission.(2002) A Focus on General Practice in England. London: Audit Commission for Local Authorities and the National Health Service in England and Wales.
3. Bhasale, A. and Miller, G. and Reid, S. and Britt, H. (1998) Analysing potential harm in Australian general practice: An incident-monitoring study Medical Journal of Australia, 169, pp. 73-76.
4. Bogner, M. (2003) Safety issues Minimally Invasive Therapy & Allied Technologies, 12, pp. 121-124.
5. Busse, D. and Johnson, C.(1999) Identification and Analysis of Incidents in Complex, Medical Environments. Glasgow: Department of Computing Science, University of Glasgow. GAAG Technical Report G99 - 1, First Workshop on Human Error and Clinical Systems
6. Coles, J. and Pryce, D. and Shaw, C.(2001) The reporting of adverse clinical incidents - achieving high quality reporting: The results of a short research study. Report for the Patient Safety Research Programme in England. In. Available online at: http://pcpoh.bham.ac.uk/ publichealth/psrp/Pdf/coles_shaw_adverse_clinical_incidents.pdf (accessed 20 October 2004)
7. Department of Health.(2000) An Organisation with a Memory. London: The Stationery Office.
8. Dovey, S. and Meyers, D. and Phillips, R. and Green, L. and Fryer, G. and Galliher, J. and Kappus, J. and Grob, P. (2002) A preliminary taxonomy of medical errors in family practice Quality and Safety in Health Care, 11, pp. 233-238.
9. Flanagan, J. (1954) The critical incident technique Psychological Bulletin, 51, pp. 327-358.
10. Fleishman, E. and Quaintance, M.(1984) Taxonomies of Human Performance: The Description of Human Tasks. Orlando FL: Academic Press, Inc.
11. Isaac, A. and Shorrock, S. and Kirwan, B. (2002) Human error in European air traffic management: The HERA project Reliability Engineering & System Safety, 75, pp. 257-272.
12. Kaplan, H. and Rabin Fastman, B. (2003) Organization of event reporting data for sense making and system improvement Quality and Safety in Health Care, 12(supp. 2), pp. 68-72.
13. Kirwan, B.(1994) A Guide to Practical Human Reliability Assessment. London: Taylor & Francis.
14. Kirwan, B. (1998) Human error identification techniques for risk assessment of high risk systems - Part 1: Review and evaluation of techniques Applied Ergonomics, 29, pp. 157-177.
15. Kostopoulou, O. and Shepherd, A. (2000) Fragmentation of care and the potential for human error in neonatal intensive care Topics in Health Information Management (special edition of Human Error in Clinical Information Systems), 20, pp. 78-92.
16. Luchins, A. (1942) Mechanization in problem solving. The effect of Einstellung Psychological Monographs, 54, pp. 248.
17. Moray, N.(1994) Error reduction as a systems problem. In Human Error in Medicine. (pp. 67-91). Hillsdale NJ: Lawrence Erlbaum Associates.
18. Nickerson, R. (1998) Confirmation bias: A ubiquitous phenomenon in many guises Review of General Psychology, 2, pp. 175-220.
19. Norman, D.(1988) The Psychology of Everyday Things. New York: Basic Books.
20. O'Hare, D. (2000) The 'Wheel of Misfortune': A taxonomic approach to human factors in accident investigation and analysis in aviation and other complex systems Ergonomics, 43, pp. 2001-2019.
21. Rasmussen, J. (1982) Human errors: A taxonomy for describing human malfunction in industrial installations Journal of Occupational Accidents, 4, pp. 311-333.
22. Rasmussen, J.(1994) Afterword. In Human Error in Medicine. (pp. 385-393). Hillsdale NJ: Lawrence Erlbaum Associates.
23. Rasmussen, J. and Pedersen, O. and Carnino, A. and Griffon, M. and Mancini, G. and Gagnolet, P.(1981) Classification System for Reporting Events Involving Human Malfunctions. Luxemburg: Commission of the European Communities. EUR 7444 EN
24. Rasmussen, J. and Pejtersen, A. and Schmidt, K.(1990) Taxonomy for Cognitive Work Analysis. Roskilde: Riso National Laboratory. Riso-M-2871
25. Reason, J.(1987) A framework for classifying errors. In New technology and Human Error. J. Rasmussen, K. Duncan, and J. Leplat (Eds.) Chichester: Wiley.
26. Reason, J.(1990) Human Error. Cambridge: Cambridge University Press.
27. Reason, J.(1997) Managing the Risks of Organizational Accidents. Aldershot: Ashgate.
28. Rubin, G. and George, A. and Chinn, D. and Richardson, C. (2003) Errors in general practice: Development of an error classification and pilot study of a method for detecting errors Quality and Safety in Health Care, 12, pp. 443-447.
29. Sellen, A. (1994) Detection of everyday errors Applied Psychology: An International Review, 43, pp. 475-498.
30. Senders, J. and Moray, N.(1991) Human Error: Cause, Prediction, and Reduction. Hove: Lawrence Erlbaum Associates.
31. Shen, S. and Smidts, C. and Mosleh, A. (1997) A methodology for collection and analysis of human error data based on a cognitive model: IDA Nuclear Engineering and Design, 172, pp. 157-186.
32. Shepherd, A.(2001) Hierarchical Task Analysis. London: Taylor & Francis.
33. Shorrock, S. and Kirwan, B. (2002) Development and application of a human error identification tool for air traffic control Applied Ergonomics, 33, pp. 319-336.
34. Silk, N. (2000) What went wrong in 1000 negligence claims Health Care Risk Report, 7, pp. 13-15.
35. Tversky, A. and Kahneman, D.(1982) Availability: A heuristic for judging frequency and probability. In Judgment Under Uncertainty: Heuristics and Biases. (pp. 163-178). New York: Cambridge University Press.
36. van der Schaaf, T.(1992) Near miss reporting in the chemical process industry. In. Technische Universiteit Eindhoven. PhD thesis
37. van der Schaaf, T. and Kanse, L. (2004) Biases in incident reporting databases: An empirical study in the chemical process industry Safety Science, 42, pp. 57-67.
38. Wallace, B. and Ross, A. and Davies, J. and Wright, L. and White, M. (2002) The creation of a new minor event coding system Cognition, Technology & Work, 4, pp. 1-8.
39. Wickens, C.(1992) Engineering Psychology and Human Performance 2nd ed. New York: Harper-Collins.
40. Wickens, C. and Hollands, J.(2000) Engineering Psychology and Human Performance 3rd ed. New Jersey: Prentice Hall.
41. Wolf, F. and Gruppen, L. and Billi, J. (1985) Differential diagnosis and the competing hypotheses heuristic: A practical approach to judgment under uncertainty and Bayesian probability The Journal of the American Medical Association, 253, pp. 2858-2862.
42. Zhang, J. and Patel, V. and Johnson, T. and Shortliffe, E. (2004) A cognitive taxonomy of medical errors Journal of Biomedical Informatics, 37, pp. 193-204.