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Bitan Y

Between Choice and Chance: The Role of Human Factors in Acute Care Equipment Decisions
    (2009), Journal of Patient Safety , 5(2) , 114-121
Can a log of infusion device events be used to understand infusion accidents?
    (2007), Journal of Patient Safety , 3(4) , 208-13
Determining the Weights of Scheduling and Responding in the Control of a Dynamic System
    (2003), Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting
Failure in context: linking observed behavior to cognition, tasks, and adverse events
    (2005), Anesthesiology , 103 , A1296
Learning from investigation: Experience with understanding healthcare adverse events
    (2006), Proceedings of the Human Factors and Ergonomics Society Annual Meeting , San Francisco, CA
Let the record show: an infusion device doesn't record critical evidence
    (2007), Anesthesiology , 107 , A1600
Not a black box: infusion devices are not used like aviation data recorders in accident analysis
    (2007), Anesthesiology , 107 , A1595
Nurses' reactions to alarms in a neonatal intensive care unit
    (2004), Cognition, Technology & Work , 6(4) , 239-46
Scheduling of Actions and Reliance on Warnings in a Simulated Control Task
    (1999), Proceeding sof the Human Factors and Ergonomics Society 43rd Annual Meeting , 251-5
Scheduling of Activities and Responding to Alarms in the Control of a Complex System
    (2003), Dissertation Submitted to the Senate of Ban-Gurion University of the Negev
Self-initiated and respondent actions in a simulated control task
    (2007), Ergonomics , 50(5) , 763-88
Staff Actions and Alarms in a Neonatal Intensive Care Unit
    (2000), Proceedings of the Human Factors and Ergonomics Society 44th Annual Meeting
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), Journal of Patient Safety , 2(3) , 124-31
Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety
    (2009), Quality and Safety in Health Care , 18(6) , 505-9
What are they saying? Device logs don't tell us as much as they could about events
    (2007), Anesthesiology , 107 , A1598
Why Better Operators Receive Worse Warnings
    (2002), Human Factors , 44(3) , 343-53

Cook RI

"Those found responsible have been sacked": some observations on the usefulness of error
    (2010), Cognition, Technology & Work , 12 , 87-93
A Brief Look at Gaps in the Continuity of Care and how Practitioners Compensate for Them
    (2005)
A brief look at Going Solid and the Dynamics of Safety
    (2005)
A Brief Look at the New Look in Complex System Failure, Error, Safety & Resilience
    (2005)
A Study of How Cognitive Artifacts Affect Distributed Cognition in Operating Room Management
    (2002), Anesthesiology , 97(3A) , A1183
A Tale of Two Stories: Contrasting Views of Patient Safety
    (1998), National Health Care Safety Council of the National Patient Safety Foundation at the AMA , Chicago
Above Board: Issues in Medical Account Investigation and Analysis
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting
Adapting to New Technology in the Operating Room
    (1996), Human Factors , 38(4) , 593-613
Afterwords: The Quality of Medical Accident Investigations and Analyses
    (2004), Human Factors and Ergonomics Society National Conference , New Orleans
Automation, interaction, complexity and failure: A case study
    (2005), Paper presented at the 2nd Workshop on Complexity in Design and Engineering , University of Glasgow, Scotland
Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work Analysis
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 757-63
Before I forget: How clinicians cope with uncertainty through ICU sign-outs
    (2006), Proceedings of the Human Factors and Ergonomics Society Annual Meeting , San Francisco, CA
Behind Human Error: Taming Complexity to Improve Patient Safety
    (2007), In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ , Lawrence Erlbaum Associates , 459-76
Being Bumpable: Consequences of Resource Saturation and Near-Saturation for Cognitive Demands on ICU Practitioners
    (2006), Joint Cognitive Systems: Patterns in Cognitive Systems Engineering , 23-35
Being Bumpable:Consequences of Resource Saturation and Near-saturation for Cognitive Demand on ICU Practitioners
    (2003), International Anesthesia Research Society National Conference , New Orleans
Between Choice and Chance: The Role of Human Factors in Acute Care Equipment Decisions
    (2009), Journal of Patient Safety , 5(2) , 114-121
Between Shifts: Healthcare Communication in the PICU
    (2008), In Nemeth CP (Ed.), Improving Healthcare Team Communication , Aldershot: Ashgate , 135-53
BIS Monitoring to Prevent Awareness During General Anesthesia
    (2001), Anesthesiology , 94(3) , 520-2
Brave New World: Medical Devices, Clinical Information Systems, Networks, and Patient Safety
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting
Case 2-1992. Unintentional Delivery of Vasoactive Drugs with an Electromechanical Infusion Devise
    (1992), Journal of Cardiothoracic and Vascular Anesthesia , 6(2) , 238-44
Characteristics of Patient Safety
    (1998)
Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding
    (2005), Advances in Patient Safety: From Research to Implementation , Agency for Healthcare Research. Washington, DC. 2 , 279-92
Collaborative Cross-Checking to Enhance Resilience
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting , 512-6
Collaborative cross-checking to enhance resilience
    (2007), Cognition, Technology & Work , 9(3) , 155-62
Crafting Information Technology Solutions, Not Experiments, for the Emergency Department
    (2004), Academic Emergency Medicine , 11(11) , 1114-7
Creating resilient IT: How the sign-out sheet shows clinicans make healthcare work
    (2006), Proceedings of the American Medical Informatics Association Annual Symposium , Washington, DC , 584-8
Deriving the Most Benefit from Bar Coded Medication Administration
    (2004), APSF Newsletter , 19(2) , 24
Discovering and Supporting Temporal Cognition in Complex Environments
    (2004), In Proceedings of theTwenty-Sixth Annual Conference of the Cognitive Science Society , Chicago , 1005-10
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work
    (2006), Organization Studies: Special issue on Naturalistic Decision Making , 27(7) , 1011-35
Discovering variability in infusion device flow rates by automated gravimetric measurement
    (2005), Anesthesiology , 103 , A885
Distancing Through Differencing: An Obstacle to Organizational Learning Following Accidents
    (2006), In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts , Aldershot: Ashgate , 329-38
Distributed cognition: how hand-off communication actually works
    (2005), Anesthesiology , 103 , A1289
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims
    (2003), SCCM , San Antonio
Evaluating the Human Enginering of Microprocessor-Controlled Operating Room Devices
    (1991), Journal of Clinical Monitoring , 7(3) , 217-26
Examining the Complexity Behind a Medication Error: Generic Patterns in Communication
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 749-56
Failure in context: linking observed behavior to cognition, tasks, and adverse events
    (2005), Anesthesiology , 103 , A1296
Features of Infusion Device Related Incidents Revealed by Systematic Analysis of an Incident Reporting Database
    (2002), Anesthesiology , 97(3A) , A1073
Fixing Drug and Pump Mismatches: How Practitioners Make Up the Difference Through Coping Strategies
    (2004), Anesthesiology , 101 , A1284
For resilient IT: Don't mimic the past, leverage the future
    (2008), Conference on Systems Engineering Research , Redondo Beach, CA
From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety.
    (2001), In Zipperer L & Cushman S (Eds.). Lessons in Patient Safety. A Primer , National Patient Safety Foundation. Chicago, 89-97
Gaps and resilience
    (2007), In MS Bogner (Ed). Human Error in Medicine (2nd ed.) , (in press)
Gaps in the continuity of care and progress on patient safety
    (2000), British Medical Journal , 320(7237) , 791-4
Getting to the Point: Developing IT for the Sharp End of Healthcare
    (2005), Journal of Biomedical Informatics , 38(1) , 18-25
Going Solid: A Model of System Dynamics and Consequences for Patient Safety
    (2005), Quality & Safety in Health Care , 14(2) , 130-4
Healthcare IT as a Source of Resilience
    (2007), In Nemeth, C. (chair) Symposium on Resilience in Health Systems. Proceedings of the International Conference on Systms, Man and Cybernetics , Montreal
Hiding in plain sight: What Koppel et al. Tell Us About Healthcare IT
    (2005), Journal of Biomedical Informatics , 38 (4) , 262-3
Hobson’s choices: Matching and mismatching in transplantation work processes
    (2006), In Wailoo K, Livingston J & Guarnaccia P (Eds.). A Death Retold: Jesica Santillan, the Bungled Transplant, and Paradoxes of Medical Citizenship , University of North Carolina Press , 46-69
How Cognitive Artifact Support of Acute Care Distributed Cognition Affects Patient Safety
    (2004), International Conference on Probabilistic Safety Assessment and Management (PSAM) Conference , Berlin
How Complex Systems Fail
    (2000)
How Complex Systems Fail
    (2010), In Allspaw J & Robbins J. Web Operations: Keeping the Data On Time , 0
Human Performance in Anesthesia: A Corpus of Cases
    (1991), CSEL Report CSEL91.003
Human-Computer Interaction in Context: Physician Interaction with Automated Intravenous Controllers in the Heart Room
    (1993), In HG Stassen (Ed), Analysis, Design and Evaluation of Man-Machine Systems 1992 , New York: Pergamon Press , 263-74
Implications of Automation Surprises in Aviation for TIVA
    (1996), Journal of Clinical Anesthesia , 8(3 Suppl) , 29S-37S
Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration
    (2002), Journal of the American Medical Information Association , 9(5) , 540-53
Incidents - Markers of Resilience or Brittleness?
    (2006), In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts , Aldershot: Ashgate , 69-76
Infusion Device Characteristics Related to User Error during Programming and Operation Determined by Finite State Modeling
    (2002), Anesthesiology , 97(3A) , A520
Laying Traps: How Infusion Device Interface Design Contributes to Adverse Events
    (2004), Anesthesiology , 101 , A1296
Learning from investigation: Experience with understanding healthcare adverse events
    (2006), Proceedings of the Human Factors and Ergonomics Society Annual Meeting , San Francisco, CA
Learning Theories Implicit in Medical School Lectures
    (1989), JAMA , 261(15) , 2244-5
Lessons from the War on Cancer
    (2005), Journal of Patient Safety , 1(1) , 7-8
Let the record show: an infusion device doesn't record critical evidence
    (2007), Anesthesiology , 107 , A1600
Lost in Menuspace: User Interactions with Complex Medical Devices.
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 736-42
Lost in Menuspace: Variability among Users Programming Infusion Devices under Controlled Conditions
    (2002), Anesthesiology , 97(3A) , A521
Making Information Technology a Team Player in Safety: The Case of Infusion Devices.
    (2005), In K. Henricksen & J. B. Battles & E. Marks & D. I. Lewin (Eds.). Advances in Patient Safety: From Research to Implementation , Agency for Health Care Research. Washington, DC. 1 , 319-30
Making Sense of Risks: A Field Study in an Intensive Care Unit
    (2005), In Tartaglia R, Bagnara S Bellandi T & Albolino S (Eds). Healthcare Systems Ergonomics and Patient Safety , 208-14
Mapping Cognitive Work: The Way Out of Healthcare IT System Failures
    (2005), Proceedings of the American Medical Informatics Association Annual Symposium , Washington, DC , 560-4
Medical event data collection and analysis service (MEDCAS), an NTSB for medicine
    (2007), Anesthesiology , 107 , A1789
Minding the gaps: Creating resilience in healthcare, In K Henriksen, JB Battles, MA Keyes and ML Grady (Eds.)
    (2008), Advances in patient safety: New directions and alternative approaches. Vol. 3. Performance and Tools, AHRQ Publication No. 08-0034-3 , Rockville, MD: AHRQ , 259-71
Mistaking error
    (2004), In Youngberg BJ & Hatlie MJ (eds), The Patient Safety Handbook , Sundbury, MA: Jones and Bartlett Publishers , 95-108
New Artic Air Crash Aftermath Role-Play Simulation: Orchestrating a Fundamental Surprise
    (2001), Proceedings of the Human Factors and Ergonomics Society 45th Annual Meeting
Nine Steps to Move Forward from Error
    (2002), Cognitive Technology & Work , 4(2) , 137-44
Not a black box: infusion devices are not used like aviation data recorders in accident analysis
    (2007), Anesthesiology , 107 , A1595
Observations on RISKS and Risks
    (1997), Communications of the ACM , 40(3) , 122
On Attributing Critical Incidents to Factors in the Environment
    (1989), Anesthesiology , 71(5) , 808
Operating at the Sharp End: The Complexity of Human Error
    (1994), In Bogner MS (Ed.). Human Error in Medicine , Hillsdale, NJ , Lawrence Erlbaum Associates. 255-310
Operating at the sharp end: The human factors of complex technical work and its implication for patient safety
    (2004), In Manuel BM & Nora PF (eds), Surgical Patient Safety: Essential Information for Surgeons in Today's Environment , Chicago: American College of Surgeons , 19-30
Perspectives on Human Error: Hindsight Bias and Local Rationality
    (1999), In Durso F, Nickerson R & Schvanevelt J (Eds.). Handbook of Applied Cognition , New York , John Wiley & Sons, 141-71
Probabilistic Risk Assessment of Accidental ABO-Incompatible Thoracic Organ Transplantation Before and After 2003
    (2007), Transplantation , 84(12) , 162-9
Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare
    (2007), Cognition, Technology and work , 9(3) , 139-48
Reliability Versus Resilience: What Does Healthcare Really Need?
    (2007), In Dominguez, C. (chair) Symposium on High Reliability in Healthcare. Proceedings of the Human Factors and Ergonomics Society Annual Meeting , Baltimore , 621-5
RePresenting Reality: The Human Factors of Health Care Information
    (2007), In Carayon, P. (Ed.). The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ , Lawrence Erlbaum Associates , 439-55
Safety Technology: Solutions or Experiments
    (2002), Nursing Economics , 20(2) , 80-2
SARS, emerging infections, and bioterrorism preparedness
    (2004), The Lancet infectious diseases , 4 , 483-4
Scenarios for bedside medical data communication
    (1988), ACM SIGBIO Newsletter , 10(4) , 8-14
Seeing is Believing
    (2003), Annals of Surgery , 237(4) , 472-3
Sensemaking, safety, and cooperative work in the intensive care unit
    (2007), Cognition, Technology & Work , 9(3) , 131-7
Studying the technical work of Emergency Care
    (2007), Annals of Emergency Medicine , 50(4) , 384-6
Syringe pump assemblies and the natural history of clinical technology
    (2000), Canadian Journal of Anesthesia , 47(10) , 929-35
Taking Things in One's Stride: Cognitive Features of Two Resilient Preformances
    (2006), In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts , Aldershot: Ashgate , 205-21
Technical Work Studies: Understanding Human Work Amid Complexity, Uncertainty, and Conflict
    (2004), Administration for Healthcare Research and Quality 3rd Annual Patient Safety Research Conference , Arlington, VA
Temporal Cognitive Work: Discovering Requirements for Digital Artifacts
    (2005), Eleventh International Conference on Human-Computer Interaction , Las Vegas
The Cognitive Systems Engineering of Automated Medical Evacuation Scheduling and its Implications
    (1996), 3rd Annual Symposium of Human Interaction with Complex Systems , Dayton, OH
The End of the Beginning: Complexity and Craftsmanship and the Era of Sustained Work on Patient Safety
    (2001), The Joint Commision Journal on Quality Improvement , 27(10) , 507-8
The Illusion of Explanation
    (2004), Acedemic Emergency Medicine , 11(10) , 1064-5
The Impact of Technology on Physician Cognition and Performance
    (1995), Journal of Clinical Monitoring , 11(1) , 5-8
The Messy Details: Insights from Technical Work in Healthcare
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 689-92
The Path to Resilience in Ambulatory Care
    (2008), AHRQ 2008 Conference: Promoting Quality...Partnering for Change
The Role of Automation in Complex System Failures
    (2005), Journal of Patient Safety , 1(1) , 56-61
Thinking About Accidents and Systems
    (2005), In Manasse HR & Thompson KK (Eds.), Medication Safety: A Guide to Health Care Facilities , Bethesda, MD:ASHP , 73-87
Three Key Levers for Achieving Resilience in Medication Delivery with Information Technology
    (2006), Journal of Patient Safety , 2(1) , 33-8
To err is not always human
    (2006), Medicine on the Midway , 60(1) , 40-1
Toward a Theory of Patient Safety - Lessons From the First Decade
    (2005), In Tartaglia R, Bagnara S Bellandi T & Albolino S (Eds). Healthcare Systems Ergonomics and Patient Safety , 23-6
Two Years Before the Mast: Learning How to Learn about Patient Safety
    (1998), Enhancing Patient Safety and Reducing Errors in Health Care , Rancho Mirage, CA
Understanding Sign Outs: Conversation Analysis Reveals ICU Handoff Content and Form
    (2004), Critical Care Medicine , 32 (12) , A29
Upper Bound for Performance of Incident Reporting Systems Based on Experience with Phase III Adverse Event Reporting
    (2002), Anesthesiology , 97(3A) , A1089
Using Cognitive Artifacts to Understand Distributed Cognition
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 726-35
Using Cognitive Artifacts to Understand Distributed Cognition (HFES)
    (2003), In Xiao Y, Special Session on Distributed Planning. IEEE International Conference on Systems, Man & Cybernetics , Washington, DC
Using Finite State Modeling To Compare and Contrast Infusion Devices in the Context of Device Specificity
    (2003), Anesthesiology , 99(3A) , A532
Verite, Abstraction, and Ordinateur Systems in the Evolution of Complex Process Control
    (1996), 3rd Annual Symposium of Human Interaction with Complex Systems , Dayton, OH
What are they saying? Device logs don't tell us as much as they could about events
    (2007), Anesthesiology , 107 , A1598
What went wrong at the Beatson Oncology Centre
    (2008), In Hollnagel E, Nemeth CP & Dekker S (Eds.), Resilience Engineering Perspectives, Volume 1: Remaining Sensitive to the Possibility of Failure , Aldershot: Ashgate , 225-35
What's Missing
    (2008), Presentation at the International System Safety Conference 2008
Who's Sorry Now?
    (2002), SEA Meeting

Klock PA

A Study of How Cognitive Artifacts Affect Distributed Cognition in Operating Room Management
    (2002), Anesthesiology , 97(3A) , A1183
Before I forget: How clinicians cope with uncertainty through ICU sign-outs
    (2006), Proceedings of the Human Factors and Ergonomics Society Annual Meeting , San Francisco, CA
Between Shifts: Healthcare Communication in the PICU
    (2008), In Nemeth CP (Ed.), Improving Healthcare Team Communication , Aldershot: Ashgate , 135-53
Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding
    (2005), Advances in Patient Safety: From Research to Implementation , Agency for Healthcare Research. Washington, DC. 2 , 279-92
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work
    (2006), Organization Studies: Special issue on Naturalistic Decision Making , 27(7) , 1011-35
Distributed cognition: how hand-off communication actually works
    (2005), Anesthesiology , 103 , A1289
Getting to the Point: Developing IT for the Sharp End of Healthcare
    (2005), Journal of Biomedical Informatics , 38(1) , 18-25
How Cognitive Artifact Support of Acute Care Distributed Cognition Affects Patient Safety
    (2004), International Conference on Probabilistic Safety Assessment and Management (PSAM) Conference , Berlin
Making Information Technology a Team Player in Safety: The Case of Infusion Devices.
    (2005), In K. Henricksen & J. B. Battles & E. Marks & D. I. Lewin (Eds.). Advances in Patient Safety: From Research to Implementation , Agency for Health Care Research. Washington, DC. 1 , 319-30
Mapping Cognitive Work: The Way Out of Healthcare IT System Failures
    (2005), Proceedings of the American Medical Informatics Association Annual Symposium , Washington, DC , 560-4
Temporal Cognitive Work: Discovering Requirements for Digital Artifacts
    (2005), Eleventh International Conference on Human-Computer Interaction , Las Vegas
Using Cognitive Artifacts to Understand Distributed Cognition
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 726-35
Using Cognitive Artifacts to Understand Distributed Cognition (HFES)
    (2003), In Xiao Y, Special Session on Distributed Planning. IEEE International Conference on Systems, Man & Cybernetics , Washington, DC

Nemeth CP

"Those found responsible have been sacked": some observations on the usefulness of error
    (2010), Cognition, Technology & Work , 12 , 87-93
A Healthcare Team Communication Research Agenda
    (2008), In Nemeth CP (Ed.), Improving Healthcare Team Communication , Aldershot: Ashgate , 245-50
A Study of How Cognitive Artifacts Affect Distributed Cognition in Operating Room Management
    (2002), Anesthesiology , 97(3A) , A1183
Above Board: Issues in Medical Account Investigation and Analysis
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting
Afterwords: The Quality of Medical Accident Investigations and Analyses
    (2004), Human Factors and Ergonomics Society National Conference , New Orleans
Assessing Risk: The Role of Probabilistic Risk Assessment (PRA) in Patient Safety Improvement
    (2004), Quality & Safety in Health Care , 13(3) , 206-12
Before I forget: How clinicians cope with uncertainty through ICU sign-outs
    (2006), Proceedings of the Human Factors and Ergonomics Society Annual Meeting , San Francisco, CA
Being Bumpable:Consequences of Resource Saturation and Near-saturation for Cognitive Demand on ICU Practitioners
    (2003), International Anesthesia Research Society National Conference , New Orleans
Between Choice and Chance: The Role of Human Factors in Acute Care Equipment Decisions
    (2009), Journal of Patient Safety , 5(2) , 114-121
Between Shifts: Healthcare Communication in the PICU
    (2008), In Nemeth CP (Ed.), Improving Healthcare Team Communication , Aldershot: Ashgate , 135-53
Brave New World: Medical Devices, Clinical Information Systems, Networks, and Patient Safety
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting
Clinical human-centered research: Bridging social science and engineering
    (2006), Paper presented at the ABMS-ACGME: Assessing and Improving Patient Care Conference , Rosemont, IL
Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding
    (2005), Advances in Patient Safety: From Research to Implementation , Agency for Healthcare Research. Washington, DC. 2 , 279-92
Cognitive Artifacts in Complex Work.
    (2005), In Cai Y (Ed.). Ambient Intelligence for Scientific Discovery: Foundations, Theories, and Systems. Lecture Notes in Computer Science , 3345 , 152-83
Crafting Information Technology Solutions, Not Experiments, for the Emergency Department
    (2004), Academic Emergency Medicine , 11(11) , 1114-7
Creating resilient IT: How the sign-out sheet shows clinicans make healthcare work
    (2006), Proceedings of the American Medical Informatics Association Annual Symposium , Washington, DC , 584-8
Discovering and Supporting Temporal Cognition in Complex Environments
    (2004), In Proceedings of theTwenty-Sixth Annual Conference of the Cognitive Science Society , Chicago , 1005-10
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work
    (2006), Organization Studies: Special issue on Naturalistic Decision Making , 27(7) , 1011-35
Discovering variability in infusion device flow rates by automated gravimetric measurement
    (2005), Anesthesiology , 103 , A885
Distributed cognition: how hand-off communication actually works
    (2005), Anesthesiology , 103 , A1289
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims
    (2003), SCCM , San Antonio
Failure in context: linking observed behavior to cognition, tasks, and adverse events
    (2005), Anesthesiology , 103 , A1296
Fixing Drug and Pump Mismatches: How Practitioners Make Up the Difference Through Coping Strategies
    (2004), Anesthesiology , 101 , A1284
For resilient IT: Don't mimic the past, leverage the future
    (2008), Conference on Systems Engineering Research , Redondo Beach, CA
Further Thoughts on Being Forehanded
    (2004), Conference on Surgical Errors , U.S. Army Medical Command (MEDCOM) , Washington, DC
Get Real: The Need for Effective Design Research. Special Issue: Research in Communication Design
    (2003), Visible Language , 37(1)
Getting to the Point: Developing IT for the Sharp End of Healthcare
    (2005), Journal of Biomedical Informatics , 38(1) , 18-25
Groups at work: lessons from research into large-scale coordination
    (2007), Cognition, Technology & Work , 9(1) , 1-4
Health Care Forensics.
    (2005), In Noy, YI. and Karwowski, W. (Eds.). Handbook of Human Factors in Litigation , New York, CRC Press , 37-1 to 37-18
Healthcare groups at work: further lessons from research into large-scale coordination
    (2007), Cognition, Technology & Work , 9(3) , 127-30
Healthcare IT as a Source of Resilience
    (2007), In Nemeth, C. (chair) Symposium on Resilience in Health Systems. Proceedings of the International Conference on Systms, Man and Cybernetics , Montreal
Hiding in plain sight: What Koppel et al. Tell Us About Healthcare IT
    (2005), Journal of Biomedical Informatics , 38 (4) , 262-3
How Cognitive Artifact Support of Acute Care Distributed Cognition Affects Patient Safety
    (2004), International Conference on Probabilistic Safety Assessment and Management (PSAM) Conference , Berlin
How Cognitive Artifacts Support Acute Care Distributed Cognition. In Cook R, Woods D, Insights From Technical Work Studies in Healthcare
    (2003), Symposium at Human Factors and Ergonomics Society National Conference , Denver , 381-5
Human Factors Methods for Design
    (2004), Book , London , Taylor and Francis/ CRC Press
Large Scale Coordination: The Study of Groups at Work
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting , 527-8
Laying Traps: How Infusion Device Interface Design Contributes to Adverse Events
    (2004), Anesthesiology , 101 , A1296
Learning from investigation: Experience with understanding healthcare adverse events
    (2006), Proceedings of the Human Factors and Ergonomics Society Annual Meeting , San Francisco, CA
Lost in Menuspace: User Interactions with Complex Medical Devices.
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 736-42
Making Information Technology a Team Player in Safety: The Case of Infusion Devices.
    (2005), In K. Henricksen & J. B. Battles & E. Marks & D. I. Lewin (Eds.). Advances in Patient Safety: From Research to Implementation , Agency for Health Care Research. Washington, DC. 1 , 319-30
Mapping Cognitive Work: The Way Out of Healthcare IT System Failures
    (2005), Proceedings of the American Medical Informatics Association Annual Symposium , Washington, DC , 560-4
Medical event data collection and analysis service (MEDCAS), an NTSB for medicine
    (2007), Anesthesiology , 107 , A1789
Minding the gaps: Creating resilience in healthcare, In K Henriksen, JB Battles, MA Keyes and ML Grady (Eds.)
    (2008), Advances in patient safety: New directions and alternative approaches. Vol. 3. Performance and Tools, AHRQ Publication No. 08-0034-3 , Rockville, MD: AHRQ , 259-71
Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare
    (2007), Cognition, Technology and work , 9(3) , 139-48
Reliability Versus Resilience: What Does Healthcare Really Need?
    (2007), In Dominguez, C. (chair) Symposium on High Reliability in Healthcare. Proceedings of the Human Factors and Ergonomics Society Annual Meeting , Baltimore , 621-5
Replacing hindsight with insight: Toward better understanding of diagnostic failures
    (2007), Annals of Emergency Medicine , 49(2) , 206-9
RePresenting Reality: The Human Factors of Health Care Information
    (2007), In Carayon, P. (Ed.). The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ , Lawrence Erlbaum Associates , 439-55
Resilience Engineering Perspectives, Volume 1: Remaining Sensitive to the Possibility of Failure
    (2008), Book , Aldershot,UK: Ashgate Publishing
Resilience Engineering: The Birth of a Notion
    (2008), In Hollnagel E, Nemeth CP & Dekker S (Eds.), Resilience Engineering Perspectives, Volume 1: Remaining Sensitive to the Possibility of Failure , Aldershot: Ashgate , 3-9
Studying the technical work of Emergency Care
    (2007), Annals of Emergency Medicine , 50(4) , 384-6
Taking Things in One's Stride: Cognitive Features of Two Resilient Preformances
    (2006), In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts , Aldershot: Ashgate , 205-21
Technical Work Studies: Understanding Human Work Amid Complexity, Uncertainty, and Conflict
    (2004), Administration for Healthcare Research and Quality 3rd Annual Patient Safety Research Conference , Arlington, VA
Temporal Cognitive Work: Discovering Requirements for Digital Artifacts
    (2005), Eleventh International Conference on Human-Computer Interaction , Las Vegas
The Context for Improving Healthcare Team Communications
    (2008), In Nemeth CP (Ed.), Improving Healthcare Team Communication , Aldershot: Ashgate , 1-7
The Master Schedule: How Cognitive Artifacts Affect Distributed Cognition in Acute Care
    (2003), Dissertation Abstracts International 64/08 , 3990, (UMI No. AAT 3101124)
The Messy Details: Insights from Technical Work in Healthcare
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 689-92
The Path to Resilience in Ambulatory Care
    (2008), AHRQ 2008 Conference: Promoting Quality...Partnering for Change
Understanding Sign Outs: Conversation Analysis Reveals ICU Handoff Content and Form
    (2004), Critical Care Medicine , 32 (12) , A29
Using Cognitive Artifacts to Understand Distributed Cognition
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 726-35
Using Cognitive Artifacts to Understand Distributed Cognition (HFES)
    (2003), In Xiao Y, Special Session on Distributed Planning. IEEE International Conference on Systems, Man & Cybernetics , Washington, DC
What went wrong at the Beatson Oncology Centre
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Nunnally ME

O'Connor MF

Being Bumpable:Consequences of Resource Saturation and Near-saturation for Cognitive Demand on ICU Practitioners
    (2003), International Anesthesia Research Society National Conference , New Orleans
BIS Monitoring to Prevent Awareness During General Anesthesia
    (2001), Anesthesiology , 94(3) , 520-2
Central Venous Oxygen Saturation Does Not Correlate with Serum Lactate in Patients with Cardiogenic Shock after Cardiac Surgery
    (2005), Anesthesiology , 103 , A293
Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding
    (2005), Advances in Patient Safety: From Research to Implementation , Agency for Healthcare Research. Washington, DC. 2 , 279-92
Crafting Information Technology Solutions, Not Experiments, for the Emergency Department
    (2004), Academic Emergency Medicine , 11(11) , 1114-7
Creating resilient IT: How the sign-out sheet shows clinicans make healthcare work
    (2006), Proceedings of the American Medical Informatics Association Annual Symposium , Washington, DC , 584-8
Deriving the Most Benefit from Bar Coded Medication Administration
    (2004), APSF Newsletter , 19(2) , 24
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work
    (2006), Organization Studies: Special issue on Naturalistic Decision Making , 27(7) , 1011-35
Discovering variability in infusion device flow rates by automated gravimetric measurement
    (2005), Anesthesiology , 103 , A885
Distributed cognition: how hand-off communication actually works
    (2005), Anesthesiology , 103 , A1289
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims
    (2003), SCCM , San Antonio
Don't Close the Valve! The Effect of Closing the Valve on Ventilation in Patients Undergoing ECT
    (2006), Anesthesiology , 105 , A939
Failure in context: linking observed behavior to cognition, tasks, and adverse events
    (2005), Anesthesiology , 103 , A1296
Fixing Drug and Pump Mismatches: How Practitioners Make Up the Difference Through Coping Strategies
    (2004), Anesthesiology , 101 , A1284
For resilient IT: Don't mimic the past, leverage the future
    (2008), Conference on Systems Engineering Research , Redondo Beach, CA
Getting to the Point: Developing IT for the Sharp End of Healthcare
    (2005), Journal of Biomedical Informatics , 38(1) , 18-25
How Cognitive Artifact Support of Acute Care Distributed Cognition Affects Patient Safety
    (2004), International Conference on Probabilistic Safety Assessment and Management (PSAM) Conference , Berlin
Laying Traps: How Infusion Device Interface Design Contributes to Adverse Events
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Lost in Menuspace: Variability among Users Programming Infusion Devices under Controlled Conditions
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Making Information Technology a Team Player in Safety: The Case of Infusion Devices.
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Mapping Cognitive Work: The Way Out of Healthcare IT System Failures
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Medical event data collection and analysis service (MEDCAS), an NTSB for medicine
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Operating at the sharp end: The human factors of complex technical work and its implication for patient safety
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Please Do Not Leave Your Bags Unattended!
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Potassium Administration and Drug Safety
    (1998), Proceedings of the Human Factors and Ergonomics Society National Conference , Chicago
Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare
    (2007), Cognition, Technology and work , 9(3) , 139-48
RePresenting Reality: The Human Factors of Health Care Information
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Return to Sender(s): More Questions Than Answers
    (2002), Third International Conference on the Nature and Source of Human Error , Chicago. Washington, DC , U.S. Food and Drug Administration
SARS, emerging infections, and bioterrorism preparedness
    (2004), The Lancet infectious diseases , 4 , 483-4
Sensemaking, safety, and cooperative work in the intensive care unit
    (2007), Cognition, Technology & Work , 9(3) , 131-7
Temporal Cognitive Work: Discovering Requirements for Digital Artifacts
    (2005), Eleventh International Conference on Human-Computer Interaction , Las Vegas
The Ambu Bag is Superior to the Mapleson D for Hyperventilating Electroconvulsive Therapy Patients
    (2006), Anesthesiology , 105 , A1277
Thinking About Accidents and Systems
    (2005), In Manasse HR & Thompson KK (Eds.), Medication Safety: A Guide to Health Care Facilities , Bethesda, MD:ASHP , 73-87
Upper Bound for Performance of Incident Reporting Systems Based on Experience with Phase III Adverse Event Reporting
    (2002), Anesthesiology , 97(3A) , A1089
Using Cognitive Artifacts to Understand Distributed Cognition
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 726-35
Using Cognitive Artifacts to Understand Distributed Cognition (HFES)
    (2003), In Xiao Y, Special Session on Distributed Planning. IEEE International Conference on Systems, Man & Cybernetics , Washington, DC
Using Finite State Modeling To Compare and Contrast Infusion Devices in the Context of Device Specificity
    (2003), Anesthesiology , 99(3A) , A532