A Tale of Two Stories
National Patient Safety Foundation

  Report from a Workshop on
Assembling the Scientific Basis
for Progress on Patient Safety

 

 

 

 

References

 



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Cook RI, Woods DD, Howie MB. Unintentional delivery of vasoactive drugs with an electromechanical infusion device. Journal of Cardiothoracic and Vascular Anesthesia. 1992; 6: 238-244.

Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: A study of human factors. Anesthesiology. 1978; 49: 399-406.

Dominguez C. (1998). Expertise in laparoscopic surgery: anticipation and affordances. In: Proceedings of Naturalistic Decision Making 4, Warrenton VA, May 1998.

Dominguez C, Flach J, Lake P, McKellar D, Dunn M. (in press). The conversion decision in laparoscopic surgery: Knowing your limits and limiting your risks. In Shanteau J, Smith K, & Johnson P, (eds). Psychological Explorations of Competent Decision Making. New York: Cambridge University Press.

Feltovich PJ, Spiro RJ, Coulson R. (1989). The nature of conceptual understanding in biomedicine: The deep structure of complex ideas and the development of misconceptions. In: Evans D, Patel V, (eds). Cognitive Science In Medicine: Biomedical Modeling. Cambridge, MA: MIT Press.

Feltovich PJ, Ford KM, Hoffman RR, (eds). (1997). Expertise in Context. Cambridge MA: MIT Press.

Guerlain S, Smith PJ, Obradovich JH, et al. Dealing with brittleness in the design of expert systems for immunohematology. Immunohematology. 1996; 12(3): 101-107.

Hollnagel E. (1993). Human Reliability Analysis: Context and Control. London: Academic Press.

Holzman RS, Cooper JB, Gaba DM, Philip JH, Small S, Feinstein D. 1995; Anesthesia crisis resource management: Real-life simulation training in operating room crises. Journal of Clinical Anesthesia. 1996; 7: 675-687.

Howard SK, Gaba DM, Fish KJ, Yang GS, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviation, Space, and Environmental Medicine. 1992; 63: 763-770.

Klein GA. (1998). Sources of Power: How People Make Decisions. MIT Press, Cambridge MA.

Leape LL. Error in Medicine. JAMA. 1994; 272: 1851-1857.

Moll van Charante E, Cook RI, Woods DD, et al. Human-computer interaction in context: physician interaction with automated intravenous controllers in the heart room. In Stassen HG (ed), Analysis, Design and Evaluation of Man-Machine Systems 1992, Pergamon Press. 1993: 263-274.

Obradovich JH, Smith PJ, Guerlain S, et al. Empirical evaluation of the transfusion medicine tutor. Immunohematology. 1996; 12(4): 169-174.

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Woods DD, Sarter N. (in press). Learning from automation surprises and going sour accidents. In Sarter N, and Amalberti R. (eds). Cognitive Engineering in the Aviation Domain, Erlbaum, Hillsdale NJ.

Woods DD, Johannesen L, Cook RI, Sarter N. (1994). Behind Human Error: Cognitive Systems, Computers and Hindsight. Crew Systems Ergonomic Information and Analysis Center, WPAFB, Dayton OH.

Yue L, Woods DD, Cook, RI. (1992). Reducing the Potential for Error Through Device Design: Infusion Controllers in Cardiac Surgery. Cognitive Systems Engineering Laboratory Report TR-01-92, The Ohio State University, Columbus OH, January 1992.


 

Appendix A: List of Participants

Table of Contents

 

 

Copyright 1998 National Patient Safety Foundation at the AMA

Prepared for Web publication by
Annenberg Center for Health Sciences