Operating at the sharp end: The complexity of human error

Human Error in Medicine

Volumn , Issue , 2018, Pages 255-310

  Cook, Richard I ^a   Woods, David D ^a  

^a OHIO STATE UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 85052440163     PISSN: None     EISSN: None     Source Type: Book    
DOI: 10.1201/9780203751725     Document Type: Chapter

References (84)

1. Andrews, J. J. (1990). Inhaled anesthesia delivery systems. In R. D. Miller (Ed.), Anesthesia (3rd ed., pp. 171-223). New York: Churchill Livingstone.
2. Arens, J. F. (1993). A practice parameters overview. Anesthesiology, 78, 229-230.
3. Baron, J., & Hershey, J. (1988). Outcome bias in decision evaluation. Journal of Personality and Social Psychology, 54(4), 569-579
4. Boeing Product Safety Organization. (1993). Statistical summary of commercial jet aircraft accidents: Worldwide operations, 1959-1992. Seattle, WA: Boeing Commercial Airplanes.
5. Bransford, J., Sherwood, R., Vye, N., & Rieser J. (1986). Teaching and problem solving: Research foundations. American Psychologist, 41,1078-1089.
6. Caplan, R. A., Posner, K. L., Cheney, F. W. (1991). Effect of outcome on physician judgments of appropriateness of care. Journal of the American Medical Association, 265,1957-1960.
7. Chi, M., Glaser, R., & Farr, M. (1988). The nature of expertise. Hillsdale, NJ: Lawrence Erlbaum Associates.
8. Chopra, V., Bovill, J. G., Spierdijk, J., & Koornneef, F. (1992). Reported significant observations during anaesthesia: A prospective analysis over an 18-month period. British Journal of Anaesthesia, 68,13-17.
9. Cook, R. I., McDonald, J. S., & Smalhout, R. (1989). Human error in the operating room: Identifying cognitive lock up. (Cognitive Systems Engineering Laboratory Tech. Rep. 89-TR-07). Columbus, OH: The Ohio State University.
10. Cook, R. I., Potter, S. S., Woods, D. D., & McDonald, J. S. (1991). Evaluating the human engineering of microprocessor controlled operating room devices. Journal of Clinical Monitoring, 7, 217-226.
11. Cook, R. I., Woods, D. D., & Howie, M. B. (1990). The natural history of introducing new information technology into a dynamic high-risk environment. Proceedings of the 34th Annual Human Factors Society Meeting (pp. 429-433).
12. Cook, R. I., Woods, D. D., & Howie, M. B. (1992). Unintentional delivery of vasoactive drugs with an electromechanical infusion device. Journal of Cardiothoracic and Vascular Anesthesia, 6,1-7.
13. Cook, R. I., Woods, D. D., & McDonald, J. S. (1991). Human performance in anesthesia: A corpus of cases. Report to the Anesthesia Patient Safety Foundation. (Cognitive Systems Engineering Laboratory Technical Report 91-TR-03). Columbus, OH: The Ohio State University.
14. Cooper, J. B., Newbower, R. S., & Kitz, R. J. (1984). An analysis of major errors and equipment failures in anesthesia management: Conditions for prevention and detection. Anesthesiology, 60, 43-42.
15. Cooper, J. B., Newbower, R. S., Long, C. D., & McPeek, B. (1978). Preventable anesthesia mishaps: A study of human factors. Anesthesiology, 49, 399-406.
16. DeKeyser, V., & Woods, D. D. (1990). Fixation errors: Failures to revise situation assessment in dynamic and risky systems. In A. G. Colombo & A. Saiz de Bustamante (Eds.), System reliability assessment (pp. 231-251). Dordercht, The Netherlands: Kluwer.
17. Dorner, D. (1983). Heuristics and cognition in complex systems. In R. Groner, M. Groner, & W. F. Bischof (Eds.), Methods of heuristics (pp. 89-107). Hillsdale, NJ: Lawrence Erlbaum Associates.
18. Eddy, D. M. (1993a). Clinical decision making: Broadening the responsibilities of practitioners [Letters]. Journal of the American Medical Association, 270,708-710.
19. Eddy, D. M. (1993b). Redefining the role of practitioners: The team approach. Journal of the American Medical Association, 269,1849-1855.
20. Edwards, W. (1984). How to make good decisions. Acta Psycholgica, 56, 5-27.
21. Feltovich, P. J., Spiro, R. J., & Coulson, R. (1989). The nature of conceptual understanding in biomedicine: The deep structure of complex ideas and the development of misconceptions. In D. Evans & V. Patel (Eds.), Cognitive science in medicine: Biomedical modeling. Cambridge, MA: MIT Press.
22. Feltovich, P. J., Spiro, R. J., & Coulson, R. (1993). Learning, teaching and testing for complex conceptual understanding. In N. Fredericksen, R. Mislevy, & I. Bejar (Eds.), Test theory for a new generation of tests. Hillsdale, NJ: Lawrence Erlbaum Associates.
23. Fischhoff, B. (1975). Hindsight does not equal foresight: The effect of outcome knowledge on judgment under uncertainty. Journal of Experimental Psychology: Human Perception and Performance, 1, 288-299.
24. Fischhoff, B. (1982). For those condemned to study the past: Heuristics and biases in hindsight. In D. Kahneman, P. Slovic, & A. Tversky (Eds.), Judgment under uncertainty: Heuristics and biases (pp. 335-354). New York: Cambridge University Press.
25. Gaba, D. M., & DeAnda, A. (1989). The response of anesthesia trainees to simulated critical incidents. Anesthesia and Analgesia, 68, 444-451.
26. Gaba, D. M., Maxwell, M., & DeAnda, A. (1987). Anesthetic mishaps: Breaking the chain of accident evolution. Anesthesiology, 66, 670-676.
27. Gentner, D., & Stevens, A. L. (Eds.). (1983). Mental models. Hillsdale, NJ: Lawrence Erlbaum Associates.
28. Gopher, D. (1991). The skill of attention control: Acquisition and execution of attention strategies. In Attention and performance XIV (pp. 299-322) Hillsdale, NJ: Lawrence Erlbaum Associates.
29. Hirschhom, L. (1993). Hierarchy versus bureaucracy: The case of a nuclear reactor. In K. H. Roberts (Ed.), New challenges to understanding organizations, (pp. 137-149). New York: Macmillan.
30. Hollister, W. M. (Ed.). (1986). Improved guidance and control automation at the man-machine interface (AGARD Advisory Report No. 228). AGARD-AR-228.
31. Hollnagel, E. (1993). Reliability of cognition: Foundations of human reliability analysis. London: Academic Press.
32. Johnson, P. E., Moen, J. B., & Thompson, W. B. (1988). Garden path errors in diagnostic reasoning. In L. Bolec & M. J. Coombs (Eds.), Expert system applications (pp. 395-428) New York: Springer-Verlag.
33. Johnson, P. E., & Thompson, W. B. (1981). Strolling down the garden path: Detection and recovery from error in expert problem solving. Paper presented at the Seventh International Joint Conference on Artificial Intelligence. Vancouver, British Columbia.
34. Keats, A. S. (1979). Anesthesia mortality-A new mechanism. Anesthesiology, 68,2-4.
35. Keats, A. S. (1990). Anesthesia mortality in perspective. Anesthesia and Analgesia, 71, 113-119.
36. Kemeny, J. G., et al. (1979) Report of the President’s Commission on the accident at Three Mile Island. New York: Pergamon.
37. Klein, G. A., & Crandall, B. (in press). The role of mental simulation in problem solving and decision making. In J. Flach, P. Hancock, J. Caird, & K. Vicente (Eds.), The ecology of human-machine systems. Hillsdale, NJ: Lawrence Erlbaum Associates.
38. Klein, G. A., Orasanu, J., Calderwood, R., & Zsambok, C. (Eds.). (1993). Decision making in action: Models and methods. Norwood, NJ: Ablex.
39. Layton, C., Smith, P. J., & McCoy, E. (in press). Design of a cooperative problem solving system for enroute flight planning: An empirical evaluation. Human Factors.
40. Leveson, N. G., & Turner, C. S. (1993, July). An investigation of the Therac-25 accidents. IEEE Computer, 18-41.
41. Lipshitz, R. (1989). “Either a medal or a corporal”: The effects of success and failure on the evaluation of decision making and decision makers. Organizational Behavior and Human Decision Processes, 44, 380-395.
42. Lubar, S. (1993, May 21). Review of “The evolution of useful things” by Henry Petroski. Science, 260,1166-1168.
43. Moll van Charante, E., Cook, R. I., Woods, D. D., Yue, Y., & Howie, M. B. (1993). Human-computer interaction in context: Physician interaction with automated intravenous controllers in the heart room. In H. G. Stassen (Ed.), Analysis, design and evaluation of man-machine systems 1992 (pp. 263-274). London: Pergamon.
44. Moshansky, V. P. (1992). Final report of the Commission of Inquiry into the Air Ontario crash at Dryden, Ontario. Ottawa: Minister of Supply and Services, Canada.
45. National Transportation Safety Board (1990). Marine accident report: Grounding of the U.S. Tankship Exxon Valdez on Bligh Reef Prince William Sound, Near Valdez, Alaska, March 24,1989 (Report No. NTSB/MAT-90/04). Springfield, VA: National Technical Information Service.
46. National Transportation Safety Board (1993). US Air Flight 405 LaGuardia Airport March 22,1992 (Report No. AAR-93/02). Springfield, VA: National Technical Information Service.
47. Neisser, U. (1976). Cognition and reality: Principles and implications of cognitive psychology. San Francisco, CA: Freeman.
48. Norman, D. A. (1988). The psychology of everyday things. New York: Basic Books.
49. Norman, D. A. (1992). Turn signals are the facial expressions of automobiles. New York: Addison-Wesley.
50. Orasanu, J. (1990). Shared mental models and crew decision making (Tech. Rep. No. 46). Princeton NJ: Princeton University, Cognitive Science Laboratory.
51. Payne, J. W., Bettman, J. R., & Johnson, E. J. (1988). Adaptive strategy selection in decision making. Journal of Experimental Psychology: Learning, Memory, and Cognition, 14, 534-552.
52. Payne, J. W., Johnson, E. J., Bettman, J. R., & Coupey, E. (1990). Understanding contingent choice: A computer simulation approach. IEEE Transactions on Systems, Man, and Cybernetics, 20, 296-309.
53. Perrow, C. (1984). Normal accidents. Living with high-risk technologies. New York: Basic Books.
54. Perkins, D., & Martin, F. (1986). Fragile knowledge and neglected strategies in novice programmers. In E. Soloway & S. Iyengar (Eds.), Empirical studies of programmers (Vol. 1, pp. 213-279). Norwood, NJ: Ablex.
55. Rasmussen, J. (1986). Information processing and human-machine interaction: An approach to cognitive engineering. New York: North-Holland.
56. Rasmussen, J., Duncan, K., & Leplat, J. (Eds.). (1987). New technology and human error. New York: Wiley.
57. Reason, J. (1990). Human error. Cambridge, England: Cambridge University Press.
58. Roberts, K. H., & Rousseau, D. M. (1989). Research in nearly failure-free, highreliability organizations: Having the bubble. IEEE Transactions in Engineering Management, 36, 132-139.
59. Rochlin, G. I., La Porte, T. R., & Roberts, K. H. (1987, Autumn). The Self-designing high-reliability organization: Aircraft carrier flight operations at sea. Naval War College Review, pp. 76-90.
60. Rochlin, G. I. (1991). Iran Air Flight 655 and the USS Vincennes. In T. LaPorte (Ed.), Social responses to large technical systems (pp. 99-126). Dordrecht, Netherlands: Kluwer Academic.
61. Rogers, W. P., et al. (1986). Report of the Presidential Commission on the Space Shuttle Challenger Accident. Washington, DC: U.S. Government Printing Agency.
62. Roth, E. M., Bennett, K. B., & Woods, D. D. (1987). Human interaction with an “intelligent” machine. International Journal of Man-Machine Studies, 27,479-525.
63. Roth, E. M., Woods, D. D., & Pople, H. E., Jr. (1992). Cognitive simulation as a tool for cognitive task analysis. Ergonomics, 35,1163-1198.
64. Rouse, W. B., & Morris, N. M. (1986). On looking into the black box: Prospects and limits in the search for mental models. Psychological Bulletin, 100, 359-363.
65. Sarter, N. B., & Woods, D. D. (1991). Situation awareness: A critical but ill-defined phenomenon. International Journal of Aviation Psychology, 1, 43-55.
66. Sarter, N. B., & Woods, D. D. (1992). Pilot interaction with cockpit automation I: Operational experiences with the Flight Management System. International Journal of Aviation Psychology, 2, 303-321.
67. Sarter, N. B., & Woods, D. D. (1994). Pilot interaction with cockpit automation II: An experimental study of pilots’ mental model and awareness of the Flight Management System (FMS). International Journal of Aviation Psychology, 4,1-28.
68. Sarter, N. B., & Woods, D. D. (in press). “How in the world did we get into that mode?" Mode error and awareness in supervisory control. Human Factors (Special Issue on Situation Awareness).
69. Suchman, L. (1987). Plans and situated actions. The problem of human machine communication. Cambridge, England: Cambridge University Press.
70. Tenney, Y. J., Jager Adams, M., Pew, R. W., Huggins, A. W. F., & Rogers, W. H. (1992). A principled approach to the measurement of situation awareness in commercial aviation (NASA Contractor Report No. NAS1-18788). Hampton, VA: NASA Langley Research Center.
71. Turner, B. A. (1978). Man-made disasters. London: Wykeham.
72. Tversky, A, & Kahneman, D. (1974). Judgment under uncertainty: Heuristics and biases. Science, 185,1124-1131.
73. U.S. Department of Defense. (1988). Report of the formal investigation into the circumstances surrounding the downing of Iran Air Flight 655 on 3 July 1988. Washington, DC: Author.
74. U.S. House of Representatives Committee on Armed Services. (1987). Report on the staff investigation into the Iraqi attack on the USS Stark. Springfield, VA: National Technical Information Service.
75. Wagenaar, W., & Keren, G. (1986). Does the expert know? The reliability of predictions and confidence ratings of experts. Decision making in complex systems. In E. Hollnagel, G. Mancini, & D. D. Woods (Eds.), Intelligent decision making in process control environments (pp. 87-103). Berlin: Springer-Verlag.
76. Wiener, E. L. (1989). Human factors of advanced technology (‘glass cockpit’) transport aircraft (Tech. Rep. 117528). Moffett Field, CA: NASA Ames Research Center.
77. Wiener, E., Kanki, B., & Helmreich, R. (Eds.). (1993). Cockpit resource management. New York: Academic Press.
78. Woods, D. D. (1988). Coping with complexity: The psychology of human behavior in complex systems. In L. P. Goodstein, H. B. Andersen, & S. E. Olsen, (Eds.), Tasks, errors, and mental models (pp. 128-148). New York: Taylor & Francis.
79. Woods, D. D. (1992). The alarm problem and directed attention. (Cognitive Systems Engineering Laboratory Technical Report 92-TR-01). Columbus, OH: The Ohio State University.
80. Woods, D. D. (1994). Cognitive demands and activities in dynamic fault management: Abductive reasoning and disturbance management. In N. Stanton (Ed.), The human factors of alarm design (pp. 63-92). London: Taylor & Francis.
81. Woods, D. D., O’Brien, J., & Hanes, L. F. (1987). Human factors challenges in process control: The case of nuclear power plants. In G. Salvendy (Ed.), Handbook of human factors/ergonomics. New York: Wiley.
82. Woods, D. D., & Roth, E. M. (1988). Cognitive systems engineering. In M. Helander (Ed.), Handbook of human-computer interaction. New York: Elsevier.
83. Woods, D. D., Johannesen, L., Cook, R. I., & Sarter, N. (1994). Behind human error: Cognitive system, computers and hindsight. Wright-Patterson AFB, OH: Crew Systems Ergonomics Information Analysis Center.
84. Wright, D., Mackenzie, S. J., Buchan, I., Cairns, C. S., & Price, L. E. (1991, September 14). Critical incidents in the intensive therapy unit. Lancet, 338, 676-678.