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Volumn , Issue , 2013, Pages

Preface: On the need for resilience in health care

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EID: 84900742218     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Editorial
Times cited : (164)

References (420)
  • 1
    • 84900690422 scopus 로고    scopus 로고
    • Migration, remittances, livelihood trajectories, and social resilience
    • Adger, W.N., et al. (2002). Migration, remittances, livelihood trajectories, and social resilience. Ambio, 32, 921-31.
    • (2002) Ambio , vol.32 , pp. 921-931
    • Adger, W.N.1
  • 2
    • 84899837118 scopus 로고    scopus 로고
    • Agency for Healthcare Research and Quality, Online at, accessed 18 June 2012
    • Agency for Healthcare Research and Quality. (2008). Patient Safety Indicators Composite Measure Workgroup (final report). Online at http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/PSI%20Composite%20Development.pdf, accessed 18 June 2012.
    • (2008) Patient Safety Indicators Composite Measure Workgroup (final Report)
  • 5
    • 0034347218 scopus 로고    scopus 로고
    • Doing occupational demarcation - The 'boundary-work' of nurse managers in a district general hospital
    • Allen, D. (2000). Doing occupational demarcation - The 'boundary-work' of nurse managers in a district general hospital. Journal of Contemporary Ethnography, 29(3), 326-56.
    • (2000) Journal of Contemporary Ethnography , vol.29 , Issue.3 , pp. 326-356
    • Allen, D.1
  • 7
    • 40449101969 scopus 로고    scopus 로고
    • Optimum system safety and optimum system resilience: Agonist or antagonists concepts?
    • E. Hollnagel, D. Woods and N. Leveson (eds), Aldershot, UK: Ashgate
    • Amalberti, R. (2006). Optimum system safety and optimum system resilience: Agonist or antagonists concepts? In E. Hollnagel, D. Woods and N. Leveson (eds), (2006) Resilience Engineering: Concepts and Precepts. Aldershot, UK: Ashgate, pp. 238-56.
    • (2006) Resilience Engineering: Concepts and Precepts , pp. 238-256
    • Amalberti, R.1
  • 9
    • 17844392604 scopus 로고    scopus 로고
    • Five system barriers to achieving ultrasafe health care
    • Amalberti, R., et al. (2005). Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine, 142(9), 756-64.
    • (2005) Annals of Internal Medicine , vol.142 , Issue.9 , pp. 756-764
    • Amalberti, R.1
  • 10
    • 33845734591 scopus 로고    scopus 로고
    • Violations and migrations in healthcare: A framework for understanding and management
    • i66-i71
    • Amalberti, R., et al. (2006). Violations and migrations in healthcare: A framework for understanding and management. Quality & Safety in Health Care, 15, i66-71.
    • (2006) Quality & Safety in Health Care , vol.15
    • Amalberti, R.1
  • 11
    • 79957589686 scopus 로고    scopus 로고
    • Adverse events in medicine: Easy to count, complicated to understand, and complex to prevent
    • Amalberti, R., et al. (2011). Adverse events in medicine: Easy to count, complicated to understand, and complex to prevent. Journal of Biomedical Informatics, 44(3), 390-94.
    • (2011) Journal of Biomedical Informatics , vol.44 , Issue.3 , pp. 390-394
    • Amalberti, R.1
  • 12
    • 40949109534 scopus 로고    scopus 로고
    • Limits on adaptation: Modeling resilience and brittleness in hospital emergency departments
    • E. Hollnagel and E. Rigaud (eds), Juan-les-Pins, France, 8-10 November. Nov. 8-10
    • Anders, S., et al. (2006). Limits on adaptation: Modeling resilience and brittleness in hospital emergency departments. In E. Hollnagel and E. Rigaud (eds), Proceedings of the Second International Symposium on Resilience Engineering. Juan-les-Pins, France, 8-10 November. Nov. 8-10.
    • (2006) Proceedings of the Second International Symposium on Resilience Engineering
    • Anders, S.1
  • 14
    • 84900736552 scopus 로고    scopus 로고
    • Aftermath of sars
    • A.T. Ahuja and C.G.C. Ooi (eds), Cambridge: Cambridge University Press
    • Antonio, G.E., Griffith, J.F. and Ahuja, A.T. (2004). Aftermath of SARS. In A.T. Ahuja and C.G.C. Ooi (eds), Imaging in SARS. Cambridge: Cambridge University Press (pp. 159-64).
    • (2004) Imaging in SARS , pp. 159-164
    • Antonio, G.E.1    Griffith, J.F.2    Ahuja, A.T.3
  • 17
    • 33644554148 scopus 로고    scopus 로고
    • Canadian cardiovascular society consensus conference recommendations on heart failure 2006: Diagnosis and management
    • Arnold, J.M., et al. (2006). Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: Diagnosis and management. Canadian Journal of Cardiology, 22, 23-45.
    • (2006) Canadian Journal of Cardiology , vol.22 , pp. 23-45
    • Arnold, J.M.1
  • 19
    • 0005096601 scopus 로고
    • Requisite variety and its implications for the control of complex systems
    • Ashby, W.R. (1958). Requisite variety and its implications for the control of complex systems. Cybernetica, 1, 83-99.
    • (1958) Cybernetica , vol.1 , pp. 83-99
    • Ashby, W.R.1
  • 20
    • 33847131017 scopus 로고    scopus 로고
    • The ethics of everyday practice: Healthcare environments as moral communities
    • Austin, W. (2007). The ethics of everyday practice: Healthcare environments as moral communities. Advances in Nursing Science, 30(1), 81-8.
    • (2007) Advances in Nursing Science , vol.30 , Issue.1 , pp. 81-88
    • Austin, W.1
  • 23
    • 0001792554 scopus 로고    scopus 로고
    • Making patients safer! Reducing error in canadian healthcare
    • Baker, G.R. and Norton, P. (2001). Making patients safer! Reducing error in Canadian healthcare. Healthcare Papers, 2(1), 10-31.
    • (2001) Healthcare Papers , vol.2 , Issue.1 , pp. 10-31
    • Baker, G.R.1    Norton, P.2
  • 24
    • 2942571128 scopus 로고    scopus 로고
    • The canadian adverse events study: The incidence of adverse events among hospital patients in Canada
    • Baker, G. R., et al. (2004). The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170(11), 1678-86.
    • (2004) Canadian Medical Association Journal , vol.170 , Issue.11 , pp. 1678-1686
    • Baker, G.R.1
  • 25
    • 35148877128 scopus 로고    scopus 로고
    • Communication and decision making in cancer care: Setting research priorities for decision support / patients' decision aids
    • Barnato, A.E., et al. (2007). Communication and decision making in cancer care: Setting research priorities for decision support / patients' decision aids. Medical Decision Making, 27, 625-34.
    • (2007) Medical Decision Making , vol.27 , pp. 625-634
    • Barnato, A.E.1
  • 26
    • 33846998311 scopus 로고    scopus 로고
    • The macro / micro problem of structure and agency
    • G. Ritzer and B. Smart (eds), Thousand Oaks, CA: Sage
    • Barnes, B. (2001). The macro / micro problem of structure and agency. In G. Ritzer and B. Smart (eds), Handbook of Social Theory. Thousand Oaks, CA: Sage (pp. 339-52).
    • (2001) Handbook of Social Theory , pp. 339-352
    • Barnes, B.1
  • 27
    • 0141445409 scopus 로고    scopus 로고
    • On the relationship between social and cognitive modes of organization
    • S. Chaiken and Y. Trope (eds), S. Chaiken and Y. Trope. New York: The Guilford Press
    • Baron, R.M. and Misovich, S.J. (1999). On the relationship between social and cognitive modes of organization. In S. Chaiken and Y. Trope (eds), Dual-process Theories in Social Psychology. S. Chaiken and Y. Trope. New York: The Guilford Press (pp. 586-605).
    • (1999) Dual-process Theories in Social Psychology , pp. 586-605
    • Baron, R.M.1    Misovich, S.J.2
  • 29
    • 0037495031 scopus 로고    scopus 로고
    • Improving safety with information technology
    • Bates, D.W. and Gawande, A.A. (2003). Improving safety with information technology. New England Journal of Medicine, 348(25), 2526-34.
    • (2003) New England Journal of Medicine , vol.348 , Issue.25 , pp. 2526-2534
    • Bates, D.W.1    Gawande, A.A.2
  • 31
    • 0001986555 scopus 로고    scopus 로고
    • Getting past blame: How can we save the next victim?
    • 15 June
    • Belkin, L. (1997). Getting past blame: How can we save the next victim? New York Times Sunday Magazine. 15 June.
    • (1997) New York Times Sunday Magazine
    • Belkin, L.1
  • 32
    • 33847364092 scopus 로고    scopus 로고
    • Capacity for survival: Exploring strengths of homeless street youth
    • Bender, K., et al. (2007). Capacity for survival: Exploring strengths of homeless street youth. Child Youth Care Forum, 36(1), 25-42.
    • (2007) Child Youth Care Forum , vol.36 , Issue.1 , pp. 25-42
    • Bender, K.1
  • 34
    • 1542648590 scopus 로고    scopus 로고
    • Improvement, trust, and the healthcare workforce
    • Berwick, D.M. (2003). Improvement, trust, and the healthcare workforce. Quality and Safety in Health Care, 12(6), 448-52.
    • (2003) Quality and Safety in Health Care , vol.12 , Issue.6 , pp. 448-452
    • Berwick, D.M.1
  • 35
    • 79961175960 scopus 로고    scopus 로고
    • Resilience: The concept, a literature review and future directions
    • Bhamra, R., Dani, S. and Burnard, K. (2011). Resilience: The concept, a literature review and future directions. International Journal of Production Research, 49(18), 5375-93.
    • (2011) International Journal of Production Research , vol.49 , Issue.18 , pp. 5375-5393
    • Bhamra, R.1    Dani, S.2    Burnard, K.3
  • 36
    • 0035624789 scopus 로고    scopus 로고
    • The incident command system: Organizing for high reliability in complex and unpredictable environments
    • Bigley, G.A. and Roberts, K.H. (2001). The incident command system: Organizing for high reliability in complex and unpredictable environments. Academy of Management Journal, 44(6), 1,281-99.
    • (2001) Academy of Management Journal , vol.44 , Issue.6 , pp. 1281-1299
    • Bigley, G.A.1    Roberts, K.H.2
  • 37
    • 33750165146 scopus 로고    scopus 로고
    • A sensemaking lens on reliability
    • Blatt, R., et al. (2006). A sensemaking lens on reliability. Journal of Organizational Behavior, 27, 897-917.
    • (2006) Journal of Organizational Behavior , vol.27 , pp. 897-917
    • Blatt, R.1
  • 38
    • 34249935592 scopus 로고    scopus 로고
    • Comparison of learning curves in classical and robotic laparoscopy according to the viewing condition
    • Blavier A., et al. (2007). Comparison of learning curves in classical and robotic laparoscopy according to the viewing condition. American Journal of Surgery, 194, 115-21.
    • (2007) American Journal of Surgery , vol.194 , pp. 115-121
    • Blavier, A.1
  • 40
    • 77957120048 scopus 로고    scopus 로고
    • Recognising and managing key transitions in end of life care
    • Boyd, K. and Murray, S.A. (2010). Recognising and managing key transitions in end of life care. British Medical Journal, 341, 649-52.
    • (2010) British Medical Journal , vol.341 , pp. 649-652
    • Boyd, K.1    Murray, S.A.2
  • 41
    • 80053273250 scopus 로고    scopus 로고
    • Health and social services expenditures: Associations with health outcomes
    • Bradley, E.H., et al. (2011). Health and social services expenditures: Associations with health outcomes. British Medical Journal Quality and Safety, 20(10), 826-31.
    • (2011) British Medical Journal Quality and Safety , vol.20 , Issue.10 , pp. 826-831
    • Bradley, E.H.1
  • 42
    • 28844499872 scopus 로고    scopus 로고
    • Hunter-gatherer human nature and health system safety: An evolutionary cleft stick?
    • Braithwaite, J. (2005). Hunter-gatherer human nature and health system safety: An evolutionary cleft stick? International Journal for Quality in Health Care, 17(6), 541-5.
    • (2005) International Journal for Quality in Health Care , vol.17 , Issue.6 , pp. 541-545
    • Braithwaite, J.1
  • 43
    • 33845449067 scopus 로고    scopus 로고
    • Analysing structural and cultural change in acute settings using a giddens-weick paradigmatic approach
    • 7, 11
    • Braithwaite, J. (2006). Analysing structural and cultural change in acute settings using a Giddens-Weick paradigmatic approach. Health Care Analysis, 14(2), 91-102. [7, 11]
    • (2006) Health Care Analysis , vol.14 , Issue.2 , pp. 91-102
    • Braithwaite, J.1
  • 44
    • 78649758070 scopus 로고    scopus 로고
    • Between-group behaviour in health care: Gaps, edges, boundaries, disconnections, weak ties, spaces and holes
    • Online at, accessed 29 August 2012
    • Braithwaite, J. (2010). Between-group behaviour in health care: Gaps, edges, boundaries, disconnections, weak ties, spaces and holes. A systematic review. BMC Health Services Research. Online at http://www.biomedcentral.com/1472-6963/10/330, accessed 29 August 2012.
    • (2010) A systematic review. BMC Health Services Research
    • Braithwaite, J.1
  • 47
    • 12744279656 scopus 로고    scopus 로고
    • Rethinking clinical organisational structures: An attitude survey of doctors, nurses and allied health staff in clinical directorates
    • Braithwaite, J. and Westbrook, M. (2005). Rethinking clinical organisational structures: An attitude survey of doctors, nurses and allied health staff in clinical directorates. Journal of Health Services and Research Policy, 10(1), 10-17.
    • (2005) Journal of Health Services and Research Policy , vol.10 , Issue.1 , pp. 10-17
    • Braithwaite, J.1    Westbrook, M.2
  • 49
    • 61849098736 scopus 로고    scopus 로고
    • Towards safer, better healthcare: Harnessing the natural properties of complex sociotechnical systems
    • Braithwaite, J., Runciman, W.B. and Merry, A.F. (2009). Towards safer, better healthcare: Harnessing the natural properties of complex sociotechnical systems. Quality and Safety in Health Care, 18(1), 37-41.
    • (2009) Quality and Safety in Health Care , vol.18 , Issue.1 , pp. 37-41
    • Braithwaite, J.1    Runciman, W.B.2    Merry, A.F.3
  • 52
    • 33845896777 scopus 로고    scopus 로고
    • Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme
    • Braithwaite, J., et al. (2006). Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Quality and Safety in Health Care, 15(6), 393.
    • (2006) Quality and Safety in Health Care , vol.15 , Issue.6
    • Braithwaite, J.1
  • 53
    • 35348905105 scopus 로고    scopus 로고
    • Are health systems changing in support of patient safety? A multi-methods evaluation of education, attitudes and practice
    • Braithwaite, J., et al. (2007). Are health systems changing in support of patient safety? A multi-methods evaluation of education, attitudes and practice. International Journal of Health Care Quality Assurance, 20(7), 585-601.
    • (2007) International Journal of Health Care Quality Assurance , vol.20 , Issue.7 , pp. 585-601
    • Braithwaite, J.1
  • 54
    • 77953840997 scopus 로고    scopus 로고
    • Cultural and other associated enablers, and barriers, to adverse incident reporting
    • Braithwaite, J., et al. (2010). Cultural and other associated enablers, and barriers, to adverse incident reporting. Quality and Safety in Health Care, 19, 229-33.
    • (2010) Quality and Safety in Health Care , vol.19 , pp. 229-233
    • Braithwaite, J.1
  • 55
    • 84873420157 scopus 로고    scopus 로고
    • Continuing differences between health professions' attitudes: The saga of accomplishing systems-wide interprofessionalism
    • Braithwaite, J., et al. (2013). Continuing differences between health professions' attitudes: The saga of accomplishing systems-wide interprofessionalism. International Journal of Quality in Healthcare. 25(1), 8-15.
    • (2013) International Journal of Quality in Healthcare , vol.25 , Issue.1 , pp. 8-15
    • Braithwaite, J.1
  • 56
    • 13644249838 scopus 로고    scopus 로고
    • Use of antimicrobial prophylaxis for major surgery
    • Bratzler, D., et al. (2005). Use of antimicrobial prophylaxis for major surgery. Arch Surg, 140, 174-82.
    • (2005) Arch Surg , vol.140 , pp. 174-182
    • Bratzler, D.1
  • 58
    • 0025924692 scopus 로고
    • Incidence of adverse events and negligence in hospitalized patients: Results of the harvard medical practice study I
    • Brennan, T.A., et al. (1991). Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine, 324, 370-76.
    • (1991) New England Journal of Medicine , vol.324 , pp. 370-376
    • Brennan, T.A.1
  • 59
    • 0003004505 scopus 로고    scopus 로고
    • Traitement cognitif et organisationnel des micro-incidents dans le domaine du contrôle aérien: Analyse des boucles de régulation formelles et informelles
    • G. de Terssac and E. Friedberg (eds), G. De Terssac and E. Friedberg. Toulouse: Octares
    • Bressolle, M.C., et al. (1996). Traitement cognitif et organisationnel des micro-incidents dans le domaine du contrôle aérien: Analyse des boucles de régulation formelles et informelles. In G. de Terssac and E. Friedberg (eds), Coopération et conception G. De Terssac and E. Friedberg. Toulouse: Octares (pp. 267-88).
    • (1996) Coopération Et Conception , pp. 267-288
    • Bressolle, M.C.1
  • 60
    • 79955518858 scopus 로고    scopus 로고
    • The benefits of health information technology: A review of the recent literature shows predominantly positive results
    • Buntin, M.B., et al. (2011). The benefits of health information technology: A review of the recent literature shows predominantly positive results. Health Affairs, 30(3), 464-71.
    • (2011) Health Affairs , vol.30 , Issue.3 , pp. 464-471
    • Buntin, M.B.1
  • 61
    • 77956125224 scopus 로고    scopus 로고
    • Organisational readiness: Exploring the preconditions for success in organisation-wide patient safety improvement programmes
    • Burnett, S., et al. (2010). Organisational readiness: Exploring the preconditions for success in organisation-wide patient safety improvement programmes. Quality and Safety in Health Care, 19(4), 313-17.
    • (2010) Quality and Safety in Health Care , vol.19 , Issue.4 , pp. 313-317
    • Burnett, S.1
  • 62
    • 84989061245 scopus 로고
    • Reconciling logical incrementalism and synoptic formalism - An integrated approach to designing strategic planning processes
    • Camillus, J.C. (1982). Reconciling logical incrementalism and synoptic formalism - an integrated approach to designing strategic planning processes. Strategic Management Journal, 3(3), 277-83.
    • (1982) Strategic Management Journal , vol.3 , Issue.3 , pp. 277-283
    • Camillus, J.C.1
  • 65
    • 84862544486 scopus 로고    scopus 로고
    • Successful risk analysis may not always lead to successful risk control: A systematic review of the risk control literature
    • Card, A.J., Ward, J.R. and Clarkson, P.J. (2012). Successful risk analysis may not always lead to successful risk control: A systematic review of the risk control literature. Journal of Healthcare Risk Management, 31(3), 6-12.
    • (2012) Journal of Healthcare Risk Management , vol.31 , Issue.3 , pp. 6-12
    • Card, A.J.1    Ward, J.R.2    Clarkson, P.J.3
  • 66
    • 84900726818 scopus 로고    scopus 로고
    • M.Sc. Lund University. [online] Lund University Master's Program in Human Factors and System Safety. Online at, accessed 30 July 2012
    • Cardiff, K. (2007). Is Quality Safety? Is Safety Quality? M.Sc. Lund University. [online] Lund University Master's Program in Human Factors and System Safety. Online at http://www.leonardo.lth.se/education/masters_program/masters_theses/, accessed 30 July 2012.
    • (2007) Is Quality Safety? Is Safety Quality?
    • Cardiff, K.1
  • 67
    • 84861155735 scopus 로고    scopus 로고
    • Assessing the adaptive capacity of hospital facilities to cope with climate-related extreme weather events: A risk management approach
    • Carthey, J., Chandra, V. and Loosemore, M. (2008). Assessing the adaptive capacity of hospital facilities to cope with climate-related extreme weather events: A risk management approach. Association of Researchers in Construction Management, 742-57.
    • (2008) Association of Researchers in Construction Management , pp. 742-757
    • Carthey, J.1    Chandra, V.2    Loosemore, M.3
  • 68
    • 85015489673 scopus 로고    scopus 로고
    • Adapting Australian health facilities to cope with climate-related extreme weather events
    • Carthey, J., Chandra, V. and Loosemore, M. (2009). Adapting Australian health facilities to cope with climate-related extreme weather events. Journal of Facilities Management, 7(1), 36-51.
    • (2009) Journal of Facilities Management , vol.7 , Issue.1 , pp. 36-51
    • Carthey, J.1    Chandra, V.2    Loosemore, M.3
  • 70
    • 84900714705 scopus 로고    scopus 로고
    • Breaking the rules: Understanding non-compliance with policies and guidelines
    • Carthey, J., et al. (2011). Breaking the rules: Understanding non-compliance with policies and guidelines, British Medical Journal, 343-7.
    • (2011) British Medical Journal , pp. 343-347
    • Carthey, J.1
  • 71
    • 84860485822 scopus 로고    scopus 로고
    • Choosing wisely: Helping physicians and patients make smart decisions about their care
    • Cassel, C.K. and Guest, J.A. (2012). Choosing wisely: Helping physicians and patients make smart decisions about their care. Jama, 307(17), 1801-2.
    • (2012) Jama , vol.307 , Issue.17 , pp. 1801-1802
    • Cassel, C.K.1    Guest, J.A.2
  • 73
    • 16844378215 scopus 로고    scopus 로고
    • The JCAHO patient safety event taxonomy: A standardized terminology and classification schema for near misses and adverse events
    • Chang, A., et al. (2005). The JCAHO patient safety event taxonomy: A standardized terminology and classification schema for near misses and adverse events. International Journal for Quality in Health Care, 17(2), 92-105.
    • (2005) International Journal for Quality in Health Care , vol.17 , Issue.2 , pp. 92-105
    • Chang, A.1
  • 74
    • 34848904566 scopus 로고    scopus 로고
    • Patterns of weight change preceding hospitalization for heart failure
    • Chaudhry, S.I., et al. (2007). Patterns of weight change preceding hospitalization for heart failure. Circulation, 116, 1549-54.
    • (2007) Circulation , vol.116 , pp. 1549-1554
    • Chaudhry, S.I.1
  • 76
    • 79955832205 scopus 로고    scopus 로고
    • Sensemaking, high reliability organizing, and resilience
    • P. Croskerry, et al. (eds), P. Croskerry, K. Cosby, S. Schenkel and R. Wears. Philadelphia, PA: Lippincott Williams and Wilkins
    • Christianson, M.K. and Sutcliffe, K.M. (2009). Sensemaking, high reliability organizing, and resilience. In P. Croskerry, et al. (eds), Patient Safety in Emergency Medicine. P. Croskerry, K. Cosby, S. Schenkel and R. Wears. Philadelphia, PA: Lippincott Williams and Wilkins (pp. 27-33).
    • (2009) Patient Safety in Emergency Medicine , pp. 27-33
    • Christianson, M.K.1    Sutcliffe, K.M.2
  • 77
    • 84900730213 scopus 로고    scopus 로고
    • Standardization versus adaptation for patient safety: A lesson learnt from three scabies outbreaks
    • Middelfart, Denmark, 3 June 2012
    • Chuang, S.W. (2012). Standardization versus Adaptation for Patient Safety: A Lesson Learnt from Three Scabies Outbreaks. Resilient Health Care Net Symposium, Middelfart, Denmark, 3 June 2012.
    • (2012) Resilient Health Care Net Symposium
    • Chuang, S.W.1
  • 78
    • 84886018632 scopus 로고    scopus 로고
    • Beyond root cause analysis: An enriched system oriented event analysis model for wide applications
    • DOI10.1002/sys.21246
    • Chuang, S.W. and Howley P. (2012). Beyond root cause analysis: An enriched system oriented event analysis model for wide applications. System Engineering, 16(3), DOI10.1002/sys.21246.
    • (2012) System Engineering , vol.16 , Issue.3
    • Chuang, S.W.1    Howley, P.2
  • 80
    • 84864200558 scopus 로고    scopus 로고
    • Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure
    • Chun, S., et al. (2012). Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure. Circulation Heart Failure, 5(4), 414-21.
    • (2012) Circulation Heart Failure , vol.5 , Issue.4 , pp. 414-421
    • Chun, S.1
  • 84
    • 38649115655 scopus 로고    scopus 로고
    • Venous thromboembolism risk and prophylaxis in the acute hospital care setting (endorse study): A multinational cross-sectional
    • Cohen, A., et al. (2008). Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): A multinational cross-sectional. Lancet. 371(9610), 387-94.
    • (2008) Lancet , vol.371 , Issue.9610 , pp. 387-394
    • Cohen, A.1
  • 85
    • 0346520898 scopus 로고    scopus 로고
    • Resilience, flexibility, and diversity in managing the risks of technologies
    • C. Hood and D.K.C. Jones (eds), London: Taylor and Francis
    • Collingridge, D. (1996). Resilience, flexibility, and diversity in managing the risks of technologies. In C. Hood and D.K.C. Jones (eds), Accident and Design: Contemporary Debates on Risk Management. London: Taylor and Francis.
    • (1996) Accident and Design: Contemporary Debates on Risk Management
    • Collingridge, D.1
  • 89
    • 77952426921 scopus 로고    scopus 로고
    • Those found responsible have been sacked': Some observations on the usefulness of error
    • Cook, R.I. and Nemeth, C.P. (2010). 'Those found responsible have been sacked': Some observations on the usefulness of error. Cognition Technology & Work, 12, 87-93.
    • (2010) Cognition Technology & Work , vol.12 , pp. 87-93
    • Cook, R.I.1    Nemeth, C.P.2
  • 90
    • 17144398832 scopus 로고    scopus 로고
    • Going solid': A model of system dynamics and consequences for patient safety
    • Cook, R.I. and Rasmussen, J. (2005). 'Going solid': A model of system dynamics and consequences for patient safety. Quality and Safety in Health Care, 14(2), 130.
    • (2005) Quality and Safety in Health Care , vol.14 , Issue.2 , pp. 130
    • Cook, R.I.1    Rasmussen, J.2
  • 91
    • 85052440163 scopus 로고
    • Operating at the sharp end: The complexity of human error
    • M.S. Bogner (ed.), Hillsdale, NJ: Lawrence Erlbaum Associates
    • Cook, R.I. and Woods, D.D. (1994). Operating at the sharp end: The complexity of human error. In M.S. Bogner (ed.), Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 255-310.
    • (1994) Human Error in Medicine , pp. 255-310
    • Cook, R.I.1    Woods, D.D.2
  • 92
    • 0034681866 scopus 로고    scopus 로고
    • Gaps in the continuity of care and progress on patient safety
    • Cook, R.I., Render, M. and Woods, D.D. (2000). Gaps in the continuity of care and progress on patient safety. British Medical Journal, 320(7237), 791-94.
    • (2000) British Medical Journal , vol.320 , Issue.7237 , pp. 791-794
    • Cook, R.I.1    Render, M.2    Woods, D.D.3
  • 96
    • 67650642098 scopus 로고    scopus 로고
    • The frontiers of patient safety: Breaking the traditional mold
    • Degos, L., et al. (2009). The frontiers of patient safety: Breaking the traditional mold. British Medical Journal, (338), b2585.
    • (2009) British Medical Journal , Issue.338
    • Degos, L.1
  • 98
    • 33749166607 scopus 로고    scopus 로고
    • Resilience engineering: Chronicling the emergence of confused consensus
    • E. Hollnagel, D.D. Woods and N. Leveson (eds), E. Hollnagel, D. D. Woods and N. Leveson. Aldershot, UK: Ashgate
    • Dekker, S.W.A. (2006b). Resilience engineering: Chronicling the emergence of confused consensus. In E. Hollnagel, D.D. Woods and N. Leveson (eds), Resilience Engineering: Concepts and Precepts E. Hollnagel, D. D. Woods and N. Leveson. Aldershot, UK: Ashgate (p. 82).
    • (2006) Resilience Engineering: Concepts and Precepts , pp. 82
    • Dekker, S.W.A.1
  • 102
    • 79955675090 scopus 로고    scopus 로고
    • The complexity of failure: Implications of complexity theory for safety investigations
    • Dekker, S.W.A. (2011). The complexity of failure: Implications of complexity theory for safety investigations, Safety Science, 49, 939-45.
    • (2011) Safety Science , vol.49 , pp. 939-945
    • Dekker, S.W.A.1
  • 105
    • 0004225223 scopus 로고    scopus 로고
    • Department of Health, London: TSO
    • Department of Health (2000). An Organisation with a Memory. London: TSO.
    • (2000) An Organisation with a Memory
  • 106
    • 33947242754 scopus 로고    scopus 로고
    • Requisite expertise, firm reputation and status in venture capital investment allocation decisions
    • Dimov, D.P., Shepherd, D.A. and Sutcliffe, K.M. (2007). Requisite expertise, firm reputation and status in venture capital investment allocation decisions. Journal of Business Venturing, 22, 481-502.
    • (2007) Journal of Business Venturing , vol.22 , pp. 481-502
    • Dimov, D.P.1    Shepherd, D.A.2    Sutcliffe, K.M.3
  • 107
    • 79957983451 scopus 로고    scopus 로고
    • Problems and promises of innovation: Why healthcare needs to rethink its love /hate relationship with the new
    • i47-i51
    • Dixon Woods, M., et al. (2011). Problems and promises of innovation: Why healthcare needs to rethink its love /hate relationship with the new. British Medical Journal Quality and Safety, 20, i47-i51.
    • (2011) British Medical Journal Quality and Safety , vol.20
    • Dixon Woods, M.1
  • 108
    • 58849088488 scopus 로고    scopus 로고
    • An international language for patient safety: Global progress in patient safety requires classification of key concepts
    • Donaldson, L. (2009). An international language for patient safety: Global progress in patient safety requires classification of key concepts. International Journal for Quality in Health Care, 2, 1.
    • (2009) International Journal for Quality in Health Care , vol.2 , pp. 1
    • Donaldson, L.1
  • 110
    • 84875013007 scopus 로고    scopus 로고
    • An infection, unnoticed, turns unstoppable
    • 11 July
    • Dwyer, J. (2012). An infection, unnoticed, turns unstoppable. The New York Times. 11 July, A15.
    • (2012) The New York Times
    • Dwyer, J.1
  • 111
    • 0004947991 scopus 로고
    • Clinical decision making: From theory to practice. Designing a practice policy. Standards, guidelines, and options
    • 3,084
    • Eddy, D.M. (1990). Clinical decision making: From theory to practice. Designing a practice policy. Standards, guidelines, and options. Journal of the American Medical Association, 263(22), 3077-3081, 3,084.
    • (1990) Journal of the American Medical Association , vol.263 , Issue.22 , pp. 3077-3081
    • Eddy, D.M.1
  • 112
    • 0042362247 scopus 로고    scopus 로고
    • Speaking up in the operating room: How team leaders promote learning in interdisciplinary action teams
    • Edmondson, A.C. (2003). Speaking up in the operating room: How team leaders promote learning in interdisciplinary action teams. Journal of Management Studies, 40(6), 1419-52.
    • (2003) Journal of Management Studies , vol.40 , Issue.6 , pp. 1419-1452
    • Edmondson, A.C.1
  • 113
    • 84900709805 scopus 로고    scopus 로고
    • Interpersonal relationships and decision-making about patient flow: What and who really matters?
    • J. Braithwaite, P. Hyde and C. Pope (eds), J. Braithwaite, P. Hyde and C. Pope. Basingstoke: Palgrave Macmillan
    • Eljiz, K., Fitzgerald, A. and Sloan, T. (2010). Interpersonal relationships and decision-making about patient flow: What and who really matters? In J. Braithwaite, P. Hyde and C. Pope (eds), Culture and Climate in Health Care Organizations J. Braithwaite, P. Hyde and C. Pope. Basingstoke: Palgrave Macmillan, 70-81.
    • (2010) Culture and Climate in Health Care Organizations , pp. 70-81
    • Eljiz, K.1    Fitzgerald, A.2    Sloan, T.3
  • 114
    • 81855203311 scopus 로고    scopus 로고
    • Complex adaptive systems (CAS): An overview of key elements, characteristics and application to management theory
    • Ellis, B. and Herbert, S.I. (2011). Complex adaptive systems (CAS): An overview of key elements, characteristics and application to management theory. Informatics in Primary Care, 19(1), 33-7.
    • (2011) Informatics in Primary Care , vol.19 , Issue.1 , pp. 33-37
    • Ellis, B.1    Herbert, S.I.2
  • 115
    • 24944432257 scopus 로고
    • Evidence-based medicine. A new approach to teaching the practice of medicine
    • Evidence-Based Medicine Working Group
    • Evidence-Based Medicine Working Group. (1992). Evidence-based medicine. A new approach to teaching the practice of medicine. Journal of the American Medical Association, 268.
    • (1992) Journal of the American Medical Association , pp. 268
  • 116
    • 1842368593 scopus 로고
    • Le travail en tant qu'activité de récupération
    • Faverge, J.-M. (1979-1980). Le travail en tant qu'activité de récupération. Bulletin de Psychologie, XXXIII(344), 203-6.
    • (1979) Bulletin De Psychologie , vol.33 , Issue.344 , pp. 203-206
    • Faverge, J.-M.1
  • 117
    • 0141904440 scopus 로고    scopus 로고
    • Issues of expert flexibility in contexts characterized by complexity and change
    • P.J. Feltovich, K.M. Ford and R.R. Hoffman (eds), Menlo Park, CA: AAAI Press
    • Feltovich, P.J., Spiro, R.J. and Coulson, R.L. (1997). Issues of expert flexibility in contexts characterized by complexity and change. In P.J. Feltovich, K.M. Ford and R.R. Hoffman (eds), Expertise in Context: Human and Machine. Menlo Park, CA: AAAI Press.
    • (1997) Expertise in Context: Human and Machine
    • Feltovich, P.J.1    Spiro, R.J.2    Coulson, R.L.3
  • 118
    • 79851513013 scopus 로고    scopus 로고
    • Overcoming the challenges of conducting research with people who have advanced heart failure and palliative care needs
    • Fitzsimons, D. and Strachan, P.H. (2012). Overcoming the challenges of conducting research with people who have advanced heart failure and palliative care needs. European Journal of Cardiovascular Nursing, 11(2), 248-54.
    • (2012) European Journal of Cardiovascular Nursing , vol.11 , Issue.2 , pp. 248-254
    • Fitzsimons, D.1    Strachan, P.H.2
  • 119
    • 34249951706 scopus 로고    scopus 로고
    • Measuring safety culture in healthcare: A case for accurate diagnosis
    • Flin, R. (2007). Measuring safety culture in healthcare: A case for accurate diagnosis. Safety Science, 45(6), 653-67.
    • (2007) Safety Science , vol.45 , Issue.6 , pp. 653-667
    • Flin, R.1
  • 121
    • 0019260307 scopus 로고
    • The evolution of uncertainty
    • Fox, R. (1980). The evolution of uncertainty. Milbank Quarterly, 58(1), 1-49.
    • (1980) Milbank Quarterly , vol.58 , Issue.1 , pp. 1-49
    • Fox, R.1
  • 124
    • 0035818380 scopus 로고    scopus 로고
    • Coping with complexity: Educating for capability
    • Fraser, S.W. and Greenhalgh, T. (2001). Coping with complexity: Educating for capability. British Medical Journal, 323, 799-803.
    • (2001) British Medical Journal , vol.323 , pp. 799-803
    • Fraser, S.W.1    Greenhalgh, T.2
  • 125
    • 0037680431 scopus 로고    scopus 로고
    • Positive emotions
    • C.R. Snyder and S.J. Lopez (eds), New York: Oxford University Press
    • Fredrickson, B.L. (2002). Positive emotions. In C.R. Snyder and S.J. Lopez (eds), Handbook of Positive Psychology. New York: Oxford University Press (pp. 120-34).
    • (2002) Handbook of Positive Psychology , pp. 120-134
    • Fredrickson, B.L.1
  • 128
    • 8444234737 scopus 로고    scopus 로고
    • Evidence based guidelines or collectively constructed 'mindlines?' ethnographic study of knowledge management in primary care
    • Gabbay, J. and May, A. (2004). Evidence based guidelines or collectively constructed 'mindlines?' Ethnographic study of knowledge management in primary care. British Medical Journal, 329(7473), 1013.
    • (2004) British Medical Journal , vol.329 , Issue.7473 , pp. 1013
    • Gabbay, J.1    May, A.2
  • 130
    • 84860233032 scopus 로고    scopus 로고
    • Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals
    • Gagnon, M.P., et al. (2012). Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. Journal of Medical Systems, 36(1), 241.
    • (2012) Journal of Medical Systems , vol.36 , Issue.1 , pp. 241
    • Gagnon, M.P.1
  • 132
    • 84900716827 scopus 로고    scopus 로고
    • Failure and rescue
    • [online 4 June]. Online at, accessed 25 September 2012
    • Gawande, A. (2012). Failure and rescue. The New Yorker [online 4 June]. Online at http://www.newyorker.com/online/blogs/newsdesk/2012/06/atul-gawande-failure-and-rescue.html, accessed 25 September 2012.
    • (2012) The New Yorker
    • Gawande, A.1
  • 133
    • 84909145252 scopus 로고    scopus 로고
    • Arithmetical development: Commentary on chapters 9 through 15 and future directions
    • A.J. Baroody and A. Dowker (eds), Mahwah, NJ: Lawrence Erlbaum Associates
    • Geary, D.C. (2003). Arithmetical development: Commentary on Chapters 9 through 15 and future directions. In A.J. Baroody and A. Dowker (eds), The Development of Arithmetic Concepts and Skills: Constructing Adaptive Expertise. Mahwah, NJ: Lawrence Erlbaum Associates (pp. 453-64).
    • (2003) The Development of Arithmetic Concepts and Skills: Constructing Adaptive Expertise , pp. 453-464
    • Geary, D.C.1
  • 135
    • 70349610473 scopus 로고    scopus 로고
    • Variation in hospital mortality associated with inpatient surgery
    • Ghaferi, A.A., Birkmeyer, J.D. and Dimick, J.B. (2009a). Variation in hospital mortality associated with inpatient surgery. The New England Journal of Medicine, 361(14), 1368-74.
    • (2009) The New England Journal of Medicine , vol.361 , Issue.14 , pp. 1368-1374
    • Ghaferi, A.A.1    Birkmeyer, J.D.2    Dimick, J.B.3
  • 136
    • 73449114588 scopus 로고    scopus 로고
    • Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients
    • Ghaferi, A.A., Birkmeyer, J.D. and Dimick, J.B. (2009b). Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Annals of Surgery, 250(6), 1029-34.
    • (2009) Annals of Surgery , vol.250 , Issue.6 , pp. 1029-1034
    • Ghaferi, A.A.1    Birkmeyer, J.D.2    Dimick, J.B.3
  • 137
    • 46949109976 scopus 로고    scopus 로고
    • Nowcasting: The real-time informational content of macroeconomic data
    • Giannone, D., Reichlin, L. and Small, D. (2008). Nowcasting: The real-time informational content of macroeconomic data. Journal of Monetary Economics, 55(4), 665-76.
    • (2008) Journal of Monetary Economics , vol.55 , Issue.4 , pp. 665-676
    • Giannone, D.1    Reichlin, L.2    Small, D.3
  • 138
    • 54349095419 scopus 로고    scopus 로고
    • Classification of air force aviation accidents: Mishap trends and prevention
    • Gibb, R.W. and Olson, W. (2008). Classification of Air Force aviation accidents: Mishap trends and prevention. The International Journal of Aviation Psychology, 18(4), 305-25.
    • (2008) The International Journal of Aviation Psychology , vol.18 , Issue.4 , pp. 305-325
    • Gibb, R.W.1    Olson, W.2
  • 140
    • 34548836814 scopus 로고    scopus 로고
    • Pessimism, computer failure, and information systems development in the public sector
    • Goldfinch, S. (2007). Pessimism, computer failure, and information systems development in the public sector. Public Administration Review, 67(5), 917-29.
    • (2007) Public Administration Review , vol.67 , Issue.5 , pp. 917-929
    • Goldfinch, S.1
  • 141
    • 84900723489 scopus 로고    scopus 로고
    • Accountability probe could lead to regulation for managers
    • Online at, accessed 29 October 2012
    • Golding, N. (2012). Accountability probe could lead to regulation for managers. Health Service Journal. Online at http://www.hsj.co.uk/news/policy/accountability-probe-could-lead-to-regulation-for-managers/5050422.article, [accessed 29 October 2012].
    • (2012) Health Service Journal
    • Golding, N.1
  • 142
    • 33745925886 scopus 로고    scopus 로고
    • System failure versus personal accountability - The case for clean hands
    • Goldmann, D. (2006). System failure versus personal accountability - the case for clean hands. New England Journal of Medicine, 355, 121-3.
    • (2006) New England Journal of Medicine , vol.355 , pp. 121-123
    • Goldmann, D.1
  • 143
    • 3042706745 scopus 로고    scopus 로고
    • Consensus statement: Palliative and supportive care in advanced heart failure
    • Goodlin, S.J., et al. (2004). Consensus statement: Palliative and supportive care in advanced heart failure. Journal of Cardiac Failure, 10(3), 200-209.
    • (2004) Journal of Cardiac Failure , vol.10 , Issue.3 , pp. 200-209
    • Goodlin, S.J.1
  • 144
    • 80054807504 scopus 로고    scopus 로고
    • ABS Technical Papers 2007. Presented at SNAME, Ft. Lauderdale, Florida, November 2007. Available at, accessed 18 October 2012
    • Grabowski, M.R., et al. (2007). Accident precursors and safety nets: Initial results from the Leading Indicators of Safety Project. ABS Technical Papers 2007. Presented at SNAME, Ft. Lauderdale, Florida, November 2007. Available at http://www.eagle.org/eagleExternalPortalWEB/ShowProperty/BEA%20Repository/References/Technical%20Papers/2007/AccidentPrecursors, accessed 18 October 2012.
    • (2007) Accident Precursors and Safety Nets: Initial Results from the Leading Indicators of Safety Project
    • Grabowski, M.R.1
  • 146
    • 84900753479 scopus 로고    scopus 로고
    • How do doctors refer to patient-reported outcome measures (PROMS) in oncology consultations?
    • Epub ahead of print
    • Greenhalgh, J., et al. (2012). How do doctors refer to patient-reported outcome measures (PROMS) in oncology consultations? Quality of Life Research [Epub ahead of print].
    • (2012) Quality of Life Research
    • Greenhalgh, J.1
  • 147
    • 75149116797 scopus 로고    scopus 로고
    • Rules management as source for loose coupling in highrisk systems
    • Juan-les-Pins, France. Online at, accessed 31 August 2012
    • Grote, G. (2006). Rules management as source for loose coupling in highrisk systems. Proceedings of the 2nd Symposium on Resilience Engineering, Juan-les-Pins, France. Online at http://www.resilience-engineering.org/, accessed 31 August 2012.
    • (2006) Proceedings of the 2nd Symposium on Resilience Engineering
    • Grote, G.1
  • 149
    • 0034028034 scopus 로고    scopus 로고
    • The nature of safety culture: A review of theory and research
    • Guldenmund, F. (2000). The nature of safety culture: A review of theory and research. Safety Science, 34(1), 215-57.
    • (2000) Safety Science , vol.34 , Issue.1 , pp. 215-257
    • Guldenmund, F.1
  • 152
    • 60549098613 scopus 로고    scopus 로고
    • Sources of resiliency among successful foster youth
    • Hass, M. and Graydon, K. (2009). Sources of resiliency among successful foster youth. Children and Youth Services Review, 31, 457-63.
    • (2009) Children and Youth Services Review , vol.31 , pp. 457-463
    • Hass, M.1    Graydon, K.2
  • 155
    • 84993746848 scopus 로고    scopus 로고
    • Reconceptualizing school learning using insight from expertise research
    • Hatano, G. and Oura, Y. (2003). Reconceptualizing school learning using insight from expertise research. Educational Researcher, 32(8), 26-9.
    • (2003) Educational Researcher , vol.32 , Issue.8 , pp. 26-29
    • Hatano, G.1    Oura, Y.2
  • 156
    • 0000618550 scopus 로고
    • Linking manufacturing process and product life cycle
    • Hayes, R.H. and Wheelwrite, S.C. (1979a). Linking manufacturing process and product life cycle. Harvard Business Review, 57, 133-40.
    • (1979) Harvard Business Review , vol.57 , pp. 133-140
    • Hayes, R.H.1    Wheelwrite, S.C.2
  • 157
    • 0000618550 scopus 로고
    • The dynamics of process-product lifecycles
    • Hayes, R.H. and Wheelwrite, S.C. (1979b). The dynamics of process-product lifecycles. Harvard Business Review, 57, 127-36.
    • (1979) Harvard Business Review , vol.57 , pp. 127-136
    • Hayes, R.H.1    Wheelwrite, S.C.2
  • 158
    • 79953791718 scopus 로고    scopus 로고
    • Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention
    • Haynes, A.B., et al. (2011). Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Quality and Safety, 20(1), 102-7.
    • (2011) BMJ Quality and Safety , vol.20 , Issue.1 , pp. 102-107
    • Haynes, A.B.1
  • 161
    • 0346325824 scopus 로고    scopus 로고
    • Hindsight bias, outcome knowledge and adaptive learning
    • Henriksen, K. and Kaplan H. (2003). Hindsight bias, outcome knowledge and adaptive learning. Quality and Safety in Health Care, 12(2, Suppl.), 46-50.
    • (2003) Quality and Safety in Health Care , vol.12 , Issue.2 SUPPL. , pp. 46-50
    • Henriksen, K.1    Kaplan, H.2
  • 162
    • 33644758133 scopus 로고    scopus 로고
    • What matters most in end-of-life care: Perceptions of seriously ill patients and their family members; canadian researchers end-of-life network (CARENET)
    • Heyland, D.K., et al. (2006). What matters most in end-of-life care: Perceptions of seriously ill patients and their family members; Canadian Researchers End-of-Life Network (CARENET). Canadian Medical Association Journal, 174(5), 627-33.
    • (2006) Canadian Medical Association Journal , vol.174 , Issue.5 , pp. 627-633
    • Heyland, D.K.1
  • 163
    • 20444443626 scopus 로고    scopus 로고
    • Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial
    • Hillman, K., et al. (2005). Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial. Lancet, 365(9477), 2091-7.
    • (2005) Lancet , vol.365 , Issue.9477 , pp. 2091-2097
    • Hillman, K.1
  • 165
    • 79951681699 scopus 로고    scopus 로고
    • Crico's handoff-related malpractice cases
    • Hoffman, J. (2007). CRICO's handoff-related malpractice cases. Forum, 25, 1-21.
    • (2007) Forum , vol.25 , pp. 1-21
    • Hoffman, J.1
  • 166
    • 83655191311 scopus 로고    scopus 로고
    • Beyond simon's slice: Five fundamental trade-offs that bound the performance of macrocognitive work systems
    • Hoffman, R.R. and Woods, D.D. (2011). Beyond Simon's slice: Five fundamental trade-offs that bound the performance of macrocognitive work systems. IEEE Intelligent Systems, 26(6), 67-71.
    • (2011) IEEE Intelligent Systems , vol.26 , Issue.6 , pp. 67-71
    • Hoffman, R.R.1    Woods, D.D.2
  • 167
    • 0001997708 scopus 로고    scopus 로고
    • Engineering resilience versus ecological resilience
    • In P. Schulze (ed.), Washington, DC: National Academy Press
    • Holling, C.S. (1996). Engineering resilience versus ecological resilience. In P. Schulze (ed.), Engineering Within Ecological Constraints. Washington, DC: National Academy Press (pp. 31-44).
    • (1996) Engineering Within Ecological Constraints , pp. 31-44
    • Holling, C.S.1
  • 170
    • 85122845048 scopus 로고    scopus 로고
    • Investigation as an impediment to learning
    • E. Hollnagel, C.P. Nemeth and S.W.A. Dekker (eds), Aldershot, UK: Ashgate
    • Hollnagel, E. (2008). Investigation as an impediment to learning. In E. Hollnagel, C.P. Nemeth and S.W.A. Dekker (eds), Remaining Sensitive to the Possibility of Failure. Aldershot, UK: Ashgate (pp. 259-68).
    • (2008) Remaining Sensitive to the Possibility of Failure , pp. 259-268
    • Hollnagel, E.1
  • 171
    • 84900177828 scopus 로고    scopus 로고
    • The etto principle: Efficiency-thoroughness trade-off
    • Aldershot, UK: Ashgate
    • Hollnagel, E. (2009a). The ETTO Principle: Efficiency-Thoroughness Trade-Off. Why Things that Go Right Sometimes Go Wrong. Aldershot, UK: Ashgate.
    • (2009) Why Things that Go Right Sometimes Go Wrong
    • Hollnagel, E.1
  • 172
    • 85051311801 scopus 로고    scopus 로고
    • The four cornerstones of resilience engineering
    • C.P. Nemeth, E. Hollnagel and S.W.A. Dekker (eds), Aldershot, UK: Ashgate, 177
    • Hollnagel, E. (2009b). The four cornerstones of resilience engineering. In C.P. Nemeth, E. Hollnagel and S.W.A. Dekker (eds), Resilience Engineering Perspectives: Preparation and Restoration. Aldershot, UK: Ashgate (pp. 117-33, 177).
    • (2009) Resilience Engineering Perspectives: Preparation and Restoration , pp. 117-133
    • Hollnagel, E.1
  • 174
    • 84901568977 scopus 로고    scopus 로고
    • Prologue: The scope of resilience engineering
    • E. Hollnagel, J. Pariès, D.D. Woods and J. Wreathall (eds), Farnham, UK: Ashgate
    • Hollnagel, E. (2011b). Prologue: The scope of resilience engineering. In E. Hollnagel, J. Pariès, D.D. Woods and J. Wreathall (eds), Resilience Engineering in Practice: A Guidebook. Farnham, UK: Ashgate (pp. xxix-xxxix).
    • (2011) Resilience Engineering in Practice: A Guidebook
    • Hollnagel, E.1
  • 182
    • 77950558360 scopus 로고    scopus 로고
    • End of life planning in heart failure: It should be the end of the beginning
    • Howlett, J., et al. (2010). End of life planning in heart failure: It should be the end of the beginning. Canadian Journal of Cardiology, 26(3), 135-41.
    • (2010) Canadian Journal of Cardiology , vol.26 , Issue.3 , pp. 135-141
    • Howlett, J.1
  • 183
    • 77956104087 scopus 로고    scopus 로고
    • Bad stars or guiding lights? Learning from disasters to improve patient safety
    • Hughes, C., Travaglia, J. and Braithwaite, J. (2010). Bad stars or guiding lights? Learning from disasters to improve patient safety. Quality and Safety in Health Care, 19(4), 332-6.
    • (2010) Quality and Safety in Health Care , vol.19 , Issue.4 , pp. 332-336
    • Hughes, C.1    Travaglia, J.2    Braithwaite, J.3
  • 184
    • 80053217549 scopus 로고    scopus 로고
    • Regional variation in mortality and subsequent hospitalization of nursing residents with heart failure
    • Hutt, E., et al. (2011). Regional variation in mortality and subsequent hospitalization of nursing residents with heart failure. Journal of the American Medical Directors Association, 12, 585-601.
    • (2011) Journal of the American Medical Directors Association , vol.12 , pp. 585-601
    • Hutt, E.1
  • 186
    • 33745820816 scopus 로고    scopus 로고
    • A root cause analysis: Confronting the disjunction between formal rules and situated clinical activity
    • Iedema, R.A.M., et al. (2006). A root cause analysis: Confronting the disjunction between formal rules and situated clinical activity. Social Science & Medicine, 63(5), 1201-12.
    • (2006) Social Science & Medicine , vol.63 , Issue.5 , pp. 1201-1212
    • Iedema, R.A.M.1
  • 188
    • 84880203793 scopus 로고    scopus 로고
    • Institute for Healthcare Improvement, Online at, accessed 31 August 2012
    • Institute for Healthcare Improvement (2012). Institute for Healthcare Improvement: IHI offerings. Online at http://www.ihi.org/offerings/Pages/default.aspx, accessed 31 August 2012.
    • (2012) Institute for Healthcare Improvement: IHI Offerings
  • 191
    • 84855511471 scopus 로고    scopus 로고
    • Drug shortages: National survey reveals high level of frustration, low level of safety
    • Institute for Safe Medical Practices
    • Institute for Safe Medical Practices. (2010). Drug shortages: National survey reveals high level of frustration, low level of safety. ISMP Medication Safety Alert, 15, 1-3.
    • (2010) ISMP Medication Safety Alert , vol.15 , pp. 1-3
  • 192
    • 66249108231 scopus 로고    scopus 로고
    • Palliative care in heart failure: A position statement from the palliative care workshop of the heart failure association of the european society of cardiology
    • Advanced Heart Failure Study Group of the HFA of the ESC
    • Jaarsma, T., et al. (2009). Palliative care in heart failure: A position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. (Advanced Heart Failure Study Group of the HFA of the ESC.) European Journal of Heart Failure, 11, 433-43.
    • (2009) European Journal of Heart Failure , vol.11 , pp. 433-443
    • Jaarsma, T.1
  • 195
    • 77956027434 scopus 로고    scopus 로고
    • The reality of drug shortages - The case of the injectable agent propofol
    • Jensen, V. and Rappaport, B.A. (2010). The reality of drug shortages - the case of the injectable agent propofol. New England Journal of Medicine, 363(9), 806-7.
    • (2010) New England Journal of Medicine , vol.363 , Issue.9 , pp. 806-807
    • Jensen, V.1    Rappaport, B.A.2
  • 196
    • 80053268828 scopus 로고    scopus 로고
    • Managing palliative care for patients with advanced heart failure
    • Kaasalainen, S., et al. (2011). Managing palliative care for patients with advanced heart failure. Canadian Journal of Nursing Research, 43(3), 38-57.
    • (2011) Canadian Journal of Nursing Research , vol.43 , Issue.3 , pp. 38-57
    • Kaasalainen, S.1
  • 197
    • 0037663736 scopus 로고    scopus 로고
    • Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review
    • Kaushal, R., Shojania, K.G. and Bates, D.W. (2003). Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review. Archives of Internal Medicine, 163(12), 1409.
    • (2003) Archives of Internal Medicine , vol.163 , Issue.12 , pp. 1409
    • Kaushal, R.1    Shojania, K.G.2    Bates, D.W.3
  • 202
    • 0033092367 scopus 로고    scopus 로고
    • High reliability perinatal units: An approach to the prevention of patient injury and medical malpractice claims
    • Knox, G.E., Simpson, K.R. and Garite, T. J. (1999). High reliability perinatal units: An approach to the prevention of patient injury and medical malpractice claims. Journal of Healthcare Risk Management, 19(2), 24-32.
    • (1999) Journal of Healthcare Risk Management , vol.19 , Issue.2 , pp. 24-32
    • Knox, G.E.1    Simpson, K.R.2    Garite, T.J.3
  • 203
    • 38349034540 scopus 로고    scopus 로고
    • Life expectancy after an index hospitalization for patients with heart failure: A population-based study
    • Ko, D. T., et al. (2008). Life expectancy after an index hospitalization for patients with heart failure: A population-based study. American Heart Journal, 155, 324-31.
    • (2008) American Heart Journal , vol.155 , pp. 324-331
    • Ko, D.T.1
  • 205
    • 0036596101 scopus 로고    scopus 로고
    • The need for risk management to evolve to assure a culture of safety
    • Kuhn, A.M. and Youngberg, B.J. (2002). The need for risk management to evolve to assure a culture of safety. Quality & Safety in Health Care, 11, 158-62.
    • (2002) Quality & Safety in Health Care , vol.11 , pp. 158-162
    • Kuhn, A.M.1    Youngberg, B.J.2
  • 206
    • 0002591228 scopus 로고    scopus 로고
    • Factors and processes contributing to resilience: The positive resilience framework
    • M.D. Glantz and J.L. Johnson (eds), New York: Academic /Plenum Publishers
    • Kumpfer, K.L. (1999). Factors and processes contributing to resilience: The positive resilience framework. In M.D. Glantz and J.L. Johnson (eds), Resilience and Development: Positive Life Adaptions. New York: Academic /Plenum Publishers (pp. 179-224).
    • (1999) Resilience and Development: Positive Life Adaptions , pp. 179-224
    • Kumpfer, K.L.1
  • 208
    • 79951813723 scopus 로고    scopus 로고
    • Maux du travail, dégradation, recomposition ou illusion?
    • Lallement, M., et al. (2011). Maux du travail, dégradation, recomposition ou illusion? Sociologie du travail, 53, 3-36.
    • (2011) Sociologie Du Travail , vol.53 , pp. 3-36
    • Lallement, M.1
  • 210
    • 78649439268 scopus 로고    scopus 로고
    • Temporal trends in rates of patient harm resulting from medical care
    • Landrigan, C.P., et al. (2010). Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine, 363, 2, 124-34.
    • (2010) New England Journal of Medicine , vol.363 , Issue.2 , pp. 124-134
    • Landrigan, C.P.1
  • 211
    • 39049177651 scopus 로고    scopus 로고
    • Broadening the safety agenda to include home care services
    • Lang, A., et al. (2009). Broadening the safety agenda to include home care services. Healthcare Quarterly, 9, 124-6.
    • (2009) Healthcare Quarterly , vol.9 , pp. 124-126
    • Lang, A.1
  • 212
    • 82355166474 scopus 로고    scopus 로고
    • Introducing 'perspective on process organization studies
    • T. Hernes and S. Maitlis (eds), New York: Oxford University Press
    • Langley, A. and Tsoukas, H. Introducing 'perspective on process organization studies'. In T. Hernes and S. Maitlis (eds), Process, Sensemaking, and Organizing. New York: Oxford University Press (pp. 1-26).
    • Process, Sensemaking, and Organizing , pp. 1-26
    • Langley, A.1    Tsoukas, H.2
  • 215
    • 0026022279 scopus 로고
    • The nature of adverse events in hospitalized patients. Results of the harvard medical practice study II
    • Leape, L.L., et al. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine, 324, 377-84.
    • (1991) New England Journal of Medicine , vol.324 , pp. 377-384
    • Leape, L.L.1
  • 216
    • 80052166815 scopus 로고    scopus 로고
    • Palliative care and hospice in advanced heart failure
    • LeMond, L. and Allen, L.A. (2011). Palliative care and hospice in advanced heart failure. Progress in Cardiovascular Disease, 54, 168-78.
    • (2011) Progress in Cardiovascular Disease , vol.54 , pp. 168-178
    • Lemond, L.1    Allen, L.A.2
  • 218
    • 61849170213 scopus 로고    scopus 로고
    • Moving beyond normal accidents and high reliability organizations: A systems approach to safety in complex systems
    • Leveson, N., et al. (2009). Moving beyond normal accidents and high reliability organizations: A systems approach to safety in complex systems. Organization Studies, 30(2-3), 227-49.
    • (2009) Organization Studies , vol.30 , Issue.2-3 , pp. 227-249
    • Leveson, N.1
  • 220
    • 0002427157 scopus 로고
    • The science of 'muddling through
    • Lindblom, C.A. (1959). The science of 'muddling through'. Public Administration Review, 19(2), 79-88.
    • (1959) Public Administration Review , vol.19 , Issue.2 , pp. 79-88
    • Lindblom, C.A.1
  • 221
    • 0004154108 scopus 로고
    • Seattle: University of Washington Press
    • Lorenz, E.N. (1993). The Essence of Chaos. Seattle: University of Washington Press.
    • (1993) The Essence of Chaos
    • Lorenz, E.N.1
  • 222
    • 67650358008 scopus 로고    scopus 로고
    • Models of cognition, the contextualisation of knowledge and organisational theory
    • Lorenz, E. (2001). Models of cognition, the contextualisation of knowledge and organisational theory. Journal of Management and Governance, 5(3-4), 307-30.
    • (2001) Journal of Management and Governance , vol.5 , Issue.3-4 , pp. 307-330
    • Lorenz, E.1
  • 223
    • 79952186871 scopus 로고    scopus 로고
    • Palliative care in advanced heart failure: An international review of the perspectives of recipients and health professionals on care provision
    • Low, J., et al. (2011). Palliative care in advanced heart failure: An international review of the perspectives of recipients and health professionals on care provision. Journal of Cardiac Failure, 17(3), 231-52.
    • (2011) Journal of Cardiac Failure , vol.17 , Issue.3 , pp. 231-252
    • Low, J.1
  • 224
    • 69249248112 scopus 로고    scopus 로고
    • What-you-look-for- Is-what-you-find - The consequence of underlying accident models in eight accident investigation manuals
    • Lundberg, J., Rollenhagen, C. and Hollnagel, E. (2009). What-You-Look-For- Is-What-You-Find - The consequence of underlying accident models in eight accident investigation manuals. Safety Science, 47(10), 1297-311.
    • (2009) Safety Science , vol.47 , Issue.10 , pp. 1297-1311
    • Lundberg, J.1    Rollenhagen, C.2    Hollnagel, E.3
  • 225
    • 84876950443 scopus 로고    scopus 로고
    • Regulating resilience? Regulatory work in high-risk arenas
    • B. Hutter (ed.), Cambridge: Cambridge University Press
    • Macrae, C. (2010). Regulating resilience? Regulatory work in high-risk arenas. In B. Hutter (ed.), Anticipating Risks and Organising Risk Regulation. Cambridge: Cambridge University Press.
    • (2010) Anticipating Risks and Organising Risk Regulation
    • Macrae, C.1
  • 226
    • 0347403546 scopus 로고    scopus 로고
    • Defining and classifying clinical indicators for quality improvement
    • Mainz, J. (2003). Defining and classifying clinical indicators for quality improvement. International Journal for Quality in Health Care, 15(6), 523-30.
    • (2003) International Journal for Quality in Health Care , vol.15 , Issue.6 , pp. 523-530
    • Mainz, J.1
  • 228
    • 0035214901 scopus 로고    scopus 로고
    • Process versus outcome indicators in the assessment of quality of health care
    • Mant, J. (2001). Process versus outcome indicators in the assessment of quality of health care. International Journal for Quality in Health Care, 13(6), 475-80.
    • (2001) International Journal for Quality in Health Care , vol.13 , Issue.6 , pp. 475-480
    • Mant, J.1
  • 229
    • 0029161449 scopus 로고
    • Detecting differences in quality of care: The sensitivity of measures of process and outcome in treating acute myocardial infarction
    • Mant, J. and Hicks, N. (1995). Detecting differences in quality of care: The sensitivity of measures of process and outcome in treating acute myocardial infarction. British Medical Journal, 311, 793-9.
    • (1995) British Medical Journal , vol.311 , pp. 793-799
    • Mant, J.1    Hicks, N.2
  • 230
    • 84892480446 scopus 로고    scopus 로고
    • Understanding organizational context and heart failure management in long term care homes in ontario, Canada
    • Marcella, J., et al. (2012). Understanding organizational context and heart failure management in long term care homes in Ontario, Canada. Health, 4(9), 725-34.
    • (2012) Health , vol.4 , Issue.9 , pp. 725-734
    • Marcella, J.1
  • 232
    • 58149425798 scopus 로고
    • A theory of human motivation
    • Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-96.
    • (1943) Psychological Review , vol.50 , Issue.4 , pp. 370-396
    • Maslow, A.H.1
  • 233
    • 77955162637 scopus 로고    scopus 로고
    • Resilience over the lifespan: Developmental perspectives on resistance, recovery, and transformation
    • J. Reich, A.J. Zautra and J. Hall (eds), New York: The Guilford Press
    • Masten, A. and Wright, M.O. (2010). Resilience over the lifespan: Developmental perspectives on resistance, recovery, and transformation. In J. Reich, A.J. Zautra and J. Hall (eds), Handbook of Adult Resilience. New York: The Guilford Press (pp. 213-23).
    • (2010) Handbook of Adult Resilience , pp. 213-223
    • Masten, A.1    Wright, M.O.2
  • 234
    • 67650457674 scopus 로고    scopus 로고
    • A model-integrated, guideline-driven, clinical decision-support system
    • Mathe, J.L., et al. (2009). A model-integrated, guideline-driven, clinical decision-support system. IEEE Software, 26(4), 54-61.
    • (2009) IEEE Software , vol.26 , Issue.4 , pp. 54-61
    • Mathe, J.L.1
  • 235
    • 33644675165 scopus 로고    scopus 로고
    • Rules, safety and the narrativisation of identity: A hospital operating theatre case study
    • McDonald, R., Waring, J. and Harrison, S. (2006). Rules, safety and the narrativisation of identity: A hospital operating theatre case study. Sociology of Health & Illness, 28(2), 178-202.
    • (2006) Sociology of Health & Illness , vol.28 , Issue.2 , pp. 178-202
    • McDonald, R.1    Waring, J.2    Harrison, S.3
  • 236
    • 0038482206 scopus 로고    scopus 로고
    • The quality of health care delivered to adults in the united states
    • McGlynn, E.A., et al. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348, 2635-45.
    • (2003) New England Journal of Medicine , vol.348 , pp. 2635-2645
    • McGlynn, E.A.1
  • 237
    • 0021050324 scopus 로고
    • The critical attitude in medicine: The need for a new ethics
    • 24-31 December
    • McIintyre, N. and Popper, K. (1983). The critical attitude in medicine: The need for a new ethics. British Medical Journal, 287(24-31 December), 1919-23.
    • (1983) British Medical Journal , vol.287 , pp. 1919-1923
    • McIintyre, N.1    Popper, K.2
  • 238
    • 79960831092 scopus 로고    scopus 로고
    • The 2011 canadian cardiovascular society heart failure management guidelines update: Focus on sleep apnea, renal dysfunction, mechanical circulatory support, and palliative care
    • McKelvie, R.S., et al. (2011). The 2011 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on sleep apnea, renal dysfunction, mechanical circulatory support, and palliative care. Canadian Journal of Cardiology, 27, 319-38.
    • (2011) Canadian Journal of Cardiology , vol.27 , pp. 319-338
    • McKelvie, R.S.1
  • 239
    • 33748768966 scopus 로고    scopus 로고
    • Selecting indicators for patient safety at the health system level in oecd countries
    • McLoughlin, V., et al. (2006). Selecting indicators for patient safety at the health system level in OECD countries. International Journal for Quality in Health Care, 18(Suppl. 1), 14-20.
    • (2006) International Journal for Quality in Health Care , vol.18 , Issue.SUPPL. 1 , pp. 14-20
    • McLoughlin, V.1
  • 240
    • 84900698920 scopus 로고    scopus 로고
    • Bullying, culture, and climate in health care organizations: A theoretical framework
    • J. Braithwaite, P. Hyde and C. Pope (eds), Basingstoke: Palgrave Macmillan
    • McMahon, J., MacCurtain, S. and O'Sullivan, M. (2010). Bullying, culture, and climate in health care organizations: A theoretical framework. In J. Braithwaite, P. Hyde and C. Pope (eds), Culture and Climate in Health Organizations. Basingstoke: Palgrave Macmillan (pp. 82-96).
    • (2010) Culture and Climate in Health Organizations , pp. 82-96
    • McMahon, J.1    MacCurtain, S.2    O'Sullivan, M.3
  • 242
    • 78049483987 scopus 로고    scopus 로고
    • Leverage points: Places to intervene in a system
    • Meadows, D. (1999). Leverage points: Places to intervene in a system. Solutions, 1(1), 41-9.
    • (1999) Solutions , vol.1 , Issue.1 , pp. 41-49
    • Meadows, D.1
  • 244
    • 79952369874 scopus 로고    scopus 로고
    • Patient-reported outcome measures: An overview
    • Meadows, K.A. (2011). Patient-reported outcome measures: An overview. British Journal of Community Nursing, 16(3), 146-51.
    • (2011) British Journal of Community Nursing , vol.16 , Issue.3 , pp. 146-151
    • Meadows, K.A.1
  • 246
    • 74049118060 scopus 로고    scopus 로고
    • Self-organisation, integration and curriculum in the complex world of medical education
    • Mennin, S. (2010). Self-organisation, integration and curriculum in the complex world of medical education. Medical Education, 44(1), 20-30.
    • (2010) Medical Education , vol.44 , Issue.1 , pp. 20-30
    • Mennin, S.1
  • 247
    • 0001239049 scopus 로고
    • The unanticipated consequences of social action
    • Merton, R.K. (1936). The unanticipated consequences of social action. American Sociological Review, 1, 894-904.
    • (1936) American Sociological Review , vol.1 , pp. 894-904
    • Merton, R.K.1
  • 248
    • 71749110569 scopus 로고    scopus 로고
    • The geography of patient safety: A topical analysis of sterility
    • Mesman, J. (2009). The geography of patient safety: A topical analysis of sterility. Social Science & Medicine, 69(12), 1705-12.
    • (2009) Social Science & Medicine , vol.69 , Issue.12 , pp. 1705-1712
    • Mesman, J.1
  • 249
    • 84900208326 scopus 로고    scopus 로고
    • Resources of strength: An exnovation of hidden competencies to preserve patient safety
    • E. Rowley, and J. Waring (eds), Aldershot, UK: Ashgate
    • Mesman, J. (2011). Resources of strength: An exnovation of hidden competencies to preserve patient safety. In E. Rowley, and J. Waring (eds), A Socio-Cultural Perspective on Patient Safety. Aldershot, UK: Ashgate.
    • (2011) A Socio-Cultural Perspective on Patient Safety
    • Mesman, J.1
  • 250
    • 0742287193 scopus 로고    scopus 로고
    • Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals
    • Michel, P., et al. (2004). Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. British Medical Journal, 328, 1-5.
    • (2004) British Medical Journal , vol.328 , pp. 1-5
    • Michel, P.1
  • 251
    • 0344014920 scopus 로고
    • The architecture of simplicity
    • Miller, D. (1993). The architecture of simplicity. Academy of Management Review, 18, 116-38.
    • (1993) Academy of Management Review , vol.18 , pp. 116-138
    • Miller, D.1
  • 254
    • 79959841840 scopus 로고    scopus 로고
    • Online at, accessed 22 June 2012
    • Moen, R. and Norman, C. (2012). Evolution of the PDCA Cycle. Online at http://www.pkpinc.com/files/NA01MoenNormanFullpaper.pdf, accessed 22 June 2012.
    • (2012) Evolution of the PDCA Cycle
    • Moen, R.1    Norman, C.2
  • 255
    • 40449107919 scopus 로고    scopus 로고
    • Articulating the differences between safety and resilience: The decision-making of professional sea fishing skippers
    • Morel, G., Amalberti, R. and Chauvin, C. (2008). Articulating the differences between safety and resilience: The decision-making of professional sea fishing skippers. Human Factors, 1, 1-16.
    • (2008) Human Factors , vol.1 , pp. 1-16
    • Morel, G.1    Amalberti, R.2    Chauvin, C.3
  • 256
    • 84861394046 scopus 로고    scopus 로고
    • What is preventable harm in healthcare? A systematic review of definitions
    • Nabhan, M., et al. (2012). What is preventable harm in healthcare? A systematic review of definitions. BMC Health Services Research. 12, 128.
    • (2012) BMC Health Services Research , vol.12 , pp. 128
    • Nabhan, M.1
  • 261
    • 84892480151 scopus 로고    scopus 로고
    • Barriers to the management of heart failure in ontario long-term care homes: An interprofessional care perspective
    • Newhouse, I., et al. (2012). Barriers to the management of heart failure in Ontario long-term care homes: An interprofessional care perspective. Journal of Research in Interprofessional Education and Practice, 2(3), 278-95.
    • (2012) Journal of Research in Interprofessional Education and Practice , vol.2 , Issue.3 , pp. 278-295
    • Newhouse, I.1
  • 262
    • 79960208168 scopus 로고    scopus 로고
    • Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap
    • Nicolini, D., Waring, J. and Mengis, J. (2011). Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Social Science & Medicine, 73(2), 217-25.
    • (2011) Social Science & Medicine , vol.73 , Issue.2 , pp. 217-225
    • Nicolini, D.1    Waring, J.2    Mengis, J.3
  • 263
    • 50149087194 scopus 로고    scopus 로고
    • The interactionist self and grounded research: Reflexivity in a study of emergency department clinicians
    • Nugus, P. (2008). The interactionist self and grounded research: Reflexivity in a study of emergency department clinicians. Qualitative Sociology Review, 4(1), 189-204.
    • (2008) Qualitative Sociology Review , vol.4 , Issue.1 , pp. 189-204
    • Nugus, P.1
  • 264
    • 74549151336 scopus 로고    scopus 로고
    • The dynamic interaction of quality and efficiency in the emergency department: Squaring the circle?
    • Nugus, P. and Braithwaite, J. (2010). The dynamic interaction of quality and efficiency in the emergency department: Squaring the circle? Social Science & Medicine, 70(4), 511-17.
    • (2010) Social Science & Medicine , vol.70 , Issue.4 , pp. 511-517
    • Nugus, P.1    Braithwaite, J.2
  • 265
    • 78349310571 scopus 로고    scopus 로고
    • Integrated care in the emergency department: A complex adaptive systems perspective
    • Nugus, P., et al. (2010). Integrated care in the emergency department: A complex adaptive systems perspective. Social Science & Medicine, 17(11), 1997-2004.
    • (2010) Social Science & Medicine , vol.17 , Issue.11 , pp. 1997-2004
    • Nugus, P.1
  • 266
    • 34547466820 scopus 로고    scopus 로고
    • Coordination in hospitals: Organized or emergent process?
    • Nyssen, A.S. (2007). Coordination in hospitals: Organized or emergent process? Cognition, Technology & Work, 9(3), 149-57.
    • (2007) Cognition, Technology & Work , vol.9 , Issue.3 , pp. 149-157
    • Nyssen, A.S.1
  • 267
    • 0029659167 scopus 로고    scopus 로고
    • Analysis of synchronization constraints and associated errors in collective work environments
    • Nyssen, A.S. and Javaux, D. (1996). Analysis of synchronization constraints and associated errors in collective work environments. Ergonomics, 39, 1249-64.
    • (1996) Ergonomics , vol.39 , pp. 1249-1264
    • Nyssen, A.S.1    Javaux, D.2
  • 268
    • 84882956243 scopus 로고    scopus 로고
    • An evaluation of the effectiveness of the crew resource management programme in naval aviation
    • O'Connor, P., et al. (2012). An evaluation of the effectiveness of the crew resource management programme in naval aviation. International Journal of Human Factors and Ergonomics, 1(1), 21-40.
    • (2012) International Journal of Human Factors and Ergonomics , vol.1 , Issue.1 , pp. 21-40
    • O'Connor, P.1
  • 269
    • 65549088652 scopus 로고    scopus 로고
    • Professional communication and team collaboration
    • R. Hughes (ed.), Rockville, MD: Agency for Healthcare Research and Quality
    • O'Daniel, M. and Rosenstein, A. (2008). Professional communication and team collaboration. In R. Hughes (ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality.
    • (2008) Patient Safety and Quality: An Evidence-Based Handbook for Nurses
    • O'Daniel, M.1    Rosenstein, A.2
  • 271
    • 84990934648 scopus 로고    scopus 로고
    • Health expenditure in relation to GDP
    • OECD, OECD Publishing. Online at, accessed 30 August 2012
    • OECD. (2011). Health expenditure in relation to GDP. In Health at a Glance 2011: OECD Indicators. OECD Publishing. Online at http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en, accessed 30 August 2012.
    • (2011) Health at a Glance 2011: OECD Indicators
  • 272
    • 77956106797 scopus 로고    scopus 로고
    • Beyond markets and states: Polycentric governance of complex economic systems
    • Ostrom, E. (2010). Beyond markets and states: Polycentric governance of complex economic systems. American Economic Review, 100, 641-72.
    • (2010) American Economic Review , vol.100 , pp. 641-672
    • Ostrom, E.1
  • 274
    • 0004109465 scopus 로고
    • Philadelphia, PA: Temple University Press
    • Paget, M.A. (1988). The Unity of Mistakes. Philadelphia, PA: Temple University Press.
    • (1988) The Unity of Mistakes
    • Paget, M.A.1
  • 275
    • 0031426242 scopus 로고    scopus 로고
    • Dynamic structure of a food web model: Comparison with a food chain model
    • Pahl-Wostl, C. (1997). Dynamic structure of a food web model: Comparison with a food chain model. Ecological Modelling, 100(1-3), 103-23.
    • (1997) Ecological Modelling , vol.100 , Issue.1-3 , pp. 103-123
    • Pahl-Wostl, C.1
  • 276
    • 84885836353 scopus 로고    scopus 로고
    • Lessons from the hudson
    • E. Hollnagel, et al. (eds), Farnham, UK: Ashgate
    • Pariès, J. (2011). Lessons from the Hudson. In E. Hollnagel, et al. (eds), Resilience Engineering in Practice: A Guidebook. Farnham, UK: Ashgate.
    • (2011) Resilience Engineering in Practice: A Guidebook
    • Pariès, J.1
  • 279
    • 39349117322 scopus 로고    scopus 로고
    • Structuring flexibility: The potential good, bad and ugly in standardization of handovers
    • Patterson, E.S. (2008). Structuring flexibility: The potential good, bad and ugly in standardization of handovers. Quality & Safety in Health Care, 17, 4-5.
    • (2008) Quality & Safety in Health Care , vol.17 , pp. 4-5
    • Patterson, E.S.1
  • 281
    • 84965867502 scopus 로고
    • Framework for the comparative analysis of organizations
    • Perrow, C. (1967). Framework for the comparative analysis of organizations. American Sociological Review, 32(2), 194-208.
    • (1967) American Sociological Review , vol.32 , Issue.2 , pp. 194-208
    • Perrow, C.1
  • 285
    • 77949505793 scopus 로고    scopus 로고
    • Frequency of inappropriate medical exceptions to quality measures
    • Persell, S., et al. (2012). Frequency of inappropriate medical exceptions to quality measures. Annals of Internal Medicine. 152, 225-31.
    • (2012) Annals of Internal Medicine , vol.152 , pp. 225-231
    • Persell, S.1
  • 286
    • 77952344801 scopus 로고    scopus 로고
    • Recasting the rca: An improved model for performing root cause analyses
    • Pham, J.C., et al. (2010). ReCASTing the RCA: An improved model for performing root cause analyses. American Journal of Medical Quality, 25, 186-91.
    • (2010) American Journal of Medical Quality , vol.25 , pp. 186-191
    • Pham, J.C.1
  • 287
    • 70349437625 scopus 로고    scopus 로고
    • Searching electronic health records for temporal patterns in patient histories: A case study with microsoft amalga
    • Plaisant, C., et al. (2008). Searching electronic health records for temporal patterns in patient histories: A case study with Microsoft Amalga. AMIA Annual Symposium, 601.
    • (2008) AMIA Annual Symposium , vol.601
    • Plaisant, C.1
  • 289
    • 79955790630 scopus 로고    scopus 로고
    • Professional conceptualisation and accomplishment of patient safety in mental health care: An ethnographic approach
    • [online]. Retrieved 29 August 2012 from
    • Plumb, J., et al. (2011). Professional conceptualisation and accomplishment of patient safety in mental health care: An ethnographic approach. BMC Health Services Research, 11 [online]. Retrieved 29 August 2012 from http://www.biomedcentral.com/content/pdf/1472-6963-11-100.pdf.
    • (2011) BMC Health Services Research , vol.11
    • Plumb, J.1
  • 290
    • 84982740717 scopus 로고
    • Doing business in the temple: Managers and quality assurance in public services
    • Pollitt, C. (1990). Doing business in the temple: Managers and quality assurance in public services. Public Administration, 68(4), 435-42.
    • (1990) Public Administration , vol.68 , Issue.4 , pp. 435-442
    • Pollitt, C.1
  • 292
    • 77954074918 scopus 로고    scopus 로고
    • The lived experience of heart failure at the end of life: A systematic literature review
    • Pratt Hopp, F., Thornton, N. and Martin, L. (2010). The lived experience of heart failure at the end of life: A systematic literature review. Health & Social Work, 35(2), 109-117.
    • (2010) Health & Social Work , vol.35 , Issue.2 , pp. 109-117
    • Pratt Hopp, F.1    Thornton, N.2    Martin, L.3
  • 293
    • 84900688015 scopus 로고    scopus 로고
    • Educating the healthcare professional for capability
    • In D. Kernick (ed.), Oxford: Radcliffe Medical Press
    • Price, J. (2004). Educating the healthcare professional for capability. In D. Kernick (ed.), Complexity and Healthcare Organization: A View from the Street. Oxford: Radcliffe Medical Press (pp. 227-40).
    • (2004) Complexity and Healthcare Organization: A View from the Street , pp. 227-240
    • Price, J.1
  • 294
    • 33845880922 scopus 로고    scopus 로고
    • An intervention to decrease catheter-related bloodstream infections in the ICU
    • Pronovost, P., et al. (2006a). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725-32.
    • (2006) New England Journal of Medicine , vol.355 , Issue.26 , pp. 2725-2732
    • Pronovost, P.1
  • 295
    • 33746344296 scopus 로고    scopus 로고
    • Creating high reliability in healthcare organizations
    • Pt 2
    • Pronovost, P.J., et al. (2006b). Creating high reliability in healthcare organizations. Health Services Research, 41(4 Pt 2), 1599-617.
    • (2006) Health Services Research , vol.41 , Issue.4 , pp. 1599-1617
    • Pronovost, P.J.1
  • 296
  • 297
    • 79953768389 scopus 로고    scopus 로고
    • Doctors' handovers in hospitals: A literature review
    • Raduma-Tomàs, M.A., et al. (2011). Doctors' handovers in hospitals: A literature review. BMJ Quality & Safety, 20, 128-33.
    • (2011) BMJ Quality & Safety , vol.20 , pp. 128-133
    • Raduma-Tomàs, M.A.1
  • 298
    • 0031279121 scopus 로고    scopus 로고
    • Risk management in a dynamic society: A modeling problem
    • Rasmussen, J. (1997). Risk management in a dynamic society: A modeling problem, Safety Science, 27, 183-213.
    • (1997) Safety Science , vol.27 , pp. 183-213
    • Rasmussen, J.1
  • 299
    • 0016286123 scopus 로고
    • Mental procedures in real-life tasks: A case study of electronic troubleshooting
    • Rasmussen, J. and Jensen, A. (1974). Mental procedures in real-life tasks: A case study of electronic troubleshooting, Ergonomics, 17, 293-307.
    • (1974) Ergonomics , vol.17 , pp. 293-307
    • Rasmussen, J.1    Jensen, A.2
  • 300
    • 0002643228 scopus 로고
    • Actions not as planned: The price of automatization
    • G. Underwood and R. Stevens (eds), London: Academic Press
    • Reason, J.T. (1979). Actions not as planned: The price of automatization. In G. Underwood and R. Stevens (eds), Aspects of Consciousness. Vol. I, Psychological Issues. London: Academic Press.
    • (1979) Aspects of Consciousness. Vol. I, Psychological Issues
    • Reason, J.T.1
  • 301
    • 0004223940 scopus 로고
    • Cambridge: Cambridge University Press
    • Reason, J.T. (1990). Human Error. Cambridge: Cambridge University Press.
    • (1990) Human Error
    • Reason, J.T.1
  • 302
    • 0345301763 scopus 로고
    • The identification of latent organizational failures in complex systems
    • J.A. Wise, D.V. Hopkin and P. Stager (eds), Berlin: Springer Verlag
    • Reason, J.T. (1993). The identification of latent organizational failures in complex systems. In J.A. Wise, D.V. Hopkin and P. Stager (eds), Verification and Validation of Complex Systems: Human Factors Issues. Berlin: Springer Verlag.
    • (1993) Verification and Validation of Complex Systems: Human Factors Issues
    • Reason, J.T.1
  • 305
    • 0035623034 scopus 로고    scopus 로고
    • Nobody ever gets credit for fixing problems that never happened: Creating and sustaining process improvement
    • Repenning, N.P. and Sterman, J.D. (2001). Nobody ever gets credit for fixing problems that never happened: Creating and sustaining process improvement. California Management Review, 43(4), 64-88.
    • (2001) California Management Review , vol.43 , Issue.4 , pp. 64-88
    • Repenning, N.P.1    Sterman, J.D.2
  • 307
    • 70349757495 scopus 로고    scopus 로고
    • State of the science: Promoting self-care in persons with heart failure: A scientific statement from the american heart association
    • Riegel, B., et al. (2009). State of the science: Promoting self-care in persons with heart failure: A scientific statement from the American Heart Association. Circulation, 120, 1141-63.
    • (2009) Circulation , vol.120 , pp. 1141-1163
    • Riegel, B.1
  • 308
    • 9944238860 scopus 로고
    • Dilemmas in a general theory of planning
    • Rittel, H. and Webber, M. (1973). Dilemmas in a general theory of planning, Policy Sciences, 4, 155-169,
    • (1973) Policy Sciences , vol.4 , pp. 155-169
    • Rittel, H.1    Webber, M.2
  • 309
    • 33746370069 scopus 로고    scopus 로고
    • Enhancing patient safety through organizational learning: Are patient safety indicators a step in the right direction?
    • Rivard, P.E., Rosen, A.K. and Carroll, J.S. (2006). Enhancing patient safety through organizational learning: Are patient safety indicators a step in the right direction? Health Service Research, 41(4), 1633-53.
    • (2006) Health Service Research , vol.41 , Issue.4 , pp. 1633-1653
    • Rivard, P.E.1    Rosen, A.K.2    Carroll, J.S.3
  • 311
    • 84934563541 scopus 로고
    • Some characteristics of one type of high reliability organization
    • Roberts, K.H. (1990). Some characteristics of one type of high reliability organization. Organization Science, 1(2), 160-76.
    • (1990) Organization Science , vol.1 , Issue.2 , pp. 160-176
    • Roberts, K.H.1
  • 312
    • 20644442014 scopus 로고    scopus 로고
    • A case of the birth and death of a high reliability healthcare organisation
    • Roberts, K.H., et al. (2005). A case of the birth and death of a high reliability healthcare organisation. Quality and Safety in Health Care, 14, 216-20.
    • (2005) Quality and Safety in Health Care , vol.14 , pp. 216-220
    • Roberts, K.H.1
  • 313
    • 33645566091 scopus 로고
    • Decision dynamics in two high reliability military organizations
    • Roberts, K.H., Stout, S.K. and Halpern, J.T. (1994). Decision dynamics in two high reliability military organizations. Management Science, 40, 614-24.
    • (1994) Management Science , vol.40 , pp. 614-624
    • Roberts, K.H.1    Stout, S.K.2    Halpern, J.T.3
  • 314
    • 0032699873 scopus 로고    scopus 로고
    • Safe operation as a social construct
    • Rochlin, G.I. (1999). Safe operation as a social construct. Ergonomics, 42(11), 1549-60.
    • (1999) Ergonomics , vol.42 , Issue.11 , pp. 1549-1560
    • Rochlin, G.I.1
  • 315
    • 0002683301 scopus 로고
    • Self-designing high reliability: Aircraft carrier flight operations at sea
    • Rochlin, G.I., La Porte, T.R. and Roberts, K.H. (1987). Self-designing high reliability: Aircraft carrier flight operations at sea. Naval War College Review, 40(4), 76-90.
    • (1987) Naval War College Review , vol.40 , Issue.4 , pp. 76-90
    • Rochlin, G.I.1    la Porte, T.R.2    Roberts, K.H.3
  • 317
    • 79960993458 scopus 로고    scopus 로고
    • Computerized clinical decision support systems for chronic disease management: A decision-maker-researcher partnership systematic review
    • Roshanov, P.S., et al. (2011). Computerized clinical decision support systems for chronic disease management: A decision-maker-researcher partnership systematic review. Implementation Science, 6, 92.
    • (2011) Implementation Science , vol.6 , pp. 92
    • Roshanov, P.S.1
  • 319
    • 69949136472 scopus 로고    scopus 로고
    • The dynamics of action-oriented problem solving: Linking interpretation and choice
    • Rudolph, J.W., Morrison, J.B. and Carroll, J.S. (2009). The dynamics of action-oriented problem solving: Linking interpretation and choice. Academy of Management Review, 34(4), 733-56.
    • (2009) Academy of Management Review , vol.34 , Issue.4 , pp. 733-756
    • Rudolph, J.W.1    Morrison, J.B.2    Carroll, J.S.3
  • 320
    • 84866494685 scopus 로고    scopus 로고
    • Caretrack: Assessing the appropriateness of health care delivery in Australia
    • Runciman, W.B., et al. (2012a). CareTrack: Assessing the appropriateness of health care delivery in Australia. Medical Journal of Australia, 197(2), 100-105.
    • (2012) Medical Journal of Australia , vol.197 , Issue.2 , pp. 100-105
    • Runciman, W.B.1
  • 321
    • 84866498464 scopus 로고    scopus 로고
    • Towards the delivery of appropriate health care in Australia
    • Runciman, W.B., et al. (2012b). Towards the delivery of appropriate health care in Australia. Medical Journal of Australia, 197(2), 78.
    • (2012) Medical Journal of Australia , vol.197 , Issue.2 , pp. 78
    • Runciman, W.B.1
  • 322
    • 84856880635 scopus 로고    scopus 로고
    • Multidisciplinary heart failure management and end of life care
    • Ryder, M., et al. (2011). Multidisciplinary heart failure management and end of life care. Current Opinion in Supportive and Palliative Care, 4, 317-21.
    • (2011) Current Opinion in Supportive and Palliative Care , vol.4 , pp. 317-321
    • Ryder, M.1
  • 323
    • 56849118939 scopus 로고    scopus 로고
    • Does team training work? Principles for health care
    • Salas, E., et al. (2008). Does team training work? Principles for health care. Academic Emergency Medicine, 15(11), 1002-9.
    • (2008) Academic Emergency Medicine , vol.15 , Issue.11 , pp. 1002-1009
    • Salas, E.1
  • 324
    • 33745963936 scopus 로고    scopus 로고
    • Does crew resource management training work? An update, an extension, and some critical needs
    • Salas, E., et al. (2006). Does crew resource management training work? An update, an extension, and some critical needs. Human Factors, 48(2), 392-412.
    • (2006) Human Factors , vol.48 , Issue.2 , pp. 392-412
    • Salas, E.1
  • 325
    • 49149086882 scopus 로고    scopus 로고
    • Incident reporting or storytellling? Competing schemes in a safety-critical and hazardous work setting
    • Sanne J.M. (2008). Incident reporting or storytellling? Competing schemes in a safety-critical and hazardous work setting. Safety Science, 46, 1205-22.
    • (2008) Safety Science , vol.46 , pp. 1205-1222
    • Sanne, J.M.1
  • 326
    • 30244520419 scopus 로고
    • Statut et fonction des communications dans l'activité des équipes de travail
    • Savoyant, A. and Leplat J. (1983), Statut et fonction des communications dans l'activité des équipes de travail. Psychologie Française, 28(3), 247-53.
    • (1983) Psychologie Française , vol.28 , Issue.3 , pp. 247-253
    • Savoyant, A.1    Leplat, J.2
  • 327
    • 78349264666 scopus 로고    scopus 로고
    • After the abolition of the national patient safety agency
    • Scarpello, J. (2010). After the abolition of the National Patient Safety Agency. British Medical Journal, 341, 1005-6.
    • (2010) British Medical Journal , vol.341 , pp. 1005-1006
    • Scarpello, J.1
  • 330
    • 0002990522 scopus 로고
    • Analysis of high reliability organizations: A comparative framework
    • K.H. Roberts (ed.), New York, NY: Macmillan
    • Schulman, P.R. (1993). Analysis of high reliability organizations: A comparative framework. In K.H. Roberts (ed.), New Challenges to Understanding Organizations. New York, NY: Macmillan.
    • (1993) New Challenges to Understanding Organizations
    • Schulman, P.R.1
  • 331
    • 10344255611 scopus 로고    scopus 로고
    • General attributes of safe organizations
    • i39-i44
    • Schulman, P.R. (2004). General attributes of safe organizations. Quality and Safety in Health Care, 13(Suppl. II), ii39-ii44.
    • (2004) Quality and Safety in Health Care , vol.13 , Issue.SUPPL. II
    • Schulman, P.R.1
  • 332
    • 84864518405 scopus 로고    scopus 로고
    • The growing role of emergency departments in hospital admissions
    • Schuur, J.D. and Venkatesh, A.K. (2012). The growing role of emergency departments in hospital admissions. New England Journal of Medicine, 367(5), 391-3.
    • (2012) New England Journal of Medicine , vol.367 , Issue.5 , pp. 391-393
    • Schuur, J.D.1    Venkatesh, A.K.2
  • 334
    • 84900755662 scopus 로고    scopus 로고
    • Implementing recommendations for safer hospitals in europe: Sanitas project
    • Shaw, C.D., Jelfs, E. and Franklin, P. (2012). Implementing recommendations for safer hospitals in Europe: Sanitas Project. Eurohealth, 18(2), 26-8.
    • (2012) Eurohealth , vol.18 , Issue.2 , pp. 26-28
    • Shaw, C.D.1    Jelfs, E.2    Franklin, P.3
  • 336
    • 84959810873 scopus 로고
    • A behavioral model of rational choice
    • Simon, H.A. (1955). A behavioral model of rational choice. Quarterly Journal of Economics, 69, 99-118.
    • (1955) Quarterly Journal of Economics , vol.69 , pp. 99-118
    • Simon, H.A.1
  • 337
    • 58149433367 scopus 로고
    • Rational choice and the structure of the environment
    • Simon, H.A. (1956). Rational choice and the structure of the environment. Psychological Review, 63(2), 129-38.
    • (1956) Psychological Review , vol.63 , Issue.2 , pp. 129-138
    • Simon, H.A.1
  • 338
    • 84986799029 scopus 로고
    • Rational decision-making in business organizations
    • Simon, H.A. (1979). Rational decision-making in business organizations. American Economic Review, 69, 493-513.
    • (1979) American Economic Review , vol.69 , pp. 493-513
    • Simon, H.A.1
  • 339
    • 34548442822 scopus 로고    scopus 로고
    • How quickly do systematic reviews go out of date? A survival analysis
    • Sjohania, K., et al. (2007). How quickly do systematic reviews go out of date? A survival analysis. Annals of International Medicine, 147, 224-33.
    • (2007) Annals of International Medicine , vol.147 , pp. 224-233
    • Sjohania, K.1
  • 340
    • 59349116916 scopus 로고    scopus 로고
    • Reforming new south wales public hospitals: An assessment of the garling inquiry
    • Skinner, C.A., et al. (2009). Reforming New South Wales public hospitals: An assessment of the Garling inquiry. Medical Journal of Australia, 190(2), 78-9.
    • (2009) Medical Journal of Australia , vol.190 , Issue.2 , pp. 78-79
    • Skinner, C.A.1
  • 341
    • 0031839945 scopus 로고    scopus 로고
    • Lessons from the denver medication error /criminal negligence case: Look beyond blaming individuals
    • Smetzer, J. and Cohen, M. (1998). Lessons from the Denver medication error /criminal negligence case: Look beyond blaming individuals. Hospital Pharmacy, 33, 640-56.
    • (1998) Hospital Pharmacy , vol.33 , pp. 640-656
    • Smetzer, J.1    Cohen, M.2
  • 342
    • 0000472274 scopus 로고
    • Concepts of culture and organizational analysis
    • Smircich, L. (1983). Concepts of culture and organizational analysis. Administrative Science Quarterly, 28(3), 339-58.
    • (1983) Administrative Science Quarterly , vol.28 , Issue.3 , pp. 339-358
    • Smircich, L.1
  • 344
    • 0008232765 scopus 로고    scopus 로고
    • Princeton and Oxford: Princeton University Press
    • Snook, S.A. (2000). Friendly Fire. Princeton and Oxford: Princeton University Press.
    • (2000) Friendly Fire
    • Snook, S.A.1
  • 347
    • 59349111202 scopus 로고    scopus 로고
    • Implementation of the garling recommendations can offer real hope for rescuing the new south wales public hospital system
    • Stewart, G.J. and Dwyer, J.M. (2010). Implementation of the Garling recommendations can offer real hope for rescuing the New South Wales public hospital system. Medical Journal of Australia, 190(2), 80.
    • (2010) Medical Journal of Australia , vol.190 , Issue.2 , pp. 80
    • Stewart, G.J.1    Dwyer, J.M.2
  • 349
    • 70549112145 scopus 로고    scopus 로고
    • Mind the gap: Opportunities for improving endof-life care for patients with advanced heart failure
    • Strachan, P.H., et al. (2009). Mind the Gap: Opportunities for improving endof-life care for patients with advanced heart failure. The Canadian Journal of Cardiology, 25(11), 635-40.
    • (2009) The Canadian Journal of Cardiology , vol.25 , Issue.11 , pp. 635-640
    • Strachan, P.H.1
  • 351
    • 0002657549 scopus 로고
    • The hospital and its negotiated order
    • E. Freidson (ed), London: Free Press of Glencoe
    • Strauss, A.L., et al. (1963). The hospital and its negotiated order. In E. Freidson (ed), The Hospital in Modern Society. London: Free Press of Glencoe (pp. 147-69).
    • (1963) The Hospital in Modern Society , pp. 147-169
    • Strauss, A.L.1
  • 352
    • 1542318881 scopus 로고    scopus 로고
    • Communication failures: An insidious contributor to medical mishaps
    • Sutcliffe, K.M., Lewton, E. and Rosenthal, M.M. (2004). Communication failures: An insidious contributor to medical mishaps. Academic Medicine, 79(2), 186-94.
    • (2004) Academic Medicine , vol.79 , Issue.2 , pp. 186-194
    • Sutcliffe, K.M.1    Lewton, E.2    Rosenthal, M.M.3
  • 354
    • 20444447022 scopus 로고    scopus 로고
    • Adaptive-creative versus routine-reproductive expertise in hypermedia design: An exploratory study
    • Syer, C.A., et al. (2003). Adaptive-creative versus routine-reproductive expertise in hypermedia design: An exploratory study. Cognition, Technology & Work, 5, 94-106.
    • (2003) Cognition, Technology & Work , vol.5 , pp. 94-106
    • Syer, C.A.1
  • 357
    • 0004204459 scopus 로고    scopus 로고
    • (2nd Edition). Milwaukee: ASQ Quality Press
    • Tague, N.R. (2004). The Quality Toolbox (2nd Edition). Milwaukee: ASQ Quality Press, 390-92.
    • (2004) The Quality Toolbox , pp. 390-392
    • Tague, N.R.1
  • 358
    • 59249100936 scopus 로고    scopus 로고
    • Evolution des soins intensifs en suisse: Historique, situation actuelle et perspectives
    • Tassaux, D., et al. (2008). Evolution des soins intensifs en Suisse: historique, situation actuelle et perspectives. Revue Médicale Suisse, 4(183), pp. 2672-6.
    • (2008) Revue Médicale Suisse , vol.4 , Issue.183 , pp. 2672-2676
    • Tassaux, D.1
  • 359
    • 84870378557 scopus 로고    scopus 로고
    • The New York Times, (10 July). Online at, accessed 25 October 2012
    • The New York Times (2010). Factory Efficiency Comes to the Hospital (10 July). Online at http://www.nytimes.com/2010/07/11/business/11seattle.html?pagewanted=all&_r=0, accessed 25 October 2012.
    • (2010) Factory Efficiency Comes to the Hospital
  • 360
    • 6344243282 scopus 로고    scopus 로고
    • Translating teamwork behaviours from aviation to healthcare: Development of behavioural markers for neonatal resuscitation
    • Thomas, E., Sexton, J. and Helmreich, R. (2004). Translating teamwork behaviours from aviation to healthcare: Development of behavioural markers for neonatal resuscitation. Quality and Safety in Health Care, 13, 57-64.
    • (2004) Quality and Safety in Health Care , vol.13 , pp. 57-64
    • Thomas, E.1    Sexton, J.2    Helmreich, R.3
  • 361
    • 0013865890 scopus 로고
    • Habituation: A model phenomenon for the study of neuronal substrates of behavior
    • Thompson, R.F. and Spencer, W.A. (1966). Habituation: A model phenomenon for the study of neuronal substrates of behavior. Psychological Review, 73(1), 16-43.
    • (1966) Psychological Review , vol.73 , Issue.1 , pp. 16-43
    • Thompson, R.F.1    Spencer, W.A.2
  • 363
    • 65249163551 scopus 로고    scopus 로고
    • Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals
    • Travaglia, J.F., Westbrook, M.T. and Braithwaite, J. (2009). Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals. Health, 13(3), 277-96.
    • (2009) Health , vol.13 , Issue.3 , pp. 277-296
    • Travaglia, J.F.1    Westbrook, M.T.2    Braithwaite, J.3
  • 366
    • 0037412617 scopus 로고    scopus 로고
    • Why hospitals don't learn from failures: Organizational and psychological dynamics that inhibit system change
    • Tucker, A.L. and Edmondson, A.C. (2003). Why hospitals don't learn from failures: Organizational and psychological dynamics that inhibit system change. California Management Review, 45(2), 55-72.
    • (2003) California Management Review , vol.45 , Issue.2 , pp. 55-72
    • Tucker, A.L.1    Edmondson, A.C.2
  • 368
    • 41849127047 scopus 로고    scopus 로고
    • Resilience across cultures
    • Ungar, M. (2008). Resilience across cultures. British Journal of Social Work, 38(2), 218-35.
    • (2008) British Journal of Social Work , vol.38 , Issue.2 , pp. 218-235
    • Ungar, M.1
  • 369
    • 49749108915 scopus 로고    scopus 로고
    • Measuring patientreported outcomes: Moving from clinical trials into clinical practice
    • Valderas, J.M., Alonso, J. and Guyatt, G.H. (2008). Measuring patientreported outcomes: Moving from clinical trials into clinical practice. Medical Journal of Australia, 189, 93-4.
    • (2008) Medical Journal of Australia , vol.189 , pp. 93-94
    • Valderas, J.M.1    Alonso, J.2    Guyatt, G.H.3
  • 370
    • 70349630182 scopus 로고    scopus 로고
    • Conceptualizing, investigating, and enhancing adaptive expertise in mathematics education
    • Verschaffel, L., Torbeyns, J. and Van Dooren, W. (2009). Conceptualizing, investigating, and enhancing adaptive expertise in mathematics education. European Journal of Psychology of Education, XXIV(3), 335-59x.
    • (2009) European Journal of Psychology of Education , vol.24 , Issue.3 , pp. 335-359
    • Verschaffel, L.1    Torbeyns, J.2    van Dooren, W.3
  • 371
    • 0008284355 scopus 로고
    • The study of errors and accidents in medicine
    • C. Vincent, M. Ennis and R. Audley (eds), Oxford: Oxford University Press
    • Vincent, C. (1993). The study of errors and accidents in medicine. In C. Vincent, M. Ennis and R. Audley (eds), Medical Accidents. Oxford: Oxford University Press.
    • (1993) Medical Accidents
    • Vincent, C.1
  • 372
    • 19544388999 scopus 로고    scopus 로고
    • (2nd Edition). Oxford: Wiley Blackwell
    • Vincent, C. (2010). Patient Safety (2nd Edition). Oxford: Wiley Blackwell.
    • (2010) Patient Safety
    • Vincent, C.1
  • 373
    • 57349175943 scopus 로고    scopus 로고
    • Is health care getting safer?
    • Vincent, C., et al. (2008). Is health care getting safer? British Medical Journal, 337(7680), 1205-7.
    • (2008) British Medical Journal , vol.337 , Issue.7680 , pp. 1205-1207
    • Vincent, C.1
  • 376
    • 33847152273 scopus 로고    scopus 로고
    • The safety organizing scale: Development and validation of a behavioral measure of safety culture in hospital nursing units
    • Vogus, T.J. and Sutcliffe, K.M. (2007a). The safety organizing scale: Development and validation of a behavioral measure of safety culture in hospital nursing units. Medical Care, 45(1), 46-54.
    • (2007) Medical Care , vol.45 , Issue.1 , pp. 46-54
    • Vogus, T.J.1    Sutcliffe, K.M.2
  • 377
    • 34748833499 scopus 로고    scopus 로고
    • The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units
    • Vogus, T.J. and Sutcliffe, K.M. (2007b). The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Medical Care, 45(10), 997-1,002.
    • (2007) Medical Care , vol.45 , Issue.10 , pp. 997-1001
    • Vogus, T.J.1    Sutcliffe, K.M.2
  • 378
    • 77952359694 scopus 로고    scopus 로고
    • Patient safety at ten: Unmistakable progress, troubling gaps
    • Wachter, R. (2010). Patient safety at ten: Unmistakable progress, troubling gaps. Health Affairs, 29(1), 165-73.
    • (2010) Health Affairs , vol.29 , Issue.1 , pp. 165-173
    • Wachter, R.1
  • 380
    • 20444454972 scopus 로고    scopus 로고
    • Resilience, adaptability and transformability in social-ecological systems
    • Walker, B., et al. (2004). Resilience, adaptability and transformability in social-ecological systems. Ecology and Society, 9(2), 5.
    • (2004) Ecology and Society , vol.9 , Issue.2 , pp. 5
    • Walker, B.1
  • 382
    • 14644403712 scopus 로고    scopus 로고
    • Beyond blame: The cultural barriers to medical incident reporting
    • Waring, J. (2005). Beyond blame: The cultural barriers to medical incident reporting. Social Science & Medicine, 60, 1927-35.
    • (2005) Social Science & Medicine , vol.60 , pp. 1927-1935
    • Waring, J.1
  • 384
    • 33947584812 scopus 로고    scopus 로고
    • Adaptive regulation or governmentality: Patient safety and the changing regulation of medicine
    • Waring, J. (2007b). Adaptive regulation or governmentality: Patient safety and the changing regulation of medicine. Sociology of Health and Illness, 29(2), 163-79.
    • (2007) Sociology of Health and Illness , vol.29 , Issue.2 , pp. 163-179
    • Waring, J.1
  • 385
    • 84900711226 scopus 로고    scopus 로고
    • Critical risk management: Moral entrepreneurship in the pursuit of patient safety
    • G. Currie, et al. (eds), London: Routledge
    • Waring, J. (2010). Critical risk management: Moral entrepreneurship in the pursuit of patient safety. In G. Currie, et al. (eds), Critical Public Sector Management. London: Routledge.
    • (2010) Critical Public Sector Management
    • Waring, J.1
  • 386
    • 34248375662 scopus 로고    scopus 로고
    • A culture of safety or coping: Ritualistic behaviours in the operating department
    • Waring, J., Harrison, S. and McDonald, R. (2007). A culture of safety or coping: Ritualistic behaviours in the operating department. Journal of Health Services Research and Policy, 12(1, Suppl. 1), 3-9.
    • (2007) Journal of Health Services Research and Policy , vol.12 , Issue.1 SUPPL. 1 , pp. 3-9
    • Waring, J.1    Harrison, S.2    McDonald, R.3
  • 387
    • 33745081489 scopus 로고    scopus 로고
    • Safety and complexity: The inter-departmental threats to patient safety in the operating department
    • Waring, J., McDonald, R. and Harrison, S. (2006). Safety and complexity: The inter-departmental threats to patient safety in the operating department. Journal of Health, Organisation and Management, 20(3), 227-42.
    • (2006) Journal of Health, Organisation and Management , vol.20 , Issue.3 , pp. 227-242
    • Waring, J.1    McDonald, R.2    Harrison, S.3
  • 388
    • 77949507543 scopus 로고    scopus 로고
    • A narrative review of the uk patient safety research portfolio
    • Waring, J., et al. (2010). A narrative review of the UK Patient Safety Research Portfolio. Journal of Health Services Research and Policy, 15(1, Suppl. 2), 26-32.
    • (2010) Journal of Health Services Research and Policy , vol.15 , Issue.1 SUPPL. 2 , pp. 26-32
    • Waring, J.1
  • 393
    • 84968080940 scopus 로고
    • Organizational culture as a source of high reliability
    • Weick, K.E. (1987). Organizational culture as a source of high reliability. California Management Review, 29(2), 112-27.
    • (1987) California Management Review , vol.29 , Issue.2 , pp. 112-127
    • Weick, K.E.1
  • 395
    • 84980230901 scopus 로고    scopus 로고
    • Enacted sense-making in crisis situations
    • Weick, K.E. (1998). Enacted sense-making in crisis situations. Journal of Management Studies, 25(4), 305-17.
    • (1998) Journal of Management Studies , vol.25 , Issue.4 , pp. 305-317
    • Weick, K.E.1
  • 396
    • 79551677961 scopus 로고    scopus 로고
    • Organizing for transient reliability: The production of dynamic non-events
    • Weick, K.E. (2011). Organizing for transient reliability: The production of dynamic non-events. Journal of Contingencies and Crisis Management, 19(1), 21-7.
    • (2011) Journal of Contingencies and Crisis Management , vol.19 , Issue.1 , pp. 21-27
    • Weick, K.E.1
  • 397
    • 85047875702 scopus 로고
    • Collective mind in organizations: Heedful interrelating on flight decks
    • Weick, K.E. and Roberts, K.H. (1993). Collective mind in organizations: Heedful interrelating on flight decks. Administrative Science Quarterly, 38(3), 357-81.
    • (1993) Administrative Science Quarterly , vol.38 , Issue.3 , pp. 357-381
    • Weick, K.E.1    Roberts, K.H.2
  • 398
    • 33746698903 scopus 로고    scopus 로고
    • Mindfulness and the quality of organizational attention
    • Weick, K.E. and Sutcliffe, K.M. (2006). Mindfulness and the quality of organizational attention. Organization Science, 17(4), 514-24.
    • (2006) Organization Science , vol.17 , Issue.4 , pp. 514-524
    • Weick, K.E.1    Sutcliffe, K.M.2
  • 400
    • 0002810129 scopus 로고    scopus 로고
    • Organizing for high reliability: Processes of collective mindfulness
    • B.M. Staw and L.I. Cummings (eds), Greenwich, CT: JAI Press
    • Weick, K.E., Sutcliffe, K.M. and Obstfeld, D. (1999). Organizing for high reliability: Processes of collective mindfulness. In B.M. Staw and L.I. Cummings (eds), Research in Organizational Behavior. Greenwich, CT: JAI Press (pp. 81-123).
    • (1999) Research in Organizational Behavior , pp. 81-123
    • Weick, K.E.1    Sutcliffe, K.M.2    Obstfeld, D.3
  • 402
    • 33750250827 scopus 로고
    • Thinking by groups, organizations and networks: A sociologist's view of the social psychology of science and technology
    • W.R. Shadish and S. Fuller (eds), NY: Guilford Press
    • Westrum, R. (1994). Thinking by groups, organizations and networks: A sociologist's view of the social psychology of science and technology. In W.R. Shadish and S. Fuller (eds), The Social Psychology of Science. NY: Guilford Press (pp. 329-39).
    • (1994) The Social Psychology of Science , pp. 329-339
    • Westrum, R.1
  • 403
    • 84937559187 scopus 로고    scopus 로고
    • A typology of resilience situations
    • E. Hollnagel, D.D. Woods and N. Leveson (eds), Aldershot, UK: Ashgate
    • Westrum, R. (2006). A typology of resilience situations. In E. Hollnagel, D.D. Woods and N. Leveson (eds), Resilience Engineering: Concepts and Precepts. Aldershot, UK: Ashgate. (pp. 55-65.)
    • (2006) Resilience Engineering: Concepts and Precepts , pp. 55-65
    • Westrum, R.1
  • 404
    • 84900685739 scopus 로고    scopus 로고
    • WHO Collaborating Centre for Patient Safety Solutions, Online at, accessed 28 July 2012
    • WHO Collaborating Centre for Patient Safety Solutions (2007). Communication During Patient Hand-Overs, Patient Safety Solutions, 1, 1-4. Online at http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution3.pdf, accessed 28 July 2012.
    • (2007) Communication During Patient Hand-Overs, Patient Safety Solutions , vol.1 , pp. 1-4
  • 405
    • 0032721844 scopus 로고    scopus 로고
    • Human error and crew resource management failures in naval aviation mishaps: A review of us naval safety center data, 1990-96
    • Wiegmann, D.A. and Shappell, S.A. (1999). Human error and crew resource management failures in naval aviation mishaps: A review of US Naval Safety Center data, 1990-96. Aviation, Space, and Environmental Medicine, 70(12), 1147-51.
    • (1999) Aviation, Space, and Environmental Medicine , vol.70 , Issue.12 , pp. 1147-1151
    • Wiegmann, D.A.1    Shappell, S.A.2
  • 406
    • 0004165744 scopus 로고
    • Berkeley, CA: University of California Press
    • Wildavsky, A. (1988). Searching for Safety. Berkeley, CA: University of California Press.
    • (1988) Searching for Safety
    • Wildavsky, A.1
  • 407
    • 0033519201 scopus 로고    scopus 로고
    • An analysis of the causes of adverse events from the quality in Australian health care study
    • Wilson, R.M., et al. (1999). An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Medical Journal of Australia, 170(9), 411-15.
    • (1999) Medical Journal of Australia , vol.170 , Issue.9 , pp. 411-415
    • Wilson, R.M.1
  • 409
    • 33646695679 scopus 로고    scopus 로고
    • The investigation and analysis of critical incidents and adverse events in healthcare
    • Woloschynowych, M., et al. (2005). The investigation and analysis of critical incidents and adverse events in healthcare. Health Technologies Assessment, 9(19).
    • (2005) Health Technologies Assessment , vol.9 , Issue.19
    • Woloschynowych, M.1
  • 411
    • 84937563307 scopus 로고    scopus 로고
    • Essential characteristics of resilience
    • E. Hollnagel, D.D. Woods and N. Leveson (eds), Aldershot, UK: Ashgate
    • Woods, D.D. (2006). Essential characteristics of resilience. In E. Hollnagel, D.D. Woods and N. Leveson (eds), Resilience Engineering: Concepts and Precepts. Aldershot, UK: Ashgate (pp. 21-33).
    • (2006) Resilience Engineering: Concepts and Precepts , pp. 21-33
    • Woods, D.D.1
  • 412
    • 77952550810 scopus 로고    scopus 로고
    • Resilience and the ability to anticipate
    • E. Hollnagel, et al. (eds), Farnham, UK: Ashgate
    • Woods, D.D. (2010). Resilience and the ability to anticipate. In E. Hollnagel, et al. (eds), Resilience Engineering in Practice: A Guidebook. Farnham, UK: Ashgate.
    • (2010) Resilience Engineering in Practice: A Guidebook
    • Woods, D.D.1
  • 413
    • 84901530660 scopus 로고    scopus 로고
    • Basic patterns in how adaptive systems fail
    • E. Hollnagel, et al. (eds), Farnham, UK: Ashgate
    • Woods, D.D. and Branlat, M. (2011a). Basic patterns in how adaptive systems fail. In E. Hollnagel, et al. (eds), Resilience Engineering in Practice: A Guidebook. Farnham, UK: Ashgate.
    • (2011) Resilience Engineering in Practice: A Guidebook
    • Woods, D.D.1    Branlat, M.2
  • 416
    • 0002545284 scopus 로고    scopus 로고
    • Distant supervision - Local action given the potential for surprise
    • Woods, D.D. and Shattuck, L.G. (2000). Distant supervision - Local action given the potential for surprise. Cognition, Technology & Work, I, 86-96.
    • (2000) Cognition, Technology & Work , vol.1 , pp. 86-96
    • Woods, D.D.1    Shattuck, L.G.2
  • 417
    • 34548225409 scopus 로고    scopus 로고
    • World Alliance for Patient Safety, Online at, accessed 22 June 2012
    • World Alliance for Patient Safety (2005). WHO draft guidelines for adverse event reporting and learning systems. Online at http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf, accessed 22 June 2012.
    • (2005) WHO Draft Guidelines for Adverse Event Reporting and Learning Systems
  • 419
    • 80053058790 scopus 로고    scopus 로고
    • Herd behavior in a complex adaptive system
    • Zhao, L., et al. (2011). Herd behavior in a complex adaptive system. Proceedings of the National Academy of Science USA, 108(37), 15058-63.
    • (2011) Proceedings of the National Academy of Science USA , vol.108 , Issue.37 , pp. 15058-15063
    • Zhao, L.1


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