A life in error: From little slips to big disasters

A Life in Error: From Little Slips to Big Disasters

Volumn , Issue , 2013, Pages 1-133

  Reason, James ^a  

^a UNIVERSITY OF MANCHESTER   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 84900180187     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Book

References (58)

1. Rasmussen, J. (1983). Skills, rules, knowledge: signals, signs, and symbols, and other distinctions in human performance models. IEEE Transactions: Systems, Man and Cybernetics. SMC 13: 257-67.
2. Reason, James and Mycielska, Klara (1982). Absentminded? The Psychology of Mental Lapses and Everyday Errors. Englewood Cliffs: Prentice Hall.
3. Reason, James (1990). Human Error. Cambridge: Cambridge University Press.
4. Reason, James (1997). Managing the Risks of Organizational Accidents. Aldershot: Ashgate Publishing.
5. Reason, James and Hobbs, Alan (2003). Managing Maintenance Error. Aldershot: Ashgate Publishing.
6. Reason, James (2008). The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Farnham: Ashgate Publishing.
7. Freud, S. (1914). The Psychopathology of Everyday Life. London: Ernest Benn.
8. Reason, J. (1990). Human Error. New York: Cambridge University Press.
9. Reason, J. (1993). Self-report questionnaires in cognitive psychology: Have they delivered the goods? In A. Baddeley and L.Weiskrantz, Attention: Selection, Awareness and Control. Oxford: Oxford Science Publications.
10. Broadbent, D. et al. (1982). The Cognitive Failures Questionnaire (CFQ) and its correlates. British Journal of Clinical Psychology, 21: 1-16.
11. Rabbit, P. and Abson, V. (1990). 'Lost and found': some logical and methodological limitations of self-report questionnaires as tools to study cognitive ageing. British Journal of Psychology, 81: 1-16.
12. Reason, J. (1989). Stress and cognitive failure. In Handbook of Life Stress, Cognition and Health (ed. S. Fisher and J. Reason), pp. 405-21. Chichester: Wiley.
13. Reason, J. (1993). Self-report questionnaires.
14. Reason, J. and Lucas, D. (1984). Absent-mindedness in shops: its correlates and consequences. British Journal of Clinical Psychology, 23: 121-31.
15. Freud, S. (1922). Introductory Lectures on Psycho-Analysis. London: George Allen & Unwin.
16. Freud, S. (1922). Introductory Lectures on Psycho-Analysis. London: George Allen & Unwin, p. 22.
17. Freud, S. (1922). Introductory Lectures on Psycho-Analysis. London: George Allen & Unwin, p. 36.
18. Freud, S. (1914). The Psychopathology of Everyday Life. London: Ernest Benn.
19. Timpanaro, S. (1976). The Freudian slip. London: NLB.
20. Freud, S. The Psychopathology of Everyday Life, pp. 136-7.
21. Norman, D. (1981). Categorization of action slips. Psychological Review, 88: 1-15.
22. I am deeply indebted to the editor of The Psychologist, who permitted me to use large parts of an article that had appeared in 2000, vol. 13, 12.
23. Tuchman, B. (1962). The Guns of August. London: Four Square Books.
24. Klumb, P. (1988). The economics of violating. Personal communication.
25. The Hon. Lord Cullen (1990). Public inquiry into the Piper Alpha Disaster. London: Department of Energy, HMSO.
26. Reason, J. (2008). The Human Contribution. Farnham: Ashgate.
27. Reason, J. (1997). Managing the Risks of Organizational Accidents. Farnham: Ashgate.
28. Reason, J. (1998). Achieving a safe culture: Theory and practice. Work & Stress, 12: 293-306.
29. Weick, K.E., Sutcliffe, K.M. and Obstfeld, D. (1999). Organising for high reliability processes of collective mindfulness. Research Into Organizational Behavior, 21: 23-81.
30. Weick, K.E. (1991). Organizational culture as a source of high reliability. California Management Review, 29: 112-27.
31. Westrum, R. (1996). Safety of a technological system. NTSB Symposium on Corporate Culture and Transportation Safety. 24-5 April, Crystal City, VA.
32. Weick, K.E. and Sutcliffe, K.M. (2003). Hospitals as cultures of entrapment. California Management Review, 45: 73-84.
33. Morrison, E.W. and Milliken, F.J. (2000). Organizational silence: a barrier to change and development in a pluralistic world. Academy of Management Review, 25: 708-25.
34. Tucker, A.L. and Edmondson, A.C. (2003). Why hospitals don't learn from failures. California Management Review, 45: 55-72.
35. Vaughan, D. (1996). The Challenger Launch Decision. Chicago: University of Chicago Press.
36. Institute of Medicine (2000). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press.
37. Donaldson, L. (2000). An Organisation with a Memory. London: Department of Health.
38. Carthey, J., de Leval, M. and Reason, J. (2001). Assessing the resilience of health care institutions to the risk of patient mishaps. Quality in Health Care, 10: 29-32.
39. Reason, J. (1997). Managing the Risks of Organizational Accidents. Aldershot: Ashgate.
40. Reason, J. (1990). Human Error. New York: Cambridge University Press.
41. Donaldson, L. (2000). An Organisation with a Memory. London: Department of Health.
42. Marchev, M. (2003). Medical Malpractice and Medical Disclosure: Balancing Facts and Fears. Portland, ME: National Academy for State Health Policy.
43. Wu, A.W. et al. (1991). Do House Officers Learn from Their Mistakes? JAMA, 265: 2089-94.
44. Blendon, R.J. et al. (2002). View of practicing physicians and the public on medical errors. New England Journal of Medicine, 347: 1933-40.
45. Vincent, C. et al. (1994). Why do people sue doctors? A study of patients and relatives taking legal action. Lancet, 343: 1609-13.
46. Runciman, W.B. et al. (2003). Error, blame and the law in healthcare-an antipodean perspective. Annals of Internal Medicine, 138: 974-9.
47. Marchev, M. (2003).
48. Kraman, G. and Hamm, G. (2007) Letter to the Editor. Health Affairs, 26, 3 June.
49. Lamo, N. (2011). Disclosure of medical errors: The right thing to do, but what is the cost? Lockton Companies.
50. Berlin, L. (2006). Will saying 'I'm sorry' prevent a malpractice lawsuit? American Journal of Roentgenology, 187: 10-15.
51. Lamo, N.
52. Boothman, R. (2010). Message on National Patient Safety Foundation Listserv (20 November).
53. Studdert, D. et al. (2007). Health Affairs, 26: 215-26.
54. Mello, M. et al. (2007). An analysis of adverse events costs, the medical liability system and incentives for patient safety improvement. Journal of Empirical Legal Studies, 4: 835-60.
55. Kraman and Hamm.
56. Lamo, N.
57. Sheen, Mr Justice. (1987). MV Herald of Free Enterprise. Report of Court No. 8074. Formal Investigation. London: Department of Transport.
58. Perneger, T. (2005). The Swiss cheese model of safety incidents: Are there holes in this metaphor? BMC Health Services Research, 5: 71.