High-Risk Organizations_ Human Error _ Human Factors

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					  The Society of Thoracic Surgeons Patient Safety Information

              High-Risk Organizations, Human Error & Human Factors

The similarities between healthcare and other complex, high-risk organizations became apparent in the
1990s. The works of James Reason and the dramatic improvement in aviation safety have had an
increasing effect on health care systems around the world. See Organizations & Online Resources for
information on Crew Resource Management (CRM) and its application to health care.

Pronovost PJ, et al. Creating High Reliability in Health Care Organizations. Health Serv Res 2006 Aug;41(4
Pt 2):1599-617.

Mills P, Neily J, Dunn E. Teamwork and Communication in Surgical Teams: Implications for Patient
Safety. J Am Coll Surg 2008 Jan;206(1):107-12.

McGreevy JM, Otten TD. Briefing and debriefing in the operating room using fighter pilot crew resource
management. J Am Coll Surg 2007 Jul;205(1):169-76

Lingard L, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and
anesthesiologists to reduce failures in communication. Arch Surg 2008 Jan;143(1):12-7.

Greenberg CC, et al. Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients. J
Am Coll Surg 2007 Apr;204(4):533-40.

Amalberti R, et al, Five System Barriers to Achieving Ultrasafe Health Care. Ann Intern Med 2005 May

Barach P, S. S. (2000). Reporting and Preventing Medical Mishaps: Lessons from Non-Medical
Near Miss Reporting Systems. BMJ 2000; 320(7237): 753– 63. 320(7237): 753-63.

Gawron, V. J., C. G. Drury, et al. (2006). Medical Error and Human Factors Engineering: Where are
We Now? Am J Med Qual 21(1): 57-67.

Helmreich, R.L. (1997). Managing Human Error in Aviation. Sci Am 276(5): 62-7.

Reason, J. (1990). The Contribution of Latent Human Failures to the Breakdown of Complex
Systems. Philos Trans R Soc Lond B Biol Sci 327(1241): 475-84.

Spencer, F.C. (2000). Human Error in Hospitals and Industrial Accidents: Current Concepts. J Am
Coll Surg 191(4): 410-8.

Vincent, C. (2003). Understanding and Responding to Adverse Events. N Engl J Med 348(11): 1051-

Mayo Clinic Human Factors web site:

Barach, P. (2003). The End of the Beginning: Lessons Learned from the Patient Safety Movement.
J Leg Med 24(1): 7-27.

Gosbee, J. (2002). Human Factors Engineering and Patient Safety. Qual Saf Health Care 11(4): 352-

Green, R. (1999). The Psychology of Human Error. Eur J Anaesthesiol 16(3): 148-55.
Reason, J. (1995). Understanding Adverse Events: Human Factors. Qual Health Care 4(2): 80-9.

Reason, J. (2000). Human Error: Models and Management. Bmj 320(7237): 768-70.

Schaefer, H. G et al (1995). Safety in the Operating Theatre: Part 1: Interpersonal Relationships
and Team Performance, Curr Anaesth Crit Care, 6 48-53.

Reason, J. (2005). Safety in the Operating Theatre: Part II: Human Error and Organizational
Failure. Qual Saf Health Care 14(1): 56-60.

Singleton, W.T. (1973). Theoretical Approaches to Human Error. Ergonomics 16(6): 727-37.

Weick, K.E. Organizational Culture as a Source of High Reliability. Calif Manage Rev. 1987;29:112-

Wiegmann, D.A., S., Scott. A Human Error Approach to Aviation Accident Analysis: The Human
Factors Analysis and Classification System. (2003). Ashgate Publishing Company: Burlington, VT.

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