메뉴 건너뛰기




Volumn 19, Issue 4, 2010, Pages 332-336

Bad stars or guiding lights? Learning from disasters to improve patient safety

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DISASTER; DISASTER PLANNING; EMERGENCY TREATMENT; HEALTH CARE DELIVERY; HUMAN; INDUSTRY; LEARNING; MEDICAL ERROR; PATIENT SAFETY; STANDARD;

EID: 77956104087     PISSN: 14753898     EISSN: 14753901     Source Type: Journal    
DOI: 10.1136/qshc.2008.030148     Document Type: Article
Times cited : (9)

References (38)
  • 1
    • 0003768535 scopus 로고
    • Simpson J, Weiner E, eds, Oxford: Oxford University Press
    • Simpson J, Weiner E, eds. Oxford English Dictionary. Oxford: Oxford University Press, 1989.
    • (1989) Oxford English Dictionary
  • 2
    • 0003103823 scopus 로고
    • Operating at the sharp end: The complexity of human error
    • Bogner MS, ed, Hillsdale, NJ: Lawrence Erlbaum Associates
    • Cook R, Woods D. Operating at the sharp end: the complexity of human error. In: Bogner MS, ed. Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994.
    • (1994) Human Error in Medicine
    • Cook, R.1    Woods, D.2
  • 5
    • 1542401109 scopus 로고    scopus 로고
    • A personal note on normal accidents
    • Perrow C. A personal note on normal accidents. Organ Environ 2004;17:9-24.
    • (2004) Organ Environ. , vol.17 , pp. 9-24
    • Perrow, C.1
  • 8
    • 0011137862 scopus 로고
    • Working in practice by not in theory: Theoretical challenges of 'high reliability organizations'
    • La Porte TR, Consolini PM. Working in practice by not in theory: theoretical challenges of 'high reliability organizations'. J Public Admin Res Theory 1991;1:19-47.
    • (1991) J. Public Admin Res. Theory , vol.1 , pp. 19-47
    • La Porte, T.R.1    Consolini, P.M.2
  • 9
    • 0002926044 scopus 로고    scopus 로고
    • Must accidents happen? Lessons from high-reliability organizations
    • Roberts KH, Bea R. Must accidents happen? Lessons from high-reliability organizations. Acad Manage Exec 2001;15:70-79.
    • (2001) Acad. Manage Exec , vol.15 , pp. 70-79
    • Roberts, K.H.1    Bea, R.2
  • 10
    • 12444267092 scopus 로고    scopus 로고
    • Patient safety is an organisational systems issue: Lessons from a variety of industries
    • Youngberg BJ, Hatlie MJ, eds, Sudbury, Massachusetts: Jones and Bartlett Publishers
    • Roberts KH, Yu K, van Stralen D. Patient safety is an organisational systems issue: lessons from a variety of industries. In:Youngberg BJ, Hatlie MJ, eds. The patient safety handbook. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2004.
    • (2004) The Patient Safety Handbook
    • Roberts, K.H.1    Yu, K.2    Van Stralen, D.3
  • 13
    • 33845327850 scopus 로고    scopus 로고
    • Learning from incidents: From normal accidents to high reliability
    • Cooke DL, Rohleder TR. Learning from incidents: from normal accidents to high reliability. Syst Dyn Rev 2006;22:213-39.
    • (2006) Syst. Dyn Rev. , vol.22 , pp. 213-239
    • Cooke, D.L.1    Rohleder, T.R.2
  • 15
    • 33748316043 scopus 로고    scopus 로고
    • An organization development framework for transformational change in patient safety: A guide for senior hospital leaders
    • Youngberg BJ, Hatlie MJ, eds, Sudbury, Massachusetts: Jones and Bartlett Publishers
    • Behal R. An organization development framework for transformational change in patient safety: a guide for senior hospital leaders. In:Youngberg BJ, Hatlie MJ, eds. The patient safety handbook. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2004.
    • (2004) The Patient Safety Handbook
    • Behal, R.1
  • 17
    • 34848878616 scopus 로고    scopus 로고
    • From the margins to the mainstream? Disaster research at the crossroads
    • Tierney KJ. From the margins to the mainstream? Disaster research at the crossroads. Ann Rev Soc 2007;33:503-25.
    • (2007) Ann. Rev. Soc. , vol.33 , pp. 503-525
    • Tierney, K.J.1
  • 20
    • 33947373630 scopus 로고    scopus 로고
    • Sydney: Parliament of New South Wales, accessed 10 Mar. 2009
    • McInerney PA. Special commission of inquiry into the waterfall rail accident. Sydney: Parliament of New South Wales, 2005. http://www.transport.nsw. gov. au/sites/default/file/inquiries/waterfall-final-reportpdf (accessed 10 Mar. 2009).
    • (2005) Special Commission of Inquiry Into the Waterfall Rail Accident
    • McInerney, P.A.1
  • 21
    • 77956127016 scopus 로고    scopus 로고
    • Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile BEA. Accident on 25 July 2000 at La Patte d'Oie in Gonesse 95 to the Concorde registered F-BTSC operated by Air France. Le Bourget: Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile BEA, 2000, accessed 10 Mar. 2009
    • Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA). Accident on 25 July 2000 at La Patte d'Oie in Gonesse (95) to the Concorde registered F-BTSC operated by Air France. Le Bourget: Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA), 2000. http://www.bea-fr.org/docspa/2000/f-sc000725a/ htm/f-sc000725a.html (accessed 10 Mar. 2009).
  • 23
    • 0011137824 scopus 로고
    • Great Britain Department of Transport, Merchant Shipping Act 1894 Formal Investigations Department of Transport. London: HMSO
    • Great Britain Department of Transport. The MV Herald of Free Enterprise: Report of Court No. 8074 (Merchant Shipping Act 1894 Formal Investigations Department of Transport). London: HMSO, 1987.
    • (1987) The MV Herald of Free Enterprise: Report of Court No. 8074
  • 25
    • 0003865717 scopus 로고    scopus 로고
    • Province of Nova Scotia: Lieutenant Governor in Council by the Westray Mine Public Inquiry, accessed 10 Mar. 2009
    • Richard KP. The Westray story: a predictable path to disaster. Province of Nova Scotia: Lieutenant Governor in Council by the Westray Mine Public Inquiry, 1997. https://govns.ca/lwd/pubs/westray/(accessed 10 Mar. 2009).
    • (1997) The Westray Story: A Predictable Path to Disaster
    • Richard, K.P.1
  • 26
  • 27
    • 0003710674 scopus 로고    scopus 로고
    • Peay J, ed, London: Duckworth
    • Peay J, ed. Inquiries after homicide. London: Duckworth, 1996.
    • (1996) Inquiries After Homicide
  • 28
    • 20344402557 scopus 로고    scopus 로고
    • Twenty-five-year experience with the BjorkeShiley convexoeconcave heart valve: A continuing clinical concern
    • Blot WJ, Ibrahim MA, Ivey TD, et al. Twenty-five-year experience with the BjorkeShiley convexoeconcave heart valve: a continuing clinical concern. Circulation 2005;111:2850-7.
    • (2005) Circulation , vol.111 , pp. 2850-2857
    • Blot, W.J.1    Ibrahim, M.A.2    Ivey, T.D.3
  • 29
    • 77950315273 scopus 로고    scopus 로고
    • Westmead File No. 161/2007. Sydney: NSW Coroner's Court Westmead, accessed 1 Aug. 2008
    • Milovanovich C. Inquest into the death of Vanessa Ann Anderson. Westmead File No. 161/2007. Sydney: NSW Coroner's Court Westmead, 2008. http://www.lawlink. nsw.govau/lawlink/coroners-court/ll-coroners.nsf/pages/ coroners-findings (accessed 1 Aug. 2008).
    • (2008) Inquest Into the Death of Vanessa Ann. Anderson
    • Milovanovich, C.1
  • 32
    • 77956114450 scopus 로고    scopus 로고
    • Health and Disability Commissioner. Southland District Health Board Mental Health Services FebruaryeMarch 2001. Auckland: Health and Disability Commissioner, accessed 10 Mar. 2009
    • Health and Disability Commissioner. Southland District Health Board Mental Health Services (FebruaryeMarch 2001). Auckland: Health and Disability Commissioner, 2001. http://www.hdc.org.nz/files/hdc/publications/ othersouthlandreportpdf (accessed 10 Mar. 2009).
    • (2001)
  • 35
    • 68049144922 scopus 로고    scopus 로고
    • Sydney: State of New South Wales through the Special Commission of Inquiry into Acute Care in NSW Public Hospitals, accessed 10 Mar. 2009
    • Garling P. Final report of the Special Commission of Inquiry: acute care in NSW public hospitals. Sydney: State of New South Wales through the Special Commission of Inquiry into Acute Care in NSW Public Hospitals, 2008. http://www.lawlink.nsw. govau/lawlink/Special-Projects/ll-splprojects.nsf/pages/ acsi-finalreport (accessed 10 Mar. 2009).
    • (2008) Final Report of the Special Commission of Inquiry: Acute Care in NSW Public Hospitals
    • Garling, P.1
  • 36
    • 0032487550 scopus 로고    scopus 로고
    • Professional misconduct: The bristol case
    • Bolsin SN. Professional misconduct: the Bristol case. MJA 1998;169:369-72.
    • (1998) MJA , vol.169 , pp. 369-372
    • Bolsin, S.N.1
  • 37
    • 8744272747 scopus 로고
    • The challenger disaster: Moral responsibilities and the working engineer
    • Johnson DG, ed, Upper Saddle River, New Jersey: Prentice Hall
    • Boisjoly RM. The challenger disaster: Moral responsibilities and the working engineer. In: Johnson DG, ed. Ethical issues in engineering. Upper Saddle River, New Jersey: Prentice Hall, 1991:6-14.
    • (1991) Ethical Issues in Engineering , pp. 6-14
    • Boisjoly, R.M.1
  • 38
    • 47049094801 scopus 로고    scopus 로고
    • Another inquiry into public hospitals?
    • Travaglia JF, Lloyd JE, Braithwaite J. Another inquiry into public hospitals? MJA 2008;188:437-38.
    • (2008) MJA , vol.188 , pp. 437-438
    • Travaglia, J.F.1    Lloyd, J.E.2    Braithwaite, J.3


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.