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Volumn 48, Issue 5, 2010, Pages 625-639

A human factors and reliability approach to clinical risk management: Evidence from Italian cases

Author keywords

Clinical risk management; Healthcare management; Human factors theory; Human Reliability Analysis; Patient safety; Socio technical systems

Indexed keywords

CLINICAL RISKS; HEALTHCARE MANAGEMENT; HUMAN FACTORS; HUMAN RELIABILITY ANALYSIS; PATIENT SAFETY; SOCIOTECHNICAL SYSTEMS;

EID: 77950526585     PISSN: 09257535     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.ssci.2010.01.014     Document Type: Article
Times cited : (46)

References (131)
  • 3
    • 0035323957 scopus 로고    scopus 로고
    • Modelling multimodal human-computer interaction using critical path analysis
    • Baber C., Mellor B.A. Modelling multimodal human-computer interaction using critical path analysis. Int. J. Human Comput. Studies 2001, 54:613-636.
    • (2001) Int. J. Human Comput. Studies , vol.54 , pp. 613-636
    • Baber, C.1    Mellor, B.A.2
  • 4
    • 0029871644 scopus 로고    scopus 로고
    • Human error identification techniques applied to public technology: predictions compared with observed use
    • Baber C., Stanton N.A. Human error identification techniques applied to public technology: predictions compared with observed use. Appl. Ergon. 1996, 27(2):119-131.
    • (1996) Appl. Ergon. , vol.27 , Issue.2 , pp. 119-131
    • Baber, C.1    Stanton, N.A.2
  • 7
    • 0021136841 scopus 로고
    • Human factors in aircraft incidents: results of a 7years study
    • Billings C., Reynard W. Human factors in aircraft incidents: results of a 7years study. Aviat. Space Environ. Med. 1984, 55(10):960-965.
    • (1984) Aviat. Space Environ. Med. , vol.55 , Issue.10 , pp. 960-965
    • Billings, C.1    Reynard, W.2
  • 10
    • 0031725509 scopus 로고    scopus 로고
    • Safety culture as an ongoing process: culture surveys as opportunities for enquiry and change
    • Carroll J.S. Safety culture as an ongoing process: culture surveys as opportunities for enquiry and change. Work Stress 1998, 12:272-284.
    • (1998) Work Stress , vol.12 , pp. 272-284
    • Carroll, J.S.1
  • 11
    • 0036752770 scopus 로고    scopus 로고
    • Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant
    • Carroll J.S., Rudolph J.W., Hatakenaka S. Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Qual. Safety Health Care 2002, 11(3):266-269.
    • (2002) Qual. Safety Health Care , vol.11 , Issue.3 , pp. 266-269
    • Carroll, J.S.1    Rudolph, J.W.2    Hatakenaka, S.3
  • 12
    • 0034938647 scopus 로고    scopus 로고
    • The human factor in cardiac surgery: errors and near misses in a high technology medical domain
    • Carthey J., De Leval M.R., Reason J.T. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann. Thorac. Surg. 2001, 72(1):300-305.
    • (2001) Ann. Thorac. Surg. , vol.72 , Issue.1 , pp. 300-305
    • Carthey, J.1    De Leval, M.R.2    Reason, J.T.3
  • 13
    • 77950543454 scopus 로고
    • CCPS (Center for Chemical Process Safety),. Guidelines for Preventing Human Error in Process Safety. American Institute of Chemical Engineers, New York.
    • CCPS (Center for Chemical Process Safety), 1994. Guidelines for Preventing Human Error in Process Safety. American Institute of Chemical Engineers, New York.
    • (1994)
  • 14
    • 16544364421 scopus 로고    scopus 로고
    • Seven steps to patient safety
    • Chamberlain-Webber J. Seven steps to patient safety. Prof. Nurse 2004, 20(3):10-14.
    • (2004) Prof. Nurse , vol.20 , Issue.3 , pp. 10-14
    • Chamberlain-Webber, J.1
  • 15
    • 36949020795 scopus 로고    scopus 로고
    • The nature of safety culture: a survey of the state-of the-art
    • Choudhry R.M., Fang D., Mohamed S. The nature of safety culture: a survey of the state-of the-art. Safety Sci. 2006.
    • (2006) Safety Sci.
    • Choudhry, R.M.1    Fang, D.2    Mohamed, S.3
  • 16
    • 0033084310 scopus 로고    scopus 로고
    • Perceptions of organizational safety: implications for the development of safety culture
    • Clarke S. Perceptions of organizational safety: implications for the development of safety culture. J. Organ. Behav. 1999, 20:185-198.
    • (1999) J. Organ. Behav. , vol.20 , pp. 185-198
    • Clarke, S.1
  • 17
    • 0017566934 scopus 로고
    • Factors in successful occupational safety programs
    • Cohen A. Factors in successful occupational safety programs. J. Safety Res. 1977, 9(4):168-178.
    • (1977) J. Safety Res. , vol.9 , Issue.4 , pp. 168-178
    • Cohen, A.1
  • 20
    • 0034158686 scopus 로고    scopus 로고
    • Towards a model of safety culture
    • Cooper M.D. Towards a model of safety culture. Safety Sci. 2000, 36:111-136.
    • (2000) Safety Sci. , vol.36 , pp. 111-136
    • Cooper, M.D.1
  • 21
    • 9244233332 scopus 로고    scopus 로고
    • Exploratory analysis of the safety climate and safety behaviour relationship
    • Cooper M.D., Philips R.A. Exploratory analysis of the safety climate and safety behaviour relationship. J. Safety Res. 2004, 35(5):497-512.
    • (2004) J. Safety Res. , vol.35 , Issue.5 , pp. 497-512
    • Cooper, M.D.1    Philips, R.A.2
  • 22
    • 0031759095 scopus 로고    scopus 로고
    • Safety culture: philosopher's stone or man of straw ?
    • Cox S., Flin R. Safety culture: philosopher's stone or man of straw ?. Work Stress 1998, 12(3):189-201.
    • (1998) Work Stress , vol.12 , Issue.3 , pp. 189-201
    • Cox, S.1    Flin, R.2
  • 25
    • 0002073620 scopus 로고
    • A safety climate measure for construction sites
    • DeDobbeleer N., Beland F. A safety climate measure for construction sites. J. Safety Res. 1991, 22:97-103.
    • (1991) J. Safety Res. , vol.22 , pp. 97-103
    • DeDobbeleer, N.1    Beland, F.2
  • 26
    • 0036580468 scopus 로고    scopus 로고
    • Using health care failure mode and effect analysis: the VA National Center for Patient Safety's prospective risk analysis system
    • DeRosier J., Stalhandske E., Bagian J.P., Nudell T. Using health care failure mode and effect analysis: the VA National Center for Patient Safety's prospective risk analysis system. Joint Commission J. Qual. Improve. 2002, 28(5):248-267.
    • (2002) Joint Commission J. Qual. Improve. , vol.28 , Issue.5 , pp. 248-267
    • DeRosier, J.1    Stalhandske, E.2    Bagian, J.P.3    Nudell, T.4
  • 27
    • 0034335593 scopus 로고    scopus 로고
    • A framework for linking culture and improvement initiatives in organizations
    • Detert J.R., Schroeder R.G., Mauriel J.J. A framework for linking culture and improvement initiatives in organizations. Acad. Manage. Rev. 2000.
    • (2000) Acad. Manage. Rev.
    • Detert, J.R.1    Schroeder, R.G.2    Mauriel, J.J.3
  • 31
    • 77950545135 scopus 로고    scopus 로고
    • Organizational safety culture. In: Proceedings of the Tenth International Symposium on Aviation Psychology. Department of Aviation, Columbus, OH,
    • Eiff, G., 1999. Organizational safety culture. In: Proceedings of the Tenth International Symposium on Aviation Psychology. Department of Aviation, Columbus, OH, pp. 1-14.
    • (1999) , pp. 1-14
    • Eiff, G.1
  • 32
    • 77950528020 scopus 로고
    • SHERPA: A Systematic Approach for Assessing and Reducing Human Error in Process Plants
    • Embrey D.E. SHERPA: A Systematic Approach for Assessing and Reducing Human Error in Process Plants. Human Reliability Associated Ltd. 1986.
    • (1986) Human Reliability Associated Ltd.
    • Embrey, D.E.1
  • 33
    • 47949103721 scopus 로고
    • The critical incident technique
    • Flanagan J.C. The critical incident technique. Psychol. Bull. 1954, 51(4):327-358.
    • (1954) Psychol. Bull. , vol.51 , Issue.4 , pp. 327-358
    • Flanagan, J.C.1
  • 34
    • 0029705872 scopus 로고    scopus 로고
    • The offshore supervisor's role in safety management: law enforcer or risk manager. Paper Presented at the Third International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production. New Orleans, LA.
    • Fleming, M.T., Flin, R., Mearns, K., Gordon, R., 1996. The offshore supervisor's role in safety management: law enforcer or risk manager. Paper Presented at the Third International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production. New Orleans, LA.
    • (1996)
    • Fleming, M.T.1    Flin, R.2    Mearns, K.3    Gordon, R.4
  • 35
    • 10344228729 scopus 로고    scopus 로고
    • Leadership for safety: industrial experience
    • Flin R., Yule S. Leadership for safety: industrial experience. Qual. Safety Health Care 2004, 13(Suppl. II):ii45-ii51.
    • (2004) Qual. Safety Health Care , vol.13 , Issue.SUPPL. 2
    • Flin, R.1    Yule, S.2
  • 36
    • 0034037458 scopus 로고    scopus 로고
    • Measuring safety climate: identifying the common features
    • Flin R., Mearns K., O'Connor P., Bryden R. Measuring safety climate: identifying the common features. Safety Sci. 2000, 34(1/3).
    • (2000) Safety Sci. , vol.34 , Issue.1-3
    • Flin, R.1    Mearns, K.2    O'Connor, P.3    Bryden, R.4
  • 37
    • 77950521769 scopus 로고    scopus 로고
    • Introduzione al risk management: un approccio integrato alla gestione dei rischi aziendali. ETAS, Milano.
    • Floreani, A., 2005. Introduzione al risk management: un approccio integrato alla gestione dei rischi aziendali. ETAS, Milano.
    • (2005)
    • Floreani, A.1
  • 38
    • 0034681804 scopus 로고    scopus 로고
    • Anaesthesiology as a model for patient safety in health care
    • Gaba D.M. Anaesthesiology as a model for patient safety in health care. BMJ 2000, 320(7237):785-788.
    • (2000) BMJ , vol.320 , Issue.7237 , pp. 785-788
    • Gaba, D.M.1
  • 39
    • 0034557582 scopus 로고    scopus 로고
    • Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries
    • Gaba D.M. Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries. Calif. Manage. Rev. 2001, 43:83-102.
    • (2001) Calif. Manage. Rev. , vol.43 , pp. 83-102
    • Gaba, D.M.1
  • 40
    • 0034077365 scopus 로고    scopus 로고
    • Perspectives on safety culture
    • Glendon A.I., Stanton N.A. Perspectives on safety culture. Safety Sci. 2000, 34(1/3):193-214.
    • (2000) Safety Sci. , vol.34 , Issue.1-3 , pp. 193-214
    • Glendon, A.I.1    Stanton, N.A.2
  • 41
    • 0029702550 scopus 로고    scopus 로고
    • Assessing the human factors causes of accidents in the offshore oil industry. Paper Presented at the Third International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production. New Orleans, LA.
    • Gordon, R., Flin, R., Mearns, K., Fleming, M.T., 1996. Assessing the human factors causes of accidents in the offshore oil industry. Paper Presented at the Third International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production. New Orleans, LA.
    • (1996)
    • Gordon, R.1    Flin, R.2    Mearns, K.3    Fleming, M.T.4
  • 42
    • 0036904946 scopus 로고    scopus 로고
    • Human factors engineering and patient safety
    • Gosbee J.W. Human factors engineering and patient safety. Qual. Safety Health Care 2002, 11:352-354.
    • (2002) Qual. Safety Health Care , vol.11 , pp. 352-354
    • Gosbee, J.W.1
  • 44
    • 0034028034 scopus 로고    scopus 로고
    • The nature of safety culture: a review of theory and research
    • Guldenmund F.W. The nature of safety culture: a review of theory and research. Safety Sci. 2000, 34:215-257.
    • (2000) Safety Sci. , vol.34 , pp. 215-257
    • Guldenmund, F.W.1
  • 45
    • 69249157692 scopus 로고    scopus 로고
    • Applying root cause analysis and failure mode and effect analysis to our compliance programs
    • Hambleton M. Applying root cause analysis and failure mode and effect analysis to our compliance programs. J. Health Care Compliance 2005.
    • (2005) J. Health Care Compliance
    • Hambleton, M.1
  • 46
    • 0034438431 scopus 로고    scopus 로고
    • Risk management in practice: how are we managing?
    • Harris A. Risk management in practice: how are we managing?. Brit. J. Clin. Govern. 2000, 5.
    • (2000) Brit. J. Clin. Govern. , pp. 5
    • Harris, A.1
  • 47
    • 0034681762 scopus 로고    scopus 로고
    • On error management: lessons from aviation
    • Helmreich R.L. On error management: lessons from aviation. Brit. Med. J. 2000, 320:781-785.
    • (2000) Brit. Med. J. , vol.320 , pp. 781-785
    • Helmreich, R.L.1
  • 48
    • 33750921264 scopus 로고    scopus 로고
    • An investigation of the relationship between safety climate and medication errors as well as other nurse patent outcomes
    • Hofmann D.A., Mark B. An investigation of the relationship between safety climate and medication errors as well as other nurse patent outcomes. Pers. Psychol. 2006, 59:847-869.
    • (2006) Pers. Psychol. , vol.59 , pp. 847-869
    • Hofmann, D.A.1    Mark, B.2
  • 50
    • 33750295472 scopus 로고    scopus 로고
    • Studying organisational cultures and their effects on safety
    • Hopkins A. Studying organisational cultures and their effects on safety. Safety Sci. 2006, 44:875-889.
    • (2006) Safety Sci. , vol.44 , pp. 875-889
    • Hopkins, A.1
  • 51
    • 77950523663 scopus 로고    scopus 로고
    • HSC - Health and Safety Commission,. HSE Books.
    • HSC - Health and Safety Commission, 2001. HSE Books.
    • (2001)
  • 52
    • 0347403555 scopus 로고    scopus 로고
    • Applying the lessons of high risk industries to health care
    • Hudson P. Applying the lessons of high risk industries to health care. Qual. Safety Health Care 2003, 12.
    • (2003) Qual. Safety Health Care , pp. 12
    • Hudson, P.1
  • 53
    • 10844224647 scopus 로고    scopus 로고
    • Application of human reliability analysis to nursing errors in hospitals
    • Inoue K., Koizumi A. Application of human reliability analysis to nursing errors in hospitals. Risk Anal. 2004, 24(6):1459-1473.
    • (2004) Risk Anal. , vol.24 , Issue.6 , pp. 1459-1473
    • Inoue, K.1    Koizumi, A.2
  • 54
    • 77950548288 scopus 로고    scopus 로고
    • JCAHO - Joint Commission on Accreditation of Healthcare Organization,. Revisions to Joint Commission Standards in Support of Patient Safety and Medical/Health Care Error Reduction. JCAHO, OakBrook Terrace, IL.
    • JCAHO - Joint Commission on Accreditation of Healthcare Organization, 2001. Revisions to Joint Commission Standards in Support of Patient Safety and Medical/Health Care Error Reduction. JCAHO, OakBrook Terrace, IL.
    • (2001)
  • 55
    • 0032483947 scopus 로고    scopus 로고
    • Errors enacted during laparoscopic surgery - a human reliability analysis
    • Joice P., Hanna G.B., Cuschieri A. Errors enacted during laparoscopic surgery - a human reliability analysis. Appl. Ergon. 1998, 29:409-414.
    • (1998) Appl. Ergon. , vol.29 , pp. 409-414
    • Joice, P.1    Hanna, G.B.2    Cuschieri, A.3
  • 56
    • 0347586852 scopus 로고    scopus 로고
    • Organization of event reporting data for sense making and system improvement
    • Kaplan H.S., Fastman B.R. Organization of event reporting data for sense making and system improvement. Qual. Safety Health Care 2003, 12:ii68.
    • (2003) Qual. Safety Health Care , vol.12
    • Kaplan, H.S.1    Fastman, B.R.2
  • 57
    • 0342483948 scopus 로고
    • Psychological climate and accidents in an automobile plant
    • Keenan V., Kerr C., Sherman W. Psychological climate and accidents in an automobile plant. J. Appl. Psychol. 1951, 35:108-111.
    • (1951) J. Appl. Psychol. , vol.35 , pp. 108-111
    • Keenan, V.1    Kerr, C.2    Sherman, W.3
  • 60
    • 3042855818 scopus 로고    scopus 로고
    • Cognitive task analysis of teams
    • Lawrence Erlbaum, Mahwan, New Jersey, J.M. Schraagen, S.F. Chipman, V.L. Shalin (Eds.)
    • Klein G. Cognitive task analysis of teams. Cognitive Task Analysis 2000, 417-431. Lawrence Erlbaum, Mahwan, New Jersey. J.M. Schraagen, S.F. Chipman, V.L. Shalin (Eds.).
    • (2000) Cognitive Task Analysis , pp. 417-431
    • Klein, G.1
  • 62
    • 33744787654 scopus 로고    scopus 로고
    • From cognition to the system: developing a multi-level taxonomy of patient safety on general practice
    • Kostopoulou O. From cognition to the system: developing a multi-level taxonomy of patient safety on general practice. Ergonomics 2006, 49(5-6):486-502.
    • (2006) Ergonomics , vol.49 , Issue.5-6 , pp. 486-502
    • Kostopoulou, O.1
  • 63
    • 0036596101 scopus 로고    scopus 로고
    • The need for risk management to evolve to assure a culture of safety
    • Kuhn A.M., Youngberg B.J. The need for risk management to evolve to assure a culture of safety. Qual. Safety Health Care 2002, 11:158-162.
    • (2002) Qual. Safety Health Care , vol.11 , pp. 158-162
    • Kuhn, A.M.1    Youngberg, B.J.2
  • 64
    • 59349106285 scopus 로고    scopus 로고
    • Optimizing FMEA and RCA efforts in health care
    • Latino R.J. Optimizing FMEA and RCA efforts in health care. ASHRM J. 2004, 24:23.
    • (2004) ASHRM J. , vol.24 , pp. 23
    • Latino, R.J.1
  • 65
    • 0028097184 scopus 로고
    • Error in medicine
    • Leape L.L. Error in medicine. JAMA 1994, 272(23):1851-1857.
    • (1994) JAMA , vol.272 , Issue.23 , pp. 1851-1857
    • Leape, L.L.1
  • 66
    • 0032956035 scopus 로고    scopus 로고
    • Why should we report adverse incidents?
    • Leape L.L. Why should we report adverse incidents?. J. Eval. Clin. Practice 1999, 5:l-4.
    • (1999) J. Eval. Clin. Practice , vol.5
    • Leape, L.L.1
  • 67
    • 0031757283 scopus 로고    scopus 로고
    • Assessment of safety culture at a nuclear reprocessing plant
    • Lee T. Assessment of safety culture at a nuclear reprocessing plant. Work Stress 1998, 12(3):217-237.
    • (1998) Work Stress , vol.12 , Issue.3 , pp. 217-237
    • Lee, T.1
  • 69
    • 0141504980 scopus 로고    scopus 로고
    • Using human reliability analysis to detect surgical error in endoscopic DCR surgery
    • Malik R., White P.S., Macewent C.J. Using human reliability analysis to detect surgical error in endoscopic DCR surgery. Clin. Otolaryngol. Allied Sci. 2003, 28(5):456-460.
    • (2003) Clin. Otolaryngol. Allied Sci. , vol.28 , Issue.5 , pp. 456-460
    • Malik, R.1    White, P.S.2    Macewent, C.J.3
  • 70
    • 77950522803 scopus 로고    scopus 로고
    • Development of the human error template - a new methodology for assessing design induced errors on aircraft flight decks. ERRORPRED Final Report E1970.
    • Marshall, A., Stanton, N., Young, M., Salmon, P., Harris, D., Demalagalski, J., Waldmann, T., Dekker, S., 2003. Development of the human error template - a new methodology for assessing design induced errors on aircraft flight decks. ERRORPRED Final Report E1970.
    • (2003)
    • Marshall, A.1    Stanton, N.2    Young, M.3    Salmon, P.4    Harris, D.5    Demalagalski, J.6    Waldmann, T.7    Dekker, S.8
  • 71
    • 33644844674 scopus 로고    scopus 로고
    • Stories from the sharp end: case studies in safety improvement
    • McCarthy D., Blumenthal D. Stories from the sharp end: case studies in safety improvement. Milbank Quart. 2006, 84(1):165-200.
    • (2006) Milbank Quart. , vol.84 , Issue.1 , pp. 165-200
    • McCarthy, D.1    Blumenthal, D.2
  • 72
    • 33645243551 scopus 로고    scopus 로고
    • Exploring strategies for reducing hospital errors
    • McFadden K.L., Stock G.N., Gowen C.R. Exploring strategies for reducing hospital errors. J. Health Care Manage. 2006, 51(2):,123-136.
    • (2006) J. Health Care Manage. , vol.51 , Issue.2 , pp. 123-136
    • McFadden, K.L.1    Stock, G.N.2    Gowen, C.R.3
  • 73
    • 77950545649 scopus 로고    scopus 로고
    • Human performance, organizational factors and safety culture. Paper Presented on National Summit by NTSB on Transportation Safety. Washington, DC.
    • Meshkati, N., 1997. Human performance, organizational factors and safety culture. Paper Presented on National Summit by NTSB on Transportation Safety. Washington, DC.
    • (1997)
    • Meshkati, N.1
  • 74
    • 77950529467 scopus 로고    scopus 로고
    • Applied cognitive task analysis (ACTA): a practitioner's toolkit for understanding cognitive task demands
    • Taylor and Francis, London, J. Annette, N.S. Stanton (Eds.)
    • Militello L.G., Hutton J.B. Applied cognitive task analysis (ACTA): a practitioner's toolkit for understanding cognitive task demands. Task Analysis 2000, 90-113. Taylor and Francis, London. J. Annette, N.S. Stanton (Eds.).
    • (2000) Task Analysis , pp. 90-113
    • Militello, L.G.1    Hutton, J.B.2
  • 75
    • 33846367080 scopus 로고    scopus 로고
    • Establishing a culture for patient safety - the role of education
    • Milligan F.J. Establishing a culture for patient safety - the role of education. Nurse Educ. Today 2007, 27.
    • (2007) Nurse Educ. Today , pp. 27
    • Milligan, F.J.1
  • 76
    • 77950522802 scopus 로고    scopus 로고
    • Ministero della Salute, Il Risk Management in sanità. Il problema degli errori. Commissione tecnica sul rischio. Roma.
    • Ministero della Salute, 2004. Il Risk Management in sanità. Il problema degli errori. Commissione tecnica sul rischio. Roma.
    • (2004)
  • 79
    • 0034681823 scopus 로고    scopus 로고
    • Accreditation's role in reducing medical errors
    • O'Leary D.S. Accreditation's role in reducing medical errors. BMJ 2000, 320.
    • (2000) BMJ , pp. 320
    • O'Leary, D.S.1
  • 81
    • 33646507651 scopus 로고    scopus 로고
    • A framework for understanding the development of organisational safety culture
    • Parker D., Lawrie M., Hudson P. A framework for understanding the development of organisational safety culture. Safety Sci. 2006, 44:551-562.
    • (2006) Safety Sci. , vol.44 , pp. 551-562
    • Parker, D.1    Lawrie, M.2    Hudson, P.3
  • 82
    • 0038510105 scopus 로고    scopus 로고
    • Managing clinical risk: the RCOG approach
    • Penney G. Managing clinical risk: the RCOG approach. Clin. Risk 2003, 9:94-98.
    • (2003) Clin. Risk , vol.9 , pp. 94-98
    • Penney, G.1
  • 83
    • 0034028204 scopus 로고    scopus 로고
    • Man-made disasters: why technology and organizations (sometimes) fail
    • Pidgeon N., O'Leary M. Man-made disasters: why technology and organizations (sometimes) fail. Safety Sci. 2000, 34(1/3).
    • (2000) Safety Sci. , vol.34 , Issue.1-3
    • Pidgeon, N.1    O'Leary, M.2
  • 84
    • 0005365039 scopus 로고    scopus 로고
    • THEA: a technique for human error assessment early in design
    • IOS Press, Amsterdam, M. Hirose (Ed.)
    • Pocock S., Harrison M.D., Wright P.C., Johnson P. THEA: a technique for human error assessment early in design. Interact01 2001, 247-254. IOS Press, Amsterdam. M. Hirose (Ed.).
    • (2001) Interact01 , pp. 247-254
    • Pocock, S.1    Harrison, M.D.2    Wright, P.C.3    Johnson, P.4
  • 85
    • 0000876413 scopus 로고
    • Cognitive walkthrough: a method for theory based evaluation of user interfaces
    • Polson P.G., Lewis C., Rienam C., Wharton C. Cognitive walkthrough: a method for theory based evaluation of user interfaces. Int. J. Man-Mach. Studies 1992, 36:741-773.
    • (1992) Int. J. Man-Mach. Studies , vol.36 , pp. 741-773
    • Polson, P.G.1    Lewis, C.2    Rienam, C.3    Wharton, C.4
  • 87
    • 23644459784 scopus 로고    scopus 로고
    • Assessing safety cultures: guidelines and recommendations
    • Pronovost P., Sexton J. Assessing safety cultures: guidelines and recommendations. Qual. Safety Health Care 2005, 14:231-233.
    • (2005) Qual. Safety Health Care , vol.14 , pp. 231-233
    • Pronovost, P.1    Sexton, J.2
  • 88
    • 33745611771 scopus 로고    scopus 로고
    • How will we know patients are safer? An organization-wide approach to measuring and improving safety
    • Pronovost P., Holzmueller C., Needham D.M. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit. Care Med. 2006, 34(7):1988-1995.
    • (2006) Crit. Care Med. , vol.34 , Issue.7 , pp. 1988-1995
    • Pronovost, P.1    Holzmueller, C.2    Needham, D.M.3
  • 89
    • 0031279121 scopus 로고    scopus 로고
    • Risk management in a dynamic society: a modelling problem
    • Rasmussen J. Risk management in a dynamic society: a modelling problem. Safety Sci. 1997, 27(2/3):183-213.
    • (1997) Safety Sci. , vol.27 , Issue.2-3 , pp. 183-213
    • Rasmussen, J.1
  • 90
    • 0004223940 scopus 로고
    • Cambridge University Press, New York
    • Reason J.T. Human Error 1990, Cambridge University Press, New York.
    • (1990) Human Error
    • Reason, J.T.1
  • 91
    • 0001945177 scopus 로고
    • Understanding adverse events: human factors
    • British Medical Journal Publishing Group, London, C. Vincent (Ed.)
    • Reason J.T. Understanding adverse events: human factors. Clinical Risk Management 1995, 31-54. British Medical Journal Publishing Group, London. C. Vincent (Ed.).
    • (1995) Clinical Risk Management , pp. 31-54
    • Reason, J.T.1
  • 93
    • 0034681819 scopus 로고    scopus 로고
    • Human error: models and management
    • Reason J.T. Human error: models and management. Brit. Med. J. 2000, 320:768-770.
    • (2000) Brit. Med. J. , vol.320 , pp. 768-770
    • Reason, J.T.1
  • 94
    • 84934563541 scopus 로고
    • Some characteristics of high reliability organizations
    • Roberts K.H. Some characteristics of high reliability organizations. Organ. Sci. 1990, 1(2):160-177.
    • (1990) Organ. Sci. , vol.1 , Issue.2 , pp. 160-177
    • Roberts, K.H.1
  • 95
    • 38249001207 scopus 로고
    • From Bhopal to banking: organizational design can mitigate risk
    • Roberts K.H., Libuser C. From Bhopal to banking: organizational design can mitigate risk. Organ. Dyn. 1993, 21(4):15.
    • (1993) Organ. Dyn. , vol.21 , Issue.4 , pp. 15
    • Roberts, K.H.1    Libuser, C.2
  • 96
    • 34250800434 scopus 로고
    • Research in nearly failure-free, high-reliability organizations: having the bubble
    • Roberts K.H., Rousseau D.M. Research in nearly failure-free, high-reliability organizations: having the bubble. IEEE Trans. Eng. Manage. 1989, 36(2):132.
    • (1989) IEEE Trans. Eng. Manage. , vol.36 , Issue.2 , pp. 132
    • Roberts, K.H.1    Rousseau, D.M.2
  • 97
    • 0002926044 scopus 로고    scopus 로고
    • Must accidents happen? Lessons from high reliability organizations/executive commentary
    • Roberts K.H., Bea R., Bartles D.L. Must accidents happen? Lessons from high reliability organizations/executive commentary. Acad. Manage. Exec. 2001, 15(3):70-79.
    • (2001) Acad. Manage. Exec. , vol.15 , Issue.3 , pp. 70-79
    • Roberts, K.H.1    Bea, R.2    Bartles, D.L.3
  • 98
    • 0036752174 scopus 로고    scopus 로고
    • Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system - is this the right model?
    • Runciman W.B. Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system - is this the right model?. Qual. Safety Health Care 2002, 11:46-251.
    • (2002) Qual. Safety Health Care , vol.11 , pp. 46-251
    • Runciman, W.B.1
  • 100
    • 4043057940 scopus 로고    scopus 로고
    • FMEA and RCA: the mantras of modern risk management
    • Senders J.W. FMEA and RCA: the mantras of modern risk management. Qual. Safety Health Care 2004, 13.
    • (2004) Qual. Safety Health Care , pp. 13
    • Senders, J.W.1
  • 101
    • 0009501815 scopus 로고    scopus 로고
    • The development of TRACEr: a technique for the retrospective analysis of cognitive errors
    • Ashgate Publishing, Aldershot, UK
    • Shorrock S.T., Kirwan B. The development of TRACEr: a technique for the retrospective analysis of cognitive errors. Engineering Psychology and Cognitive Ergonomics 1999, vol. 3. Ashgate Publishing, Aldershot, UK.
    • (1999) Engineering Psychology and Cognitive Ergonomics , vol.3
    • Shorrock, S.T.1    Kirwan, B.2
  • 103
    • 0017941943 scopus 로고
    • Characteristics of a successful safety program
    • Smith M.J., Cohen H.H., Cohen A. Characteristics of a successful safety program. J. Safety Res. 1978, 10:5-15.
    • (1978) J. Safety Res. , vol.10 , pp. 5-15
    • Smith, M.J.1    Cohen, H.H.2    Cohen, A.3
  • 104
    • 0033814423 scopus 로고    scopus 로고
    • Human error in hospitals and industrial accidents: current concepts
    • Spencer F.C. Human error in hospitals and industrial accidents: current concepts. J. Am. Coll. Surg. 2000, 191:410-418.
    • (2000) J. Am. Coll. Surg. , vol.191 , pp. 410-418
    • Spencer, F.C.1
  • 107
    • 77950542633 scopus 로고
    • Handbook of Reliability Analysis with Emphasis on Nuclear Plant Applications. Technical Report NUREG/CR-1278, Nuclear Regulatory Commission, Washington, DC.
    • Swain, A.D., Guttmann, H.E., 1983. Handbook of Reliability Analysis with Emphasis on Nuclear Plant Applications. Technical Report NUREG/CR-1278, Nuclear Regulatory Commission, Washington, DC.
    • (1983)
    • Swain, A.D.1    Guttmann, H.E.2
  • 108
    • 0033104230 scopus 로고    scopus 로고
    • A method for analysing adverse events in medicine
    • Taylor-Adams S., Vincent C.A., Stanhope N. A method for analysing adverse events in medicine. Safety Sci. 1999, 31:143-159.
    • (1999) Safety Sci. , vol.31 , pp. 143-159
    • Taylor-Adams, S.1    Vincent, C.A.2    Stanhope, N.3
  • 109
    • 33646524265 scopus 로고    scopus 로고
    • A quantitative approach to clinical risk assessment: the CREA method
    • Trucco P.M., Cavallin M. A quantitative approach to clinical risk assessment: the CREA method. Safety Sci. 2006.
    • (2006) Safety Sci.
    • Trucco, P.M.1    Cavallin, M.2
  • 110
    • 0037412617 scopus 로고    scopus 로고
    • Why hospitals don't learn from failures: organizational and psychological dynamics that inhibit system change
    • Tucker A.L., Edmondson A.C. Why hospitals don't learn from failures: organizational and psychological dynamics that inhibit system change. Calif. Manage. Rev. 2003, 45(2):55.
    • (2003) Calif. Manage. Rev. , vol.45 , Issue.2 , pp. 55
    • Tucker, A.L.1    Edmondson, A.C.2
  • 111
    • 77950539009 scopus 로고    scopus 로고
    • Risk, safety and the dark side of quality
    • Vincent C. Risk, safety and the dark side of quality. BMJ 1997, 314.
    • (1997) BMJ , pp. 314
    • Vincent, C.1
  • 112
    • 77950546238 scopus 로고    scopus 로고
    • Understanding and responding to adverse events
    • Vincent C. Understanding and responding to adverse events. Health Policy Report 2003, 328.
    • (2003) Health Policy Report , pp. 328
    • Vincent, C.1
  • 113
    • 0036489347 scopus 로고    scopus 로고
    • Patient safety: what about the patient
    • Vincent C., Coulter A. Patient safety: what about the patient. Qual. Safety Health Care 2002, 11(1):76-80.
    • (2002) Qual. Safety Health Care , vol.11 , Issue.1 , pp. 76-80
    • Vincent, C.1    Coulter, A.2
  • 114
    • 0035799063 scopus 로고    scopus 로고
    • Adverse events in British hospitals: preliminary retrospective record review
    • Vincent C., Neale G., Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001, 322:517-519.
    • (2001) BMJ , vol.322 , pp. 517-519
    • Vincent, C.1    Neale, G.2    Woloshynowych, M.3
  • 115
    • 84866688974 scopus 로고    scopus 로고
    • Verbal protocol analysis
    • Boca Raton Editing, N.A. Stanton, A. Hedge, K. Brookhuis, E. Salas, H. Hendrick (Eds.)
    • Walker G.H. Verbal protocol analysis. The Handbook of Human Factors and Ergonomics Methods 2005, Boca Raton Editing. N.A. Stanton, A. Hedge, K. Brookhuis, E. Salas, H. Hendrick (Eds.).
    • (2005) The Handbook of Human Factors and Ergonomics Methods
    • Walker, G.H.1
  • 117
    • 0032349231 scopus 로고    scopus 로고
    • A dealing with clinical risk: implications of the rise of evidence-based health care
    • October December
    • Walshe K., Sheldon T. A dealing with clinical risk: implications of the rise of evidence-based health care. Public Money Manage. 1998, October December:15-20.
    • (1998) Public Money Manage. , pp. 15-20
    • Walshe, K.1    Sheldon, T.2
  • 118
    • 84968080940 scopus 로고
    • Organizational culture as a source of high reliability
    • Weick K.E. Organizational culture as a source of high reliability. Calif. Manage. Rev. 1987, 24:112-127.
    • (1987) Calif. Manage. Rev. , vol.24 , pp. 112-127
    • Weick, K.E.1
  • 120
    • 32944474992 scopus 로고    scopus 로고
    • Human factors experts beginning to focus on organizational factors in safety
    • Westrum R. Human factors experts beginning to focus on organizational factors in safety. ICAO J. 1996, 15-26.
    • (1996) ICAO J. , pp. 15-26
    • Westrum, R.1
  • 121
    • 33644954637 scopus 로고
    • Minimising the cause of human error
    • Taylor and Francis, London, B. Kirwan, L.K. Ainsworth (Eds.)
    • Whalley S.J. Minimising the cause of human error. A Guide to Task Analysis 1988, Taylor and Francis, London. B. Kirwan, L.K. Ainsworth (Eds.).
    • (1988) A Guide to Task Analysis
    • Whalley, S.J.1
  • 123
    • 77950526669 scopus 로고    scopus 로고
    • A Synthesis of Safety Culture and Safety Climate Research. Technical Report ARL-02-3/FAA-02-2.
    • Wiegmann, D.A., Zhang, H., von Thaden, T.L., Sharma, G., Mitchell, A.A., 2002. A Synthesis of Safety Culture and Safety Climate Research. Technical Report ARL-02-3/FAA-02-2.
    • (2002)
    • Wiegmann, D.A.1    Zhang, H.2    von Thaden, T.L.3    Sharma, G.4    Mitchell, A.A.5
  • 124
    • 0037323613 scopus 로고    scopus 로고
    • From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care
    • Wilf-Miron R., Lewenhoff I., Benjamini Z. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care. Qual. Safety Health Care 2003, 12(1):35-39.
    • (2003) Qual. Safety Health Care , vol.12 , Issue.1 , pp. 35-39
    • Wilf-Miron, R.1    Lewenhoff, I.2    Benjamini, Z.3
  • 125
    • 0022955233 scopus 로고
    • HEART - a proposed method for assessing and reducing human error. In: 9th Advances in Reliability Technology Symposium. University of Bradford.
    • Williams, J.C., 1986. HEART - a proposed method for assessing and reducing human error. In: 9th Advances in Reliability Technology Symposium. University of Bradford.
    • (1986)
    • Williams, J.C.1
  • 126
    • 0021835301 scopus 로고
    • Validation of human reliability assessment techniques
    • Williams J.C. Validation of human reliability assessment techniques. Reliab. Eng. 1989, 11:149-162.
    • (1989) Reliab. Eng. , vol.11 , pp. 149-162
    • Williams, J.C.1
  • 127
    • 0028850116 scopus 로고
    • The quality in Australian health care study
    • Wilson R.M., Runciman W.B., Gibberd R.W., et al. The quality in Australian health care study. Med. J. Aust. 1995, 163:458-471.
    • (1995) Med. J. Aust. , vol.163 , pp. 458-471
    • Wilson, R.M.1    Runciman, W.B.2    Gibberd, R.W.3
  • 129
    • 77950533111 scopus 로고    scopus 로고
    • Modeling managerial influence on safety climate. Paper Presented at Society for Industrial and Organizational Psychology (SIOP) Conference. San Diego, CA.
    • Yule, S.J., Flin, R., Murdy, A.J., 2001. Modeling managerial influence on safety climate. Paper Presented at Society for Industrial and Organizational Psychology (SIOP) Conference. San Diego, CA.
    • (2001)
    • Yule, S.J.1    Flin, R.2    Murdy, A.J.3
  • 130
    • 0018979343 scopus 로고
    • Safety climate in industrial organizations: theoretical and applied implications
    • Zohar D. Safety climate in industrial organizations: theoretical and applied implications. J. Appl. Psychol. 1980, 65:96-102.
    • (1980) J. Appl. Psychol. , vol.65 , pp. 96-102
    • Zohar, D.1
  • 131
    • 0034237997 scopus 로고    scopus 로고
    • A group-level model of safety climate: testing the effect of group climate on micro-accidents in manufacturing jobs
    • Zohar D. A group-level model of safety climate: testing the effect of group climate on micro-accidents in manufacturing jobs. J. Appl. Psychol. 2000, 85:587-596.
    • (2000) J. Appl. Psychol. , vol.85 , pp. 587-596
    • Zohar, D.1


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