Patient safety: A human factors approach

Patient Safety: A Human Factors Approach

Volumn , Issue , 2016, Pages 1-262

  Dekker, Sidney ^a  

^a GRIFFITH UNIVERSITY   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 85122715760     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Book

References (465)

1. Aggarwal, R., Grantcharov, T. P., Darzi, A. (2007). Framework for systematic training and assessment of technical skills. Journal of the American College of Surgeons, 204(4), 697-705.
2. Amalberti, R. (2001). The paradoxes of almost totally safe transportation systems. Safety Science, 37(2-3), 109-126.
3. Amalberti, R., Auroy, Y., Berwick, D., Barach, P. (2005). Five system barriers to achieving ultrasafe healthcare. Annals of Internal Medicine, 142(9), 756-764.
4. Arvigo, R., Epstein, N., Yaquinto, M. (1994). Sastun: My apprenticeship with a Maya healer. San Francisco: HarperSanFrancisco.
5. Berlinger, N. (2005). After harm: Medical error and the ethics of forgiveness. Baltimore: Johns Hopkins University Press.
6. Berwick, D. M. (2003). Improvement, trust, and the healthcare workforce. Quality and Safety in Health Care, 12(6), 448-452.
7. Bosk, C. (2003). Forgive and remember: Managing medical failure. Chicago: University of Chicago Press.
8. Bradley Hagerty, B. (Writer). (2010, April 12). Vatican: Bishops must report alleged abuse to police [Radio broadcast]. Washington, DC: NPR.
9. Cacciabue, P. C., Vella, G. (2010). Human factors engineering in healthcare systems: The problem of human error and accident management. International Journal of Medical Informatics, 79(4), 1-17.
10. Campbell, R. D., Bagshaw, M. (1991). Human performance and limitations in aviation. Oxford, UK: Blackwell Science.
11. Carroll, J. D., Messenger, J. C. (2008). Medical simulation: The new tool for training and skill assessment. Perspectives in Biology and Medicine, 51(1), 47-60.
12. Cohen-Charash, Y., Spector, P. E. (2001). The role of justice in organizations: A metaanalysis. Organizational Behavior and Human Decision Processes, 86(2), 278-321.
13. Conley, R. J. (2005). Cherokee medicine man: The life and work of a modern-day healer. Norman: University of Oklahoma Press.
14. Cook, R., Rasmussen, J. (2005). "Going solid": A model of system dynamics and consequences for patient safety. Quality and Safety in Health Care, 14(2), 130-134.
15. Davis-Floyd, R., St. John, G. (1998). From doctor to healer: The transformative journey. New Brunswick, NJ: Rutgers University Press.
16. Dekker, S. W. A. (2003). Failure to adapt or adaptations that fail: Contrasting models on procedures and safety. Applied Ergonomics, 34(3), 233-238.
17. Dekker, S. W. A. (2007). Criminalization of medical error: Who draws the line? ANZ Journal of Surgery, 77(10), 831-837.
18. DeVille, K. (2004). God, science, and history: The cultural origins of medical error. In V.A. Sharpe (Ed.), Accountability: Patient safety and policy reform (pp. 143-158). Washington, DC: Georgetown University Press.
19. Drazen, J. M., Epstein, A. M. (2002). Rethinking medical training: The critical work ahead. New England Journal of Medicine, 347, 1271-1272.
20. Dunn, E., Wolfe, J. (2002). What's not wrong with this prescription? Drug Topics, 146(9), 25-26.
21. Farrington-Darby, T., Wilson, J. R. (2006). The nature of expertise: A review. Applied Ergonomics, 37, 17-32.
22. Federal Aviation Administration. (1996). Federal Aviation Administration Human Factors Team report on the interfaces between flightcrews and modern flight deck systems. Washington, DC: Author.
23. Fonarow, G. C., Abraham, W. T., Albert, N. M., Stough, W. G., Gheorghiade, M., Greenberg, B. H., et al. (2007). Association between performance measures and clinical outcomes for patients hospitalized with heart failure. Journal of the American Medical Association, 297(1), 61-70.
24. Gander, P. H., Merry, A., Millar, M. M., Weller, J. (2000). Hours of work and fatigue-related error: A survey of New Zealand anaesthetists. Anaesthesia and Intensive Care, 28(2), 178-183.
25. Gawande, A. (2002). Complications: A surgeon's notes on an imperfect science. New York: Picador.
26. Gawande, A. (2008). Better: A surgeon's notes on performance. New York: Picador.
27. Gawande, A. (2010). The checklist manifesto: How to get things right. New York: Metropolitan Books.
28. Green, J. (2003). The ultimate challenge for risk technologies: Controlling the accidental. In J. Summerton & B. Berner (Eds.), Constructing risk and safety in technological practice. London: Routledge.
29. Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H., Dellinger, E. P., et al. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491-499.
30. Helmreich, R. L. (2000). On error management: Lessons from aviation. British Medical Journal, 320(7237), 781-785.
31. Hirshhorn, C. (2000). Poor penmanship costs MD $225, 000. CMAJ: Canadian Medical Association Journal, 162(1), 91-92.
32. Hugh, T. B. (2002). New strategies to prevent laparoscopic bile duct injury-Surgeons can learn from pilots. Surgery, 132(5), 826-835.
33. Hugh, T. B., Dekker, S. W. A. (2008). Laparoscopic bile duct injury: Understanding the psychology and heuristics of the error. ANZ Journal of Surgery, 78(12), 1109-1114.
34. Karnieli-Miller, O., Vu, T. R., Holtman, M. C., Clyman, S. G., Inui, T. S. (2010). Medical students' professionalism narratives: A window on the informal and hidden curriculum. Academic Medicine, 85(1), 124-133.
35. Klein, G. A. (1993). A recognition-primed decision (RPD) model of rapid decision making. In G.A. Klein, J. Orasanu, R. Calderwood, & C. E. Zsambok (Eds.), Decision making in action: Models and methods (pp. 138-147). Norwood, NJ: Ablex.
36. Kohn, L. T., Corrigan, J., Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
37. Landrigan, C. P., Rothschild, J. M., Cronin, J. W., Kaushal, R., Burdick, E., Katz, J. T., et al. (2004). Effect of reducing interns' work hours on serious medical errors in intensive care units. New England Journal of Medicine, 351(18), 1838-1848.
38. Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272(23), 1851-1857.
39. McDonald, N., Corrigan, S., Ward, M. (2002). Well-intentioned people in dysfunctional systems. Paper presented at the Fifth Workshop on Human Error, Safety and Systems Development, June 2002, Newcastle, Australia.
40. McDonald, R., Harrison, S. (2004). The micropolitics of clinical guidelines: An empirical study. Policy and Politics, 32(2), 223-229.
41. McDonald, R., Waring, J., Harrison, S. (2006). Rules, safety and the narrativization of identity: A hospital operating theatre case study. Sociology of Health and Illness, 28(2), 178-202.
42. Miles, S. H. (2004). The Hippocratic oath and the ethics of medicine. Oxford, UK: Oxford University Press.
43. Mulcahy, J. B. (2001). Birth and rebirth on an Alaskan island: The life of an Alutiiq healer. Athens: University of Georgia Press.
44. Nemeth, C., Nunnally, M., O'Connor, M., Klock, P. A., Cook, R. (2005). Getting to the point: Developing IT for the sharp end of healthcare. Journal of Biomedical Informatics, 58(1), 18-25.
45. Outram, D. (2005). The enlightenment (2nd ed.). Cambridge, UK: Cambridge University Press.
46. Parker, D., Lawton, R. (2000). Judging the use of clinical protocols by fellow professionals. Social Science & Medicine, 51(5), 669-677.
47. Patterson, E. S., Roth, E. M., Woods, D. D., Chow, R., Gomes, J. O. (2004). Handoff strategies in settings with high consequences for failure: Lessons for health care operations. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care, 16(2), 125-132.
48. Pellegrino, E. D. (2004). Prevention of medical error: Where professional and organizational ethics meet. In V.A. Sharpe (Ed.), Accountability: Patient safety and policy reform (pp. 83-98). Washington, DC: Georgetown University Press.
49. Pellegrino, E. D., Thomasma, D. C., Kissell, J. L. (2000). The health care professional as friend and healer: Building on the work of Edmund D. Pellegrino. Washington, DC: Georgetown University Press.
50. Peterson, G. M., Wu, M. S. H., Bergin, J. K. (1999). Pharmacists' attitudes towards dispensing errors: Their causes and prevention. Journal of Clinical Pharmacy and Therapeutics, 24(1), 57-71.
51. Petroski, H. (1985). To engineer is human: The role of failure in successful design. New York: St. Martin's Press.
52. Pilz, A. (1988). Manang Jabing Anak Incham: A study of an Iban healer/Sarawak. Berlin: Reimer.
53. Pink, D. H. (2005). A whole new mind: Moving from the information age to the conceptual age. New York: Riverhead Books.
54. Pronovost, P. J., Vohr, E. (2010). Safe patients, smart hospitals. New York: Hudson Street Press.
55. Rawls, J. (2003). A theory of justice. Cambridge, MA: Harvard University Press.
56. Rochlin, G. I., LaPorte, T. R., Roberts, K. H. (1987). The self-designing high reliability organization: Aircraft carrier flight operations at sea. Naval War College Review, 76-90.
57. Rogers, A. E., Hwang, W. T., Scott, L. D., Aiken, L. H., Dinges, D. F. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs (Project Hope), 25(4), 202-212.
58. Stewart, P. J., Strathern, A. (2004). Witchcraft, sorcery, rumors, and gossip. Cambridge, UK: Cambridge University Press.
59. Stokes, A., Kite, K. (1994). Flight stress: Stress, fatigue, and performance in aviation. Aldershot, UK: Avebury Aviation.
60. Sugden, C., Aggarwal, R., Darzi, A. (2010). Re: Sleep deprivation, fatigue, medical error and patient safety. American Journal of Surgery, 199(3), 433-434.
61. Tammelin, A., Karell, A.-C., Nilsson, P., Samuelson, A., Tillman, E., Ortqvist, Å. (2007). Sjukvårdskladsel måste forena bra fortroende och god hygien [Doctor's dress must combine confidence with good hygiene]. Lakartidningen, 104(5), 350-351.
62. Vaughan, D. (1996). The Challenger launch decision: Risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press.
63. Velo Giampaolo, P., Minuz, P. (2009). Medication errors: Prescribing faults and prescription errors. British Journal of Clinical Pharmacology, 67(6), 624-628.
64. Vincent, C. (2006). Patient safety. London: Churchill Livingstone.
65. Vogel, L. (2010). Nursing degree "opens doors beyond bags, beds and bedpans." CMAJ: Canadian Medical Association Journal, 182(2), 131-132.
66. Wachter, R. M. (2008). Understanding patient safety. New York: McGraw-Hill.
67. Wagner, L. J., Hallmark, B., Farrar, C., Overstreet, M. (2008). Tennessee Nursing Partnership promotes skill-advancement in simulation technology for nurse educators in Tennessee. Tennessee Nurse/Tennessee Nurses Association, 71(3), 1, 5.
68. Waldrop, W. B., Murray, D. J., Boulet, J. R., Kras, J. F. (2009). Management of anesthesia equipment failure: A simulation-based resident skill assessment. Anesthesia and Analgesia, 109(2), 426-433.
69. Wang, E. E., Quinones, J., Fitch, M. T., Dooley-Hash, S., Griswold-Theodorson, S., Medzon, R., et al. (2008). Developing technical expertise in emergency medicine-The role of simulation in procedural skill acquisition. Academic Emergency Medicine, 15(11), 1046-1057.
70. Wears, R. L., Perry, S. J. (2002). Human factors and ergonomics in the emergency department. Annals of Emergency Medicine, 40(2), 206-212.
71. Welch, D. L. (1998). Human factors usability test and evaluation. Biomedical Instrumentation & Technology/Association for the Advancement of Medical Instrumentation, 32(2), 183-187.
72. Wennberg, J. E., Freeman, J. L., Culp, W. J. (1987). Are hospital services rationed in New Haven or over-utilised in Boston? Lancet, 1(8543), 1185-1189.
73. Wong, D., Nye, K., Hollis, P. (1991). Microbial flora on doctors' white coats. British Medical Journal, 303(6817), 1602-1604.
74. Yentis, S. (2010). Of humans, factors, failings and fixations. Anaesthesia, 65(1), 1-4.
75. Young, D. E., Ingram, G., Swartz, L. (1989). Cry of the eagle: Encounters with a Cree healer. Toronto: University of Toronto Press.
76. American Medical Association. (1998). A tale of two stories: Contrasting views of patient safety. Chicago: Author.
77. Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J., et al. (2004). The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170(11), 965-968.
78. Bartlett, F. (1932). Remembering: An experimental and social study. Cambridge, UK: Cambridge University Press.
79. Berwick, D. M., Calkins, D. R., McCannon, C. J., Hackbarth, A. D. (2006). The 100, 000 lives campaign: Setting a goal and a deadline for improving health care quality. Journal of the American Medical Association, 295(3), 324-327.
80. Berwick, D. M., Hackbarth, A. D., McCannon, C. J. (2006). IHI replies to "The 100, 000 Lives Campaign: A scientific and policy review." Joint Commission Journal on Quality and Patient Safety/Joint Commission Resources, 32(11), 628-630; discussion 631-623.
81. 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).
82. Chapanis, A. (2004). Foreword. In M.S. Bogner (Ed.), Misadventures in health care: Inside stories (pp. xi-xiv). Mahwah, NJ: Erlbaum.
83. Cook, R. I. (1998). Two years before the mast: Learning how to learn about patient safety. Paper presented at Enhancing Patient Safety and Reducing Errors in Health Care: A Multidisciplinary Leadership Conference, November 1998, Rancho Mirage, CA.
84. Cook, R. I., Render, M., Woods, D. D. (2000). Gaps in the continuity of care and progress on patient safety. British Medical Journal, 320(7237), 791-795.
85. Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A., Schug, S. (2002). Adverse events in New Zealand public hospitals I: Occurrence and impact. The New Zealand Medical Journal, 115(1167), U271.
86. Dekker, S. W. A. (2005). Ten questions about human error: A new view of human factors and system safety. Mahwah, NJ: Erlbaum.
87. Dekker, S. W. A. (2006). The field guide to understanding human error. Aldershot, UK: Ashgate.
88. Dekker, S. W. A., Hugh, T. B. (2010). Balancing "no blame" with accountability in patient safety. New England Journal of Medicine, 362(3), 275.
89. Department of Health. (2000). An organization with a memory: The report of an expert group on learning from adverse events. London: Her Majesty's Stationery Office.
90. Fischhoff, B. (1975). Hindsight ≠ foresight: The effect of outcome knowledge on judgment under uncertainty. Journal of Experimental Psychology: Human Perception and Performance, 1(3), 288-299.
91. Gawande, A. (2002). Complications: A surgeon's notes on an imperfect science. New York: Picado.
92. Gawande, A. (2010). The checklist manifesto: How to get things right. New York: Metropolitan Books.
93. Gawande, A., Thomas, E. J., Zinner, M. J., Brennan, T. A. (1999). The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery, 126(1), 66-75.
94. Golden-Biddle, K., Locke, K. (1993). Appealing work: An investigation of how ethnographic texts convince. Organization Science, 4(4), 595-616.
95. Hayward, R. A., Hofer, T. P. (2001). Estimating hospital deaths due to medical errors: Preventability is in the eye of the reviewer. Journal of the American Medical Association, 286(4), 415-420.
96. Helmreich, R. L. (2000). On error management: Lessons from aviation. British Medical Journal, 320(7237), 781-785.
97. Hollnagel, E. (2009). The ETTOprinciple: Efficiency-thoroughness trade-off. Why things that go right sometimes go wrong. Aldershot, UK: Ashgate.
98. Hollnagel, E., Pedersen, O. M., Rasmussen, J. (1981). Notes on human performance analysis. Roskilde, Denmark: Risø National Laboratory.
99. Hugh, T. B., Dekker, S. W. A. (2009). Hindsight bias and outcome bias in the social construction of medical negligence: A review. Journal of Law and Medicine, 16(5), 846-857.
100. Klein, G. A. (1993). Decision making in action: Models and methods. Norwood, NJ: Ablex.
101. Klein, G. A. (1998). Sources of power: How people make decisions. Cambridge, MA: MIT Press.
102. Kohn, L. T., Corrigan, J., Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
103. Leape, L. L., Brennan, T. A., Laird, N., Lawthers, A. G., Localio, A. R., Barnes, B. A., 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(6), 377-384.
104. Mach, E. (1976). Knowledge and error: Sketches on the psychology of enquiry. Dordrecht, Netherlands: Reidel.
105. Morreim, E. H. (2004). Medical errors: Pinning the blame versus blaming the system. In V.A. Sharpe (Ed.), Accountability: Patient safety and policy reform (pp. 213-232). Washington, DC: Georgetown University Press.
106. National Safety Council. (2004). Injury facts 2004 edition. Itasca, IL: National Safety Council.
107. Neale, G., Woloshynowych, M., Vincent, C. (2001). Exploring the causes of adverse events in NHS hospital practice. Journal of the Royal Society of Medicine, 94(7), 322-330.
108. Neisser, U. (1976). Cognition and reality: Principles and implications of cognitive psychology. San Francisco: Freeman.
109. Newell, A., Simon, H. A. (1972). Human problem solving. Englewood Cliffs, NJ: Prentice-Hall.
110. Paget, M. A. (2004). The unity of mistakes: A phenomenological interpretation of medical work. Philadelphia: Temple University Press.
111. Pellegrino, E. D. (2004). Prevention of medical error: Where professional and organizational ethics meet. In V.A. Sharpe (Ed.), Accountability: Patient safety and policy reform (pp. 83-98). Washington, DC: Georgetown University Press.
112. Perrow, C. (1984). Normal accidents: Living with high-risk technologies. New York: Basic Books.
113. Rasmussen, J. (1985). Trends in human reliability analysis. Ergonomics, 28(8), 1185-1195.
114. Rasmussen, J., Batstone, R. (1989). Why do complex organizational systems fail? Washington, DC: World Bank.
115. Rasmussen, J., Duncan, K., Leplat, J. (1987). New technology and human error. Chichester, UK; Wiley.
116. Reason, J. T. (1990). Human error. New York: Cambridge University Press.
117. Reason, J. T. (1997). Managing the risks of organizational accidents. Aldershot, UK: Ashgate.
118. Reason, J. T. (2000). Grace under fire: Compensating for adverse events in cardiothoracic surgery. Paper presented at the Fifth Conference on Naturalistic Decision Making May 2000, Stockholm, Sweden.
119. Roscoe, S. N. (1997). The adolescence of engineering psychology. In S.M. Casey (Ed.), Volume 1, Human factors history monograph series. Santa Monica, CA: Human Factors and Ergonomics Society.
120. Shappell, S. A., Wiegmann, D. A. (2001). Applying reason: The human factors analysis and classification system. Human Factors and Aerospace Safety, 1, 59-86.
121. Snook, S. A. (2000). Friendly fire: The accidental shootdown of U.S. Black Hawks over northern Iraq. Princeton, NJ: Princeton University Press.
122. Starbuck, W. H., Milliken, F. J. (1988). Challenger: Fine-tuning the odds until something breaks. The Journal of Management Studies, 25(4), 319-341.
123. Thomas, E. J., Studdert, D. M., Burstin, H. R., Orav, E. J., Zeena, T., Williams, E. J., et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care, 38(3), 261-271.
124. Thomas, E. J., Studdert, D. M., Runciman, W. B., Webb, R. K., Sexton, E. J., Wilson, R. M., et al. (2000). A comparison of iatrogenic injury studies in Australia and the USA. I: Context, methods, casemix, population, patient and hospital characteristics. International Journal for Quality in Health Care, 12(5), 371-378.
125. Tuchman, B. W. (1981). Practicing history: Selected essays. New York: Knopf.
126. Turner, B. A. (1978). Man-made disasters. London: Wykeham.
127. Vicente, K. J. (1999). Cognitive work analysis: Toward safe, productive, and healthy computer-based work. Mahwah, NJ: Erlbaum.
128. Vincent, C., Neale, G., Woloshynowych, M. (2001). Adverse events in British hospitals: Preliminary retrospective record review. British Medical Journal, 322(7285), 517-519.
129. Wachter, R. M., Pronovost, P. J. (2006). The 100, 000 Lives Campaign: A scientific and policy review. Joint Commission Journal on Quality and Patient Safety/Joint Commission Resources, 32(11), 621-627.
130. Wachter, R. M., Pronovost, P. J. (2009). Balancing "no blame" with accountability in patient safety. New England Journal of Medicine, 361, 1401-1406.
131. Weick, K. E. (1995). Sensemaking in organizations. Thousand Oaks, CA: Sage.
132. World Health Organization. (2005). World alliance for patient safety: Forward program 2005. Geneva: World Health Organization.
133. Woods, D. D., Dekker, S. W. A., Cook, R. I., Johannesen, L. J., Sarter, N. B. (2010). Behind human error. Aldershot, UK: Ashgate.
134. Woods, D. D., Patterson, E. S., Cook, R. I. (2005). Behind human error: Taming complexity to improve patient safety. Columbus, OH: Institute for Ergonomics, The Ohio State University.
135. Xiao, Y., Hunter, W. A., Mackenzie, C. F., Jeffries, N. J., Horst, R. L., Group, L. (1996). Task complexity in emergency medical care and its implications for team coordination. Human Factors, 38, 636-645.
136. Cook, R. I., McDonald, J. S., Smalhout, R. (1989). Human error in the operating room: Identifying cognitive lock up. Columbus, OH: The Ohio State University.
137. De Keyser, 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). Dordrecht, Netherlands: Kluwer Academic.
138. Dekker, S. W. A. (2006). The field guide to understanding human error. Aldershot, UK: Ashgate.
139. Dekker, S. W. A., Hugh, T. B. (2010). Balancing "no blame" with accountability in patient safety. New England Journal of Medicine, 362(3), 275.
140. Dismukes, R. K. (2006). Concurrent task management and prospective memory: Pilot error as a model for the vulnerability of experts. Paper presented at the Human Factors and Ergonomics Society 50th Annual Meeting, October 2006, San Francisco.
141. 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.
142. 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: Erlbaum.
143. Hancock, P. A., Weaver, J. L. (2005). On time distortion under stress. Theoretical Issues in Ergonomics Science, 6(2), 193-211.
144. Hugh, T. B., Dekker, S. W. A. (2008). Laparoscopic bile duct injury: Understanding the psychology and heuristics of the error. ANZ Journal of Surgery, 78(12), 1109-1114.
145. Johnson, P. E., Duran, A. S., Hassebrock, F., Moller, J., Prietula, M., Feltovich, P. J., et al. (1981). Expertise and error in diagnostic reasoning. Cognitive Science, 5(3), 235-283.
146. Loukopoulos, L. D., Dismukes, K., Barshi, I. (2009). The multitasking myth: Handling complexity in real-world operations. Farnham, UK: Ashgate.
147. Mintzberg, H. (1979). The structuring of organizations: A synthesis of the research. Englewood Cliffs, NJ: Prentice-Hall.
148. Montgomery, K. (2006). How doctors think: Clinical judgment and the practice of medicine. Oxford, UK: Oxford University Press.
149. Neisser, U. (1976). Cognition and reality: Principles and implications of cognitive psychology. San Francisco: Freeman.
150. Orasanu, J. M., Martin, L. (1998). Errors in aviation decision making: A factor in accidents and incidents. In Human Error, Safety and Systems Development Workshop (HESSD) 1998. Retrieved February 2008, from http://www.dcs.gla.ac.uk/~johnson/papers/ seattle_hessd/judithlynnep
151. Sarter, N. B., Woods, D. D. (1994). Pilot interaction with cockpit automation II: An experimental study of pilots' model and awareness of the flight management system. International Journal of Aviation Psychology, 4(1), 1-29.
152. Weick, K. E. (1995). Sensemaking in organizations. Thousand Oaks, CA: Sage.
153. Weick, K. E., Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed.). San Francisco: Jossey-Bass.
154. 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. New York: Taylor and Francis.
155. Woods, D. D., Dekker, S. W. A., Cook, R. I., Johannesen, L. J., Sarter, N. B. (2010). Behind human error. Aldershot, UK: Ashgate.
156. Woods, D. D., Patterson, E. S. (2000). How unexpected events produce an escalation of cognitive and coordinate demands. In P.A. Hancock & P. Desmond (Eds.), Stress, workload and fatigue. Mahwah, NJ: Erlbaum.
157. Xiao, Y., Milgram, P., Doyle, J. (1997). Capturing and modeling planning expertise in anesthesiology: Results of a field study. In C. Zsambok & G. Klein (Eds.), Naturalistic decision making (pp. 197-205). Mahwah, NJ: Erlbaum.
158. Bainbridge, L. (1987). Ironies of automation. In J. Rasmussen, K. Duncan, & J. Leplat (Eds.), New technology and human error (pp. 271-283). Chichester, UK: Wiley.
159. Billings, C. E. (1997). Aviation automation: The search for a human-centered approach. Mahwah, NJ: Erlbaum.
160. Cook, R. I., Nemeth, C., Dekker, S. W. A. (2008). What went wrong at the Beatson Oncology Centre? In E. Hollnagel, C. P. Nemeth, & S. W. A. Dekker (Eds.), Resilience engineering perspectives: Remaining sensitive to the possibility of failure. Aldershot, UK: Ashgate.
161. 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(3), 217-226.
162. Cordesman, A. H., Wagner, A. R. (1996). The lessons of modern war, Vol. 4: The Gulf War. Boulder, CO: Westview Press.
163. Dekker, S. W. A., Mooij, M., Woods, D. D. (2002). Envisioned practice, enhanced performance: The riddle of future (ATM) systems. International Journal of Applied Aviation Studies, 2(1), 23-32.
164. Dekker, S. W. A., Woods, D. D. (1999). To intervene or not to intervene: The dilemma of management by exception. Cognition, Technology and Work, 1(2), 86-96.
165. Flach, J. M. (2000). Discovering situated meaning: An ecological approach to task analysis. In J.M. Schraagen, S. F. Chipman, & V. L. Shalin (Eds.), Cognitive task analysis (pp. 87-100). Mahwah, NJ: Erlbaum.
166. Hartzband, P., Groopman, J. (2008). Off the record-Avoiding the pitfalls of going electronic. New England Journal of Medicine, 558(16), 1656-1658.
167. Montgomery, K. (2006). How doctors think: Clinical judgment and the practice of medicine. Oxford, UK: Oxford University Press.
168. Moray, N. (1984). Attention to dynamic visual displays in man-machine systems. In R. Parasuraman & D. R. Davies (Eds.), Varieties of attention. New York: Academic Press.
169. Nemeth, C., Nunnally, M., O'Connor, M., Klock, P. A., Cook, R. (2005). Getting to the point: Developing IT for the sharp end of healthcare. Journal of Biomedical Informatics, 58(1), 18-25.
170. 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, 527(1241), 585-593.
171. Perrow, C. (1984). Normal accidents: Living with high-risk technologies. New York: Basic Books.
172. Perry, S. J., Wears, R. L., Cook, R. I. (2005). The role of automation in complex system failures. Journal of Patient Safety, 1(1), 56-61.
173. Phillips, T. (2010). General hospital and personal use devices panel meeting. Washington, DC: Food and Drug Administration.
174. Sanders, M. S., McCormick, E. J. (1993). Human factors in engineering and design (7th ed.). New York: McGraw-Hill.
175. Sarter, N. B., Woods, D. D., Billings, C. (1997). Automation surprises. In G. Salvendy (Ed.), Handbook of human factors/ergonomics. New York: Wiley.
176. Snook, S. A. (2000). Friendly fire: The accidental shootdown of U.S. Black Hawks over northern Iraq. Princeton, NJ: Princeton University Press.
177. Wears, R. L., Perry, S. J. (2002). Human factors and ergonomics in the emergency department. Annals of Emergency Medicine, 40(2), 206-212.
178. Wiener, E. L. (1988). Cockpit automation. In E.L. Wiener & D. C. Nagel (Eds.), Human factors in aviation (pp. 433-462). San Diego, CA: Academic Press.
179. Wiener, E. L. (1989). Human factors of advanced technology ("glass cockpit") transport aircraft (No. 117528). Moffett Field, CA: NASA Ames Research Center.
180. Woods, D. D. (1995). Towards a theoretical base for representation design in the computer medium: Ecological perception and aiding human cognition. In J. Flach, P. Hancock, J. Caird, & K. Vicente (Eds.), An ecological approach to human-machine systems I: A global perspective. Hillsdale, NJ: Erlbaum.
181. Woods, D. D., Dekker, S. W. A. (2000). Anticipating the effects of technological change: A new era of dynamics for human factors. Theoretical Issues in Ergnomics Science, 1(3), 272-282.
182. Woods, D. D., Dekker, S. W. A., Cook, R. I., Johannesen, L. J., Sarter, N. B. (2010). Behind human error. Aldershot, UK: Ashgate.
183. Woods, D. D., Patterson, E. S. (2000). How unexpected events produce an escalation of cognitive and coordinate demands. In P.A. Hancock & P. Desmond (Eds.), Stress, workload and fatigue. Mahwah, NJ: Erlbaum.
184. Woods, D. D., Patterson, E. S., Roth, E. M. (2002). Can we ever escape from data overload? A cognitive systems diagnosis. Cognition, Technology and Work, 4(1), 22-36.
185. Xiao, Y., Milgram, P., Doyle, J. (1997). Capturing and modeling planning expertise in anesthesiology: Results of a field study. In C. Zsambok & G. Klein (Eds.), Naturalistic decision making (pp. 197-205). Mahwah, NJ: Erlbaum.
186. Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., 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.
187. Berwick, D. M., Calkins, D. R., McCannon, C. J., Hackbarth, A. D. (2006). The 100, 000 lives campaign: Setting a goal and a deadline for improving health care quality. Journal of the American Medical Association, 295(3), 324-327.
188. Clarke, L., Perrow, C. (1996). Prosaic organizational failure. American Behavioral Scientist, 39(8), 1040-1057.
189. Cohen, M. D., March, J. G., Olsen, J. P. (1988). A garbage can model of organizational choice. In J.G. March (Ed.), Decisions and organizations (pp. 294-334). Oxford, UK: Blackwell.
190. Columbia Accident Investigation Board. (2003). Report volume 1, August 2003. Washington, DC: Author.
191. Cook, R., Rasmussen, J. (2005). "Going solid": A model of system dynamics and consequences for patient safety. Quality and Safety in Health Care, 14(2), 130-134.
192. Cook, R. I., Render, M., Woods, D. D. (2000). Gaps in the continuity of care and progress on patient safety. British Medical Journal, 320(7237), 791-795.
193. Dekker, S. W. A. (2003). Failure to adapt or adaptations that fail: Contrasting models on procedures and safety. Applied Ergonomics, 34(3), 233-238.
194. Dekker, S. W. A. (2007). Discontinuity and disaster: Gaps and the negotiation of culpability in medication delivery. Journal of Law, Medicine and Ethics, 35(3), 463-470.
195. Feynman, R. P. (1988). "What do you care what other people think?": Further adventures of a curious character. New York: Norton.
196. Hollnagel, E. (2004). Barriers and accident prevention. Aldershot, UK: Ashgate.
197. Hugh, T. B., Dekker, S. W. A. (2008). Laparoscopic bile duct injury: Understanding the psychology and heuristics of the error. ANZ Journal of Surgery, 78(12), 1109-1114.
198. Jensen, C. (1996). No downlink: A dramatic narrative about the Challenger accident and our time. New York: Farrar, Straus, Giroux.
199. Langewiesche, W. (1998). Inside the sky: A meditation on flight. New York: Pantheon Books.
200. LaPorte, T. R., Consolini, P., M. (1991). Working in practice but not in theory: Theoretical challenges of "high-reliability organizations." Journal of Public Administration Research and Theory: J-PART, 1(1), 19-48.
201. Leveson, N., Daouk, M., Dulac, N., Marais, K. (2003). Applying STAMP in accident analysis. Cambridge, MA: Engineering Systems Division, Massachusetts Institute of Technology.
202. Leveson, N. G., Turner, C. S. (1993). An investigation of the Therac-25 accidents. Computer, 26(7), 18-41.
203. Marone, J. G., Woodhouse, E. J. (1986). Averting catastrophe: Strategies for regulating risky technologies. Berkeley: University of California Press.
204. Morath, J. M., Turnbull, J. E. (2005). To do no harm: Ensuring patient safety in health care organizations. San Francisco: Jossey-Bass.
205. Ong, M., Bostrom, A., Vidyarthi, A., McCulloch, C., Auerbach, A. (2007). House staff team workload and organization effects on patient outcomes in an academic general internal medicine inpatient service. Archives of Internal Medicine, 167, 47-52.
206. Paget, M. A. (2004). The unity of mistakes: A phenomenological interpretation of medical work. Philadelphia: Temple University Press.
207. Perrow, C. (1984). Normal accidents: Living with high-risk technologies. New York: Basic Books.
208. Pidgeon, N., O'Leary, M. (2000). Man-made disasters: Why technology and organizations (sometimes) fail. Safety Science, 34(1-3), 15-30.
209. Pronovost, P. J., Vohr, E. (2010). Safe patients, smart hospitals. New York: Hudson Street Press.
210. Rasmussen, J. (1997). Risk management in a dynamic society: A modelling problem. Safety Science, 27(2-3), 183-213.
211. Reason, J. T. (1990). Human error. New York: Cambridge University Press.
212. Rochlin, G. I. (1999). Safe operation as a social construct. Ergonomics, 42(11), 1549-1560.
213. Rochlin, G. I., LaPorte, T. R., Roberts, K. H. (1987). The self-designing high reliability organization: Aircraft carrier flight operations at sea. Naval War College Review, 76-90.
214. Rosness, R., Guttormsen, G., Steiro, T., Tinmannsvik, R. K., Herrera, I. A. (2004). Organisational accidents and resilient organizations: Five perspectives (Revision 1) (No. STF38 A 04403). Trondheim, Norway: SINTEF Industrial Management.
215. Sagan, S. D. (1993). The limits of safety: Organizations, accidents, and nuclear weapons. Princeton, NJ: Princeton University Press.
216. Snook, S. A. (2000). Friendly fire: The accidental shootdown of U.S. Black Hawks over northern Iraq. Princeton, NJ: Princeton University Press.
217. Starbuck, W. H., Milliken, F. J. (1988). Challenger: Fine-tuning the odds until something breaks. The Journal of Management Studies, 25(4), 319-341.
218. Turner, B. A. (1978). Man-made disasters. London: Wykeham.
219. Vaughan, D. (1996). The Challenger launch decision: Risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press.
220. Vaughan, D. (1999). The dark side of organizations: Mistake, misconduct, and disaster. Annual Review of Sociology, 25, 271-305.
221. Vaughan, D. (2005). System effects: On slippery slopes, repeating negative patterns, and learning from mistake? In W.H. Starbuck & M. Farjoun (Eds.), Organization at the limit: Lessons from the Columbia disaster (pp. 41-59). Malden, MA: Blackwell.
222. Wachter, R. M. (2008). Understanding patient safety. New York: McGraw-Hill.
223. Weick, K. E. (1990). The vulnerable system: An analysis of the Tenerife air disaster. Journal of Management, 16(3), 571-594.
224. Weick, K. E. (1993). The collapse of sensemaking in organizations: The Mann Gulch disaster. Administrative Science Quarterly, 38(4), 628-652.
225. Weingart, P. (1991). Large technical systems, real life experiments, and the legitimation trap of technology assessment: The contribution of science and technology to constituting risk perception. In T.R. LaPorte (Ed.), Social responses to large technical systems: Control or anticipation (pp. 8-9). Amsterdam: Kluwer.
226. Westrum, R. (1993). Cultures with requisite imagination. In J.A. Wise, V. D. Hopkin, & P. Stager (Eds.), Verification and validation of complex systems: Human factors issues. Berlin: Springer-Verlag.
227. Wildavsky, A. B. (1988). Searching for safety. New Brunswick, NJ: Transaction Books.
228. Woods, D. D., Dekker, S. W. A., Cook, R. I., Johannesen, L. J., Sarter, N. B. (2010). Behind human error. Aldershot, UK: Ashgate.
229. Woods, D. D., Hollnagel, E. (2006). Joint cognitive systems: Patterns in cognitive systems engineering. Boca Raton, FL: CRC/Taylor & Francis.
230. Woods, D. D., Patterson, E. S., Cook, R. I. (2005). Behind human error: Taming complexity to improve patient safety. Columbus, OH: Institute for Ergonomics, The Ohio State University.
231. Wynne, B. (1988). Unruly technology: Practical rules, impractical discourses and public understanding. Social Studies of Science, 18(1), 147-167.
232. American Medical Association. (1998). A tale of two stories: Contrasting views of patient safety. Chicago: Author.
233. Angell, I. O., Straub, B. (1999). Rain-dancing with pseudo-science. Cognition, Technology and Work, 1, 179-196.
234. Argyris, C., Schön, D. (1978). Organizational learning: A theory of action perspective. Reading, MA: Addison-Wesley.
235. Barach, P., Small, S. D. (2000). Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. British Medical Journal, 320(7237), 759-763.
236. Billings, C. E. (1996). Situation awareness measurement and analysis: A commentary. In D.J. Garland & M. R. Endsley (Eds.), Experimental analysis and measurement of situation awareness (pp. 1-5). Daytona Beach, FL: Embry-Riddle Aeronautical University Press.
237. Billings, C. E. (1997). Aviation automation: The search for a human-centered approach. Mahwah, NJ: Erlbaum.
238. Columbia Accident Investigation Board. (2003). Report Volume 1, August 2003. Washington, DC: Author.
239. Cook, R. I., Nemeth, C. P. (2010). ''Those found responsible have been sacked'': Some observations on the usefulness of error. Cognition, Technology and Work, 12, 87-93.
240. Cook, R. I., Nemeth, C., Dekker, S. W. A. (2008). What went wrong at the Beatson Oncology Centre? In E. Hollnagel, C. P. Nemeth, & S. W. A. Dekker (Eds.), Resilience engineering perspectives: Remaining sensitive to the possibility of failure. Aldershot, UK: Ashgate.
241. Degani, A., Heymann, M., Shafto, M. (1999). Formal aspects of procedures: The problem of sequential correctness. Paper presented at the 43rd annual meeting of the Human Factors and Ergonomics Society, September 1999 Houston, TX.
242. Degani, A., Wiener, E. L. (1990). Human factors of flight-deck checklists: The normal checklist. (Contract Report NCC2-377) Moffett Field, CA: NASA Ames Research Center.
243. De Keyser, 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). Dordrecht, the Netherlands: Kluwer Academic.
244. Dekker, S. W. A. (2002). Reconstructing the human contribution to accidents: The new view of human error and performance. Journal of Safety Research, 33(3), 371-385.
245. Dekker, S. W. A. (2007). Discontinuity and disaster: Gaps and the negotiation of culpability in medication delivery. Journal of Law, Medicine and Ethics, 35(3), 463-470.
246. Dekker, S. W. A., Hugh, T. B. (2010). Balancing "no blame" with accountability in patient safety. New England Journal of Medicine, 362(3), 275.
247. Dekker, S. W. A., Laursen, T. (2007). From punitive action to confidential reporting: A longitudinal study of organizational learning. Patient Safety and Quality Healthcare, 5, 50-56.
248. Feynman, R. P. (1988). "What do you care what other people think?": Further adventures of a curious character. New York: Norton.
249. Fischer, U., Orasanu, J. M., Montvalo, M. (1993). Efficient decision strategies on the flight deck. Paper presented at the Seventh International Symposium on Aviation Psychology, April 1993 Columbus, OH.
250. Fischhoff, B. (1975). Hindsight ≠ foresight: The effect of outcome knowledge on judgment under uncertainty. Journal of Experimental Psychology: Human Perception and Performance, 1(3), 288-299.
251. Gawande, A. (2010). The checklist manifesto: How to get things right. New York: Metropolitan Books.
252. Gergen, K. J. (1999). An invitation to social construction. Thousand Oaks, CA: Sage.
253. Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. H., Dellinger, E. P., et al. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491-499.
254. Hollnagel, E. (2009). The ETTOprinciple: Efficiency-thoroughness trade-off. Why things that go right sometimes go wrong. Aldershot, UK: Ashgate.
255. Hollnagel, E., Woods, D. D., Leveson, N. G. (2006). Resilience engineering: Concepts and precepts. Aldershot, UK: Ashgate.
256. Hooper, G., Darley, D., Patton, D., Perry, A., Skelton, R. (2006). Time-out, avoiding wrong site surgery: An audit of 6 months experience. Journal of Bone and Joint Surgery, 88(Suppl. 2), 311.
257. International Civil Aviation Organization. (1998). Human factors training manual (No. 9683- AN/950). Montreal: Author.
258. Janis, I. L. (1982). Groupthink (2nd ed.). Chicago: Houghton Mifflin.
259. Jensen, C. (1996). No downlink: A dramatic narrative about the Challenger accident and our time. New York: Farrar, Straus, Giroux.
260. Kohn, L. T., Corrigan, J., Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
261. Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272(23), 1851-1857.
262. Loukopoulos, L. D., Dismukes, K., Barshi, I. (2009). The multitasking myth: Handling complexity in real-world operations. Farnham, UK: Ashgate.
263. Mahler, J. G. (2009). Organizational learning at NASA: The Challenger and Columbia accidents. Washington, DC: Georgetown University Press.
264. Nevile, M. (2002). Coordinating talk and non-talk activity in the airline cockpit. Australian Review of Applied Linguistics, 25(11), 131-146.
265. Nevile, M. (2004). Beyond the black box: Talk-in-interaction in the airline cockpit. Aldershot, UK: Ashgate.
266. Nevile, M., Walker, M. B. (2005). A context for error: Using conversation analysis to represent and analyse recorded voice data. Canberra: Australian Transport Safety Bureau.
267. Orasanu, J. M. (1990). Shared mental models and crew decision making (No. CSL Report 46). Princeton, NJ: Cognitive Science Laboratory, Princeton University.
268. Orasanu, J. M., Martin, L. (1998). Errors in aviation decision making: A factor in accidents and incidents. In Human Error, Safety and Systems Development Workshop (HESSD) 1998. Retrieved February 2008, from http://www.dcs.gla.ac.uk/~johnson/papers/ seattle_hessd/judithlynnep
269. Page, S. E. (2007). Making the difference: Applying a logic of diversity. Academy of Management Perspectives, 11, 6-20.
270. Practicing Perfection Institute. (2007). The pre-job brief. Swanzey, NH: Author.
271. Predmore, S. C. (1991). Microcoding of communications in accident investigation: Crew coordination in United 811 and United 232. Paper presented at the Sixth International Symposium of Aviation Psychology, Columbus, OH.
272. Pronovost, P. J., Vohr, E. (2010). Safe patients, smart hospitals. New York: Hudson Street Press.
273. Reason, J. T. (1990). Human error. New York: Cambridge University Press.
274. Reason, J. T. (1997). Managing the risks of organizational accidents. Aldershot, UK: Ashgate.
275. Rochlin, G. I. (1999). Safe operation as a social construct. Ergonomics, 42(11), 1549-1560.
276. Rochlin, G. I., LaPorte, T. R., Roberts, K. H. (1987). The self-designing high reliability organization: Aircraft carrier flight operations at sea. Naval War College Review, 76-90.
277. Rogers, W. P., et al. (1986). Report of the Presidential Commission on the Space Shuttle Challenger Accident. Washington, DC.
278. Sagan, S. D. (1993). The limits of safety: Organizations, accidents, and nuclear weapons. Princeton, NJ: Princeton University Press.
279. Salas, E., Wilson, K. A., Burke, C. S. (2006). Does crew resource management training work? An update, an extension, and some critical needs. Human Factors, 48(2), 392-413.
280. Schein, E. (1992). Organizational culture and leadership (2nd ed.). San Francisco: Jossey-Bass.
281. Starbuck, W. H., Farjoun, M. (2005). Organization at the limit: Lessons from the Columbia disaster. Malden, MA: Blackwell.
282. Svenmarck, P., Dekker, S. W. A. (2003). Decision support in fighter aircraft: From expert systems to cognitive modelling. Behaviour and Information Technology, 22(3), 175-185.
283. Vaughan, D. (1996). The Challenger launch decision: Risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press.
284. Vaughan, D. (1999). The dark side of organizations: Mistake, misconduct, and disaster. Annual Review of Sociology, 25, 271-305.
285. Wachter, R. M. (2008). Understanding patient safety. New York: McGraw-Hill.
286. Weick, K. E. (1988). Enacted sense-making in crisis situations. Journal of Management Studies, 25, 305-317.
287. Weick, K. E. (1990). The vulnerable system: An analysis of the Tenerife air disaster. Journal of Management, 16(3), 571-594.
288. Wildavsky, A. B. (1988). Searching for safety. New Brunswick, NJ: Transaction Books.
289. Woods, D. D. (1993). Process-tracing methods for the study of cognition outside of the experimental laboratory. In G.A. Klein, J. M. Orasanu, R. Calderwood, & C. E. Zsambok (Eds.), Decision making in action: Models and methods (pp. 228-251). Norwood, NJ: Ablex.
290. Woods, D. D. (2006). How to design a safety organization: Test case for resilience engineering. In E. Hollnagel, D. D. Woods, & N. G. Leveson (Eds.), Resilience engineering: Concepts and precepts (pp. 296-306). Aldershot, UK: Ashgate.
291. Woods, D. D., Dekker, S. W. A., Cook, R. I., Johannesen, L. J., Sarter, N. B. (2010). Behind human error. Aldershot, UK: Ashgate.
292. Xiao, Y., Vicente, K. J. (2000). A framework for epistemological analysis in empirical (laboratory and field) studies. Human Factors, 42(1), 87-102.
293. Zaccaria, A. (2002, November 7). Malpractice insurance crisis in New Jersey. Atlantic Highlands Herald. http://www.ahherald.com/physicians_forum/2002/pf021107_malpractice.htm
294. Alicke, M. D. (2000). Culpable control and the psychology of blame. Psychological Bulletin, 126(4), 556-556.
295. Amalberti, R. (2001). The paradoxes of almost totally safe transportation systems. Safety Science, 37(2-3), 109-126.
296. Anderson, R. E. (2005). Medical malpractice: A physician's sourcebook. New York: Humana Press.
297. Beaver, E. (2002). Witchcraft, female aggression, and power in the Early Modern community. Journal of Social History, 35(4), 955-988.
298. Beck, U. (1992). Risk society: Towards a new modernity. London: Sage.
299. Becker, H. S. (1963). Outsiders: Studies in the sociology of deviance. London: Free Press of Glencoe.
300. Ben-Yehuda, N. (1983). The European witch craze: Still a sociologist's perspective. American Journal of Sociology, 88(6), 1275-1279.
301. Berlinger, N. (2005). After harm: Medical error and the ethics of forgiveness. Baltimore: Johns Hopkins University Press.
302. Bittle, S., Snider, L. (2006). From manslaughter to preventable accident: Shaping corporate criminal liability. Law and Policy, 28(4).
303. Bjarup, J. (2005). The philosophy of Scandinavian legal realism. Ratio Juris, 18(1), 1-15.
304. Blackwelder, S. P. (1996). Fearless wives and frightened shrews: The construction of the witch in Early Modern Germany. Contemporary Sociology, 25(4), 525-563.
305. Bosk, C. (2003). Forgive and remember: Managing medical failure. Chicago: University of Chicago Press.
306. Brous, E. (2008). Criminalization of unintentional error: Implications for TAANA. Journal of Nursing Law, 12(1), 5-12.
307. Chapman, C. (2009, April 18). A criminal mistake? Chemist and Druggist, 8.
308. Christensen, J. F., Levinson, W., Dunn, P. M. (1992). The heart of darkness: The impact of perceived mistakes on physicians. Journal of General Internal Medicine, 7, 424-431.
309. Christie, N. (2004). A suitable amount of crime. London: Routledge.
310. Cook, R. I., Nemeth, C. P. (2010). ''Those found responsible have been sacked'': Some observations on the usefulness of error. Cognition, Technology and Work, 12, 87-93.
311. Cooper, C. L., Payne, R. (1988). Causes, coping, and consequences of stress at work. Chichester, UK: Wiley.
312. Dekker, S. W. A. (2002). The field guide to human error investigations. Bedford, UK: Cranfield University Press.
313. Dekker, S. W. A. (2006). The field guide to understanding human error. Aldershot, UK: Ashgate.
314. Dekker, S. W. A. (2007a). Criminalization of medical error: Who draws the line? ANZ Journal of Surgery, 77(10), 831-837.
315. Dekker, S. W. A. (2007b). Discontinuity and disaster: Gaps and the negotiation of culpability in medication delivery. Journal of Law, Medicine and Ethics, 35(3), 463-470.
316. Dekker, S. W. A. (2007c). Doctors are more dangerous than gun owners: A rejoinder to error counting. Human Factors, 49(2), 177-184.
317. Dekker, S. W. A. (2007d). Just culture: Balancing safety and accountability. Aldershot, UK: Ashgate.
318. Dekker, S. W. A. (2009). Just culture: Who draws the line? Cognition, Technology and Work, 11(3), 177-185.
319. Dekker, S. W. A. (2010). We have Newton on a retainer: Reductionism when we need systems thinking. The Joint Commission Journal on Quality and Patient Safety, 36(4), 147-149.
320. Dekker, S. W. A., Hugh, T. B. (2009). Balancing "no blame" with accountability in patient safety. New England Journal of Medicine, 362(3), 275.
321. Dekker, S. W. A., Laursen, T. (2007). From punitive action to confidential reporting: A longitudinal study of organizational learning. Patient Safety and Quality Healthcare, 5, 50-56.
322. Ditton, J., Duffy, J. (1983). Bias in the newspaper reporting of crime news. British Journal of Criminology, 23(2), 159-165.
323. Douglas, M. (1992). Risk and blame: Essays in cultural theory. London: Routledge.
324. Elkin, F. (1955). Hero symbols and audience gratifications. Journal of Educational Sociology, 29(3), 97-107.
325. Engbersen, G., Van der Leun, J. (2001). The social construction of illegality and criminality. European Journal on Criminal Policy and Research, 9, 51-70.
326. Ericson, R. (Ed.). (1995). Crime and the media. Dartmouth, UK: Aldershot.
327. Erikson, K. (1966). Wayward Puritans: A study in the sociology of deviance. New York: Wiley.
328. Flight Safety Foundation. (2006). Aviation safety groups issue joint resolution condemning criminalization of accident investigations. Washington, DC: Author.
329. Foucault, M. (1975). The spectacle of the scaffold. London: Penguin Group.
330. Foucault, M. (1977). Discipline and punish: The birth of the prison. New York: Pantheon Books.
331. Friel, A., White, T., Alistair, H. (2008). Posttraumatic stress disorder and criminal responsibility. Journal of Forensic Psychiatry and Psychology, 19(1), 64-85.
332. GAIN (2004). Roadmap to a just culture: Enhancing the safety environment. Global Aviation Information Network (Group E: Flight Ops/ATC Ops Safety Information Sharing Working Group), 3
333. Garland, D. (1993). Punishment and modern society: A study in social theory. Chicago: University of Chicago Press.
334. Garland, D. (2002). The culture of control: Crime and social order in contemporary society. Chicago: University of Chicago Press.
335. Giddens, A. (1991). Modernity and self-identity: Self and society in the late modern age. Stanford, CA: Stanford University Press.
336. Goode, E. (1994). Round up the usual suspects: Crime, deviance, and the limits of constructionism. American Sociologist, 25, 90-104.
337. Green, J. (2003). The ultimate challenge for risk technologies: Controlling the accidental. In J. Summerton & B. Berner (Eds.), Constructing risk and safety in technological practice. London: Routledge.
338. Hugh, T. B., Dekker, S. W. A. (2009). Hindsight bias and outcome bias in the social construction of medical negligence: A review. Journal of Law and Medicine, 16(5), 846-857.
339. Husak, D. (2008). Overcriminalization: The limits of the criminal law. New York: Oxford University Press.
340. Innes, M. (2004). Crime as a signal, crime as a memory. Journal for Crime, Conflict and the Media, 1(2), 15-22.
341. Institute of Medicine. (2003). Patient safety: Achieving a new standard for care. Washington, DC: National Academy of Sciences, Institute of Medicine.
342. Institute for Safe Medication Practices. (2007). Criminal prosecution of human error will likely have dangerous long-term consequences. Retrieved February 4, 2010, from http:// www.ismp.org/Newsletters/acutecare/articles/20070308.asp
343. International Civil Aviation Organization. (2007). Working paper of the 36th session of the Assembly: Protection of certain accident and incident records and of safety data collection andprocessing systems in order to improve aviation safety (Vol. A36-WP/71 TE/16, 17/8/07). Montreal: Author.
344. Jacobs, J. B., Henry, J. S. (1996). The social construction of a hate crime epidemic. The Journal of Criminal Law and Criminology, 86(2), 366-391.
345. Kieckhefer, R. (1976). European witch trials, their foundations in popular and learned culture. London: Routledge.
346. Lauber, J. K. (1993). A safety culture perspective. Paper presented at the Flight Safety Foundation's 38th Corporate Aviation Safety Seminar, April 1993, Irving, Texas.
347. Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272(23), 1851-1857.
348. Leonhardt, J., Vogt, J. (2006). Critical incident stress management in aviation. Aldershot, UK: Ashgate.
349. Lerner, J. S., Tetlock, P. E. (1999). Accounting for the effects of accountability. Psychological Bulletin, 125(2), 255-275.
350. Levack, B. P. (1987). The witch-hunt in early modern Europe. London: Longman.
351. Mahler, J. G. (2009). Organizational learning at NASA: The Challenger and Columbia accidents. Washington, DC: Georgetown University Press.
352. Marx, D. (2001). Patient safety and the ''just culture": A primer for health care executives. New York: Columbia University Press.
353. McLean, B., Elkind, P. (2004). The smartest guys in the room: The amazing rise and scandalous fall of Enron. New York: Portfolio.
354. Mee, C. L. (2007). Should human error be a crime? Nursing, 37, 6.
355. Mellema, G. (2000). Scapegoats. Criminal Justice Ethics, 3-9.
356. Merry, A. F., McCall Smith, A. (2001). Errors, medicine and the law. Cambridge, UK: Cambridge University Press.
357. Merry, A. F., Peck, D. J. (1995). Anaesthetists, errors in drug administration and the law. New Zealand Medical Journal, 108, 185-187.
358. Merton, R. K. (1938). Social structure and anomie. American Sociological Review, 3(5), 672-682.
359. Meszaros, K., Fischer-Danzinger, D. (2000). Extended suicide attempt: Psychopathology, personality and risk factors. Psychopathology, 33(1), 5-10.
360. Meurier, C. E., Vincent, C. A., Parmar, D. G. (1998). Nurses' responses to severity dependent errors: A study of the causal attributions made by nurses following an error. Journal of Advanced Nursing, 27, 349-354.
361. Miyazawa, S. (2008). The politics of increasing punitiveness and the rising populism in Japanese criminal justice policy. Punishment and Society, 10(1), 47-77.
362. Moran, D. (2008). I was treated like a criminal after a harmless drug error. Nursing Standard, 22, 33.
363. Morath, J. M., Turnbull, J. E. (2005). To do no harm: Ensuring patient safety in health care organizations. San Francisco: Jossey-Bass.
364. Morreim, E. H. (2004). Medical errors: Pinning the blame versus blaming the system. In V.A. Sharpe (Ed.), Accountability: Patient safety and policy reform (pp. 213-232). Washington DC: Georgetown University Press.
365. Morrill, C., Snyderman, E., Dawson, E. J. (1997). It's not what you do, but who you are: Informal social control, social status, and normative seriousness in organizations. Sociological Forum, 12(4), 519-543.
366. Murder! Mayhem! Social order! (2005). Wilson Quarterly, 29, 94-96.
367. North, D. M. (2000). Let judicial system run its course in crash cases. Aviation Week and Space Technology, 152(20), 66-67.
368. Odegard, S. (Ed.). (2007). I rattvisans namn [In the name of justice]. Stockholm: Liber.
369. Osborne, J., Blais, K., Hayes, J. S. (1999). Nurses' perceptions: When is it a medication error? Journal of Nursing Administration, 29(4), 33-38.
370. Palmer, L. I., Emanuel, L. L., Woods, D. D. (2001). Managing systems of accountability for patient safety. Washington, DC: National Health Care Safety Council of the National Patient Safety Foundation.
371. Pandit, M. S. (2009). Medical negligence: Criminal prosecution of medical professionals, importance of medical evidence: Some guidelines for medical practitioners. Indian Journal of Urology, 25(3), 379-383.
372. Pellegrino, E. D. (2004). Prevention of medical error: Where professional and organizational ethics meet. In V.A. Sharpe (Ed.), Accountability: Patient safety and policy reform (pp. 83-98). Washington, DC: Georgetown University Press.
373. Perrow, C. (1984). Normal accidents: Living with high-risk technologies. New York: Basic Books.
374. Phillips, S., Grattet, R. (2000). Judicial rhetoric, meaning-making, and the institutionalization of hate crime law. Law and Society Review, 34(3), 567-606.
375. Pidgeon, N., O'Leary, M. (2000). Man-made disasters: Why technology and organizations (sometimes) fail. Safety Science, 34(1-3), 15-30.
376. Rafter, N. H. (1990). The social construction of crime and crime control. Journal of Research in Crime and Delinquency, 27, 376-389.
377. Reason, J. T. (1997). Managing the risks of organizational accidents. Farnham, UK: Ashgate.
378. Reissner, D. (2009). A criminal mistake? Chemist and Druggist, 271(6693), 8-9.
379. Rock, P. (1998). Rules, boundaries and the courts: Some problems in the Neo-Durkheimian sociology of deviance. The British Journal of Sociology, 49(4), 586-601.
380. Serembus, J. F., Wolf, Z. R., Youngblood, N. (2001). Consequences of fatal medication errors for healthcare providers: A secondary analysis study. MedSurg Nursing, 10(4), 193-201.
381. Sharpe, V. A. (2003). Promoting patient safety: An ethical basis for policy deliberation. Hastings Center Report, 33(5), S2-S19.
382. Sharpe, V. A. (2004). Accountability: Patient safety and policy reform. Washington, DC: Georgetown University Press.
383. Skegg, P. D. G. (1998). Criminal prosecutions of negligent health professionals: The New Zealand experience. Medical Law Review, 6(2), 220-246.
384. Snook, S. A. (2000). Friendly fire: The accidental shootdown of U.S. Black Hawks over northern Iraq. Princeton, NJ: Princeton University Press.
385. Summerton, J., Berner, B. (2003). Constructing risk and safety in technological practice. London: Routledge.
386. Thomas, G. (2007). A crime against safety. Air Transport World, 44, 57-59.
387. Tingvall, C., Lie, A. (2010). The concept of responsibility in road traffic [Ansvarsbegreppet i vagtrafiken]. Paper presented at the Transportforum, January 2010, Linkoeping, Sweden.
388. Tuchman, G. (1978). Making news: A study in the construction of reality. New York: Free Press.
389. Tyler, K. (2003). Helping employees cope with grief. HRMagazine, 48(9), 54-58.
390. Vaughan, D. (1996). The Challenger launch decision: Risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press.
391. Vaughan, D. (1999). The dark side of organizations: Mistake, misconduct, and disaster. Annual Review of Sociology, 25, 271-305.
392. Vaughan, D. (2005). System effects: On slippery slopes, repeating negative patterns, and learning from mistake? In W.H. Starbuck & M. Farjoun (Eds.), Organization at the limit: Lessons from the Columbia disaster (pp. 41-59). Malden, MA: Blackwell.
393. Weiner, B. J., Hobgood, C., Lewis, M. A. (2008). The meaning of justice in safety incident reporting. Social Science and Medicine, 66, 403-413.
394. Wilkinson, I. (2001). Anxiety in a risk society. New York: Routledge.
395. Wolf, Z. R. (1994). Medication errors: The nursing experience. Albany, NY: Delmar.
396. Woods, D. D., Dekker, S. W. A., Cook, R. I., Johannesen, L. J., Sarter, N. B. (2010). Behind human error. Aldershot, UK: Ashgate.
397. Wu, A. W. (2000). Medical error: The second victim. British Medical Journal, 320(7237), 726-728.
398. Althusser, L. (1984). Essays on ideology. London: Verso.
399. Amer-Wahlin, I., Bergström, J., Wahren, E., Dekker, S. W. A. (2010). Escalating obstetrical situations: An organizational approach. Paper presented at the Swedish Obstetrics and Gynaecology Week May 2010, Visby, Sweden.
400. Amer-Wahlin, I., Dekker, S. W. A. (2008). Fetal monitoring-A risky business for the unborn and for clinicians. Journal of Obstetrics and Gynaecology, 115(8), 935-937; discussion 1061-1062.
401. Amer-Wahlin, I., Ingemarsson, I., Marsal, K., Herbst, A. (2005). Fetal heart rate patterns and ECG ST segment changes preceding metabolic acidaemia at birth. BJOG: An International Journal of Obstetrics and Gynaecology, 112(2), 160-165.
402. Amer-Wahlin, I., Yli, B., Rosen, K. G. (2009). Changes in the ST-interval segment of the fetal electrocardiogram in relation to acid-base status at birth. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), 1138-1139; author reply 1139-1140.
403. Benner, P. E., Malloch, K., Sheets, V. (Eds.). (2010). Nursing pathways for patient safety. St. Louis, MO: Mosby Elsevier.
404. Cilliers, P. (1998). Complexity and postmodernism: Understanding complex systems. London: Routledge.
405. Cilliers, P. (2005). Complexity, deconstruction and relativism. Theory, Culture and Society, 22(5), 255-267.
406. Cilliers, P. (2010). Difference, identity and complexity. Philosophy Today, 55-65.
407. Columbia Accident Investigation Board. (2003). Report Volume 1, August 2003. Washington, DC: Author.
408. 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(3), 217-226.
409. Cook, R. I., Woods, D. D. (1996a). Adapting to new technology in the operating room. Human Factors, 38(4), 593-614.
410. Cook, R. I., Woods, D. D. (1996b). Implications of automation surprises in aviation for the future of Total Intravenous Anesthesia (TIVA). Journal of Clinical Anesthesia, 8(3), 29S-37S.
411. Cronon, W. (1992). A place for stories: Nature, history, and narrative. The Journal of American History, 78(4), 1347-1376.
412. Dekker, S. W. A. (2007). Just culture: Balancing accountability and safety. Aldershot, UK: Ashgate.
413. Dekker, S. W. A., Woods, D. D. (1999a). Automation and its impact on human cognition. In S.W. A. Dekker & E. Hollnagel (Eds.), Coping with computers in the cockpit (pp. 7-27). Aldershot, UK: Ashgate.
414. Dekker, S. W. A., Woods, D. D. (1999b). To intervene or not to intervene: The dilemma of management by exception. Cognition, Technology and Work, 1(2), 86-96.
415. De Vries, R., Lemmens, T. (2006). The social and cultural shaping of medical evidence: Case studies from pharmaceutical research and obstetrics. Social Science and Medicine, 62(11), 2694-2706.
416. Drife, J. O., Magowan, B. (2004). Clinical obstetrics and gynaecology. Edinburgh: Saunders.
417. Ehrenreich, B., English, D. (1973). Witches, midwives and nurses: A history of women healers. London: Publishing Cooperative.
418. Farrington-Darby, T., Wilson, J. R. (2006). The nature of expertise: A review. Applied Ergonomics, 37, 17-32.
419. Feyerabend, P. (1993). Against method (3rd ed.). London: Verso.
420. Fischhoff, B. (1975). Hindsight ≠ foresight: The effect of outcome knowledge on judgment under uncertainty. Journal of Experimental Psychology: Human Perception and Performance, 1(3), 288-299.
421. Fischhoff, B., Beyth, R. (1975). "I knew it would happen." Remembered probabilities of once-future things. Organizational Behavior and Human Performance, 13(1), 1-16.
422. Foucault, M. (1977). Discipline and punish: The birth of the prison. New York: Pantheon Books.
423. Foucault, M. (1980). Truth and power. In C. Gordon (Ed.), Power/knowledge (pp. 80-105). Brighton, UK: Harvester.
424. Gawande, A. (2002). Complications: A surgeon's notes on an imperfect science. New York: Picador.
425. Gawande, A. (2010). The checklist manifesto: How to get things right. New York: Metropolitan Books.
426. Global Aviation Information Network. (2004). Roadmap to a just culture: Enhancing the safety environment. Global Aviation Information Network (Group E: Flight Ops/ATC Ops Safety Information Sharing Working Group) Washington, DC.
427. Heylighen, F. (1999). Causality as distinction conservation: A theory of predictability, reversibility and time order. Cybernetics and Systems, 20, 361-384.
428. Holden, R. J. (2009). People or systems: To blame is human. The fix is to engineer. Professional Safety.
429. Hollnagel, E. (2004). Barriers and accident prevention. Aldershot, UK: Ashgate.
430. Holmes, D., Roy, B., Perron, A. (2008). The use of postcolonialism in the nursing domain: Colonial patronage, conversion and resistance. Advances in Nursing Science, 31(1), 42-51.
431. Hugh, T. B., Dekker, S. W. A. (2009). Hindsight bias and outcome bias in the social construction of medical negligence: A review. Journal of Law and Medicine, 16(5), 846-857.
432. Iedema, R., Flabouris, A., Grant, S., Jorm, C. (2006). Narrativizing errors of care: Critical incident reporting in clinical practice. Social Science and Medicine, 62, 134-144.
433. Institute for Safe Medication Practices. (2006, November 7). ISMP opposes criminal charges for Wisconsin nurse involved in medication error. Huntingdon Valley, PA: Author.
434. Jensen, C. (1996). No downlink: A dramatic narrative about the Challenger accident and our time. New York: Farrar, Straus, Giroux.
435. Kerstholt, J. H., Passenier, P. O., Houttuin, K., Schuffel, H. (1996). The effect of a priori probability and complexity on decision making in a supervisory control task. Human Factors, 38(1), 65-78.
436. Klein, G. A. (1993). A recognition-primed decision (RPD) model of rapid decision making. In G.A. Klein, J. Orasanu, R. Calderwood, & C. E. Zsambok (Eds.), Decision making in action: Models and methods (pp. 138-147). Norwood, NJ: Ablex.
437. Klein, G. A. (1998). Sources of power: How people make decisions. Cambridge, MA: MIT Press.
438. Langewiesche, W. (1998). Inside the sky: A meditation on flight. New York: Pantheon Books.
439. Leveson, N. (2002). System safety engineering: Back to the future. Boston: MIT Aeronautics and Astronautics.
440. McDonald, R., Waring, J., Harrison, S. (2006). Rules, safety and the narrativization of identity: A hospital operating theatre case study. Sociology of Health and Illness, 28(2), 178-202.
441. Moray, N., Inagaki, T. (2000). Attention and complacency. Theoretical Issues in Ergonomics Science, 1(4), 354-365.
442. Nagel, T. (1992). The view from nowhere. Oxford, UK: Oxford University Press.
443. 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.
444. Odegard, S. (Ed.). (2007). I rattvisans namn [In the name of justice]. Stockholm: Liber.
445. Orasanu, J. M., Martin, L. (1998). Errors in aviation decision making: A factor in accidents and incidents. Human Error, Safety and Systems Development Workshop (HESSD), April 1998, Seattle, WA. Retrieved February 2008, from http://www.dcs.gla. ac.uk/~johnson/papers/seattle_hessd/judithlynnep
446. Pellegrino, E. D. (2004). Prevention of medical error: Where professional and organizational ethics meet. In V.A. Sharpe (Ed.), Accountability: Patient safety and policy reform (pp. 83-98). Washington, DC: Georgetown University Press.
447. Perry, S. J., Wears, R. L., Cook, R. I. (2005). The role of automation in complex system failures. Journal of Patient Safety, 1(1), 56-61.
448. Pisek, P. E., Greenhalgh, T. (2001). Complexity science: The challenge of complexity in health care. British Medical Journal, 323, 625-628.
449. Pronovost, P. J., Vohr, E. (2010). Safe patients, smart hospitals. New York: Hudson Street Press.
450. Sarter, N. B., Woods, D. D., Billings, C. (1997). Automation surprises. In G. Salvendy (Ed.), Handbook of human factors/ergonomics. New York: Wiley.
451. Sibley, L., Sipe, T. A., Koblinsky, M. (2004). Does traditional birth attendant training improve referral of women with obstetric complications: A review of the evidence. Social Science and Medicine, 59(8), 1757-1769.
452. Smetzer, J., Baker, C., Byrne, F., Cohen, M. R. (2010). Shaping systems for better behavioral choices: Lessons learned from a fatal medication error. The Joint Commission Journal on Quality and Patient Safety, 36(4), 152-163.
453. Snook, S. A. (2000). Friendly fire: The accidental shootdown of US Black Hawks over Northern Iraq. Princeton, NJ: Princeton University Press.
454. Sorkin, R. D., Woods, D. D. (1985). Systems with human monitors: A signal detection analysis. Human-Computer Interaction, 1(1), 49-75.
455. Starbuck, W. H., Farjoun, M. (2005). Organization at the limit: Lessons from the Columbia disaster. Malden, MA: Blackwell.
456. State of Wisconsin, Circuit Court Dane County (Filed 6 November 2006). Criminal Complaint, Case number 2006 CF 2512, p. 3.
457. Tingvall, C., Lie, A. (2010). The concept of responsibility in road traffic [Ansvarsbegreppet i vagtrafiken]. Paper presented at the Transportforum, January 2010, Linkoeping, Sweden.
458. Vaughan, D. (1999). The dark side of organizations: Mistake, misconduct, and disaster. Annual Review of Sociology, 25, 271-305.
459. Vaughan, D. (2005). System effects: On slippery slopes, repeating negative patterns, and learning from mistake? In W.H. Starbuck & M. Farjoun (Eds.), Organization at the limit: Lessons from the Columbia disaster (pp. 41-59). Malden, MA: Blackwell.
460. Wachter, R. M., Pronovost, P. J. (2009). Balancing "no blame" with accountability in patient safety. New England Journal of Medicine, 361, 1401-1406.
461. Wallerstein, I. (1996). Open the social sciences: Report of the Gulbenkian Commission on the Restructuring of the Social Sciences. Stanford, CA: Stanford University Press.
462. Weick, K. E. (1993). The collapse of sensemaking in organizations: The Mann Gulch disaster. Administrative Science Quarterly, 38(4), 628-652.
463. Wiener, E. L. (1988). Cockpit automation. In E.L. Wiener & D. C. Nagel (Eds.), Human factors in aviation (pp. 433-462). San Diego, CA: Academic Press.
464. Woods, D. D., Dekker, S. W. A. (2000). Anticipating the effects of technological change: A new era of dynamics for human factors. Theoretical Issues in Ergonomics Science, 1(3), 272-282.
465. Zaccaria, A. (2002, November 7). Malpractice insurance crisis in New Jersey. Atlantic Highlands Herald. http://www.ahherald.com/physicians_forum/2002/pf021107_malpractice.htm