Learning from patient safety incidents: Creating participative risk regulation in healthcare

Health, Risk and Society

Volumn 10, Issue 1, 2008, Pages 53-67

  Macrae, Carl ^a  

^a LONDON SCHOOL OF ECONOMICS   (United Kingdom)

Author keywords

Error analysis; Incident reporting; Risk management; Safety oversight; Worker participation

Indexed keywords

ARTICLE; AVIATION; CHEMICAL INDUSTRY; CULTURAL FACTOR; FINANCIAL MANAGEMENT; HEALTH CARE ORGANIZATION; HEALTH CARE SYSTEM; HUMAN; INCIDENCE; MEDICAL PRACTICE; PATIENT SAFETY; PUBLICATION; RISK MANAGEMENT; UNITED KINGDOM;

EID: 39049137606     PISSN: 13698575     EISSN: 14698331     Source Type: Journal    
DOI: 10.1080/13698570701782452     Document Type: Article

References (50)

1. Adams, N. L. and Hartwell, N. M. (1977) Accident-reporting systems: A basic problem area in industrial society. Journal of Occupational Psychology, 50, pp. 285-298.
2. Ayres, I. and Braithwaite, J. (1992) Responsive Regulation, Oxford University Press, Oxford
3. Barach, P. and Small, D. (2000) Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. British Medical Journal, 320, pp. 759-763.
4. Beckman, U., West, L. F., Groombridge, G. J., Baldwin, I., Hart, G. K. and Clayton, D. G. (1996) The Australian Incident Monitoring Study in intensive care: AIMS-ICU. Anaesthesia and Intensive Care, 24, pp. 314-319.
5. Billings, C. (1998) Incident-reporting systems in medicine and experience with the aviation reporting system. A Tale of Two Stories: Contrasting Views of Patient Safety, US National Patient Safety Foundation, North Adams, MA
6. Bosk, C. L. (1979) Forgive and Remember: Managing Medical Failure, University of Chicago Press, Chicago
7. Carroll, J. S. (1995) Incident reviews in high-hazard industries: Sense making and learning under ambiguity and accountability. Industrial and Environmental Crisis Quarterly, 9:2, pp. 175-197.
8. Carroll, J. S. (1998) Organizational learning in high-hazard industries: the logics underlying self-analysis. Journal of Management Studies, 35:6, pp. 699-717.
9. Carroll, J. S. and Edmondson, A. C. (2002) Leading organisational learning in healthcare. Quality and Safety in Healthcare, 11, pp. 51-56.
10. Carroll, J. S., Rudolph, J. W. and Hatakenaka, S. (2002) Lessons learned from non-medical industries: Root cause analysis as culture change at a chemical plant. Quality and Safety in Healthcare, 11, pp. 266-269.
11. Department of Health (2006) On the State of the Public Health: Annual Report of the Chief Medical Officer 2005, Department of Health, London
12. Dixon, N. M. and Shofer, M. (2006) Struggling to invent high-reliability organizations in health care settings: Insights from the field. Health Services Research, 41:1, pp. 1618-1632.
13. Döös, M. and Backström, T. (2003) Constructing workplace safety through control and learning: Conflict or compatibility?. Constructing Risk and Safety in Technological Practice, Routledge, London
14. Green, J. (2003) The ultimate challenge for risk technologies: controlling the accidental. Constructing Risk and Safety in Technological Practice, Routledge, London
15. Hale, A. (2000) The Tokai Mura accident. Cognition, Technology and Work, 2:4, pp. 215-217.
16. Hopkins, A. (1999) Managing Major Hazards: The Lessons of the Moura Mine Disaster, Allen and Unwin, St Leonards
17. Hutter, B. (2001) Regulation and Risk: Occupational Health and Safety on the Railways, Oxford University Press, Oxford
18. Hutter, B. (2006) Risk, regulation and management. Risk in Social Science, Oxford University Press, Oxford
19. Hutter, B. and Lloyd-Bostock, S. (1990) The power of accidents: The social and psychological impact of accidents and the enforcement of safety regulations. The British Journal of Criminology, 30:4, pp. 409-422.
20. (2005) Organizational Encounters with Risk, Cambridge University Press, Cambridge
21. Institute of Risk Management (2002) A Risk Management Standard, IRM, ALARM and AIRMIC, London
22. Kohn, L., Corrigan, J. and Donaldson, M. E. (1999) To Err is Human, National Academy Press, Washington, DC
23. Lave, J. and Wenger, E. (1991) Situated Learning: Legitimate Peripheral Participation, Cambridge University Press, Cambridge
24. Munton, R. (2003) Deliberative democracy and environmental decision-making. Negotiating Environmental Change: New Perspectives from Social Science, Edward Elgar, Cheltenham
25. Murphy, K. (2006) What pilots can teach hospitals about patient safety. The New York Times
26. National Patient Safety Agency (2003) Seven Steps to Patient Safety: An Overview Guide for NHS Stall, National Patient Safety, London
27. National Patient Safety Agency (2005) Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety, National Patient Safety Agency, London
28. National Research Council (1996) Understanding Risk: Information Decisions in a Democratic Society, National Academy, Washington, DC
29. O'Riordan, T. and Stoll-Kleemann, S. (2002) Deliberative democracy and participatory biodiversity. Biodiversity, Sustainability and Human Communities: Protecting Beyond the Protected, Cambridge University Press, Cambridge
30. Perrow, C. (1999) Normal Accidents: Living with High-risk Technologies, Princeton University Press, Princeton
31. Pidgeon, N. and O'Leary, M. (2000) Man-made disasters: Why technology and organizations (sometimes) fail. Safety Science, 34, pp. 15-30.
32. Power, M. (2007) Organized Uncertainity: Designing a World of Risk Management, Oxford University Press, Oxford
33. Reason, J. (1997) Managing the Risks of Organizational Accidents, Ashgate, Aldershot
34. Reason, J. (2000) Human error: Models and management. British Medical Journal, 320, pp. 768-770.
35. Rochlin, G. I. (1989) Informal organizational networking as a crisis-avoidance strategy: US Naval flight operations as a case study. Industrial Crisis Quarterly, 3, pp. 159-176.
36. Sahlin-Andersson, K. and Engwall, L. (2002) Carriers, flows and sources of management knowledge. The Expansion of Management Knowledge: Carriers, Flows and Sources, Stanford University Press, London
37. Schulman, P. R. (1993) The negotiated order of organizational reliability. Administration and Society, 25:3, pp. 353-372.
38. Shearing, C. (1993) A constitutive conception of regulation. Business Regulation and Australia's Future, Australian Institute of Criminology, Canberra
39. Tamuz, M. and Thomas, E. J. (2006) Classifying and interpreting threats to patient safety in hospitals: Insights from aviation. Journal of Organizational Behaviour, 27, pp. 919-940.
40. (1991) Near Miss Reporting as a Safety Tool, Butterworth-Heinemann, Oxford
41. Vaughan, D. (1990) Autonomy, interdependence, and social control: NASA and the space shuttle. Challenger. Administrative Science Quarterly, 35, pp. 225-257.
42. Vincent, C. (2004) Analysis of clinical incidents: A window onto the system not a search for root causes. Quality, Safety and Healthcare, 13, pp. 242-243.
43. Vincent, C. (2006) Patient Safety, Elsevier, London
44. Weick, K. E. (1987) Organizational culture as a source of high reliability. California Management Review, 29:2, pp. 112-127.
45. Weick, K. E. and Sutcliffe, K. M. (2003) Hospitals as cultures of entrapment: A re-analysis of the Bristol Royal Infirmary. California Management Review, 45:2, pp. 73-84.
46. Wildavsky, A. (1988) Searching for Safety, Transaction Publishers, Oxford
47. Woods, D. D. and Shattuck, L. G. (2000) Distant supervision-local action given the potential for surprise. Cognition, Technology and Work, 2, pp. 86-96.
48. World Health Organization (2004) World Alliance for Patient Safety: Forward Programme 2005, World Health Organization, Geneva
49. Wright, D. A. and Lyons, J. E. (2001) Flight data monitoring: Its place within a safety management system. Paper presented at the 13th European aviation safety seminar Toward a safer Europe Amsterdam, Netherlands
50. Wu, A. W., Pronovost, P. and Morlock, L. (2002) ICU incident-reporting systems. Journal of Critical Care, 17, pp. 86-94.