Patient safety: The role of human factors and systems engineering

Studies in Health Technology and Informatics

Volumn 153, Issue , 2010, Pages 23-46

  Carayon, Pascale ^a,b   Wood, Kenneth E ^c  

^a University of Wisconsin Madison   (United States)

^b UNIVERSITY OF WISCONSIN MADISON   (United States)

^c UNIVERSITY OF WISCONSIN SCHOOL OF MEDICINE AND PUBLIC HEALTH   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH CARE; HUMAN ENGINEERING; SYSTEMS ENGINEERING;

CONCEPTUAL APPROACHES; GLOBAL CHALLENGES; HEALTH SCIENCE; MEDICAL ERRORS; MULTIPLE AREAS; PATIENT SAFETY; SYSTEM REDESIGN; WORK SYSTEM;

SAFETY ENGINEERING;

EID: 77954607096     PISSN: 09269630     EISSN: 18798365     Source Type: Conference Proceeding    
DOI: 10.3233/978-1-60750-533-4-23     Document Type: Conference Paper

References (141)

1. G.R. Baker, P.G. Norton, V. Flintoft, R. Blais, A. Brown, J. Cox et al., The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada, Journal of the Canadian Medical Association 170(11) (2004), 1678-1686.
2. D.W. Bates, D.L. Boyle, M.B. Vander Vliet al, e., Relationship between medication errors and adverse drug events, Journal of General Internal Medicine 10(4) (1995), 199-205.
3. D.W. Bates and A.A. Gawande, Improving safety with information technology, The New England Journal of Medicine 348(25) (2003), 2526-2534.
4. D.W. Bates, L.L. Leape and S. Petrycki, Incidence and preventability of adverse drug events in hospitalized adults. Journal of General Internal Medicine 8(6) (1993), 289-294.
5. J.B. Battles and M.A. Keyes, Technology and patient safety: A two-edged sword, Biomedical Instrumentation & Technology 36(2) (2002), 84-88.
6. C. Beach, P. Croskerry and M. Shapiro, Profiles in patient safety: emergency care transitions, Academic Emergency Medicine 10(4) (2003), 364-367. (Pubitemid 36437795)
7. C.M. Bell, J. Bajcar, A.S. Bierman, P. Li, M.M. Mamdani and D.R. Urbach, Potentially unintended discontinuation of long-term medication use after elective surgical procedures, Archives of Internal Medicine 166(22) (2006), 2525-2531.
8. D.M. Berwick, A user's manual for the IOM's 'Quality Chasm' report, Health Affairs 21(3) (2002), 80-90.
9. M.S. Bogner, The artichoke systems approach for identifying the why of error, in: Handbook of Human Factors in Health Care and Patient Safety, P. Carayon, ed., Mahwah, NJ: Lawrence Erlbaum, 2007, pp. 109-126.
10. M.S. Bogner, ed., Human Error in Medicine, Hillsdale, NJ: Lawrence Erlbaum Associates, 1994.
11. P. Bonnabry, C. Despont-Gros, D. Grauser, P. Casez, M. Despond, D. Pugin et al., A risk analysis method to evaluate the impact of a computerized provider order entry system on patient safety. Journal of the American Medical Informatics Association 15(4) (2008), 453-460.
12. K. Boockvar, E. Fishman, C.K. Kyriacou, A. Monias, S. Gavi and T. Cortes, Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. [Original Investigation], Archives of Internal Medicine 164(5) (2004), 545-550.
13. D. Bracco, J.-B. Favre, B. Bissonnette, J.-B. Wasserfallen, J.-P. Revelly, P. Ravussin et al., Human errors in a multidisciplinary intensive care unit: a 1-year prospective study, Intensive Care Medicine 27(1) (2000), 137-145.
14. P.F. Brennan and C. Safran, Patient safety. Remember who it's really for, International Journal of Medical Informatics 73(7-8) (2004), 547-550.
15. T.A. Brennan, L.L. Leape, N.M. Laird, L. Hebert, A.R. Localio, A.G. Lawthers et al., Incidence of adverse events and negligence in hospitalized patients, Results of the Harvard Medical Practice Study I, New England Journal of Medicine 324(6) (1991), 370-376.
16. J. Burgmeier, Failure mode and effect analysis: An application in reducing risk in blood transfusion, The Joint Commission Journal on Quality Improvement 28(6) (2002), 331-339.
17. P. Carayon-Sainfort, The use of computers in offices: Impact on task characteristics and worker stress, International Journal of Human Computer Interaction 4(3) (1992), 245-261.
18. P. Carayon and M.C. Haims, Information and communication technology and work organization: Achieving a balanced system, in: Humans on the Net-Information and Communication Technology (ICT), G. Bradley, ed.,Work Organization and Human Beings, Sweden: Prevent, 2001, pp. 119-138.
19. P. Carayon, Human factors of complex sociotechnical systems, Applied Ergonomics 37 (2006), 525-535. (Pubitemid 43850915)
20. P. Carayon, Human factors in patient safety as an innovation, Applied Ergonomics, to be published (2009).
21. P. Carayon, ed., Handbook of Human Factors in Health Care and Patient Safety, Mahwah, New Jersey: Lawrence Erlbaum Associates, 2007.
22. P. Carayon and C. Alvarado,Workload and patient safety among critical care nurses, Critical Care Nursing Clinics 8(5) (2007), 395-428.
23. P. Carayon, C. Alvarado and A.S. Hundt, Reducing Workload and Increasing Patient Safety Through Work and Workspace Design, Washington, DC: Institute of Medicine, 2003.
24. P. Carayon and A. Gurses, Nursing workload and patient safety in intensive care units: A human factors engineering evaluation of the literature, Intensive and Critical Care Nursing 21 (2005), 284-301.
25. P. Carayon, A.P. Gurses, A.S. Hundt, P. Ayoub and C.J. Alvarado, Performance obstacles and facilitators of healthcare providers, in: Change and Quality in Human Service Work, (Vol. 4), C. Korunka and P. Hoffmann, eds, Munchen, Germany: Hampp Publishers, 2005, pp. 257-276.
26. P. Carayon, A.S. Hundt, B.-T. Karsh, A.P. Gurses, C.J. Alvarado, M. Smith et al.,Work system design for patient safety: The SEIPS model, Quality & Safety in Health Care 15(Supplement I) (2006), i50-i58.
27. P. Carayon and M.J. Smith, Work organization and ergonomics, Applied Ergonomics 31 (2000), 649-662.
28. P. Carayon, P. Smith, A.S. Hundt, V. Kuruchittham and Q. Li, Implementation of an Electronic Health Records system in a small clinic, Behaviour and Information Technology 28(1) (2009), 5-20.
29. P. Carayon, T.B. Wetterneck, A.S. Hundt, M. Ozkaynak, J. DeSilvey, B. Ludwig et al., Evaluation of nurse interaction with bar code medication administration technology in the work environment, Journal of Patient Safety 3(1) (2007), 34-42.
30. M.A. Cimino, M.S. Kirschbaum, L. Brodsky and S.H. Shaha, Assessing medication prescribing errors in pediatric intensive care units, Pediatric Critical Care Medicine 5(2) (2004), 124-132.
31. C.M. Clancy, Care transitions: A threat and an opportunity for patient safety, American Journal of Medical Quality 21(6) (2006), 415-417. (Pubitemid 44673176)
32. E.A. Coleman, J.D. Smith, D. Raha and S.-J. Min, Posthospital medication discrepancies - Prevalence and contributing factors, Archives of Internal Medicine 165 (2005), 1842-1847. (Pubitemid 41352078)
33. R. Cook and J. Rasmussen, "Going solid": A model of system dynamics and consequences for patient safety, Quality & Safety in Health Care 14 (2005), 130-134.
34. R.I. Cook, Safety technology: Solutions or experiments? Nursing Economic 20(2) (2002), 80-82.
35. R.I. Cook, M. Render and D.D. Woods, Gaps in the continuity of care and progress on patient safety, British Medical Journal 320 (2000), 791-794. (Pubitemid 30179436)
36. R.I. Cook, D.D.Woods and C. Miller, A Tale of Two Stories: Contrasting Views of Patient Safety, Chicago, IL: National Patient Safety Foundation, 1998.
37. R.I. Cook, J. Wreathall, A. Smith, D.C. Cronin, O. Rivero, R.C. Harland et al., Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003, Transplantation 84(12) (2007), 1602-1609.
38. J.B. Cooper, Do short breaks increase or decrease anesthetic risk? Journal of Clinical Anesthesiology 1(3) (1989), 228-231.
39. D.J. Cullen, D.W. Bates, L.L. Leape and The Adverse Drug Even Prevention Study Group, Prevention of adverse drug events: A decade of progress in patient safety, Journal of Clinical Anesthesia 12 (2001), 600-614.
40. D.J. Cullen, B.J. Sweitzer, D.W. Bates, E. Burdick, A. Edmondson and L.L. Leape, Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units, Critical Care Medicine 25(8) (1997), 1289-1297.
41. J. DeRosier, E. Stalhandske, J.P. Bagian and T. Nudell, Using health care Failure Mode and Effect Analysis: The VA National Center for Patient Safety's prospective risk analysis system, Joint Commission Journal on Quality Improvement 28(5) (2002), 248-267, 209.
42. A. Donabedian, The quality of medical care, Science 200 (1978), 856-864.
43. A. Donabedian, The quality of care. How can it be assessed? Journal of the American Medical Association 260(12) (1988), 1743-1748.
44. Y. Donchin, D. Gopher, M. Olin, Y. Badihi, M. Biesky, C.L. Sprung et al., A look into the nature and causes of human errors in the intensive care unit, Critical Care Medicine 23(2) (1995), 294-300.
45. K. Eason, Information Technology and Organizational Change, London: Taylor & Francis, 1988.
46. K.D. Eason, The process of introducing information technology, Behaviour and Information Technology 1(2) (1982), 197-213.
47. J.A. Effken, M.-G. Kim and R.E. Shaw, Making the constraints visible: Testing the ecological approach to interface design, Ergonomics 40(1) (1997), 1-27.
48. R.J. Fairbanks and S. Caplan, Poor interface design and lack of usability testing facilitate medical error, Joint Commission Journal on Quality and Safety 30(10) (2004), 579-584.
49. D.O. Farley, A. Haviland, S. Champagne, A.K. Jain, J.B. Battles,W.B. Munier et al., Adverse-event-reporting practices by us hospitals: Results of a national survey, Quality & Safety in Health Care 17(6) (2008), 416-423.
50. A.J. Forster, H.D. Clark, A. Menard, N. Dupuis, R. Chernish, N. Chandok et al., Adverse events among medical patients after discharge from hospital, Canadian Medical Association Journal 170(3) (2004), 345-349. (Pubitemid 38223452)
51. T. Giraud, J.-F. Dhainaut, J.-F. Vaxelaire, T. Joseph, D. Journois, G. Bleichner et al., Iatrogenic complications in adult intensive care units: A prospective two-center study, Critical Care Medicine 21(1) (1993), 40-51.
52. J.W. Gosbeee and L.L. Gosbee, eds, Using Human Factors Engineering to Improve Patient Safety, Oakbrook Terrrace, Illinois: Joint Commission Resources, 2005.
53. F. Guerin, A. Laville, F. Daniellou, J. Duraffourg and A. Kerguelen, Understanding and Transforming Work - The Practice of Ergonomics Lyon, France: ANACT, 2006.
54. A. Gurses, P. Carayon and M. Wall, Impact of performance obstacles on intensive care nurses workload, perceived quality and safety of care, and quality of working life, Health Services Research (2009), 422-443.
55. A.P. Gurses and P. Carayon, Performance obstacles of intensive care nurses, Nursing Research 56(3) (2007), 185-194.
56. J. Hahnel, W. Friesdorf, B. Schwilk, T. Marx and S. Blessing, Can a clinician predict the technical equipment a patient will need during intensive care unit treatment? An approach to standardize and redesign the intensive care unit workstation, Journal of Clinical Monitoring 8(1) (1992), 1-6.
57. A.B. Haynes, T.G. Weiser, W.R. Berry, S.R. Lipsitz, A.H. Breizat, E.P. Dellinger et al., A surgical safety checklist to reduce morbidity and mortality in a global population, New England Journal of Medicine 360(5) (2009), 491-499.
58. H.W. Hendrick, Human factors in organizational design and management, Ergonomics 34 (1991), 743-756.
59. H.W. Hendrick, Organizational design and macroergonomics, in: Handbook of Human Factors and Ergonomics, G. Salvendy, ed., New York: John Wiley & Sons (1997), pp. 594-636.
60. H.W. Hendrick and B.M. Kleiner, Macroergonomics - An Introduction to Work System Design. Santa Monica, CA: The Human Factors and Ergonomics Society (2001).
61. G. Hendrickson, C.T. Kovner, J.R. Knickman and S.A. Finkler, Implementation of a variety of computerized bedside nursing information systems in 17 New Jersey hospitals, Computers in Nursing 13(3) (1995), 96-102.
62. T.J. Hoff, How work context shapes physician approach to safety and error, Quality Management in Health Care April/June 17(2) (2008), 140-153.
63. A.S. Hundt, P. Carayon, P.D. Smith and V. Kuruchittham, A macroergonomic case study assessing Electronic Medical Record implementation in a small clinic, The Human Factors and Ergonomics Society (Ed.), in: Proceedings of the Human Factors and Ergonomics Society 46th Annual Meeting Santa Monica, CA, 2002, pp. 1385-1388.
64. Institute of Medicine, Preventing Medication Errors, Washington, DC: The National Academies Press, 2006.
65. Institute of Medicine Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
66. B.W. Jack, V.K. Chetty, D. Anthony, J.L. Greenwald, G.M. Sanchez, A.E. Johnson et al., A reengineered hospital discharge program to decrease rehospitalization: A randomized trial, Annals of Internal Medicine 150(3) (2009), 178-187.
67. JCAHO, Delays in Treatment, Sentinel Event Alert (26) (2002).
68. C. Johnson, The causes of human error in medicine. Cognition, Technology & Work 4 (2002), 65-70.
69. B.-T. Karsh, Beyond usability: Designing effective technology implementation systems to promote patient safety, Quality and Safety in Health Care 13 (2004), 388-394.
70. B.-T. Karsh, R. J. Holden, S.J. Alper and C.K.L. Or, A human factors engineering paradigm for patient safety: Designing to support the performance of the healthcare professional, Quality & Safety in Health Care 15(i6) (2006), i59-i65.
71. B. Karsh and R. Brown, Macroergonomics and patient safety: The impact of levels on theory, measurement, analysis and intervention in medical error research, Applied Ergonomics (2009) to be published.
72. R. Kaushal and D.W. Bates, Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs), in: Making Health Care Safer: A Critical Analysis of Patient Safety Practices, K.G. Shojania, B.W. Duncan, K.M. McDonald and R.M. Wachter, eds, (Vol. Evidence Report/Technology Assessment), AHRQ, 2001, pp. 59-69.
73. S. King, Our story, Pediatric Radiology 36(4) (2006), 284-286.
74. L.T. Kohn, J.M. Corrigan and M.S. Donaldson, eds, To Err is Human: Building a Safer Health System, Washington, D.C.: National Academy Press, 1999.
75. R. Koppel, J.P. Metlay, A. Cohen, B. Abaluck, A.R. Localio, S.E. Kimmel et al., Role of computerized physician order entry systems in facilitating medications errors, Journal of the American Medical Association 293(10) (2005), 1197-1203. (Pubitemid 40327905)
76. R. Koppel, T. Wetterneck, J.L. Telles and B.-T. Karsh, Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety, Journal of the American Medical Informatics Association 15(M2616) (2008), 408-423.
77. C. Korunka and P. Carayon, Continuous implementations of information technology: The development of an interview guide and a cross-national comparison of Austrian and American organizations, The International Journal of Human Factors in Manufacturing 9(2) (1999), 165-183.
78. C. Korunka, A. Weiss and B. Karetta, Effects of new technologies with special regard for the implementation process per se, Journal of Organizational Behavior 14(4) (1993), 331-348.
79. C.Korunka, A.Weiss and S. Zauchner, An interviewstudy of "continuous" implementations of information technologies, Behaviour and Information Technology 16(1) (1997), 3-16.
80. C. Korunka, S. Zauchner and A.Weiss, New information technologies, job profiles, and external workload as predictors of subjectively experienced stress and dissatisfaction at work, International Journal of Human-Computer Interaction 9(4) (1997), 407-424. (Pubitemid 127472261)
81. C.T. Kovner, G. Hendrickson, J.R. Knickman and S.A. Finkler, Changing the delivery of nursing care - Implementation issues and qualitative findings, Journal of Nursing Administration 23(11) (1993), 24-34.
82. A. Kumar, D. Roberts, K.E. Wood, B. Light, J.E. Parrillo, S. Sharma et al., Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock, Critical Care Medicine 34(6) (2006), 1589-1596.
83. L.L. Leape, D.W. Bates, D.J. Cullen, J. Cooper, H.J. Demonaco, T. Gallivan et al., Systems analysis of adverse drug events, Journal of the American Medical Association 274(1) (1995), 35-43.
84. L.L. Leape and D.M. Berwick, Five years after To Err Is Human: What have we learned? Journal of the American Medical Association 293(19) (2005), 2384-2390. (Pubitemid 40676761)
85. J. Leplat, Error analysis, instrument and object of task analysis, Ergonomics 32(7) (1989), 813-822.
86. L. Lin, K.J. Vicente and D.J. Doyle, Patient safety, potential adverse drug events, and medical device design: A human factors engineering approach, Journal of Biomedical Informatics 34(4) (2001), 274-284.
87. E. Litvak, P.I. Buerhaus, F. Davidoff, M.C. Long, M.L. McManus and D.M. Berwick, Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety, Joint Commission Journal on Quality and Patient Safety 31(6) (2005), 330-338.
88. H. Luczak, Task analysis, in: Handbook of Human Factors and Ergonomics, (Second ed.), G. Salvendy, ed., New York: John Wiley & Sons, 1997, pp. 340-416.
89. P.B. Marr, E. Duthie, K.S. Glassman, D.M. Janovas, J.B. Kelly, E. Graham et al., Bedside terminals and quality of nursing documentation, Computers in Nursing 11(4) (1993), 176-182.
90. D.J. Mayhew, The Usability Engineering Lifecycle. San Francisco, CA: Morgan Kaufmann Publisher Inc, 1999.
91. M.L. McManus, M.C. Long, A. Cooper, J. Mandell, D.M. Berwick, M. Pagano et al., Variability in surgical caseload and access to intensive care services, Anesthesiology 98(6) (2003), 1491-1496.
92. C. Moore, J. Wisnivesky, S. Williams and T. McGinn, Medical errors related to discontinuity of care from an inpatient to an outpatient setting, Journal of General Internal Medicine 18(8) (2003), 646-651.
93. N. Moray, Error reduction as a systems problem, in: Human Error in Medicine, M.S. Bogner, ed., Hillsdale, NJ: Lawrence Erlbaum Associates, 1994, pp. 67-91.
94. L.R. Murphy and C.L. Cooper, eds, Healthy and Productive Work: An International Perspective, London: Taylor and Francis, 2000.
95. J. Nielsen, Usability Engineering, Morgan Kaufmann: Amsterdam, The Netherlands, 1993.
96. E.S. Patterson, R.I. Cook and M.L. Render, Improving patient safety by identifying side effects from introducing bar coding in medication administration, Journal of the American Medial Informatics Association 9 (2002), 540-553.
97. S. Perry, Transitions in care: studying safety in emergency department signovers, Focus on Patient Safety 7(2) (2004), 1-3.
98. P.J. Pronovost, M.W. Jenckes, T. Dorman, E. Garrett, M.J. Breslow, B.A. Rosenfeld et al., Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery, Journal of the American Medical Association 281(14) (1999), 1310-1317.
99. J. Rasmussen, The role of error in organizing behaviour, Ergonomics 33(10/11) (1990), 1185-1199.
100. J. Rasmussen, Human factors in a dynamic information society: Where are we heading? Ergonomics 43(7) (2000), 869-879. (Pubitemid 30458386)
101. J. Rasmussen, A.M. Pejtersen and L.P. Goodstein, Cognitive Systems Engineering, New York: Wiley, 1994.
102. N.K. Rathlev, J. Chessare, J. Olshaker, D. Obendorfer, S.D. Mehta, T. Rothenhaus et al., Time series analysis of variables associated with daily mean emergency department length of stay, Annals of Emergency Medicine 49(3) (2007), 265-271.
103. J. Reason, Human Error, Cambridge: Cambridge University Press, 1990.
104. J. Reason, Managing the Risks of Organizational Accidents, Burlington, Vermont: Ashgate, 1997.
105. J. Reason, Human error: Models and management, BMJ 320(7237) (2000), 768-770.
106. P.R. Reid, W.D. Compton, J.H. Grossman and G. Fanjiang, Building a Better Delivery System. A New Engineering/Health Care Partnership. Washington, D.C.: The National Academies Press, 2005.
107. D. Resnick, The Jesica Santillan tragedy: Lessons learned, The Hastings Center Report 33(4) (2003), 15-20.
108. K.H. Roberts and R. Bea, Must accidents happen? Lessons from high-reliability organizations, Academy of Management Executive 15(3) (2001), 70-78.
109. K.H. Roberts and R.G. Bea, When systems fail. Organizational Dynamics 29(3) (2001), 179-191.
110. G.I. Rochlin, Safe operation as a social construct, Ergonomics 42(11) (1999), 1549-1560.
111. J.M. Rothschild, C.P. Landrigan, J.W. Cronin, R. Kaushal, S.W. Lockley, E. Burdick et al., The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care, Critical Care Medicine 33 (2005), 1694-1700.
112. W. Runciman, P. Hibbert, R. Thomson, T. Van Der Schaaf, H. Sherman and P. Lewalle, Towards an international classification for patient safety: Key concepts and terms, International Journal for Quality in Health Care 21(1) (2009), 18-26.
113. M.A. Safren and A. Chapanis, A critical incident study of hospital medication errors - Part 1, Hospitals 34 (1960), 32-34; 57-66.
114. M.A. Safren and A. Chapanis, A critical incident study of hospital medication errors - Part 2, Hospitals 34 (1960), 53; 65-68.
115. A.P. Sage and W.B. Rouse, eds, Handbook of Systems Engineering and Management, New York: John Wiley & Sons, 1999.
116. F. Sainfort, B. Karsh, B.C. Booske and M.J. Smith, Applying quality improvement principles to achieve healthy work organizations, Journal on Quality Improvement 27(9) (2001), 469-483.
117. G. Salvendy, ed., Handbook of Human Factors and Ergonomics, (Third ed.), New York, NY: John Wiley & Sons, 2006.
118. K. Schultz, P. Carayon, A.S. Hundt and S. Springman, Care transitions in the outpatient surgery preoperative process: Facilitators and obstacles to information flow and their consequences, Cognition, Technology & Work 9(4) (2007), 219-231.
119. K.G. Shojania, The frustrating case of incident-reporting systems, Quality & Safety in Health Care 17(6) (2008), 400-402.
120. S.M. Shortell, J.E. Zimmerman, R.R. Gillies, J. Duffy, K.J. Devers, D.M. Rousseau et al., Continuously improving patient care: Practical lessons and an assessment tool from the National ICU study, Quality Review Bulletin 18(5) (1992), 150-155.
121. M.J. Smith and P. Carayon-Sainfort, A balance theory of job design for stress reduction, International Journal of Industrial Ergonomics 4(1) (1989), 67-79.
122. M.J. Smith and P. Carayon, New technology, automation, and work organization: Stress problems and improved technology implementation strategies, The International Journal of Human Factors in Manufacturing 5(1) (1995), 99-116.
123. N. Stanton, A. Hedge, K. Brookhuis, E. Salas and H.W. Hendrick, eds, Handbook of Human Factors and Ergonomics Methods, Boca Raton, FL: CRC Press, 2004.
124. E.R. Stucky, Prevention of medication errors in the pediatric inpatient setting, Pediatrics 112 (2003), 431-436. (Pubitemid 36951416)
125. V.C. Tam, S.R. Knowles, P.L. Cornish, N. Fine, R. Marchesano and E.E. Etchells, Frequency, type and clinical importance of medication history errors at admission to hospital: A systematic review, Canadian Medical Association Journal 173(5) (2005), 510-515.
126. The World Alliance For Patient Safety Drafting Group, H. Sherman, G. Castro, M. Fletcher, on behalf of The World Alliance for Patient Safety, M. Hatlie et al., Towards an international classification for patient safety: The conceptual framework, International Journal for Quality in Health Care 21(1) (2009), 2-8.
127. E.J. Thomas, D.M. Studdert, H.R. Burstin, E.J. Orav, T. Zeena, E.J. Williams et al., Incidence and types of adverse events and negligent care in Utah and Colorado, Medical Care 38(3) (2000), 261-271.
128. J. Varon and P.E. Marik, Clinical information systems and the electronic medical record in the intensive care unit, Current Opinion in Critical Care 8 (2002), 616-624. (Pubitemid 35388220)
129. K.J. Vicente, What does it take? A case study of radical change toward patient safety, Joint Commission Journal on Quality and Safety 29(11) (2003), 598-609.
130. C. Vincent, P. Aylin, B.D. Franklin, A. Holmes, S. Iskander, A. Jacklin et al., Is health care getting safer? British Medical Journal 337(7680) (2008), 1205-1207.
131. C. Vincent, S. Taylor-Adams, E.J. Chapman, D. Hewett, S. Prior, P. Strange et al., How to investigate and analyse clinical incidents: Clinical risk unit and association of litigation and risk management protocol, BMJ, 320 (2000), 777-781.
132. C. Vincent, S. Taylor-Adams and N. Stanhope, Framework for analysing risk and safety in clinical medicine, BMJ 316(7138) (1998), 1154-1157. (Pubitemid 28156466)
133. H.Wald and K. Shojania, Prevention of misidentifications, in: Making Health Care Safer: A Critical Analysis of Patient Safety Practices, D.G. Shojania, B.W. Duncan, K.M. McDonald and R.M. Wachter, eds, Washington, DC: Agency for Healthcare Research and Quality, AHRQ publication 01-E058, 2001, pp. 491-503.
134. R.L. Wears, S.J. Perry, E. Eisenberg, L. Murphy, M. Shapiro, C. Beach et al., Transitions in care: signovers in the emergency department, Paper presented at the Human Factors and Ergonomics Society 48th Annual Meeting, New Orleans, LA, 2004.
135. R.L. Wears, S.J. Perry, M. Shapiro, C. Beach, P. Croskerry and R. Behara, Shift changes among emergency physicians: best of times, worst of times, Paper presented at the Human Factors and Ergonomics Society 47th Annual Meeting, Denver, CO, 2003.
136. K.E.Weick and R.E. Quinn, Organizational change and development, Annual Review of Psychology 50 (1999), 361-386.
137. K.E. Weick and K.M. Sutcliffe, Managing the Unexpected: Assuring High Performance in an Age of Complexity, San Francisco, CA: Jossey-Bass, 2001.
138. C.R. Weinert and H.J. Mann, The science of implementation: Changing the practice of critical care, Current Opinion in Critical Care 14(4) (2008), 460-465.
139. T.B. Wetterneck, K.A. Skibinski, T.L. Roberts, S.M. Kleppin, M. Schroeder, M. Enloe et al., Using failure mode and effects analysis to plan implementation of Smart intravenous pump technology, American Journal of Health-System Pharmacy 63 (2006), 1528-1538.
140. J.R. Wilson and N. Corlett, eds, Evaluation of Human Work, (Third ed.), Boca Raton, FL: CRC Press, 2005.
141. K. Zink, Ergonomics in the past and the future: From a German perspective to an international one, Ergonomics, 43(7) (2000), 920-930.