A brief look at Going Solid and the Dynamics of Safety
    [2005] (84 KB)
A Brief Look at the New Look in Complex System Failure, Error, Safety & Resilience
    [2005] (929 KB)
A Tale of Two Stories: Contrasting Views of Patient Safety
    [1998] (1068 KB)
Above Board: Issues in Medical Account Investigation and Analysis
    [2005] (339 KB)
Afterwords: The Quality of Medical Accident Investigations and Analyses
    [2004] (173 KB)
Assessing Risk: The Role of Probabilistic Risk Assessment (PRA) in Patient Safety Improvement
    [2004] (144 KB)
Automation, interaction, complexity and failure: A case study
    [2005]
Behind Human Error: Taming Complexity to Improve Patient Safety
    [2007] (1.9 MB)
Characteristics of Patient Safety
    [1998] (22 KB)
Collaborative Cross-Checking to Enhance Resilience
    [2005] (66 KB)
Engaging Data, How Practitioners Resolve Complex Information
    [2008] (14 KB)
Failure in context: linking observed behavior to cognition, tasks, and adverse events
    [2005] (724 KB)
From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety.
    [2001] (3631 KB)
Gaps in the continuity of care and progress on patient safety
    [2000] (226 KB)
Going Solid: A Model of System Dynamics and Consequences for Patient Safety
    [2005] (174 KB)
Hobson’s choices: Matching and mismatching in transplantation work processes
    [2006] (1.32 MB)
How Complex Systems Fail
    [2000] (35 KB)
Learning from investigation: Experience with understanding healthcare adverse events
    [2006] (145 KB)
Let the record show: an infusion device doesn't record critical evidence
    [2007] (34 KB)
Lost in Menuspace: Variability among Users Programming Infusion Devices under Controlled Conditions
    [2002] (17 KB)
Medical event data collection and analysis service (MEDCAS), an NTSB for medicine
    [2007] (18 KB)
Mistaking error
    [2004] (1.52 MB)
New Artic Air Crash Aftermath Role-Play Simulation: Orchestrating a Fundamental Surprise
    [2001] (49 KB)
Nine Steps to Move Forward from Error
    [2002] (84 KB)
Not a black box: infusion devices are not used like aviation data recorders in accident analysis
    [2007] (17 KB)
Operating at the Sharp End: The Complexity of Human Error
    [1994] (669 KB)
Operating at the sharp end: The human factors of complex technical work and its implication for patient safety
    [2004] (2.2MB)
Probabilistic Risk Assessment of Accidental ABO-Incompatible Thoracic Organ Transplantation Before and After 2003
    [2007] (863 KB)
Replacing hindsight with insight: Toward better understanding of diagnostic failures
    [2007] (88KB)
Scenarios for bedside medical data communication
    [1988] (565 KB)
The End of the Beginning: Complexity and Craftsmanship and the Era of Sustained Work on Patient Safety
    [2001] (172 KB)
The Illusion of Explanation
    [2004] (43 KB)
The Role of Automation in Complex System Failures
    [2005] (101 KB)
Thinking About Accidents and Systems
    [2005] (345 KB)
To err is not always human
    [2006]
Toward a Theory of Patient Safety - Lessons From the First Decade
    [2005] (398 KB)
Two Years Before the Mast: Learning How to Learn about Patient Safety
    [1998] (994 KB)
Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety
    [2009] (494 KB)
Who's Sorry Now?
    [2002] (101 KB)

A Study of How Cognitive Artifacts Affect Distributed Cognition in Operating Room Management
    [2002] (569 KB)
Before I forget: How clinicians cope with uncertainty through ICU sign-outs
    [2006]
Being Bumpable: Consequences of Resource Saturation and Near-Saturation for Cognitive Demands on ICU Practitioners
    [2006] (7,702 KB)
Being Bumpable:Consequences of Resource Saturation and Near-saturation for Cognitive Demand on ICU Practitioners
    [2003] (200 KB)
Between Choice and Chance: The Role of Human Factors in Acute Care Equipment Decisions
    [2009] (475KB)
Between Shifts: Healthcare Communication in the PICU
    [2008]
Brave New World: Medical Devices, Clinical Information Systems, Networks, and Patient Safety
    [2005] (164 KB)
Clinical human-centered research: Bridging social science and engineering
    [2006]
Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding
    [2005] (644 KB)
Cognitive Artifacts in Complex Work.
    [2005] (1.52 MB)
Collaborative cross-checking to enhance resilience
    [2007] (133 KB)
Creating resilient IT: How the sign-out sheet shows clinicans make healthcare work
    [2006]
Discovering and Supporting Temporal Cognition in Complex Environments
    [2004] (1.07 MB)
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work
    [2006] (2.21 MB)
Distributed cognition: how hand-off communication actually works
    [2005] (1.01 MB)
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims
    [2003] (161 KB)
Engaging Data, How Practitioners Resolve Complex Information
    [2008] (14 KB)
Failure in context: linking observed behavior to cognition, tasks, and adverse events
    [2005] (724 KB)
First Do No Harm: Expertise and Metacognition in Laparoscopic Surgery
    [1997] (587 KB)
Groups at work: lessons from research into large-scale coordination
    [2007] (116 KB)
Healthcare IT as a Source of Resilience
    [2007] (184 KB)
How Cognitive Artifact Support of Acute Care Distributed Cognition Affects Patient Safety
    [2004] (322 KB)
How Cognitive Artifacts Support Acute Care Distributed Cognition. In Cook R, Woods D, Insights From Technical Work Studies in Healthcare
    [2003] (144 KB)
Human Performance in Anesthesia: A Corpus of Cases
    [1991]
Large Scale Coordination: The Study of Groups at Work
    [2005] (142 KB)
Learning from investigation: Experience with understanding healthcare adverse events
    [2006] (145 KB)
Making Information Technology a Team Player in Safety: The Case of Infusion Devices.
    [2005] (361 KB)
Making Sense of Risks: A Field Study in an Intensive Care Unit
    [2005] (4992 KB)
New Artic Air Crash Aftermath Role-Play Simulation: Orchestrating a Fundamental Surprise
    [2001] (49 KB)
On Attributing Critical Incidents to Factors in the Environment
    [1989] (604 KB)
Perspectives on Human Error: Hindsight Bias and Local Rationality
    [1999] (17189 KB)
Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare
    [2007] (266 KB)
Reliability Versus Resilience: What Does Healthcare Really Need?
    [2007] (79 KB)
RePresenting Reality: The Human Factors of Health Care Information
    [2007] (1.45 MB)
Sensemaking, safety, and cooperative work in the intensive care unit
    [2007] (461 KB)
The Cognitive Systems Engineering of Automated Medical Evacuation Scheduling and its Implications
    [1996] (791 KB)
The Context for Improving Healthcare Team Communications
    [2008] (716 KB)
The Path to Resilience in Ambulatory Care
    [2008]
Understanding Sign Outs: Conversation Analysis Reveals ICU Handoff Content and Form
    [2004] (161 KB)
Using Cognitive Artifacts to Understand Distributed Cognition
    [2004] (1221 KB)
Using Cognitive Artifacts to Understand Distributed Cognition (HFES)
    [2003] (54 KB)

Adapting to New Technology in the Operating Room
    [1996] (11,680 KB)
Brave New World: Medical Devices, Clinical Information Systems, Networks, and Patient Safety
    [2005] (164 KB)
Can a log of infusion device events be used to understand infusion accidents?
    [2007] (307 KB)
Case 2-1992. Unintentional Delivery of Vasoactive Drugs with an Electromechanical Infusion Devise
    [1992] (4849 KB)
Discovering variability in infusion device flow rates by automated gravimetric measurement
    [2005] (446 KB)
Features of Infusion Device Related Incidents Revealed by Systematic Analysis of an Incident Reporting Database
    [2002] (13 KB)
Fixing Drug and Pump Mismatches: How Practitioners Make Up the Difference Through Coping Strategies
    [2004] (1093 KB)
Human-Computer Interaction in Context: Physician Interaction with Automated Intravenous Controllers in the Heart Room
    [1993] (28 KB)
Implications of Automation Surprises in Aviation for TIVA
    [1996] (582)
Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration
    [2002] (308 KB)
Infusion Device Characteristics Related to User Error during Programming and Operation Determined by Finite State Modeling
    [2002] (14 KB)
Laying Traps: How Infusion Device Interface Design Contributes to Adverse Events
    [2004] (300 KB)
Let the record show: an infusion device doesn't record critical evidence
    [2007] (34 KB)
Lost in Menuspace: User Interactions with Complex Medical Devices.
    [2004] (566 KB)
Lost in Menuspace: Variability among Users Programming Infusion Devices under Controlled Conditions
    [2002] (17 KB)
Making Information Technology a Team Player in Safety: The Case of Infusion Devices.
    [2005] (361 KB)
Not a black box: infusion devices are not used like aviation data recorders in accident analysis
    [2007] (17 KB)
Safety Technology: Solutions or Experiments
    [2002] (576 KB)
Scenarios for bedside medical data communication
    [1988] (565 KB)
Studying the technical work of Emergency Care
    [2007] (68 KB)
Syringe pump assemblies and the natural history of clinical technology
    [2000] (45.1 KB)
The Impact of Technology on Physician Cognition and Performance
    [1995] (388 KB)
Three Key Levers for Achieving Resilience in Medication Delivery with Information Technology
    [2006] (138 KB)
Time to Get Off This Pig's Back? The Human Factors Aspects of the Mismatch Between Device and Real-World Knowledge in the Health Care Environment
    [2006] (356 KB)
Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety
    [2009] (494 KB)
Using Finite State Modeling To Compare and Contrast Infusion Devices in the Context of Device Specificity
    [2003] (17 KB)
What are they saying? Device logs don't tell us as much as they could about events
    [2007] (16 KB)
Why Better Operators Receive Worse Warnings
    [2002] (2.26 MB)

Getting to the Point: Developing IT for the Sharp End of Healthcare
    [2005] (643 KB)
Hiding in plain sight: What Koppel et al. Tell Us About Healthcare IT
    [2005] (84 KB)
Three Key Levers for Achieving Resilience in Medication Delivery with Information Technology
    [2006] (138 KB)

A Study of How Cognitive Artifacts Affect Distributed Cognition in Operating Room Management
    [2002] (569 KB)
Clinical human-centered research: Bridging social science and engineering
    [2006]
Human Factors Methods for Design
    [2004]
Lessons from the War on Cancer
    [2005] (1635 KB)
Using Finite State Modeling To Compare and Contrast Infusion Devices in the Context of Device Specificity
    [2003] (17 KB)