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

Section A. Celebrated Cases

The "celebrated" cases are medical accidents that have attracted a great deal of attention in the press and from various stakeholders. A variety of reactions from healthcare professionals, regulators, and the public appear in these articles. Most of the material included on these cases comes from newspaper articles. Also included is a more discursive document on the 'wrong leg' case that indicates the perspective of the state regulatory body and the rationale for the revocation of the surgeon's license. Also included are some cases demonstrating the recent trend towards treating medical accidents as criminal events (usually manslaughter).

A-1 (Willie King wrong leg case; Dr. Rolando Sanchez)
Agency for Health Care Administration vs. Rolando Roberto Sanchez, M.D. Fla. Div. of Admin. Hearings. Recommended order. Case no. 95-3925

Associated Press.
Tampa hospital had earlier surgical slipup. The Ledger (Lakeland, Fla). March 8, 1995; news:5B.

Wrong-leg surgeon cut: toe for two. The Commercial Appeal (Memphis). July 19, 1995; news:7A.

Bartlett R.
Hospital safety law proposed: bill would compile data on deaths, injuries, infections. The Tampa Tribune. February 9, 1996; Florida/metro:6.

Clary M.
String of errors put Florida hospital on the critical list. Los Angeles Times. April 14, 1995; part A:1.

Hagigh J.
Family sues surgeon, UCH. St. Petersburg Times. January 26, 1996; Tampa today:4B.

Landry S.
Expert: King error a group effort. St. Petersburg Times. September 14, 1995; Tampa today:1B.
Fatal error earns suspension. St. Petersburg Times. February 3, 1996; Tampa today:3B.
Surgeon fined, suspended 6 months for error. St. Petersburg Times. December 3, 1995; national:1A.

Leisner P.
Surgeon says it was too late to stop amputation on wrong leg. Associated Press, September 14, 1995.

Mahan M.
This time, hospital's error is fatal. St. Petersburg Times. March 12, 1995; Tampa Bay and state:1B.

Oppel S.
Medical board examines fatal error. St. Petersburg Times. October 26, 1995; Tampa Bay and state:1B.

Palosky CS.
Doctor's penalty reduced. The Tampa Tribune. December 3, 1995; nation/world:1.
Surgeon fights penalty. The Tampa Tribune. November 8, 1995; Florida/metro:6.
Wrong-amputation surgeon makes return. The Tampa Tribune. February 29, 1996; Florida/metro:6.

Ripley J.
Amputated foot worth more than $1-million. St. Petersburg Times. May 12, 1995; Tampa Bay and state:1B.

Rosen M.
Report: hospital cut safeguards. St. Petersburg Times. April 7, 1995; national:1A.

Ryan P. State slaps surgeon: agency says doctor "serious danger" following 2 amputation complaints. The Tampa Tribune. July 15, 1995; nation/world:1.

Shaver K, Carlton S.
Right foot amputated. St. Petersburg Times. March 8, 1995; around town:1B.

Stanley D.
Amputee recovering after wrong leg taken. The Tampa Tribune. February 28, 1995; nation/world:1.
Bill seeks hospital disclosures: sponsors want data on injuries inflicted upon patients to be made public. The Tampa Tribune. March 4, 1995; Florida/metro:1.
Federal agency tells hospital to fix problems. The Tampa Tribune. March 30, 1995; Florida/metro:1.
Hospital cites new safeguards. The Tampa Tribune. March 2, 1995; Florida/metro:1.
License won't assure surgeon job: Rolando Sanchez may be allowed to practice again, but he must convince hospitals and insurers to take him back. The Tampa Tribune. January 17, 1996; nation/world:1.
Mistake found during surgery: testimony begins in appeals hearing for doctor who amputated wrong foot. The Tampa Tribune. September 13, 1995; nation/world:1.
Surgeon faced previous claim: the same physician recently was involved in a wrong-foot amputation. The Tampa Tribune. March 2, 1995; Florida/metro:1.
"That's the wrong leg:" victim tries to cope with botched surgery. The Tampa Tribune. March 10, 1995; nation/world:1.
UCH reduces number of surgeries. The Tampa Tribune. April 7, 1995; nation/world:10.

Surgeon suspended for cutting off wrong leg. The Herald (Glasgow). December 4, 1995:6.

We don't need this kind of doctor [editorial]. The Tampa Tribune. July 20, 1995.

Wilson M.
Surgical horrors. Chicago Tribune. March 10, 1995; news:7.

 A-2 (Betsy Lehman)
 
Altman LK.
Committees find signs of weak leadership at Dana-Farber. The New York Times. October 31, 1995; sect C:5.
Hospital is disciplined by agency after errors. The New York Times. April 16, 1995; sect 1:12.

Associated Press. Settlement reached in overdose lawsuit. The New York Times. August 25, 1995; sect A:20.

Estrich S.
Why protect doctors? USA Today. March 30, 1995; news, counterpoints:13A.

Goodman E.
The diagnosis: losing patients, losing faith. The Plain Dealer. April 2, 1995; perspective:3C.

Knox RA.
Chemotherapy deaths spur safer methods. The Boston Globe. December 23, 1996; metro/region:B1.
Dana-Farber, doctor face malpractice suit. The Boston Globe. April 6, 1995; metro/region:32.
Dana-Farber head quits 2d post, vows changes. The Boston Globe. May 26, 1995; metro/region:1.
Dana-Farber probe widens: three suspended from patient care. The Boston Globe. April 1, 1995; metro/region:13.
Dana-Farber puts focus on mistakes in overdoses. The Boston Globe. October 31, 1995; metro/region:1.
Dana-Farber studies pattern in overdoses. The Boston Globe. March 26, 1995; metro/region:1.
Dana-Farber tests signaled an overdose, records show. The Boston Globe. May 2, 1995; metro/region:1.
Dana-Farber wins near-perfect score: changes follow 2 patient overdoses. The Boston Globe. June 5, 1996; metro/region:44.
Doctor's orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman. The Boston Globe. March 23, 1995; metro/region:1.
Hospital's record of sympathy faulted: says response to distress factored in death. The Boston Globe. July 16, 1995; metro/region:21.
Licensing board reprimands 3 Dana-Farber pharmacists. The Boston Globe. September 26, 1996; metro/region:B2.
Media spotlight helped spur change, shook up patients, staff. The Boston Globe. December 26, 1995; metro/region:20.
New Dana-Farber head vows "never again." The Boston Globe. September 16, 1995; metro/region:1.
New policies put in place. The Boston Globe. December 26, 1995; metro/region:20.
Overdoses still weigh heavy at Dana-Farber: more than year after tragedy, cancer institute works to balance research mission, crucial details of patient care. The Boston Globe. December 26, 1995; metro/region:1.
President of troubled Dana-Farber steps down. The Boston Globe. September 13, 1995; metro/region:1.
Response is slow to deadly mixups: too little done to avert cancer drug errors. The Boston Globe. June 26, 1995; science & technology:29.
State cites Dana-Farber failures: quality assurance program faulted. The Boston Globe. May 31, 1995; metro/region:1.
State probe cites lax management at Dana-Farber. The Boston Globe. May 25, 1995; metro/region:1.
State regulators vow multi-agency probe of Dana-Farber overdose. The Boston Globe. March 29, 1995; metro/region:21
Survivor's spirit beats a chemotherapy error. The Boston Globe. December 17, 1995; metro/region:1.
Top Dana-Farber doctor steps down. The Boston Globe. May 11, 1995; metro/region:1.

Knox RA, Blanton K. Overdoses cloud Dana-Farber bonds. The Boston Globe. March 24, 1995; economy:77.

Knox RA, Golden D.
Dana-Farber turmoil seen. The Boston Globe. May 28, 1995; metro/region:1.
Drug dosage was questioned: Dana-Farber pharmacist sent order back to doctor in breast cancer case. The Boston Globe. June 19, 1995; metro/region:1.

Kong D.
Dana-Farber given the OK for Medicare after correction. The Boston Globe. August 3, 1995; metro/region:32
State faults Dana-Farber: says center failed to tell promptly of two overdoses of cancer drug. The Boston Globe. March 24, 1995; metro/region:1.

Lasalandra M.
Dana-Farber workers probed in death. The Boston Herald. October 31, 1995; news:12.

Lessons of a life lost [editorial]. The Boston Globe. March 24, 1995; editorial page:18.

Overdose survivor forgives cancer institute in Boston. Chicago Tribune. December 18, 1995; news:1.

Pertman A.
Betsy A. Lehman, 39: Globe columnist on personal health [obituary]. The Boston Globe. December 4, 1994; obituaruies:56.

Spingarn ND.
Doctors can prevent errors just by listening [letter]. The New York Times. July 25, 1995; sect A:14.

Stein C.
Doctor sues Farber Globe in overdose case. The Boston Globe. February 3, 1996; metro/region:1.

Trafford A. The empathy gap. The Washington Post, August 29, 1995; health:Z6.

Warsh D.
Molecular medicine vs. bedside manner in the Lehman case: economic principals. The Boston Globe. September 17, 1995; economy:79.
 

A-3 (Vincent Gargano)

Associated Press. Cancer patient dies after chemotherapy overdose. June 15, 1995.

Fatal chemotherapy overdose suit filed. Chicago Tribune. June 21, 1995; metro west:3.

Fegelman A.
Chemotherapy fears increase after death: dosage checks failed, U. of C. officials admit. Chicago Tribune. June 16, 1995; Chicagoland:1.
U. of C. cancer patient dies of chemotherapy overdose. Chicago Tribune. June 15, 1995; Chicagoland:2.

The New York Times. Cancer patient in Chicago dies after chemotherapy overdose. The New York Times. June 18, 1995; sect 1:17.

Phillips SE.
Editorial's outrage misplaced [letter]. Modern Healthcare. July 17, 1995; letters:32.

Spate of errors tarnishes prestigious reputations [editorial]. Modern Healthcare. June 26, 1995; editorial:42.
 

A-4 (Ben Kolb)
 
Cox News Service.
"Medical accident" cited in boy's death. St. Petersburg Times. January 12, 1996; Tampa Bay and state:1B.
"Mistake" in surgery led to boy's death, Fla. hospital admits; family settles with "no hard feelings." The Phoenix Gazette. January 12, 1996; news:A32.

Examining Errors in Health Care: Developing a Prevention, Education and Research Agenda. A case study: how does the health care system respond to an injury caused by error? Symposium. Rancho Mirage, Calif. October 13-15, 1996.

Graulich H.
Hospital admits syringe mix-up killed boy. The Palm Beach Post. January 11, 1996; A sect:1A.

Krupnick, Campbell, Malone, Roselli, Buser, Slama & Hancock, A Professional Association. In memory of Ben: October 13, 1988 - December 14, 1995.

MMI Companies, Inc.
Developing a crisis management and communication plan. Risk Modification Strategies. July, 1995.

Reeder J. St.
Lucie boy's death ruled bad reaction to epinephrine. The Palm Beach Post. December 16, 1995; local:1B.

Trontz I.
Hospital's admission of fatal error cited as model. The Palm Beach Post. November 18, 1996; A sect:1A.
 

A-5 (Libby Zion)
 
Agus C.
Zion nurse didn't want to "hang" doc. Newsday. December 2, 1994; news:A33.

Andrews L.
"I was juror no. 6, the lone dissenter in the Libby Zion case [letter]. The New York Times. February 21, 1995; sect A:18.

Asch DA, Parker RM.
Sounding board: the Libby Zion case. The New England Journal of Medicine. March 24, 1988; 318:771-775.

Associated Press.
Doctors faulted in 1984 death of 18-year-old. The New York Times. May 26, 1990; sect 1:27.
Judge halts regents censure of two doctors in Zion case. The New York Times. June 23, 1990; sect 1:27.

Belkin L.
Effects are unclear in limits on medical residents' hours. The New York Times. February 23, 1993; A:1

Cantor C.
Hospital residents pressure for change. The New York Times. August 9, 1992; sect 13:1.

Carmody D.
New York Hospital disputes allegations on patient's death. The New York Times. January 15, 1987; sectB:2.

Cohen T.
About health; interns' hours: a red herring. Newsday. June 23, 1989; viewpoints; New York forum:80

Colburn D.
Medical education: time for reform? after a patient's death, the 36-hour shift gets new scrutiny. The Washington Post. March 29, 1988; health:Z6.

Collins D.
A father's grief, a father's fight. Los Angeles Times. February 1, 1995; life & style, part E:1.

Daley S.
Hospital interns' long hours to be reduced in New York. The New York Times. June 10, 1988; sect A:1.

Douglas RG Jr.
Zion case verdict vindicates training system [letter]. The New York Times. February 14, 1995; sect A:18.

Dubin J.
Zion case verdict vindicates training system: on the evidence [letter]. The New York Times. February 14, 1995; sect A:18.

French HW.
A limit on doctors' hours is debated. The New York Times. April 5, 1989; sect B:3.
In overhaul of hospital rules, New York slashes interns' hours. The New York Times.July 3, 1989; sect 1:1.

Fugh-Berman A.
Exhausted doctors don't serve patients well. The New York Times. March 3, 1995; sect A:26.

Handelman S.
Student's death haunts U.S. medical establishment. The Toronto Star. opinion:A29.

Hershenson R.
New rules pose conflict for interns. The New York Times. February 14, 1993; sect 13WC:1.

Hoffman J.
Doctors' accounts vary in death of Libby Zion. The New York Times. January 1, 1995; sect 1:31.
In the Zion case, a doctor and profession on the stand. The New York Times. November 19, 1994; sect 1:27.
Judge sets aside use of cocaine as part of verdict in Zion case. The New York Times. May 2, 1995; sect B:1.
Jurors find shared blame in '84 death. The New York Times. February 7, 1995; sect B:1.

Japenga A.
Endless days and sleepless nights: do long work schedules help or hinder medical residents? Los Angeles Times. March 6, 1988; view, part 6:1

Kleinfield NR.
Doctor's criticism in '84 case strains hospitals' bonds. Newsday. August 5, 1991; sect B:1.

Kocieniewski D.
Libby Zion doc admits medical team failure. The New York Times. November 17, 1994; news:5.

Landers A.
Exhausted resident questions ability to make decisions. The Houston Chronicle. November 2, 1997; lifestyle:4.

Libby Zion [obituary]. The New York Times. March 6, 1984; sect B:10.

Mitler MM, Cetel MB.
Why the doctor may fall asleep on your case. Los Angeles Times. April 9, 1989; opinion, part 5:5.

Myers MF.
When hospital doctors labor to exhaustion. The New York Times. June 12, 1987; sect A:30.

Myerson M.
Long hours of medical residents improve care [letter]. The New York Times. February 23, 1995; sect A:22.

Okie S.
New prescription for medical interns? controversial N.Y. plan would limit hours of hospital shifts. The Washington Post. June 30, 1987; sect 1:A1.

Prosecuting doctors [editorial]. The National Law Journal. September 16, 1985:12.

Roark AC.
Lack of sleep not impairing, study finds. Los Angeles Times. September 23, 1988; part 1:3

Ronches J. Must we squander the legacy of Libby Zion? Newsday. January 3, 1995; viewpoints:A24.

Rovner S.
The battle over limiting residents' hours. The Washington Post. October 16, 1990; health:Z9.

Sack K.
Appeals court clears doctors who were censured in the Libby Zion case. The New York Times. November 1, 1991; sect B:2.

Scott G. Court upholds limits on hours for medical residents. Newsday. December 30, 1990; news:18.

Segal MM, Cohen B.
Hospitals' junior doctors need senior backups. The New York Times. June 8, 1987; sect A:18.

Some limits supported for intern work hours. The New York Times. August 21, 1987; sect B:3.

Sullivan R.
Hospital admits fault in patient's death. The New York Times. March 24, 1987; sect B:3.
Third doctor is charged in death. The New York Times. August 11, 1987; sect B:3.

Two of Zion's doctors accused in her death. The New York Times. May 1, 1987; sect B:2.

Weiner E.
Panel clears Zion's doctors of wrongdoing in her death. The New York Times. September 23, 1989; sect 1:28.

Wicker T.
Blaming the system. The New York Times. February 4, 1987; sect A:27.
Doctors in the dock? The New York Times. December 23, 1985; sect A:17.

Zion S.
Doctors know best? The New York Times. May 13, 1989; sect 1:25.

A-6 (Dr. Gerald Einaugler)

Associated Press.
Doctor going to prison for fatal medical mistake. March 16, 1995.
Doctor's mistake lands him in city jail convicted of trying to hide fatal error. The Record (Bergen Record Corp). March 17, 1995; news:A14.
Doctor's order kills patient: physician goes to jail. The Commercial Appeal (Memphis). March 17, 1995; news:6A.

Bayles F.
Criminal indictments against doctors seen as "warning shot." April 12, 1995.

Bensel FP, Goldberg BD.
Prosecutions and punitives for malpractice rise, slowly. The National Law Journal. January 22, 1996; in focus, health care:B7.

Bowles P.
Doctor does prison time on weekends: L.I. internist serves sentence in B'klyn nursing-home death. Newsday. May 20, 1997; news:A8.

Cohen J, Shapiro R.
The criminalization of medical malpractice. New York Law Journal. August 28, 1995; outside counsel:1.

Crane M.
Could a clinical mistake land you in jail? the case of Gerald Einaugler. Medical Economics. February 21, 1994; 71 no.4:46.
Prosecuting doctors for bad outcomes. Medical Economics. August 21, 1995; 72 no. 16:120.
Malpractice is not criminal; mistake is? The National Law Journal. July 28, 1997; podium:A17.
Will this internist's name finally be cleared? Gerald Einaugler. Medical Economics. March 10, 1997; 74 no. 5:50.

Criminal conviction upheld, appealed. Medical Malpractice Law & Strategy. April 1997; 14 no.6:1.

Doctors in court. Capital Times (Madison, Wis.) April 12, 1995; nation/world:2C.

Doctor's sentence delayed. The New York Times. March 18, 1995; sect 1:26.

Fein EB.
Doctor in negligence case gets his sentence eased. The New York Times. June 28, 1997; sect 1:25.

Kriegel M.
Law's treatment of doc is criminal. Daily News (New York). May 21, 1997; news:19.

Malpractice or homicide? [editorial]. The Washington Post. April 18, 1995; editorial:A16.

McShane L.
Doctor spending weekends in jail: botched procedure in 1990. The Record (Bergen Record Corp). May 18, 1997; news:A6.
Doctor's error leads to death, jail. March 16, 1995.

Medical errors becoming crimes. Chattanooga Free Press. April 12, 1995.

Moy DR.
"Cover-up" allegation called unjustified [letter]. New York Law Journal. September 12, 1995; letters:2.

Nossiter A.
A mistake, a rare prosecution, and a doctor is headed for jail. The New York Times. March 16, 1995; sect A:1.

Pines D.
Doctor loses death-case appeal: negligence affirmed in treating patient. New York Law Journal. March 11, 1997:1.

Susman C.
When doctors err. The Palm Beach Post. May 27, 1995; accent:1D.

Weiner SM, Reibman M.
Doctors will get more immunity for mistakes [letter]. The New York Times. March 22, 1995; sect A:18.

A-7 (Colorado Nurses)

Newborn boy dies after improper shot. The Washington Times. October 25, 1996; part A, nation, American scene:A11.

Romano M.
Baby dies after injection: police, state probe death at St. Anthony Hospital North. Rocky Mountain News. October 24, 1996; local, ed F:5A.
Nurses fear indictments put profession on trial: charges in infant's accidental death are a first in Colorado. Rocky Mountain News. April 30, 1997; local, ed F:28A.

Metro digest: Adams County nurses trial ruling. The Denver Post. June 19, 1997; Denver & the West:B2.

Schrader A, Robinson M.
Baby's nurses face homicide charges. The Denver Post. April 29, 1997; sect A:1.
Healthy baby's tragic death at hospital being probed. The Denver Post. October 25, 1996; Denver & the West:B7.

UPI. Colo. newborn dies of improper injection. October 24, 1996.

Volume II

Section B. Synthetic Views

Also from the popular press are two broader perspectives from reporters looking across multiple accidents and attempting to synthesize a more coherent picture of error and accident in general. The article by Belkin is the most recent and most detailed piece to date. Also included is a broadside by the news commentator Sidney Zion, father of Libby Zion. This response to a media briefing conducted by the National Patient Safety Foundation provides some suggestion of the charged atmosphere surrounding patient safety issues and may presage the sorts of difficulty confronting those who seek to develop and explore a more technically grounded view.

B-1
Belkin L.
How can we save the next victim? The New York Times Magazine. June 15, 1997; sect6:28-33, 44, 50, 63, 66, 70.

Cohen M.
How can we save the next victim? [letter]. The New York Times.

Ho L.
How can we save the next victim? [letter]. The New York Times.

Meyer RH.
How can we save the next victim? [letter]. The New York Times.

B-2
Medicine's hidden costs: lack of a reporting system permits repetition of mistakes [editorial]. Pittsburgh Post-Gazette. October 31, 1993; editorial:D2.

Twedt S.
Deadly hospital mistakes are doomed to be repeated. Pittsburgh Post-Gazette. October 24, 1993; national:A1.
Despite all his precautions, an error killed his mother. Pittsburgh Post-Gazette. October 28, 1993; national:A13.
Hospital computer reveals the future. Pittsburgh Post-Gazette. October 28, 1993; national:A13.
A hospital drug mix-up turns into fatal error. Pittsburgh Post-Gazette. October 24, 1993; national:A8.
Hospitals blind to each other's mistakes.Pittsburgh Post-Gazette. October 27, 1993; national:A1.
Hospitals to discuss prevention: regional forum will share ideas, methods. October 31, 1993; national:A1.
How two lost lives helped to reform a state. Pittsburgh Post-Gazette. October 27, 1993; national:A8.
Lessons hard to learn if state requires secrecy. Pittsburgh Post-Gazette. October 27, 1993; national:A8.
"My God! That must be what I gave." Pittsburgh Post-Gazette. October 25, 1993; national:A6.
Prescriptions fraught with danger. Pittsburgh Post-Gazette. October 25, 1993; national:A1.
The slow search for an antidote to health care's deadly problem. Pittsburgh Post-Gazette. October 28, 1993; national:A13.
Syringe confusion leaves a trail of deadly mix-ups. Pittsburgh Post-Gazette. October 26, 1993; national:A1.
Tragic errors strike baby 3 times. Pittsburgh Post-Gazette. October 25, 1993; national:A7.

B-3
Zion S. At long last, some docs 'fess up. New York Daily News. October 13, 1997; opinion.

Section C. Uncelebrated cases
 
These items represent areas where some other research base is available and are chosen because they highlight some of the factors believed to affect success and failure in the particular area.

Of particular note are the results of the Harvard Medical Practice Study. This seminal study has stimulated many to look harder at the factors affecting patient safety. The study has been widely quoted and its extrapolations have become the basis for many of the estimates of the "cost of error" and scope of the problem as well as the source of sometimes heated debate within the medical community.

C-1
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH.
Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991; 324:370-376.

Leape LL, Brennan TA, Laird N, et al.
The nature of adverse events in hospitalized patients: results of the Harvard medical Practice Study II. N Engl J Med. 1991; 324:377-384

C-2
Stewart L, Way LW. Bile duct injury during laparoscopic cholecystectomy: factors that influence the results of treatment. Arch Surg. 1995; 130:1123-1128.

Way LW.
Bile duct injury during laparoscopic cholecystectomy (editorial comment). Annals of Surgery. 1992; 215:195.

C-3
Dominguez CO, Flach JM, McKellar DP, Dunn M.
Using videotaped cases to elicit perceptual expertise in laparoscopic surgery. Proceedings: Third Annual Symposium on Human Interaction With Complex Systems: HICS '96. Los Alamitos, Calif:IEEE Computer Society Press, 116-123

C-4
Cook RI, Wood DD, Howie MB, Morrow JC, Galsa DM.
Unintentional delivery of vasoactive drugs with an electromechanical infusion device. Journal of Cardiothoracic and Vascular Anesthesia. 1992; 6(2): 238-244.

C-5
Bates DW, Leape LL.
Pharmacies and prevention of potentially fatal drug interactions. JAMA. 1996; 275:1088

Cavuto NJ, Woosley RL. Sale M.
Pharmacies and prevention of potentially fatal drug interactions. JAMA. 1996; 275:1088

Kraft KE, Dore FH.
Computerized drug interaction programs: how reliable? JAMA. 1996; 275:1088.

C-6
Smith PJ, Galdes D, Fraser J, Miller T, Smith JW Jr, Svirbely JR, Blazina J, Kennedy M, Rudmann S, Thomas DL.
Coping with the complexities of multiple-solution problems: a case study. Int J Man-Machine Studies. 1991; 35:429-453.

C-7
Guerlain S.
Using the critiquing approach to cope with brittle expert systems. Proceedings of the 1995 Annual Meeting of the Human Factors and Ergonomics Society.

C-8
American Academy of Orthopaedic Surgeons.
Report of the AAOS Task Force on Wrong Site Surgery.
Advisory statement: wrong-site surgery. September, 1997.

Canadian Orthopaedic Association. Committee on Practice and Economics. Position paper on wrong sided surgery in orthopaedics. June 10, 1994.

C-9
Cook RI. Human error in the ICU: an episode. 1996.

West S, Walch K, Youngberg, BJ. (1994)
Risk management program development. In: Youngberg BJ (ed). The Risk Manager's Desk Reference. Gaithersburg, MD: Aspen.

Addendum

Billings CE.
Some hopes, and concerns, regarding medical event reporting systems: lessons from the NASA Aviation Safety Reporting System (ASRS). Arch Pathol Lab Med. 1998; 122(3): 214-215

Donchin Y, Gopher D, Badihi Y.
Recording and analysis of human errors in the intensive care unit - mission possible?!

Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov R, Cotev S.
A look into the nature and causes of human errors in the intensive care unit. Critical care medicine 1995; 23 no. 2:294-300.

Fischhoff B.
Communicate unto others... Reliability Engineering and System Safety. 1998.

Gaba D.
Organizational structures, cultures, and system aspects of safety in tertiary health care: a comparison with other high-risk industries. (Submitted to the Robert Wood Johnson Foundation Investigator Awards in Health Policy grant program, July, 1996).

Goldschmidt G, Donchin Y.
Breathing circuit disconnection during mechanical ventilation can be prevented! A human factors look into a system: report of a case and analysis.

Grabowski M, Roberts K.
Risk mitigation in large-scale systems: lessons from high reliability organizations. California Management Review. Summer, 1997; 39 no. 4:152-162.

Leape LL.
A systems analysis approach to medical error. Journal of Evaluation in Clinical Practice. 1997; 3 no.3:213-222.

Margolis H.
Introduction: Why the public and the experts disagree on environmental issues. In Dealing With Risk. Chicago: The University of Chicago Press, 1996:1-5.

Rasmussen J.
Risk management in a dynamic society: a modeling problem. Safety Science. In press.

Roberts KH, Libuser C.
From Bhopal to banking: organizational design can mitigate risk. In Organizational Dynamics. American Management Association, 1993:15-26.

Tasca LL.
The social construction of human error [dissertation]. Stony Brook: The State University of New York; 1990:iii, iv, vi, 23-60.