High Reliability Organizations and Surgical Microsystems: Re-engineering Surgical Care

Surgical Clinics of North America

Volumn 92, Issue 1, 2012, Pages 1-14

  Sanchez, Juan A ^a,b   Barach, Paul R ^c  

^a ST MARY S HOSPITAL   (United States)

^b UNIVERSITY OF CONNECTICUT HEALTH CENTER   (United States)

^c Utrecht School of Governance   (Netherlands)

Author keywords

Clinical microsystems; High reliability; Normal accident theory; Patient safety; Safe culture; Teams

Indexed keywords

HEALTH CARE MANAGEMENT; HEALTH CARE ORGANIZATION; HEALTH CARE PERSONNEL; HEALTH CARE SYSTEM; HUMAN; LEADERSHIP; PATIENT CARE; PATIENT SAFETY; PRIORITY JOURNAL; REVIEW; TEAMWORK;

HUMANS; MEDICAL ERRORS; ORGANIZATIONAL CULTURE; PATIENT CARE TEAM; PATIENT SAFETY; QUALITY ASSURANCE, HEALTH CARE; SOCIAL ENVIRONMENT; SURGERY DEPARTMENT, HOSPITAL; SYSTEMS THEORY;

EID: 84856194716     PISSN: 00396109     EISSN: 15583171     Source Type: Journal    
DOI: 10.1016/j.suc.2011.12.005     Document Type: Review

References (48)

1. Berlow E.L., Dunne J.A., Martinez N.D., et al. Simple prediction of interaction strengths in complex food webs. Proceedings of the National Academy of Sciences 2009, 106:187-219.
2. Weick K.E., Sutcliffe K.M. Managing the unexpected: assuring high performance in an age of complexity 2001, John Wiley and Sons, Inc, New York.
3. Woods D. How to design a safety organization: test case for resilience engineering. Resilience engineering: concepts and precepts 2006, 315-324. Ashgate Publishing, United Kingdom. E. Hollnagel, D.D. Woods, N. Leveson (Eds.).
4. Hollnagel E., Woods D.D., Leveson N. Resilience engineering: concepts and precepts 2006, Ashgate Publishing Limited, United Kingdom.
5. Wears R.L., Perry S., Anders S., et al. Resilience in the emergency department. Resilience engineering perspectives 1: remaining sensitive to the possibility of failure 2008, 193-209. Ashgate, Aldershot (UK). E. Hollnagel, C. Nemeth, S.W.A. Dekker (Eds.).
6. Weick K.E., Sutcliffe K.M., Obstfeld D. Organizing for high reliability: processes of collective mindfulness. Research in Organizational Behavior 1999, vol. 21:81-123. JAI, Greenwich (CT). B. Staw, R. Sutton (Eds.).
7. Reason J.T. Human error 1990, Cambridge University Press, New York.
8. Reason J.T., Carthey J., de Leval M.R. Diagnosing " vulnerable system syndrome": an essential prerequisite to effective risk management. Qual Health Care 2001, 10(Suppl 2):ii21-ii25.
9. Vaughn D. The challenger launch decision: risky technology, culture, and deviance at NASA 1996, The University of Chicago Press, Chicago.
10. Haynes A.B., Weiser T.G., Berry W.R., Safe Surgery Saves Lives Study Group, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009, 360(5):491-499.
11. Weick K.E., Roberts K.H. Collective mind in organizations: heedful interrelating on flight decks. Adm Sci Q 1993, 38:357-381.
12. Zohar D. Safety climate in industrial organizations; theoretical and applied implications. J Appl Psychol 1980, 65:96-102.
13. Sexton J., Helmreich R., Thomas E. Error, stress and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000, 320:745-749.
14. Edmondson A.C. Speaking up in the operating room: how team leaders promote learning in interdisciplinary action teams. Journal of Management Studies 2003, 40:1419-1452.
15. Sagan S.D. The limits of safety. Organizations, accidents, and nuclear weapons 1993, Princeton University Press, Princeton (NJ).
16. Tamuz M., Harrison M.I. Improving patient safety in hospitals: contributions of high-reliability theory and normal accident theory. Health Serv Res 2006, 41(4 Pt 2):1654-1676.
17. Catchpole K.R., de Leval M.R., McEwan A., et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth 2007, 17:470-478.
18. Catchpole K., Sellers R., Goldman A., et al. Patient handovers within the hospital: translating knowledge from motor racing to healthcare. Qual Saf Health Care 2010, 19:318-322.
19. Gambino R., Mallon O. Near misses-an untapped database to find root causes. Lab Report 1991, 13:41-44.
20. March J.G., Sproull L.S., Tamuz M. Learning from samples of one or fewer. Organ Sci 1991, 2:1-3.
21. Reynard W.D., Billings C.E., Cheney E.S., et al. The development of the NASA aviation safety reporting system 1986, NASA Aeronautics and Space Administration, Scientific and Technical Information Branch, NASA Reference Publication 1114. Available at:, Accessed December 4, 2011. http://www-afo.arc.nasa.gov/ASRS/callback.html.
22. Ives G. Near miss reporting pitfalls for nuclear plants. Near miss reporting as a safety tool 1991, Butterworth and Heineman, Oxford (UK). T.W. Van der Shaff, D.A. Lucas, A.R. Hale (Eds.).
23. Carroll J. Incident reviews in High-hazard industries: sense making and learning under ambiguity and accountability. Ind Environ Crisis Q 1995, 9(2):175-197.
24. Barach P., Small S.D. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000, 320:753-763.
25. Bradford D.L., Cohen A.R. Managing for excellence: the guide to developing high performance contemporary organizations 1984, John Wiley & Sons, New York.
26. Katzenbach J.R., Smith D.K. The wisdom of teams: creating the high performance organization 1993, Harvard Business School Press, Cambridge (MA).
27. Barach P. Team based risk modification program to make health care safer. Theor Issues Ergon Sci 2007, 8:481-494.
28. Barach P., Johnson J. Team based learning in microsystems-an organizational framework for success. Technology, Instruction, Cognition and Learning 2006, 3:307-321.
29. Baker D., Salas E., Barach P., et al. The relation between teamwork and patient safety. Handbook of human factors and ergonomics in health care and patient safety 2006, 259-271. Lawrence Erlbaum Associates, Inc, New Jersey. P. Carayon (Ed.).
30. Lilford R., Chilton P.J., Hemming K., et al. Evaluating policy and service interventions: a methodological classification. BMJ 2010, 341:c4413.
31. Baker D.P., Gustafson S., Beaubien J.M., et al. Medical team training programs in health care. Advances in patient safety: from research to implementation 2005, vol. 4. Programs, tools, and products. AHRQ Publication No. 05-0021-4, Agency for Healthcare Research and Quality, Rockville (MD).
32. Smith-Jentsch K.A., Zeisig R.L., Acton B., et al. Team dimensional training. Making decisions under stress: implications for individual and team training 1998, 271-297. American Psychological Association, Washington, DC. J.A. Cannon-Bowers, E. Salas (Eds.).
33. Jentsch F. Metacognitive training for junior team members: solving the " copilot's catch-22." Unpublished doctoral dissertation 1997, University of Central Florida, Orlando (FL).
34. Driskell J.E., Johnston J.H. Stress exposure training. Making decisions under stress-implications for individual and team training 1998, 191-217. American Psychological Association, Washington, DC. J.A. Cannon-Bowers, E. Salas (Eds.).
35. Performance measurement in teams. Team training series, book 2. Orlando (FL): Naval Air Warfare Center Training Systems Division.
36. Mohr J., Barach P., Cravero J., et al. Microsystems in health care. Jt Comm J Qual Saf 2003, 29:401-408.
37. Quinn J.B. Intelligent enterprise: a knowledge and service based paradigm for industry 1992, Free Press, New York.
38. Batalden P.B., Nelson E.C., Edewards W.H., et al. Microsystems in health care: part 9. Developing small clinical units to attain peak performance. Jt Comm J Qual Saf 2003, 29(11):575-585.
39. Williams I., Dickinson H., Robinson S., et al. Clinical microsystems and the NHS: a sustainable method for improvement?. J Health Organ Manag 2009, 23(1):119-132.
40. Reis M.D., Scott S.D., Rempel G.R. Including parents in the evaluation of clinical microsystems in the neonatal intensive care unit. Adv Neonatal Care 2009, 9(4):174-179.
41. Schraagen J.M., Schouten A., Smit M., et al. Improving methods for studying teamwork in cardiac surgery. Qual Saf Health Care 2010, 19:1-6.
42. Schraagen J.M., Schouten T., Smit M., et al. A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. BMJ Qual Saf 2011, 20(7):599-603.
43. Barach P., Johnson J. Assessing risk and harm in the clinical microsystem: a systematic approach to patient safety. Continuous quality improvement in health care: theory, implementations, and applications 2011, 249-274. Jones and Bartlett. 4th edition. W. Sollecito, J. Johnson (Eds.).
44. Pronovost P., Wu A., Dorman T., et al. Building safety into ICU care. J Crit Care 2002, 17:78-85.
45. Dixon Woods M., Bosk C.L., Aveling E., et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q A Multidisciplinary Journal of Population and Health Policy 2011, 89:167-205.
46. Johnson J., Barach P. Safety: mindfulness for increased reliability and safety. Clinical microsystem action guide 2010, 89-100. Trustees of Dartmouth College, Hanover (NH). 3rd edition. E. Nelson, P. Batalden, M. Godfrey (Eds.).
47. Barach P., Johnson J.K. Understanding the complexity of redesigning care around clinical microsystem. Qual Saf Health Care 2006, 15(Suppl 1):10-16.
48. Cantor M., Barach P., Derse A., et al. Disclosing adverse events to patients. Jt Comm J Qual Patient Saf 2005, 31:5-12.