Safety culture: Building and sustaining a cultural change in aviation and healthcare

Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare

Volumn , Issue , 2012, Pages 1-243

  Patankar, Manoj S ^a   Brown, Jeffrey P ^b   Sabin, Edward J ^a   Bigda Peyton, Thomas G ^c  

^a SAINT LOUIS UNIVERSITY   (United States)

^b Healthcare Team Training   (United States)

^c Center for Adaptive Solutions   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 84899302106     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Book

References (365)

1. Argyris, C. (1977). Double loop learning in organizations. Harvard Business Review.
2. Argyris, C. (1986). Skilled incompetence. Harvard Business Review. September-October, 74-79.
3. Argyris, C. (1991). Teaching smart people how to learn. Harvard Business Review. May-June, 99-109.
4. Argyris, C. (1994). Good communication that blocks learning. Harvard Business Review.
5. Argyris, C. and Schön, D. (1974). Theory in Practice: Increasing Professional Effectiveness. San Francisco: Jossey-Bass.
6. Argyris, C. and Schön, D. (1978). Organizational Learning: A Theory of Action Perspective. Reading: Addison Wesley.
7. Baird, S., Holland P. and Deacon, S. (1999). Learning from action: imbedding more learning to make a difference. Organizational Dynamics.
8. Benoit, C. and Mackenzie, K. (1994). A model of organizational learning and the diagnostic process supporting it. The Learning Organization, 1(3), 26-37.
9. CAIB (2003). Report of the Columbia accident investigation board, Volume 1. Retrieved from on August 30, 2005.
10. Carroll, J. (1998). Organizational learning activities in high-hazard industries: the logics underlying self-analysis. Journal of Management Studies, 35(6), 669-717.
11. Carroll, J. and Edmondson, A. (2002). Leading organizational learning in healthcare. Quality and Safety in Healthcare, 11, 51-56.
12. Crossan, M., Lane, H. and White, R. (1999). An organizational learning framework: from intuition to institution. Academy of Management Review.
13. Garvin, D. (1993) Building a learning organization. Harvard Business Review.
14. Goh, S. (2003). Improving organizational learning capability: lessons from two case studies. The Learning Organizaton, 10(4), 216-227.
15. Helmreich, R.L., Merritt, A.C. and Wilhelm, J.A. (1999). The evolution of crew resource management training in commercial aviation. The International Journal of Aviation Psychology, 9, 19-32.
16. Husted, K. and Michailova, S. (2002). Diagnosing and fighting knowledge-sharing hostility. Organizational Dynamics, 31(1), 60-73.
17. IOM (2001). The Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC.: National Academy Press.
18. Jerez-Gomez, P., Cespedes-Lorente, J. and Valle-Cabrera, R. (2005). Journal of Business Research, 58, 715-725.
19. Johnson, J., Miller, S. and Horowitz, S. (2009). System-based practice: improving the safety and quality of patient care by recognizing and improving the systems in which we work. Agency for Healthcare Research and Quality .
20. Johnson, S. (2007). The predictive validity of safety climate. Journal of Safety Research, 38, 511-521.
21. Kleiner, A. and Roth, G. (1997). How to make experience your company's best teacher. Harvard Business Review.
22. Kramer, T. and Sabin, E. (2003). Managing the organizational learning process to improve the bottom line. The Psychologist-Manager Journal, 6(1), 11-30.
23. Larson, E. (2002). Measuring, monitoring, and reducing medical harm from a systems perspective: a medical director's personal reflections. Academic Medicine, 77(10), 993-1000.
24. Mai, R.P. and McAdams, J.L. (1995). Learning Partnerships: How Leading American Companies Implement Organizational Learning. New York: McGraw-Hill.
25. Marsick, V. and Watkins, K. (2003). Demonstrating the value of an organization's learning culture: dimensions of the learning organization questionnaire. Advances in Developing Human Resources, 5(2), 132-151.
26. Marx, D. (2001). Patient safety and the 'just culture': a primer for healthcare executives. Retrieved from on October 11, 2004.
27. Maurino, D., Reason, J., Johnston, N. and Lee, R. (1997). Beyond Aviation Human Factors. Aldershot: Ashgate.
28. Morrison, J. and Meliza, L. (1999). Foundations of the after action review process. Special Report 42. United States Army Research Institute for the Behavioral and Social Sciences. Alexandria, Virginia.
29. Ostroff, C., Kinicki, A. and Tamkins, M. (2003). Organizational culture and climate. In: W.C. Borman, D.R. Ilgen and R.J. Klimoski (eds), Comprehensive Handbook of Psychology, Volume 12: I/O Psychology (pp. 565-594). New York: John Wiley and Sons.
30. Patankar, M.S., Bigda-Peyton, T., Sabin, E., Brown, J. and Kelly, T. (2005). A comparative review of safety cultures. Report prepared for the Federal Aviation Administration. Available from .
31. Patankar, M.S. and Sabin, E. (2008). Safety culture transformation in technical operations of the air traffic organization: project report and recommendations. Report prepared for the Federal Aviation Administration. Available from .
32. Patankar, M. and Sabin, E. (2010). The safety culture perspective. In: E. Salas and D. Maurino (eds), Human Factors in Aviation, second edition. Chennai: Elsevier.
33. Reason, J. (1997). Managing the Risk of Organizational Accidents. Aldershot: Ashgate.
34. Roberts, K.H. (ed.) (1993). New Challenges to Organizations: High Reliability Understanding Organizations. New York: Macmillan.
35. Senge, P. (1990). The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday.
36. Shaw, R. and Perkins, D. (1992). Teaching organizations to learn: the power of productive failures. In: D.A. Nadler, M.S. Gerstain and R.B. Shaw (eds), Organizational Architecture: Designs for Changing Organizations, p. 175-192. San Francisco: Josey Bass.
37. Simon, S. and Pronovost, P. (2008). Physician autonomy and informed decision making: finding the balance for patient safety and quality. Journal of the American Medical Association, 300(24), 2913-2915.
38. U.S. Army Combined Arms Center (1993). A leader's guide to after-action reviews (Training Circular 25-20). Fort Leavenworth, Kansas.
39. Vaughn, D. (1996). The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chicago: University of Chicago Press.
40. Vincent, C. (2004). Analysis of clinical incidents: a window on the system not a search for root causes. Quality and Safety in Healthcare, 13, 242-243.
41. Vincent, C., Moorthy, K., Sarker, S., Chang, A. and Darzi, A. (2004). Systems approaches to surgical quality and safety: from concept to measurement. Annals of Surgery, 239(4), 475-482.
42. Wang, C. and Ahmed, P. (2003). Organizational learning: a critical review. The Learning Organization, 10(1), 8-17.
43. Waring, J. (2007a). Getting to the 'roots' of patient safety. International Journal for Quality in Healthcare, 11, 1-2.
44. Waring, J. (2007b). Doctors' thinking about 'the system' as a threat to patient safety. Health: An Interdisciplinary Journal for the Social Study of Health, Illness, and Medicine, 11(1), 29-46.
45. Wheatley, M. (1994). Can the U.S. Army become a learning organization? Journal for Quality and Participation. March, 50-55.
46. Wiegmann, D.A., Zhang, H., von Thaden, T.L., Sharma, G. and Gibbons, A.M. (2004). Safety culture: an integrative review. The International Journal of Aviation Psychology, 14, 117-134.
47. Wu, T., Chen, C. and Li, C. (2008). A correlation among safety leadership, safety climate and safety performance. Journal of Loss Prevention in the Process Industries, 21, 307-318.
48. Yang, B., Watkins, K. and Marsick, V. (2004). The construct of the learning organization: dimensions, measurement, and validation. Human Resource Development Quarterly, 15(1), 31-55.
49. Abramovitch, H. and Schwartz, E. (1996). Three stages of medical dialogue. Theoretical Medicine, 17(2), 175-187.
50. April, K.A. (1999). Leading through communication, conversation and dialogue. Leadership and Organization Development Journal, 20(5), 231-242.
51. Arezes, P. and Miguel, A. (2003). The role of safety culture in safety performance measurement. Measuring Business Excellence, 7(4), 20-29.
52. Bernard, A. and Spencer, J. (1996). Encyclopedia of Social and Cultural Anthropology. London: Routledge.
53. Blegen, M., Gearhart, S., O'Brien, R., Sehgal, N. and Alldredge, B. (2009). AHRQ's hospital survey on patient safety culture: psychometric analyses. Journal of Patient Safety, 5(3), 139-144.
54. Bodily, S.E. and Allen, M.S. (1999). A dialogue process for choosing valuecreating strategies. Interfaces, 29(6), 16-28.
55. Buber, M. (1947; 2002). Between Man and Man. New York: Routledge.
56. Burr, M., Sorra, J. and Nieva, V. (2002). Analysis of the Veterans Administration (VA) National Center for Patient Safety (NCPS) FY 2000 patient safety questionnaire. Technical report. Rockville: Westat.
57. Campbell, D. and Stanley, J. (1963). Experimental and Quasi-experimental Designs for Research. Chicago: Rand McNally.
58. Chang, Y. and Yeh, C. (2004). A new airline safety index. Transportation Research Part B: Methodological, 38(4), 369-383.
59. Colla, J.B., Bracken, A.C., Kinney, L.M. and Weeks, W.B. (2005). Measuring patient safety climate: a review of surveys. Quality and Safety in Healthcare, 14, 364-366.
60. Cooper, M.D. and Phillips, R.A. (2004). Exploratory analysis of the safety climate and safety behavior relationship. Journal of Safety Research, 35(5), 497-512.
61. Di Pofi, J. (2002). Organizational diagnostics: integrating qualitative and quantitative methodology. Journal of Organizational Change Management, 15(2), 156-168.
62. Erickson, K. and Stull, D. (1997). Doing Team Ethnography: Warnings and Advice. Thousand Oaks: Sage.
63. Fernández-Muñiz, B., Montes-Peón, J. and Vázquez-Ordás, C. (2007). Safety culture: analysis of the causal relationships between its key dimensions. Journal of Safety Research, 38, 627-641.
64. Flin, R., Mearns, K., O'Connor, P. and Bryden, R. (2000). Measuring safety climate: identifying the common features. Safety Science, 34, 177-192.
65. Gawande, A. (2011). The Checklist Manifesto: How to Get Things Right. New York: Picador.
66. Gerard, G. and Teurfs, L. (1997). Dialogue and transformation. Executive Excellence, 14(8), 16.
67. Gordon, L. (1994). Gordon's Guide to the Surgical Morbidity and Mortality Conference. Philadelphia: Hanley and Belfus.
68. Gordon, R., Moylan, P. and Stastny, P. (2004, October-December). Improving safety through a just culture: Flight Ops/ATC Ops safety information sharing. Journal of ATC, 34-38.
69. Guth, W. and MacMillan, I. (1986). Strategy implementation versus middle management self-interest. Strategic Management Journal, July/August, 313-327.
70. Hammersley, M. and Atkinson, P. (1983). Ethnography: Principles and Practice. London: Tavistock Books.
71. Harvey, J., Erdos, G., Jackson, H. and Dennison, S. (2004). Is safety culture in differing organizations the same thing? A comparison of safety culture measures in three organizations. Risk, Decision and Policy, 9(4), 337-346.
72. Helmreich, R., Klinect, J. and Wilhelm, J. (1999). Models of threat, error, and CRM in flight operations. In: Proceedings of the Tenth International Symposium on Aviation Psychology (pp. 677-682). Columbus: The Ohio State University.
73. Helmreich, R. and Merritt, A. (1998). Culture at Work in Aviation and Medicine: National, Organizational and Professional Influences. Aldershot: Ashgate.
74. Helmreich, R., Merritt, A., Sherman, P., Gregorich, S. and Wiener, E. (1993). The flight management attitudes questionnaire (FMAQ). NASA/UT/FAA technical report 93-4. Austin: University of Texas Press.
75. Hofstede, G. (1984). Culture's Consequences: International Differences in Workrelated Values (Abridged Edition). Beverly Hills: Sage.
76. Isaacs, W.N. (1993). Taking flight: dialogue, collective thinking, and organizational learning. Organizational Dynamics, 22(2), 24-39.
77. Isaacs, W.N. (1999). Dialogue and the Art of Thinking Together. New York: Currency Doubleday.
78. Johnson, S. (2007). The predictive validity of safety climate. Journal of Safety Research, 38, 511-521.
79. Keatings, M., Martin, M., McCallum, A. and Lewis, J. (2006). Medical errors: understanding the parent's perspective. Pediatric Clinics of North America, 53, 1079-1089.
80. Kouabenan, D. (1998). Beliefs and the perception of risks and accidents. Risk Analysis, 18(3), 243-52.
81. Krueger, R.A. and Casey, M.A. (2008). Focus Groups: A Practical Guide for Applied Research. Thousand Oaks: Sage.
82. Levine, L. (1994). Listening with spirit and the art of team dialogue. Journal of Organizational Change Management, 7(1), 61-73.
83. Marsick, V. and Watkins, K. (2003). Demonstrating the value of an organization's learning culture: dimensions of the learning organization questionnaire. Advances in Developing Human Resources, 5(2), 132-151.
84. Maxfield, D., Grenny, J., McMillan, R., Patterson, K. and Switzler, A. (2005). Silence Kills: The 7 Crucial Conversations in Healthcare. Provo: VitalSmarts.
85. Maxwell, J.A. (2004). Qualitative Research Design: An Interactive Approach (second edition). Thousand Oaks: Sage Publications.
86. Mazor, K.M., Simon, S.R., Yood, R.A., Martinson, B.C., Gunter, M.J., Reed, G.W. and Gurwitz, J.H. (2004). Health plan members' views about disclosure of medical errors. Annals of Internal Medicine, 140, 409-418.
87. NASA (2006). NASA procedural requirements for mishap and close call reporting, investigating, and recordkeeping. Retrieved from on April 4, 2009.
88. Neal, A. and Griffin, M. (2002). Safety climate and safety behaviour. Australian Journal of Management, 27, 67-75.
89. NTSB (2002). National transportation safety board aviation investigation manual major team investigations. Retrieved from on April 3, 2009.
90. Patankar, M.S. (2003). A study of safety culture at an aviation organization. International Journal of Applied Aviation Studies, 3(2), 243-258. Okalahoma City: FAA Academy.
91. Patankar, M.S. and Taylor, J.C. (2004). Risk Management and Error Reduction in Aviation Maintenance. Aldershot: Ashgate.
92. Patterson, K., Grenny, J., McMillan, R. and Switzler, A. (2002). Crucial Conversations: Tools for Talking When the Stakes are High. Hightstown: McGraw Hill.
93. Paul, J. (1996). Between-method triangulation in organizational diagnosis. The International Journal of Organizational Analysis, 4(2), 135-153.
94. Pidgeon, N. (1998). Safety culture: key theoretical issues. Work and Stress, 12(3), 202-216.
95. Pierluissi, E., Fischer, M., Campbell, A. and Landefeld, S. (2003). Discussion of medical error in morbidity and mortality conferences. Journal of the American Medical Association, 290(21), 2838-2842.
96. Pronovost, P. and Sexton, B. (2005). Assessing safety culture: guidelines and recommendations. Quality and Safety in Healthcare, 14, 231-233.
97. Rochon, T.R. (1998). Culture Moves: Ideas, Activism, and Changing Values. Princeton: Princeton University Press.
98. Rosenfeld, J. (2005). Using the morbidity and mortality conference to teach and assess the ACGME general competencies. Current Surgery, 62(6), 664-669.
99. Rundmo, T. and Hale, A. (2003). Managers' attitudes towards safety and accident prevention. Safety Science, 41, 557-574.
100. Schein, E.H. (1993). On dialogue, culture, and organizational learning. Reflections, 4(4), 27-38.
101. Schein, E.H. (1999). Process Consultation Revisited: Building the Helping Relationship. Reading: Addison-Wesley.
102. Schwarz, R. (2002). The Skilled Facilitator (revised edition) San Francisco: Jossey-Bass.
103. Scott, T., Mannion, R., Davies, H. and Marshall, M. (2003). The quantitative measurement of organizational culture in healthcare: a review of the available instruments. Health Services Research, 38(3), 923-945.
104. Senge, P.M. (1990). The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday.
105. Senge, P.M. (2006). The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Currency Doubleday.
106. Senge, P.M., Kleiner, A., Roberts, C., Ross, R.B. and Smith, B.J. (1994). The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. New York: Currency Doubleday.
107. Sexton, J.B. and Helmreich, R. (2004). Frontline assessments of healthcare culture: safety attitudes questionnaire norms and psychometric properties. Austin: The University of Texas Center of Excellence for Patient Safety Research and Practice. Technical Report No. 04-01. Sponsored by the Agency for Healthcare Research and Quality.
108. Sexton, J.B., Helmreich, R.J., Neilands, T.B., Rowan, K., Vella, K., Boyden, J., Roberts, P.R. and Thomas, E.J. (2006). The safety attitudes questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Services Research, 6, 44.
109. Shackford, J. (2005). Changing airline culture: addressing the behavioral side of change. Presented at the 2005 Symposium on Managing Safety, Reliability, and Services, April 25-27, Incheon, Korea. Retrieved from on January 15, 2010.
110. Singla, A., Kitch, B., Weissman, J. and Campbell, E. (2006). Assessing patient safety culture: a review and synthesis of the measurement tools. Journal of Patient Safety, 2(3), 105-115.
111. Sloat, K. (1996). Why safety programs fail ... and what to do about it. Occupational Hazards, 58(5), 65-70.
112. Smits, M., Christiaans-Dingelhoff, I., Wagner, C., van der Wal, G. and Groenewegen, P. (2008). The psychometric properties of the hospital survey on patient safety culture in Dutch hospitals. BMC Health Services Research, 8, 230.
113. Sorra, J. and Nieva, V. (2002). Psychometric analysis of MERS-TM hospital transfusion service safety culture survey. Rockville: Westat, under contract to Barents/KPMG, Contract No. 290-96-004. Sponsored by the Agency for Healthcare Research and Quality.
114. Sorra, J. and Nieva, V. (2003). Psychometric analysis of the hospital survey on patient safety culture. Rockville: Westat, under contract to Bearing Point, Contract No. 290-96-004. Sponsored by the Agency for Healthcare Research and Quality.
115. Sorra, J. and Nieva, V. (2004). Hospital survey on patient safety culture. Rockville, MD: Westat, under Contract No. 290-96-0004. Sponsored by the Agency for Healthcare Research and Quality.
116. Spradley, J. (1979). The Ethnographic Interview. New York: Wadsworth.
117. Stewart, D., Shamdasani, P. and Rook, D. (2006). Focus Groups: Theory and Practice. Thousand Oaks: Sage.
118. Stubbs, I.R. (1998). A leverage force: reflections on the impact of servantleadership. In: L. Spears (ed.), Insights on Leadership: Service, Stewardship, Spirit and Servant-leadership (pp. 314-321). New York: John Wiley.
119. Taylor, J.C. and Christensen, T.D. (1998). Airline Maintenance Resource Management: Improving Communication. Warrendale: SAE Press.
120. Taylor, J.C. and Patankar, M.S. (1999). Cultural factors contributing to the successful implementation of macro human factors principles in aviation maintenance. In: R. Jensen (ed.), Proceedings of the Tenth International Symposium on Aviation Psychology. Columbus: Ohio State University.
121. Thomas, E., Sexton, J. and Helmreich, R. (2004). Translating teamwork behaviors from aviation to healthcare: development of behavioral markers for neonatal resuscitation. Quality and Safety in Healthcare, 13, 57-64.
122. Triola, N. (2006). Dialogue and discourse: are we having the right conversations? Critical Care Nurse, 26, 60-66.
123. van den Berg, P. and Wilderom, C. (2004). Defining, measuring, and comparing organizational cultures. Applied Psychology: An International Review, 53(4), 570-582.
124. Vogus, T. and Sutcliffe, K. (2007). The safety organizing scale: development and validation of a behavioral measure of safety culture in hospital nursing units. Medical Care, 45(1), 46-54.
125. Weick, K. (1979). The Social Psychology of Organization. New York: Random House.
126. Wiegmann, D., Zhang, H., von Thaden, T., Sharma, G. and Mitchell, A. (2002). Safety culture: a review (Technical Report ARL-02-3/FAA-02-2). Atlantic City: Federal Aviation Administration.
127. Zremski, J. (2010). Colgan is again tightening fatigue rules - says more-lenient policy after crash is being abused. The Buffalo News: City and Region, January 6. Retrieved from .
128. Aboumatar, H., Blackledge, C., Dickson, J., Heitmiller, E., Freischlag, J. and, Pronovost, P. (2007). A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1. American Journal of Medical Quality, (22), 232-238.
129. American Medical Association (ed.) (1995). Essentials and information items: accreditation council for graduate medical education. Graduate Medical Education Directory 1995-1996.
130. Bagian, J., Gosbee, J., Lee, C., Williams, L., McKnight, S., and Mannos, D. (2002). The veterans affairs root cause analysis system in action. Journal on Quality Improvement, 28(10), 531-545.
131. Bain, A. (1998). Social defenses against organizational learning. Human Relations, 51(3), 413-429.
132. Battles, J., Dixon, N., Borotkanics, R., Rabin-Fastmen, B., and Kaplan, H. (2006). Sensemaking of patient safety risks and hazards. Health Services Research, 41 (4-2), 1555-1575.
133. Berenholtz, S., Hartsell, T., and Pronovost, P. (2009). Learning from defects to enhance morbidity and mortality conferences. American Journal of Medical Quality, 24(3), 192-195.
134. Berriel-Cass, D., Adkins, F., Jones, P., and Fakih, M. (2006). Eliminating nosocomial infections at ascension health. Joint Commission Journal on Quality and Patient Safety, 32(11), 612-620.
135. Bird, D., O'Donnell, C., Silva, J., Korn, J., Burke, R., Burke, P., and Agarwal, S. (2009). Adherence to VAP bundle decreases incidence of ventilator-associated pneumonia in the surgical intensive care unit. Presented at the 90th Annual Meeting of the New England Surgical Society. Retrieved from on April 24, 2010.
136. Bosch, J.-C. Eckard, E., and Singal, V. (1998). The competitive impact of air crashes: stock market evidence. Journal of Law and Economics, 41(2), 503-519.
137. Butler, K., Mollo, P., Gale, J., and Rapp, D. (2007). Eliminating adverse drug events at ascension health. Joint Commission Journal on Quality and Patient Safety, 33(9), 527-536.
138. Carroll, J., Rudolph, J., 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, 266-269.
139. Christensen, J., Levinson, W., and Dunn, P. (1992). The heart of darkness: the impact of perceived mistakes on physicians. Journal of General Internal Medicine, 7, 424-431.
140. Deis, J., Smith, K., Warren, M., Throop, P., Hickson, G., Joers, B., and Deshpande, J. (2008). Transforming the morbidity and mortality conference into an instrument for system-wide improvement. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville: Agency for Healthcare Research and Quality.
141. Dekker, S. (2007). Just Culture: Balancing Safety and Accountability. Aldershot: Ashgate.
142. Delbanco, T. and Bell, S. (2007). Guilty, afraid, and alone: struggling with medical error. New England Journal of Medicine, 357(17), 1682-6183.
143. Engel, K., Rosenthal, M., and Sutcliffe, K. (2006). Residents' responses to medical error: coping, learning, and change. Academic Medicine, 81(1), 86-93.
144. FAA (2008). Sample SMS manual. Retrieved from on April 24, 2010.
145. Fryer-Edwards, K., Van Eaton, E., Goldstein, E., Kimball, H., Veith, R., Pellegrini, C., and Ramsey, P. (2007). Overcoming institutional challenges through continuous professionalism improvement: the University of Washington experience. Academic Medicine, 82(11), 1073-1078.
146. Gallagher, T., Waterman, A., Ebers, A., Fraser, V., and Levinson, W. (2003). Patients' and physicians' attitudes regarding the disclosure of medical errors. Journal of the American Medical Association, 289(8), 1001-1007.
147. Haig, K., Sutton, S., and Whittington, J. (2006). SBAR: a shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175.
148. Heinrich, H. (1931). Industrial Accident Prevention: A Scientific Approach. New York: McGraw-Hill.
149. Helmreich, R., Klinect, J., and Wilhelm, J. (1999). Models of threat, error, and CRM in flight operations. In: Proceedings of the Tenth International Symposium on Aviation Psychology (pp. 677-682). Columbus: The Ohio State University.
150. Houston, D. and Allt, S. (1997). Psychological distress and error making among junior house officers. British Journal of Health Psychology, 2, 141-151.
151. Jaques, E. (1955). Social systems as a defence against persecutory and depressive anxiety. In: M. Klein, P. Heimann and R.E. Money-Kyrle (eds), New directions in Psychoanalysis. London: Tavistock Publications.
152. Joint Commission Resources (2007). Pushing the envelope on root cause analysis: implementing challenging actions for long-term results. Joint Commission Perspectives on Patient Safety, 7(3), 3-14.
153. Joint Commission Resources (2008). Errors associated with new technology. Joint Commission Perspectives on Patient Safety, 7(5), 5-6 and 13-14.
154. Kravet, S., Howell, E., and Wright, S. (2006). Morbidity and mortality conference, grand rounds, and the ACGME's core competencies. Journal of General Internal Medicine, 21, 1192-1194.
155. Latino, R. and Latino, K. (2006). Root Cause Analysis: Improving Performance for Bottom-line Results. Boca Raton: CRC Press/Taylor and Francis.
156. Lazare, A. (2006). Apology in medical practice: an emerging clinical skill. Journal of the American Medical Association, 296(11), 1401-1404.
157. Leonard, M., Graham, S., and Bonacum, D. (2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Healthcare, 13, 85-90.
158. Marx, D. (2009). Wack-a-mole: The Price we Pay for Expecting Perfection. Plano: Your Side Studios.
159. McCaughey, B. (2008). Unnecessary deaths: the human and financial costs of hospital infections (3rd edition). Committee to Reduce Infection Deaths .
160. Menzies, I. (1960). A case-study in the functioning of social systems as a defence against anxiety: a report on a study of the nursing service of a general hospital. Human Relations, 13(2), 95-121.
161. Mizrahi, T. (1984). Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Social Science and Medicine, 19(2), 135-146.
162. Newman, M. (1996). The emotional impact of mistakes on family physicians. Archives of Family Medicine, 5, 71-75.
163. Orlander, J., Barber, T., and Fincke, B. (2002). The morbidity and mortality conference: the delicate nature of learning from error. Academic Medicine, 77(10), 1001-1006.
164. Ornstein, C. (2007). Actor files suit in drug mishap. Los Angeles Times, December 5. Retrieved from on April 24, 2010.
165. Paradies, M. and Unger, L. (2000). TapRoot: The System for Root Cause Analysis, Problem Investigation, and Proactive Improvement. Knoxville: System Improvements.
166. Pardee, J. (2009). Improving safety through collaborative safety initiatives. Presented to the ICAO Air Navigation Commission. Retrieved from on April 24, 2010.
167. Patankar, M.S. (2002). Root cause analysis of rule violations by aviation maintenance technicians. Grant No. 2001-G-001 Washington, DC.: FAA Office of Aviation Medicine.
168. Patankar, M.S. and Mondello, S. (2010). SMS safety investment model. Presented to the Federal Aviation Administration, April 7.
169. Patankar, M.S. and Taylor, J. (2004). Applied Human Factors in Aviation Maintenance. Aldershot: Ashgate.
170. Pierluissi, E., Fischer, M., Campbell, A., and Landefeld, C. (2003). Discussion of medical errors in morbidity and mortality conferences. Journal of the American Medical Association, 290(21), 2838-2842.
171. Reason, J. (1997). Managing the Risk of Organizational Accidents. Aldershot: Ashgate.
172. Rex, J., Turnbull, J., Allen, S., Vande Voorde, K., and Luther, K. (2000). Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Joint Commission Journal on Quality Improvement, 26(10), 563-575.
173. Shappel, S. and Wiegmann, D. (2001). Unraveling the mystery of general aviation controlled flights into terrain accidents using HFACS. Paper presented at the 11th International Symposium on Aviation Psychology. Columbus: The Ohio State University.
174. Shendell-Falik, N., Feinson, M., and Mohr, B. (2007). Enhancing patient safety: improving the patient handoff process through appreciative inquiry. Journal of Nursing Administration, 37(2), 95-104.
175. Stewart, K. (2007). Two reports from 1990s forwarded to NTSB. Courier Journal.com, March 16. Retrieved from on April 24, 2010.
176. Swing, S. (1998). ACGME launches outcomes assessment project. Journal of the American Medical Association, 279(18), 1492.
177. Szekendi, M., Barnard, C., Creamer, J., and Noskin, G. (2010). Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. Joint Commission Journal on Quality and Patient Safety, 36(1), 3-9.
178. Taxis, K., Gallivan, S., Barber, N., and Franklin, B.D. (2006). Can the Heinrich ratio be used to predict harm from medication errors? Technical Report. University of Birmingham. Retrieved from on April 24, 2010.
179. Vincent, C. (2003). Understanding and responding to adverse events. The New England Journal of Medicine, 348(11), 1051-1056.
180. Vincent, C., Taylor-Adams, S., and Stanhope, N. (1998). Framework for analysing risk and safety in clinical medicine. British Medical Journal, 316(7138), 1154-1157.
181. Wald and Shojania, K. (2001). In: Making healthcare safer: a critical analysis of patient safety practices. Chapter 5. Root cause analysis. Evidence report/ technology assessment, No. 43. AHRQ Publication No. 01-E058, July 2001. Rockville: Agency for Healthcare Research and Quality. .
182. Weiss, K., Leveson, N., Lundqvist, K., Farid, N., and Stringfellow, M. An analysis of causation in aerospace accidents. Paper presented at Space 2001. Albuquerque.
183. West, C., Huschka, M., Novotny, P., Sloan, J., Kolars, J., Habermann, T., and Shanafelt, T. (2006). Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. Journal of the American Medical Association, 296(9), 1071-1078.
184. Wilf-Miron, R., Lewenhoff, I., Benyamini, Z., and Aviram, A. (2003). From aviation safety to medicine: applying concepts of aviation safety to risk management in ambulatory care. Quality and Safety in Healthcare, 12, 35-39.
185. Wilson, P., Dell, L., and Anderson, G. (1993). Root Cause Analysis: A Tool for Total Quality Management. Milwaukee: American Society for Quality Press.
186. Woolf, S., Kuzel, A., Dovey, S., and Phillips, R. (2004). A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Annals of Family Medicine, 2(4), 317-326.
187. Wu, A., Lipshutz, A., and Pronovost, P. (2008). Effectiveness and efficiency of root cause analysis in medicine. Journal of the American Medical Association, 299(6), 685-687.
188. ACSNI (1993). ACSNI human factors study group. Third report: organising for safety, advisory committee on the safety of nuclear installations, health and safety commission.
189. Ahlstrom, V. and Hartman, D. (2001). Human error in airway facilities. Technical report DOT/FAA/CT-TN01/02. Retrieved from on November 14, 2005.
190. Argyris, C. and Schön, D. (1974). Theory in Practice: Increasing Professional Effectiveness. San Francisco: Jossey-Bass.
191. Block, E. (2008). Maintenance resource management in aviation: a systems approach to measuring training impact. Doctoral dissertation. St. Louis: Department of Psychology, Saint Louis University.
192. Bowen, B. and Headley, D. (2002). The airline quality rating 2002. Report by the University of Nebraska at Omaha and Wichita State University. Retrieved from on November 14, 2005.
193. CAIB (2003). Report of the Columbia accident investigation board, volume 1. Retrieved from on August 30, 2005.
194. Clarke, L. and Short, J. (1993). Social organization and risk: some current controversies. Annual Review of Sociology, 19, 375-399.
195. Clarke, S. (1998). Organizational factors affecting the incident reporting of train drivers. Work and Stress, 12, 6-16.
196. Collins, J.C. (2001). Good to Great: Why Some Companies Make the Leap ... and Others Don't. New York: HarperCollins.
197. Collins, J.C. and Porras, J.I. (1997). Built to Last: Successful Habits of Visionary Companies. New York: HarperCollins.
198. Drury, C. and Gramopadhye, A. (1991). Speed and accuracy in aircraft inspection. Position paper for FAA biomedical and behavioral sciences division. Washington, DC: Office of Aviation Medicine.
199. Fleming, M. and Lardner, R. (1999). Safety culture - the way forward. The Chemical Engineer, 16-18.
200. Freiberg, K. and Freiberg, J. (1996). Nuts! Southwest Airlines' Crazy Recipe for Business and Personal Success. Austin: Bard Press.
201. GAIN (2004). A roadmap to a just culture: enhancing the safety environment. A report by the global aviation information network working group E. In: Flight Safety Digest, March 2005. Flight Safety Foundation. Retrieved from on November 14, 2005.
202. Gallagher, C., Underhill, E., and Rimmer, M. (2001). Occupational health and safety management systems: a review of their effectiveness in securing healthy and safe workplaces. A report for the National Occupational Health and Safety Commission, Sydney, Australia. Retrieved from on November 14, 2005.
203. Grubbe, D.L. (2003). Safety at DuPont. Presented at the US House Science Committee Hearing on NASA organizational issues, October 29, 2003. Retrieved from on October 12, 2005.
204. Hackworth, C., Cruz, C., Jack, D., Goldman, S., and King, S. (2004). Employee attitudes within the air traffic organization. Final report. Washington, DC: Federal Aviation Administration, Department of Transportation.
205. Harper, M. and Helmreich, R. (2003). Creating and maintaining a reporting culture. In: R. Jensen (ed.) Proceedings of the Twelfth International Symposium on Aviation Psychology (pp. 496-501), April 14-17, Dayton: The Ohio State University.
206. Helmreich, R.L. (1999). Building safety on the three cultures of aviation. In: Proceedings of the IATA Human Factors Seminar (pp. 39-43). Bangkok, August 12, 1998.
207. Herzberg, F. (1966). Work and the Nature of Man. Cleveland and New York: The Word Publishing Company.
208. Kaplan, R. and Norton, D. (1998). The balanced scorecard - measures that drive performance. In: Harvard Business Review on Measuring Corporate Performance (pp. 123-146). Boston: Harvard Business School Press.
209. Knowles, R.N. (2002). The Leadership Dance: Pathways to Extraordinary Organizational Effectiveness. Niagara Falls: The Center for Self-Organizing Leadership.
210. La Porte, T. and Consolini, P. (1991). Working in practice but not in theory: theoretical challenges of high-reliability organizations. Journal of Public Administration Research Theory, 1, 19-47.
211. Marx, D. (1997). Moving toward 100 per cent error reporting in maintenance. In: Proceedings of the Eleventh International Symposium on Human Factors in Aircraft Maintenance and Inspection. Washington, DC: Federal Aviation Administration.
212. Marx, D. (2001). Patient safety and the 'just culture': a primer for health care executives. Retrieved from on October 11, 2004.
213. Patankar, M.S. (2002). Causal-comparative analysis of self-reported and FAA rule violation datasets among aircraft mechanics. International Journal of Applied Aviation Studies, 2(2), 87-100. Okalahoma City: FAA Academy.
214. Patankar, M.S., Bigda-Peyton, T., Sabin, E., Brown, J., and Kelly, T. (2005). A comparative review of safety cultures. Report prepared for the Federal Aviation Administration. Available from .
215. Patankar, M.S., Brown, J.P., and Treadwell, M. (2005). Safety Ethics: Cases from Aviation, Medicine, and Environmental and Occupational Health. Aldershot: Ashgate.
216. Patankar, M.S. and Driscoll, D. (2004). Preliminary analysis of aviation safety action programs in aviation maintenance. In: M. Patankar (ed.) Proceedings of the First Safety Across High-consequence Industries Conference (pp. 97-102) [CD-ROM], St. Louis.
217. Patankar, M.S. and Gomez, M. (2005). Proceedings of the maintenance ASAP infoshare working group meeting. June 27 and 28, 2005. St. Louis: Saint Louis University.
218. Patankar, M.S. and Sabin, E. (2008). Safety culture transformation in technical operations of the air traffic organization: project report and recommendations. Report prepared for the Federal Aviation Administration. Available from .
219. Patankar, M.S. and Taylor, J. (1999). Corporate aviation on the leading edge: systemic implementation of macro-human factors in aviation maintenance. In: Proceedings of the SAE Airframe/Engine Maintenance and Repair Conference [SAE Technical Paper Number 1999-01-1596]. Vancouver.
220. Patankar, M.S. and Taylor, J.C. (2004). Risk Management and Error Reduction in Aviation Maintenance. Aldershot: Ashgate.
221. Patankar, M.S., Taylor, J. and Goglia, J. (2002). Individual professionalism and mutual trust are key to minimizing the probability of maintenance errors. In: Proceedings of the Aviation Safety and Security Symposium, April 17 and 18, Washington.
222. Pierce, G. (2005). Building the foundation for a culture of safety. Focus on patient safety: a newsletter from the National Patient Safety Foundation, 8(2), 1-3.
223. Reason, J. (1997). Managing the Risk of Organizational Accidents. Aldershot: Ashgate.
224. Roberts, K.H. (ed.) (1993). New Challenges to Organizations: High Reliability Understanding Organizations. New York: Macmillan.
225. Roughton, J.E. and Mercurio, J.J. (2002). Developing an Effective Safety Culture: A Leadership Approach. Boston: Butterworth-Heinemann.
226. Schulman, P. (1993). The analysis of high reliability organizations: a comparative framework. In: K.H. Roberts (ed.), New Challenges to Organizations: High Reliability Understanding Organizations. New York: Macmillan.
227. Senge, P.M. (1990). The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday/Currency.
228. Sloat, K. (1996). Why safety programs fail ... and what to do about it. Occupational Hazards, 58(5), 65-70.
229. Strebel, P. (1998). Why do employees resist change? In: Harvard Business Review on Change (pp. 139-158). Boston: Harvard Business School Press.
230. Taylor, J.C. (1995). Effects of communication and participation in aviation maintenance. In: Proceedings of the Eighth International Symposium on Aviation Psychology (pp. 472-477). Columbus: The Ohio State University.
231. Taylor, J.C. (2000). Reliability and validity of the maintenance resources management/technical operations questionnaire. International Journal of Industrial Ergonomics, 26, 217-230.
232. Taylor, J.C. (2004). Prototype training materials for acceptance criteria of maintenance ASAP events occurring within social context. Moffett Field: QSS/NASA Ames Research Center. Retrieved from on November 14, 2005.
233. Taylor, J.C. and Christensen, T. (1998). Airline Maintenance Resource Management: Improving Communication. Warrendale: Society of Automotive Engineers.
234. Taylor, J.C. and Fenton, D.F. (1993). Performance by Design: Sociotechnical Systems in North America. Englewood Cliffs: Prentice Hall.
235. Taylor, J.C. and Patankar, M.S. (2001). Four generations of MRM: evolution of human error management programs in the United States. Journal of Air Transportation World Wide, 6(2), 3-32.
236. VanDrie, K.D. (2005). Risk and resource management: an analytical approach. In: Patankar, M. and Ma, J. (eds) Proceedings of the Second Safety Across High-consequence Industries Conference, Volume 1, St. Louis: Parks College of Engineering, Aviation and Technology.
237. Westrum, R. (1993). Cultures with requisite imagination. In: J. Wise and D. Hopkin (eds), Verification and Validation: Human Factors Aspects (pp. 401-416). New York: Springer.
238. Westrum, R. (1995). Organisational dynamics and safety. In: N. McDonald, N. Johnston and R. Fuller (eds), Applications of Psychology to the Aviation System (Vol. 1) (pp. 75-80). Brooksfield: Ashgate.
239. Wheatley. M.J. (1999). Leadership and the New Science: Discovering Order in a Chaotic World (second edition). San Francisco: Berrett-Koehler Publishers.
240. Zahlis, D. and Hansen, L. (2005). Beware [of] the disconnect: overcoming the conflict between measures and results. Professional Safety, 18-24. American Society of Safety Engineers.
241. Ascension Health Annual Report (2009). Integrating excellence and stewardship: 2009 ascension health annual report. St. Louis: Ascension Health. Available from .
242. Chirinos, F. (2008). Spohn probes medicine error: 14 babies were given too much blood thinner. Retrieved from on April 25, 2010.
243. Collins, J.C. and Porras, J.I. (1997). Built to Last: Successful Habits of Visionary Companies. New York: HarperCollins.
244. FAA (2006). AC 120-92 Introduction to safety management systems for air operators, AFS-800. Available at .
245. Hendrich, A., Tersigni, Al., Jeffcoat, S., Barnett, C., Brideau, L. and Pryor, D. (2007). The ascension health journey to zero: lessons learned and leadership perspectives. The Joint Commission Journal on Quality and Patient Safety, 33(12), 739-749.
246. INPO (2004). Institute of nuclear power operators: principles for a strong nuclear safety culture. Retrieved from on April 25, 2010.
247. McVenes, T. (2007). Safer skies: we are almost there. Air Line Pilot, 14-19. Air Line Pilots Association.
248. NTSB (1992). United Airlines flight 232 McDonnell Douglas DC-10-10 Sioux Gateway Airport, Sioux City, Iowa, July 19, 1989. Aviation accident report number AAR-90/06. Retrieved from .
249. Patankar, M.S. (2009). A practical guide to maintenance ASAP programs. Report prepared for the Federal Aviation Administration (FAA Document DOT/ FAA /AR-09/28). Available from .
250. Patankar, M.S. and Taylor, J.C. (1999). Corporate aviation on the leading edge: systemic implementation of macro-human factors in aviation maintenance. In: Proceedings of the SAE Airframe/Engine Maintenance and Repair Conference [SAE Technical Paper Number 1999-01-1596]. Vancouver, BC.
251. Pryor, D., Tolcin, S., Hendrich, A., Thomas, C., and Tersigni, A. (June, 2006). The clinical transformation of ascension health: Eliminating all preventable injuries and deaths. The Joint Commission Journal on Quality and Patient Safety, 32(6), 299-308.
252. Steitzer, S. (2009). Jury awards $7.1M in Comair crash lawsuit. Retrieved from on April 25, 2010.
253. Taylor, J.C. and Patankar, M.S. (2001). Four generations of MRM: evolution of human error management programs in the United States. Journal of Air Transportation World Wide, 6(2), 3-32.
254. Abma, T. and Widdershoven, G. (2005). Sharing stories: narrative and dialogue in responsive nursing evaluation. Evaluation and the Health Professions, 28, 90-109.
255. Argyris, C. (1977). Double loop learning in organizations. Harvard Business Review.
256. Argyris, C. (1995). Action science and organizational learning. Journal of Managerial Psychology, 10(6), 20-26.
257. Argyris, C. and Schön, D. (1974). Theory in Practice: Increasing Professional Effectiveness. San Francisco: Jossey-Bass.
258. Argyris, C. and Schön, D. (1978). Organizational Learning: A Theory of Action Perspective. Reading: Addison Wesley.
259. Bateson, G. (1972). Steps to an Ecology of Mind. New York: Ballantine.
260. Berry, J. (1983). Acculturation: a comparative analysis of alternative forms. In: R.J. Samuda and S.L. Woods (eds), Perspectives in Immigrant and Minority Education (pp. 66-77). Lanham: University Press of America.
261. Berry, J. (2003). Conceptual approaches to acculturation. In: K. Chun, P. Organista and G. Marín (eds). Acculturation: Advances in Theory, Measurement, and Applied Research. Washington, DC.: American Psychological Association.
262. Bierly, P.E., Kessler, E.H., and Christensen, E.W. (2000). Organizational learning, knowledge and wisdom. Journal of Organizational Change, 13(6), 595-618.
263. Bolman, L. (1980). Aviation accidents and the theory of the situation. In: G.E. Cooper (ed.), Resource Management on the Flight Deck. Moffet Field: NASA Ames Research Center.
264. Brewer, W.F. and Treyens, J.C. (1981). Role of schemata in memory for places. Cognitive Psychology, 13, 207-230.
265. Cable, D. and Parsons, C. (2001). Socialization tactics and person-organization fit. Personnel Psychology, 54(1), 1-23.
266. Cartwright, S. and Cooper, C. (1993). The role of culture compatibility in successful organizational marriage. The Academy of Management Executive, 7(2), 57-70.
267. Christopher, F. (2006). Remaking American Medicine: Healthcare for the 21st Century. A PBS Series.
268. Chun, K., Organista, P. and Marín, G. (2003). (eds). Acculturation: Advances in Theory, Measurement, and Applied Research. Washington, DC: American Psychological Association.
269. Cox, T. (1991). The multicultural organization. The Executive, 5(2), 34-47.
270. Crandall, B., Klein, G., and Hoffman, R. (2006). Working Minds: A Practitioner's Guide to Cognitive Task Analysis. Cambridge: MIT Press.
271. Dominguez, C., Uhlig, P., Brown, J., Gurevich, O., Shumar, W., Stahl, G., Zemel, A., and Zipperer, L. (2005). Studying and supporting collaborative care processes. In: Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting.
272. Edmondson, A., Bohmer, R. and Pisano, G. (2001). Speeding up team learning. Harvard Business Review, 79(9), 125-134.
273. Gittell, J.H. (2000). Organizing work to support relational coordination. International Journal of Human Resource Management, 11(3), 517-539.
274. Gittell, J.H., Fairfield, K., Bierbaum, B., Jackson, R., Kelly, R., Laskin, R., Lipson, S., Siliski, J., Thornhill, T., and Zuckerman, J. (2000). Impact of relational coordination on quality of care, post-operative pain and functioning, and length of stay: a nine hospital study of surgical patients. Medical Care, 38(8), 807-819.
275. Helmreich, R. and Merritt, A. (1998). Culture at Work in Aviation and Medicine: National, Organizational and Professional Influences. Aldershot: Ashgate.
276. Hofstede, G. (1984). Culture's Consequences: International Differences in Workrelated Values abridged edition. Beverly Hills: Sage.
277. Hollnagel, E. (2009). The ETTO Principle: Efficiency-thoroughness Trade-off. Farnham: Ashgate.
278. ICAO (1995). Six years after the Dryden tragedy, many accident investigation authorities have learned its lessons. ICAO Journal, 20-25.
279. King, S. (2006). Our story. Clinical Pediatric Emergency Medicine, 7(4), 268-270.
280. King, S. (2009). Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe. New York: Atlantic Monthly Press.
281. Klein, G. (1989). Recognition-primed decisions. In: W.B. Rouse (ed.), Advances in Man-machine Systems Research (pp. 47-92). Greenwich: JAI.
282. Klein, G. (1993). Naturalistic decision-making: implications for design (CSERIAC SOAR 93-1). Ohio.
283. Larsson, R. and Lubatkin, M. (2001). Achieving acculturation in mergers and acquisition: an international case survey. Human Relations, 54(12), 1573-1607.
284. Lawrence, D. (2002). From Chaos to Care: The Promise of Team-based Medicine. Cambridge: Perseus Publishing.
285. Lee, B., Tobia, A., Yueh, J., Bar-Meir, E., Darrah, L., Guglielmi, C., Wood, E., Carr, J., and Moorman, D. (2008). Design and impact of an intraoperative pathway: a new operating room model for team-based practice. Journal of American College of Surgeons, 207(6), 865-873.
286. Maurino, D., Reason, J., Johnston, N., and Lee, R. (1997). Beyond Aviation Human Factors. Aldershot: Ashgate.
287. McWhinney, W. (1992). Paths of Change: Strategic Choices for Organizations and Society. Newbury Park: Sage.
288. Merry, M. (2005). Hospital-medical staff culture clash: is it inevitable or preventable? The challenge of governance. The Healthcare Trustees of New York State. Retrieved from on May 1, 2010.
289. Merry, M. and Brown, J. (2001). From a culture of safety to a culture of excellence: quality science, human factors, and the future of healthcare quality. Journal of Innovative Management, 7(2), 29-46.
290. Merry, M. and Crago, M. (2001). The past, present and future of healthcare quality. The Physician Executive, September-October 2001.
291. Meyer, J. (2003). Tell me a story: eliciting organizational values from narratives. Communication Quarterly, 43(2), 210-224.
292. Nahavandi, A. and Malekzadeh, A. (1988). Acculturation in mergers and acquisitions. The Academy of Management Review, 13(1), 79-90.
293. Patankar, M.S. and Taylor, J.C. (2004). Risk Management and Error Reduction in Aviation Maintenance. Aldershot: Ashgate.
294. Patankar, M.S., Brown, J.P., and Treadwell, M. (2005). Safety Ethics: Cases from Aviation, Medicine, and Environmental and Occupational Health. Aldershot: Ashgate.
295. Patterson, E., Render, M., and Ebright, P. (2002). Repeating human performance themes in five healthcare adverse events. In: Proceedings of the Human Factors and Ergonomics Society 46th Annual Meeting. Santa Monica: California.
296. Rochon, T.R. (1998). Culture Moves: Ideas, Activism, and Changing Values. Princeton: Princeton University Press.
297. Romme, A. and van Witteloostuijn, A. (1999). Circular organizing and triple loop learning. Journal of Organizational Change Management, 12(5), 439-454.
298. Sharpe, V. and Faden, A. (1998). Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. Cambridge: Cambridge University Press.
299. Snell, R. and Man-Kuen Chak, A. (1998). The learning organization: learning and empowerment for whom? Management Learning, 29, 337-64.
300. Starr, P. (1982). The Social Transformation of American Medicine. Basic Books.
301. Taylor, J. and Patankar, M.S. (2000). The role of communication in reduction of human error. In: Proceedings of The 14th Annual FAA/CAA/Transport Canada Human Factors in Aviation Maintenance Symposium, [CD-ROM: 15.0/1-27]. Vancouver, B.C.
302. Tversky, A. and Kahneman, D. (1973). Availability: a heuristic for judging frequency and probability. Cognitive Psychology, 5.
303. Tversky, A. and Kahneman, D. (1974). Judgment under uncertainty: heuristics and biases. Science, 185, 1124-1131.
304. Wang, C. and Ahmed, P. (2003). Organisational learning: a critical review. The Learning Organization, (10)1, 8-17.
305. Woods, D.D. (2004). Conflicts between learning and accountability in patient safety. De Paul Law Review, 54, 485-502.
306. Amalberti, R., Auroy, Y., Berwick, D., and Barach, P. (2005). Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine, 142, 756-764.
307. Fernández-Muñiz, B., Montes-Peón, J., and Vázquez-Ordás, C. (2007). Safety culture: analysis of the causal relationships between its key dimensions. Journal of Safety Research, 38, 627-641.
308. Guth, W. and MacMillan, I. (1986). Strategy implementation versus middle management self-interest. Strategic Management Journal, July/August, 313-327.
309. Hendrich, A., Tersigni, A., Jeffcoat, S., Barnett, C., Brideau, L., and Pryor, D. (2007). The ascension health journey to zero: lessons learned and leadership perspective. The Joint Commission Journal on Quality and Patient Safety, 33(12), 739-749.
310. Kaplan, R. and Norton, D. (1998). The balanced scorecard - measures that drive performance. In: Harvard Business Review on Measuring Corporate Performance, 123-146. Boston: Harvard Business School Press.
311. Knowles, R.N. (2002). The Leadership Dance: Pathways to Extraordinary Organizational Effectiveness. Niagara Falls: The Center for Self-Organizing Leadership.
312. Livingston, J.S. (1988). Pygmalion in management: a manager's expectations are the key to a subordinates performance and development. Harvard Business Review, September-October.
313. Merry, M. (2003). Healthcare's need for revolutionary change. Quality Progress, 36(9), 31-36.
314. Mitroussi, K. (2003). The evolution of safety culture of IMO: a case of organizational culture change. Disaster Prevention and Management, 12(1), 16-23.
315. Moore, G. (1991). Crossing the Chasm: Marketing and Selling High-tech Products to Mainstream Customers. New York: HarperCollins.
316. Patankar, M.S. (2003). A study of safety culture at an aviation organization. International Journal of Applied Aviation Studies, 3(2), 243-258.
317. Patankar, M.S., Block, E., and Kelly, T. (2009). Integrated systems approach to improving safety culture. Presented at the Maintenance Aviation Safety Action Program Information Sharing Meeting, Dallas, March 5, 2009.
318. Patankar, M.S. and Sabin, E. (2008). Safety culture transformation project report. Report prepared for the Federal Aviation Administration. Available from .
319. Ringstad, A.J. and Szameitat, S.A. (2000). Comparative study of accident and near miss reporting systems in the German nuclear industry and the Norwegian offshore industry. In: Proceedings of the Human Factors and Ergonomics Society 44th annual meeting (pp. 380-384).
320. Rochon, T.R. (1998). Culture Moves: Ideas, Activism, and Changing Values. Princeton: Princeton University Press.
321. Sabin, E. (2005). Promoting the transfer of innovations. In: M.S. Patankar and J. Ma (eds), Proceedings of the Second Safety Across High-Consequence Industries Conference, Volume 1: St. Louis: Parks College of Engineering, Aviation and Technology.
322. Senge, P. (1990). The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday.
323. Skinner, B.F. (1976). About Behaviorism. New York: Random House.
324. Taylor, J. and Patankar, M.S. (2001). Four generations of MRM: evolution of human error management programs in the United States. Journal of Air Transportation World Wide, 6(2), 3-32.
325. Voget, F. (1963). Cultural change. Biennial Review of Anthropology, 3, 228-275.
326. Wheatley, M.J. (1999). Leadership and the New Science: Discovering Order in a Chaotic World (second edition). San Francisco: Berrett-Koehler Publishers.
327. Wiener, E.L., Kanki, B.G., and Helmreich, R.L. (1993). Cockpit Resource Management. San Diego: Academic Press.
328. Amalberti, R., Auroy, Y., Berwick, D., and Barach, P. (2005). Five system barriers to achieving ultrasafe healthcare. Annals of Internal Medicine, 142, 756-764.
329. Argyris, C. and Schön, D. (1974). Theory in Practice: Increasing Professional Effectiveness. San Francisco: Jossey-Bass.
330. Argyris, C. and Schön, D. (1978). Organizational Learning: A Theory of Action Perspective. Reading: Addison-Wesley Publishing.
331. Baumard, P. and Starbuck, W.H. (2005). Learning from failures: why it may not happen. Long Range Planning, 38, 281-298.
332. Bonn, I. (2001). Developing strategic thinking as a core competency. Management Decision, 39(1), 63-70.
333. Brodtrick, O. (1988). Well-performing organisations. In: 1988 report of the auditor general of Canada (Chapter 4). Retrieved from on May 1, 2010.
334. Cannon, M.D. and Edmondson, A.C. (2005). Failing to learn and learning to fail (intelligently): how great organizations put failure to work to innovate and improve. Long Range Planning, 38, 299-319.
335. Crainer, S. (1993). Zeebrugge: Learning from Disaster: Lessons in Corporate Responsibility. London: Herald Charitable Trust.
336. Elliott, D. (2009). The failure of organizational learning from crisis - a matter of life and death? Journal of Contingencies and Crisis Management, 17(3), 157-168.
337. Elliott, D., Smith, D., and McGuinness, M. (2000). Exploring the failure to learn: crises and the barriers to learning. Review of Business, 21(3), 17-24.
338. FAA (2002). Aviation Safety Action Program Advisory Circular and Guidance AC 12-66B. Washington, DC: Federal Aviation Administration. Retrieved from on November 14, 2005.
339. FSF (1998). Aviation safety: U.S. efforts to implement flight operational quality assurance programs. Flight Safety Digest, July-September.
340. Heinrich, H. (1931). Industrial Accident Prevention: A Scientific Approach. New York: McGraw-Hill.
341. Helmreich, R. and Merritt, A. (1998). Culture at Work in Aviation and Medicine: National, Organizational and Professional Influences. Aldershot: Ashgate.
342. Hollnagel, E., Woods, D., and Leveson, N. (eds) (2006). Resilience Engineering: Concepts and Precepts. Aldershot: Ashgate.
343. Keeney, R.L. (1994). Creativity in decision making with value-focused thinking. Sloan Management Review, Summer, 33-41.
344. Keeney, R.L. and McDaniels, T. (1992). Value-focused thinking about strategic decisions at BC Hydro. Interfaces, 22(6), 94-109.
345. La Porte, T. and Consolini, P. (1991). Working in practice but not in theory: theoretical challenges of high-reliability organizations. Journal of Public Administration Research Theory, 1, 19-47.
346. Lagadec, P. (1997). Learning process for crisis management in complex organizations. Journal of Contingencies and Crisis Management, 5(1), 24-31.
347. Marx, D. (1997). Moving toward 100 per cent error reporting in maintenance. In: Proceedings of the Eleventh International Symposium on Human Factors in Aircraft Maintenance and Inspection. Washington, DC: Federal Aviation Administration.
348. Marx, D. (2001). Patient safety and the 'just culture': a primer for healthcare executives. Retrieved from on October 11, 2004.
349. McLucas, A.C. (2000). The worst failure: repeated failure to learn. 1st International Conference on Systems Thinking in Management, 426-431.
350. Meyer, G.S. and Eisenberg, J.M. (2002). The end of the beginning: the strategic approach to patient safety research. Quality and Safety in Healthcare, 11(1), 3-4.
351. Patankar, M.S., Bigda-Peyton, T., Sabin, E., Brown, J., and Kelly, T. (2005). A comparative review of safety cultures. Report prepared for the Federal Aviation Administration. Available from .
352. Patankar, M.S. and Sabin, E. (2008). Safety culture transformation in technical operations of the air traffic organization: project report and recommendations. Report prepared for the Federal Aviation Administration. Available from: .
353. Pearson, C.M. and Mitroff, I.I. (1993). From crisis prone to crisis prepared: a framework for crisis management. The Executive, 7(1), 48-59.
354. Perrow, C. (1984). Normal Accidents: Living with High-risk Technologies. Princeton: Princeton University Press.
355. Reason, J. (1997). Managing the Risk of Organizational Accidents. Aldershot: Ashgate.
356. Roberts, K.H. (ed.) (1993). New Challenges to Organizations: High Reliability Understanding Organizations. New York: Macmillan.
357. Santayana, G. (1905-1906). The Life of Reason. New York: Scribner's Sons.
358. Sapriel, C. (2003). Effective crisis management: tools and best practice for the new millennium. Journal of Communication Management, 7(4), 348-355.
359. Shortell, S.M. and Singer, S.J. (2008). Improving patient safety by taking systems seriously. Journal of the American Medical Association, 299(4), 445-447.
360. Smallman, C. (1996). Risk and organizational behaviour: a research model. Disaster Prevention and Management, 5(2), 12-26.
361. Smith, D. and Elliott, D. (2007). Exploring the barriers to learning from crisis: organizational learning and crisis. Management Learning, 38(5), 519-538.
362. Tamuz, M. (2001). Learning disabilities for regulators: the perils of organizational learning in the air transportation industry. Administration and Society, 33, 276-302.
363. Tucker, A., Edmondson, A., and Spear, S. (2002). When problem solving prevents organizational learning. Journal of Organizational Change Management, 15(2), 122-137.
364. Vaughn, D. (1999). The dark side of organizations: mistake, misconduct, and disaster. Annual Review of Sociology, 25, 271-305.
365. Wu, A., Lipshutz, A., and Pronovost, P. (2008). Effectiveness and efficiency of root cause analysis in medicine. Journal of the American Medical Association, 299(6), 685-687.