Assessing system failures in operating rooms and intensive care units

Quality and Safety in Health Care

Volumn 16, Issue 1, 2007, Pages 45-50

  Van Beuzekom, M ^a   Akerboom, S P ^b   Boer, F ^a  

^a LEIDEN UNIVERSITY MEDICAL CENTER   (Netherlands)

^b LEIDEN UNIVERSITY   (Netherlands)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; ARTICLE; FEMALE; HEALTH SURVEY; HOSPITAL PERSONNEL; HUMAN; HUMAN EXPERIMENT; INTENSIVE CARE UNIT; MALE; MEDICAL STAFF; OPERATING ROOM; PATIENT SAFETY; PROFESSIONAL COMPETENCE; QUESTIONNAIRE; RATING SCALE; RELIABILITY; TEACHING HOSPITAL; TREATMENT FAILURE; UNIVERSITY HOSPITAL; WORK CAPACITY;

ANALYSIS OF VARIANCE; FACTOR ANALYSIS, STATISTICAL; FEMALE; HEALTH CARE SURVEYS; HOSPITALS, TEACHING; HOSPITALS, UNIVERSITY; HUMANS; INTENSIVE CARE UNITS; MALE; NETHERLANDS; OPERATING ROOMS; PROBABILITY; QUESTIONNAIRES; RISK ASSESSMENT; SAFETY MANAGEMENT; SYSTEMS ANALYSIS;

EID: 33847338405     PISSN: 14753898     EISSN: None     Source Type: Journal    
DOI: 10.1136/qshc.2005.015446     Document Type: Article

References (40)

1. Institute of Medicine. To err is human: building a safer health system. Washington DC: National Academy Press, 2000.
2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.
3. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
4. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995;163:458-71.
5. Gawande AA, Thomas EJ, Zinner MJ, et al. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 1999;126:66-75.
6. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-19.
7. Leape LL. Error in medicine. JAMA 1994;272:1851-7.
8. Reason JT. Human error. Cambridge, UK: Cambridge University Press, 1990.
9. Shojania KG, Wald H, Gross R. Understanding medical error and improving patient safety in the inpatient setting. Med Clin North Am 2002;86:847-67.
10. Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978;49:399-406.
11. Reason J. Understanding adverse events: human factors. Qual Health Care 1995;4:80-9.
12. Reason J. The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond B Biol Sci 1990;327:475-84.
13. Carthey J, de Levai MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg 2001;72:300-5.
14. Wogenaar WA, Hudson PTW, Reason JT. Cognitive failures and accidents. Appl Cogn Psychol 1990;4:273-94.
15. Schoefer HG, Helmreich RL. The importance of human factors in the operating room. Anesthesiology 1994;80:479.
16. Gaba DM. Human error in dynamic medical domains. In: Bogner SM, eds. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates, 1994:197-224.
17. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995;23:294-300.
18. Helmreich RL. Team performance in the operating room. In: Bogner SM, eds. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates, 1994:225-53.
19. Vincent C, Moorthy K, Sarker SK, et al. Systems approaches to surgical quality and safely: from concept to measurement. Ann Surg 2004;239:475-82.
20. Hudson PTW, Reason JT, Wagenaar WA, et al. Tripod Delta - proactive approach to enhanced safety. Journal of Petroleum Technology 1994;46:58-62.
21. The Joint Commission. Root causes of sentinel events. http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8F- E8AF6571E372/0/root_cause_se.jpg (accessed 24 January 2007).
22. Leape LL. Reporting of adverse events. N Engl J Med 2002;347:1633-8.
23. Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Health Care 2003;12:112-8.
24. Akerboom SP, Doef M van der, Doest L ter, et al. Results of Quality of Work study, LUMC.University Leiden, Leiden.Health Psychology, 2002.
25. Steijger N, Starren A, Keus M, et al. A checklist to judge safety improvement plans for safety awareness, behaviour and culture. Report: Uithoorn, TNO-Arbeid, 2003.
26. Cattell RB. The scree test for the number of factors. Multivariate Behav Res 1966;1:245-76.
27. Vincent C, Taylor-Adams S, Chapman EJ, et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ 2000;320:777-81.
28. Wagenaar WA. The cause of impossible accidents. Deventer: Van Loghum Slaterus, 1986.
29. Kluger MT, Bullock MF. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS)1. Anaesthesia 2002;57:1060-6.
30. Gawande AA, Zinner MJ, Studdert DM, et al. Analysis of errors reported by surgeons at three leaching hospitals. Surgery 2003;133:614-21.
31. Flin R, Fletcher G, McGeorge P, et al. Anaesthetists' attitudes to teamwork and safety. Anaesthesia 2003;58:233-42.
32. Firth-Cozens J. Why communication fails in the operating room. Qual Saf Health Care 2004;13:327.
33. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med 2004;79:186-94.
34. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745- 9.
35. Lawton R. Not working to rule: understanding procedural violations at work. Saf Sci 1998;28:77-95.
36. Endsley MR. Measurement of situation awareness in dynamic-systems. Hum Factors 1995;37:65-84.
37. Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Hum Factors 1995;37:20-31.
38. Thomas EJ, Sexton JB, Helmreich RL. Discrepant altitudes about teamwork among critical care nurses and physicians. Crit Care Med 2003;31:956-9.
39. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology 1984;60:34-42.
40. Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: Bogner SM, eds. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates, 1994.