Sociotechnical systems analysis in health care: a research agenda

IIE Transactions on Healthcare Systems Engineering

Volumn 1, Issue 3, 2011, Pages 145-160

  Carayon, Pascale ^a   Bass, Ellen J ^b   Bellandi, Tommaso ^c   Gurses, Ayse P ^d   Hallbeck, M Susan ^e   Mollo, Vanina ^f  

^a UNIVERSITY OF WISCONSIN MADISON   (United States)

^b University of Virginia   (United States)

^c CAREGGI UNIVERSITY HOSPITAL   (Italy)

^d JOHNS HOPKINS UNIVERSITY   (United States)

^e UNIVERSITY OF NEBRASKA LINCOLN   (United States)

^f IPTS CNAM39 allées Jules Guesde BP ^*  (France)

Author keywords

health information technology; human factors and ergonomics; medical devices; patient safety; patient centered care; risk management; sociotechnical systems; transitions of care; workload

Indexed keywords

ARTICLE; COMPUTERIZED PROVIDER ORDER ENTRY; ELECTRONIC MEDICAL RECORD; HEALTH CARE; HEALTH CARE SYSTEM; HUMAN; MEDICAL DEVICE; MEDICAL INFORMATION; PATIENT SAFETY; PRIORITY JOURNAL; RESEARCH; RISK MANAGEMENT; SOCIOTECHNICAL SYSTEMS ANALYSIS; SYSTEM ANALYSIS; WORKLOAD;

EID: 84981186503     PISSN: 19488300     EISSN: 19488319     Source Type: Journal    
DOI: 10.1080/19488300.2011.619158     Document Type: Article

References (153)

1. Aiken, L. J., Clarke, S. P., Sloane, D. M., Sochalski, J. A. and Silber, J. H. 2002. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16): 1987-1993.
2. Albayrak, A. 2008. Ergonomics in the Operating Room: Transition from Open to Image-based Surgery, Delft, The Netherlands: Delft University of Technology.
3. Albayrak, A., Kazemier, G., Meijer, D. W. and Bonjer, H. J. 2004. Current state of ergonomics of operating rooms of Dutch hospitals in the endoscopic era. Minimally Invasive Therapy & Allied Technologies, 13(3): 156-160.
4. Albayrak, A., van Veelen, M. A., Prins, J. F., Snijders, C. J., de Ridder, H. and Kazemier, G. 2007. A newly designed ergonomic body support for surgeons. Surgical Endoscopy, 21(10): 1835-1840.
5. Albolino, S., Tartaglia, R., Bellandi, T., Amicosante, E., Bianchini, E. and Biggeri, A. 2010. Patient safety and incident reporting: Survey of Italian healthcare workers. Quality and Safety in Health Care, 19: i8-i12.
6. Amalberti, R., Auroy, Y., Berwick, D. and Barach, P. 2005. Improving patient care: Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine, 142: 756-764.
7. Amalberti, R. and Hourlier, S. 2007. "Humane error reduction strategies in healthcare". In Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, Edited by: Carayon, P. 525-560. Mahwah, NJ: Lawrence Erlbaum Associates.
8. Arora, V., Johnson, J. J., Lovinger, D., Humphrey, H. J. and Meltzer, D. O. 2005. Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis. Quality & Safety in Health Care, 14: 401-407.
9. Ash, J. S., Sittig, D. F., Dykstra, R., Campbell, E. and Guappone, K. 2009. The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration. International Journal of Medical Informatics, 78(Suppl 1): S69-S76.
10. Bagnara, S., Parlangeli, O. and Tartaglia, R. 2010. Are hospitals becoming high reliability organizations?. Applied Ergonomics, 41(5): 713-718.
11. Barnsteiner, J. H. 2005. Medication reconciliation: Transfer of medication information across settings - keeping it free from error. Journal of Infusion Nursing, 28(Suppl 2): 31-36.
12. Bass, E. J. and Pritchett, A. R. 2008. Human-Automated Judge Learning: A methodology for examining human interaction with information analysis automation. IEEE Transactions on Systems, Man, and Cybernetics, Part A: Systems and Humans, 38(4): 759-776.
13. Bates, D. W. and Gawande, A. A. 2003. Improving safety with information technology. The New England Journal of Medicine, 348(25): 2526-2534.
14. Bates, D. W., Spell, N., Cullen, D. J., Burdick, E., Laird, N.Petersen, L. A. 1997. The cost of adverse drug events in hospitalized patients. Journal of the American Medical Association, 277(4): 307-311.
15. Baumgart, L. A., Gerling, G. J. and Bass, E. J. 2010. Characterizing the range of simulated prostate abnormalities palpable by digital rectal examination. Cancer Epidemiology, Biomarkers and Prevention, 34: 79-84.
16. Berguer, R. 1997. The application of ergonomics in the work environment of general surgeons. Reviews on Environmental Health, 12(2): 99-106.
17. Berguer, R. 1998. Surgical technology and the ergonomics of laparoscopic instruments. Surgical Endoscopy, 12(5): 458-462.
18. Berguer, R. 1999. Surgery and ergonomics. Archives of Surgery (Chicago, Ill.: 1960), 134(9): 1011-1016.
19. Berguer, R., Forkey, D. L. and Smith, W. D. 1999. Ergonomic problems associated with laparoscopic surgery. Surgical Endoscopy, 13(5): 466-468.
20. Bogner, M. S. 1994. Human Error in Medicine, Hillsdale, NJ: Lawrence Erlbaum Associates.
21. Bohr, P. C., Evanoff, B. A. and Wolf, L. 1997. Implementing participatory ergonomics teams among health care workers. American Journal of Industrial Medicine, 32(3): 190-196.
22. Bolton, M. L. and Bass, E. J. 2010. Formally verifying human-automation interaction as part of a system model: Limitations and tradeoffs. Innovations in Systems and Software Engineering, 6(3): 219-231.
23. Bolton, M. L. and Bass, E. J. 2011. Using task analytic behavior models, strategic knowledge-based erroneous human behavior generation, and model checking to evaluate human-automation Anchorage, Alaska Paper presented at the Interaction 2011 IEEE International Conference on Systems, Man, and Cybernetics, October 9-12, 2011
24. Bolton, M. L., Bass, E. J. and Siminiceanu, R. I. submitted. Generating phenotypical erroneous human behavior to evaluate human-automation interaction using model checking. The International Journal of Human-Computer Studies,
25. Bolton, M. L., Siminiceanu, R. I. and Bass, E. J. 2011. A systematic approach to model checking human-automation interaction using task-analytic models. IEEE Transactions on Systems, Man, and Cybernetics, Part A: Systems and Humans, 41(5): 961-976.
26. Borowitz, S. M., Waggoner-Fountain, L. A., Bass, E. J. and Sledd, R. M. 2008. Adequacy of information transferred at resident sign-out (inhospital handover of care): A prospective survey. Quality and Safety in Health Care, 17(6): 6-10.
27. Braby, C. D., Harris, D. and Muir, H. C. 1993. A psychophysiological approach to the assessment of work underload. Ergonomics, 36(9): 1035-1042.
28. Brennan, P. F. and Safran, C. 2004. Patient safety. Remember who it's really for. International Journal of Medical Informatics, 73(7-8): 547-550.
29. Brown-Clerk, B. J., De Laveaga, A. E., LaGrange, C. A., Lowndes, B. R., Wirth, L. M. and Hallbeck, M. S. 2010. Evalution of laparoendoscopic single-site surgery (LESS) ports in a validated inanimate laparoscopic training model. Journal of Endourology, 24(Suppl 1): A283
30. Brown, P. J., Borowitz, S. M. and Novicoff, W. 2004. Information exchange in the NICU: what sources of patient data do physicians prefer to use?. International Journal of Medical Informatics, 73(4): 349-355.
31. Buetow, S. and Elwyn, G. 2007. Patient safety and patient error. Lancet, 369(9556): 158-161.
32. Carayon, P. 2006. Human factors of complex sociotechnical systems. Applied Ergonomics, 37: 525-535.
33. Carayon, P. and Gurses, A. 2005. Nursing workload and patient safety in intensive care units: A human factors engineering evaluation of the literature. Intensive and Critical Care Nursing, 21: 284-301.
34. Carayon, P., Gurses, A. P., Hundt, A. S., Ayoub, P. and Alvarado, C. J. 2005. "Performance obstacles and facilitators of healthcare providers". In Change and Quality in Human Service Work, Edited by: Korunka, C. and Hoffmann, P. Vol. 4, 257-276. München, Germany: Hampp Publishers.
35. Carayon, P., Hundt, A. S., Karsh, B.-T., Gurses, A. P., Alvarado, C. J., Smith, M. and Brennan, P. 2006. Work system design for patient safety: The SEIPS model. Quality & Safety in Health Care, 15(Suppl I): i50-i58.
36. Carayon, P., Hundt, A. S. and Wetterneck, T. B. 2010. Nurses' acceptance of Smart IV pump technology. International Journal of Medical Informatics, 79: 401-411.
37. Carayon, P., Wetterneck, T. B., Hundt, A. S., Ozkaynak, M., DeSilvey, J., Ludwig, B., Ram, P. and Rough, S. S. 2007. Evaluation of nurse interaction with bar code medication administration technology in the work environment. Journal of Patient Safety, 3(1): 34-42.
38. Carayon, P. and Xie, A. 2011. "Decision making in healthcare system design: When human factors engineering meets health care". In Cultural Factors in Decision Making and Action, Edited by: Proctor, R. W., Noff, S. Y. and Yih, Y. Boca Raton, FL: Taylor & Francis.
39. Charles, C., Gafni, A. and Whelan, T. 1999. Decision-making in the physician-patient encounter: Revisiting the shared treatment decision-making model. Social Science and Medicine, 49(5): 651-661.
40. Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W.Roth, E. 2006. Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine, 144: E12-E22.
41. Cook, R. I., Woods, D. D. and Miller, C. 1998. A Tale of Two Stories: Contrasting Views of Patient Safety, Chicago, IL: National Patient Safety Foundation.
42. Crickmore, R. 1987. A review of stress in the intensive care unit. Intensive Care Nursing, 3: 19-27.
43. Crombie, N. A.M. and Graves, R. J. 1996. "Ergonomics of keyhole surgical instruments - patient friendly, but surgeon unfriendly". In Contemporary Ergonomics, Edited by: Robertson, S. 385-390. London: Taylor & Francis.
44. Cuschieri, A. 1995. Whither minimal access surgery: tribulations and expectations. American Journal of Surgery, 169(1): 9-19.
45. Dara, S. I. and Afessa, B. 2005. Intensivist-to-bed ratio: Association with outcomes in the medical ICU. Chest, 128: 567-572.
46. Davis, R. E., Jacklin, R. E., Sevdalis, N. and Vincent, C. A. 2007. Patient involvement in patient safety: what factors influence patient participation and engagement?. Health Expectations, 10(3): 259-267.
47. Decker, K. and Bauer, M. 2003. Ergonomics in the operating room - from the anesthesiologist's point of view. Minimally Invasive Therapy & Allied Technologies, 12(6): 268-277.
48. DeVoge, J. M., Bass, E. J., Sledd, R., Borowitz, S. M. and Waggoner-Fountain, L. 2009. Collaborating with physicians to redesign a sign-out tool. Ergonomics in Design, 17: 20-28.
49. Duffield, C. and O'Brien-Pallas, L. 2003. The causes and consequences of nursing shortages: A helicopter view of the research. Australian Health Review, 26(1): 186-193.
50. Dy, S. and Gurses, A. P. 2010. Care pathways and patient safety: Key concepts, patient outcomes, related interventions. International Journal of Care Pathways, 14(3): 124-128.
51. Ebright, P. R., Patterson, E. S., Chalko, B. A. and Render, M. L. 2003. Understanding the complexity of registered nurse work in acute care settings. Journal of Nursing Administration, 33(12): 630-638.
52. Ebright, P. R., Urden, L., Patterson, E. and Chalko, B. 2004. Themes surrounding novice nurse near-miss and adverse-event situations. Journal of Nursing Administration, 34(11): 531-538.
53. Effken, J. A. 2002. Different lenses, improved outcomes: A new approach to the analysis and design of healthcare information systems. International Journal of Medical Informatics, 65(1): 59-74.
54. Emam, T. A., Frank, T. G., Hanna, G. B. and Cuschieri, A. 2001. Influence of handle design on the surgeon's upper limb movements, muscle recruitment, and fatigue during endoscopic suturing. Surgical Endoscopy, 15(7): 667-672.
55. Falzon, P. and Mollo, V. 2007. Managing patients' demands: The practitioners' point of view. Theoretical Issues in Ergonomics Science, 8(5): 445-468.
56. Forst, L., Friedman, L. and Shapiro, D. 2006. Carpal tunnel syndrome in spine surgeons: A pilot study. Archives of Environmental & Occupational Health, 61(6): 259-262.
57. Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K. and Bates, D. W. 2003. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138(3): 161-174.
58. Gerbrands, A., Albayrak, A. and Kazemier, G. 2004. Ergonomic evaluation of the work area of the scrub nurse. Minimally Invasive Therapy & Allied Technologies, 13(3): 142-146.
59. Gurses, A. and Carayon, P. 2009. A qualitative study of performance obstacles and facilitators among ICU nurses. Applied Ergonomics, 40(3): 509-518.
60. Gurses, A., Carayon, P. and Wall, M. 2009. Impact of performance obstacles on intensive care nurses workload, perceived quality and safety of care, and quality of working life. Health Services Research, 44(2): 422-443.
61. Gurses, A. P. and Xiao, Y. 2006. A Systematic Review of the Literature on Multidisciplinary Rounds to Design Information Technology. Journal of the American Medical Informatics Association, 13(3): 267-276.
62. Gurses, A. P., Xiao, Y. and Hu, P. 2009. User-designed information tools to support communication and care coordination in a trauma hospital. Journal of Biomedical Informatics, 42(4): 667-677.
63. Hallbeck, M. S. 2010. "How to develop usable surgical devices - The view from a U.S. research university". In Advances in Occupational, Social, and Organizational Ergonomics, Edited by: Duffy, V. G. 286-295. Boca Raton, FL: CRC Press.
64. Hallbeck, M. S., Koneczny, S., Buchel, D. and Matern, U. 2008. Ergonomic usability testing of operating room devices. Studies in Health Technology and Informatics, 132: 147-152.
65. Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H.Dellinger, E. P. 2009. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5): 491-499.
66. Helms, A. S., Perez, T. E., Baltz, J., Donowitz, G., Hoke, G., Bass, E. J. and Plews-Ogan, M. L. in press. Use of an appreciative-inquiry approach to improve resident sign-out in an era of multiple shift changes. Journal of General Internal Medicine,
67. Holden, R. J. 2010. Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety. Cognition, Technology and Work, 13(1): 11-29.
68. Horwitz, L. I., Meredith, T., Schuur, J. D., Shah, N. R., Kulkarni, R. G. and Jenq, G. Y. 2009. Dropping the baton: A qualitative analysis of failures during the transition from emergency department to inpatient care. Annals of Emergency Medicine, 53(6): 701-710.
69. Horwitz, L. I., Moin, T., Krumholz, H. M., Wang, L. and Bradley, E. H. 2008. Consequences of inadequate sign-out for patient care. Archives of Internal Medicine, 168(16): 1755-1760.
70. Howard, D. L., Silber, J. H. and Jobes, D. R. 2004. Do regulations limiting residents' work hours affect patient mortality?. Journal of General Internal Medicine, 19(1): 1-7.
71. Hundt, A. S. 2007. "Organizational learning in healthcare". In Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, Edited by: Carayon, P. 127-138. Mahwah, NJ: Lawrence Erlbaum Associates.
72. Institute of Medicine Committee on Quality of Health Care in America. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century., Washington, DC: National Academy Press.
73. Israelski, E. W. and Muto, W. H. 2004. Human factors risk management as a way to improve medical device safety: A case study of the therac 25 radiation therapy system. Joint Commission Journal on Quality and Patient Safety, 30(12): 689-695.
74. Jencks, S. F., Williams, M. V. and Coleman, E. A. 2009. Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14): 1418-1428.
75. Joint Commission. 2010. http://www.jointcommission.org/SentinelEvents/Statistics/ (accessed August 29, 2011)
76. Kano, N., Yamakawa, T., Ishikawa, Y., Miyajima, N., Ohtaki, S. and Kasugai, H. 1995. Prevention of laparoscopic surgeon's thumb. Surgical Endoscopy, 9(6): 738-739.
77. Karsh, B.-T. 2004. Beyond usability: Designing effective technology implementation systems to promote patient safety. Quality and Safety in Health Care, 13: 388-394.
78. Kaya, O. I., Moran, M., Ozkardes, A. B., Taskin, E. Y., Seker, G. E. and Ozmen, M. M. 2008. Ergonomic problems encountered by the surgical team during video endoscopic surgery. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 18(1): 40-44.
79. Kirwan, B. and Ainsworth, L. K. 1992. A Guide to Task Analysis, London: Taylor & Francis.
80. Kohn, L. T., Corrigan, J. M. and Donaldson, M. S. 1999. To Err is Human: Building a Safer Health System, Washington, DC: National Academy Press.
81. Koneczny, S. 2009. The operating room: Architectural conditions and potential hazards. Work, 33(2): 145-164.
82. Koppel, R., Metlay, J. P., Cohen, A., Abaluck, B., Localio, A. R.Kimmel, S. E. 2005. Role of computerized physician order entry systems in facilitating medications errors. Journal of the American Medical Association, 293(10): 1197-1203.
83. Koppel, R., Wetterneck, T., Telles, J. L. and Karsh, B.-T. 2008. Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15: 408-423.
84. Korunka, C., Weiss, A. and Karetta, B. 1993. Effects of new technologies with special regard for the implementation process per se. Journal of Organizational Behavior, 14(4): 331-348.
85. Koutantji, M., Davis, R., Vincent, C. and Coulter, A. 2005. The patient's role in patient safety: Engaging patients, their representatives, and health professionals. Clinical Risk, 11(3): 99-104.
86. Kranenburg, L. and Gossot, D. 2004. Ergonomic problems encountered during video-assisted thoracic surgery. Minimally Invasive Therapy & Allied Technologies, 13(3): 147-155.
87. Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E.Katz, J. T. 2004. Effect of reducing interns' work hours on serious medical errors in intensive care units. New England Journal of Medicine, 351(18): 1838-1848.
88. Lau, D. H. 2002. Patient empowerment-a patient-centred approach to improved care. Hong Kong Medical Journal, 8(5): 372-374.
89. Leape, L. L. and Berwick, D. M. 2005. Five years after To Err Is Human: What have we learned?. Journal of the American Medical Association, 293(19): 2384-2390.
90. Lin, D. W., Bush, R. W., Earle, D. B. and Seymour, N. E. 2007. Performance and ergonomic characteristics of expert surgeons using a face-mounted display during virtual reality-simulated laparoscopic surgery: an electromyographically based study. Surgical Endoscopy, 21(7): 1135-1141.
91. Linton, S., Grant, C. and Pellegrini, J. 2008. Supporting families through discharge from PICU to the ward: The development and evaluation of a discharge information brochure for families. Intensive and Critical Care Nursing, 24(6): 329-337.
92. Linzer, M., Gerrity, M., Douglas, J. A., McMurray, J. E., Williams, E. S. and Konrad, T. R. 2002. Physician stress: Results from the physician worklife study. Stress and Health, 18(1): 37-42.
93. Lowe, C. M. 2006. Accidents waiting to happen: The contribution of latent conditions to patient safety. Quality and Safety in Health Care, 15(Suppl. I): i71-i75.
94. Maisel, W. H., Moynahan, M., Zuckerman, B. D., Gross, T. P., Tovar, O. H.Tillman, D. 2006. Pacemaker and ICD generator malfunctions: Analysis of Food and Drug Administration annual reports. Journal of the American Medical Association, 295(16): 1901-1906.
95. Majeed, A. W., Jacob, G., Reed, M. W. and Johnson, A. G. 1993. Laparoscopist's thumb: An occupational hazard. Archives of Surgery, 128(3): 357
96. Matern, U. 2001. Principles of ergonomic instrument handles. Minimally Invasive Therapy & Allied Technologies, 10(3): 169-173.
97. Matern, U., Giebmeyer, C., Bergmann, R., Waller, P. and Faist, M. 2002. Ergonomic aspects of four different types of laparoscopic instrument handles with respect to elbow angle. An electromyogram-based study. Surgical Endoscopy, 16(11): 1528-1532.
98. Matern, U. and Koneczny, S. 2007. Safety, hazards and ergonomics in the operating room. Surgical Endoscopy, 21(11): 1965-1969.
99. Matern, U. and Waller, P. 1999. Instruments for minimally invasive surgery: Principles of ergonomic handles. Surgical Endoscopy, 13(2): 174-182.
100. McFetridge, B., Gillespie, M., Goode, D. and Melby, V. 2007. An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit. Nursing in Critical Care, 12(6): 261-269.
101. McVicar, A. 2003. Workplace stress in nursing: A literature review. Journal of Advanced Nursing, 44(6): 633-642.
102. Mollo, V., Pernet, A., Moutel, G., Giraud, N. and Giraud, P. 2011. Le patient peut-il et doit-il participer à la gestion des risques en radiothérapie?. Cancer/radiothérapie, 5(3): 176-181.
103. Neale, G., Woloshynowych, M. and Vincent, C. 2001. Exploring the causes of adverse events in NHS hospital practice. Journal of the Royal Society of Medicine, 94(7): 322-330.
104. Nguyen, N. T., Ho, H. S., Smith, W. D., Philipps, C., Lewis, C.De Vera, R. M. 2001. An ergonomic evaluation of surgeons' axial skeletal and upper extremity movements during laparoscopic and open surgery. American Journal of Surgery, 182(6): 720-724.
105. Norman, D. A. 1990. The 'problem' with automation: Inappropriate feedback and interaction, not 'over-automation.'. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 327(1241): 585-593.
106. Oates, P. R. and Oates, R. K. 1996. Stress and work relationships in the neonatal intensive care unit: Are they worse than in the wards. Journal of Paediatrics and Child Health, 32(1): 57-59.
107. Olsen, S., Undre, S. and Vincent, C. 2005. Safety in surgery: First steps towards a systems approach. Clinical Risk, 11: 190-194.
108. Parasuraman, R., Sheridan, T. B. and Wickens, C. D. 2000. A model for types and levels of human interaction with automation. IEEE Transactions on Systems Man and Cybernetics Part A: -Systems and Humans, 30(3): 286-297.
109. Park, A., Lee, G., Seagull, F. J., Meenaghan, N. and Dexter, D. 2010. Patients benefit while surgeons suffer: An impending epidemic. Journal of the American College of Surgeons, 210(3): 306-313.
110. Patterson, E. S., Cook, R. I. and Render, M. L. 2002. Improving patient safety by identifying side effects from introducing bar coding in medication administration. Journal of the American Medical Informatics Association, 9: 540-553.
111. Pennathur, P. R., Thompson, D. H., Abernathy, J. H., Martinez, E. M., Pronovost, P. J.Bauer, L. (Submitted) Technologies in the Wild (TiW): Human factors implications for patient safety in the cardiovascular operating room.
112. Penoyer, D. 2010. Nurse staffing and patient outcomes in critical care: A concise review. Critical Care Medicine, 38(7): 1521-1528.
113. Pernet, A. and Mollo, V. 2011. "Patient participation to patient safety in radiotherapy: Reality or Necessity?". In Healthcare Systems Ergonomics and Patient Safety 2011 - An Alliance Between Professionals and Citizens for Patient Safety and Quality of Life, Edited by: Albolino, S., Bagnara, S., Bellandi, T., Llaneza, J., Rosal, G. and Tartaglia, R. 95-96. Boca Raton, FL: CRC Press.
114. Pillow, M. 2007. Improving Hand-Off Communication, Oakbrook Terrace, IL: Joint Commission Resources.
115. Pippins, J. R., Gandhi, T. K., Hamann, C., Ndumele, C. D., Labonville, S. A.Diedrichsen, E. K. 2008. Classifying and predicting errors of inpatient medication reconciliation. Journal of General Internal Medicine, 23(9): 1414-1422.
116. Plsek, P. and Greenhalgh, T. 2001. Complexity science: The challenge of complexity in health care. British Medical Journal, 323: 625-628.
117. Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A.Levtzion-Korach, O. 2010. Effect of bar-code technology on the safety of medication administration. The New England Journal of Medicine, 362(18): 1698-1707.
118. Pronovost, P., Weast, B., Schwarz, M., Wyskiel, R. M., Prow, D.Milanovich, S. N. 2003. Medication reconciliation: A practical tool to reduce the risk of medication errors. Journal of Critical Care, 18(4): 201-205.
119. Pronovost, P. J., Goeschel, C. A., Olsen, K. L., Pham, J. C., Miller, M. R.Berenholtz, S. M. 2009. Reducing health care hazards: Lessons from the Commercial aviation safety team. Health Affairs, 28(3): w479-w489.
120. Reason, J. 1997. Managing the Risks of Organizational Accidents, Burlington, VT: Ashgate.
121. Reason, J. 2009. The Human Contribution, London: Ashgate.
122. Rothschild, J., Keohane, C. A., Cook, E. F., Orav, E. J., Burdick, E.Thompson, S. 2005. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Critical Care Medicine, 33(3): 533-540.
123. Rozich, J. and Roger, R. 2001. Medication safety: one organization's approach to the challenge. Journal of Clinical Outcomes Management, 8(10): 27-34.
124. Sari, V., Nieboer, T. E., Vierhout, M. E., Stegeman, D. F. and Kluivers, K. B. 2010. The operation room as a hostile environment for surgeons: physical complaints during and after laparoscopy. Minimally Invasive Therapy & Allied Technologies, 19(2): 105-109.
125. Sarter, N. B. and Woods, D. D. 1995. How in the world did we ever get into that mode? Mode error and awareness in supervisory control. Human Factors, 37: 5-19.
126. Schraagen, J. M., Chipman, S. F. and Shalin, V. L. 2000. Cognitive Task Analysis, Mahwah, NJ: Lawrence Erlbaum Associates.
127. Sheikhzadeh, A., Gore, C., Zuckerman, J. D. and Nordin, M. 2009. Perioperating nurses and technicians' perceptions of ergonomic risk factors in the surgical environment. Applied Ergonomics, 40(5): 833-839.
128. Singh, H., Thomas, E. J., Petersen, L. A. and Studdert, D. M. 2007. Medical errors involving trainees: A study of closed malpractice claims from 5 insurers. Archives of Internal Medicine, 167(19): 2030-2036.
129. Smedley, B. D., Stith, A. Y. and Nelson, A. R. 2003. Unequal Treatment - Confronting Racial and Ethnic Disparities in Health Care, Washington, DC: The National Academies Press.
130. Smith, P. J., McCoy, C. E. and Layton, C. 1997. Brittleness in the design of cooperative problem-solving systems: the effects on user performance. IEEE Transactions on Systems, Man and Cybernetics, Part A: Systems and Humans, 27(3): 360-371.
131. Stanton, N. 2005. Human Factors Methods: A Practical Guide for Engineering and Design, Burlington, VT: Ashgate.
132. Szeto, G. P., Ho, P., Ting, A. C., Poon, J. T., Cheng, S. W. and Tsang, R. C. 2009. Work-related musculoskeletal symptoms in surgeons. Journal of Occupational Rehabilitation, 19(2): 175-184.
133. Trejo, A., Done, K. N., DiMartino, A. A., Oleynikov, D. and Hallbeck, M. S. 2006. Articulating vs. conventional laparoscopic grasping tools - Surgeons' opinions. International Journal of Industrial Ergonomics, 36(1): 25-35.
134. Trejo, A., Jung, M. C., Oleynikov, D. and Hallbeck, M. S. 2007. Effect of handle design and target location on insertion and aim with a laparoscopic surgical tool. Applied Ergonomics, 38(6): 745-753.
135. Trinkoff, A., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y. and Han, K. 2010. Linking nursing work environment and patient outcomes. Journal of Nursing Regulation, 2(1): 10-16.
136. Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y. and Kihye, H. 2011. Nurses' work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1): 1-8.
137. UK Department of Health. 2006. Safety First - A Report for Patients, Clinicians and Healthcare Managers, London: UK Department of Health.
138. Van Det, M. J., Meijerink, W. J., Hoff, C., Totte, E. R. and Pierie, J. P. 2009. Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: A review and guidelines. Surgical Endoscopy, 23(6): 1279-1285.
139. van Veelen, M. A., Meijer, D. W., Goossens, R. H. and Snijders, C. J. 2001. New ergonomic design criteria for handles of laparoscopic dissection forceps. Journal of Laparoendoscopic & Advanced Surgical Techniques, 11(1): 17-26.
140. van Veelen, M. A., Jakimowicz, J. J. and Kazemier, G. 2004. Improved physical ergonomics of laparoscopic surgery. Minimally Invasive Therapy & Allied Technologies, 13(3): 161-166.
141. van Veelen, M. A. and Meijer, D. W. 1999. Ergonomics and design of laparoscopic instruments: results of a survey among laparoscopic surgeons. Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A, 9(6): 481-489.
142. Vicente, K. J. 1999. Cognitive Work Analysis, Mahwah, NJ: Lawrence Erlbaum Associates.
143. Vicente, K. J. 2003. What does it take? A case study of radical change toward patient safety. Joint Commission Journal on Quality and Safety, 29(11): 598-609.
144. Vincent, C., Taylor-Adams, S. and Stanhope, N. 1998. Framework for analysing risk and safety in clinical medicine. BMJ, 316(7138): 1154-1157.
145. Vincent, C. A. and Coulter, A. 2002. Patient safety: What about the patient?. Quality and Safety in Health Care, 11(1): 76-80.
146. Waters, K. R. and Easton, N. 1999. Individualized care: is it possible to plan and carry out?. Journal of Advanced Nursing, 29(1): 79-87.
147. Wauben, L. S., van Veelen, M. A., Gossot, D. and Goossens, R. H. 2006. Application of ergonomic guidelines during minimally invasive surgery: a questionnaire survey of 284 surgeons. Surgical Endoscopy, 20(8): 1268-1274.
148. Wayne, J. D., Tyagi, R., Reinhardt, G., Rooney, D., Makoul, G.Chopra, S. 2008. Simple standardized patient handoff system that increases accuracy and completeness. Journal of Surgical Education, 65(6): 476-485.
149. Weick, K. E. and Quinn, R. E. 1999. Organizational change and development. Annual Review of Psychology, 50: 361-386.
150. Whittaker, J. and Ball, C. 2000. Discharge from intensive care: A view from the ward. Intensive and Critical Care Nursing, 16(3): 135-143.
151. Wickens, C. D., Lee, J. D., Liu, Y. and Becker, S. E.G. 2004. An Introduction to Human Factors Engineering, 2nd ed., Upper Saddle River, NJ: Prentice Hall.
152. Wilson, R. M., Runciman, W. B., Gibberd, R. W., Harrison, B. T., Newby, L. and Hamilton, J. D. 1995. The quality in Australian health care study. Medical Journal of Australia, 163(6): 458-471.
153. World Health Organization. 2005. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems, Geneva, Switzerland: WHO.