From cognition to the system: developing a multilevel taxonomy of patient safety in general practice

References

• Annett , J. and Duncan , K. 1967 . Task analysis and training design . Occupational Psychology , 41 : 211 – 221 .
   Google Scholar
• Audit Commission . 2002 . A Focus on General Practice in England , London : Audit Commission for Local Authorities and the National Health Service in England and Wales .
   Google Scholar
• Bhasale , A. , Miller , G. , Reid , S. and Britt , H. 1998 . Analysing potential harm in Australian general practice: an incident-monitoring study . Medical Journal of Australia , 169 : 73 – 76 .
   PubMed Web of Science ®Google Scholar
• Bogner , M. 2003 . Safety issues . Minimally Invasive Therapy & Allied Technologies , 12 : 121 – 124 .
   PubMed Web of Science ®Google Scholar
• Busse , D. and Johnson , C. 1999 . Identification and Analysis of Incidents in Complex, Medical Environments , Glasgow, , Scotland : Department of Computing Science, University of Glasgow . GAAG Technical Report G99 – 1, First Workshop on Human Error and Clinical Systems
   Google Scholar
• Coles , J. , Pryce , D. and Shaw , C. 2001 . “ The reporting of adverse clinical incidents – achieving high quality reporting: the results of a short research study. Report for the Patient Safety Research Programme in England ” . Available online at: http://pcpoh.bham.ac.uk/publichealth/psrp/Pdf/coles_shaw_adverse_clinical_incidents.pdf (accessed 20 October 2004)
   Google Scholar
• Department of Health . 2000 . An Organisation with a Memory , London : The Stationery Office .
   Google Scholar
• Dovey , S. , Meyers , D. , Phillips , R. J. , Green , L. , Fryer , G. , Galliher , J. , Kappus , J. and Grob , P. 2002 . A preliminary taxonomy of medical errors in family practice . Quality and Safety in Health Care , 11 : 233 – 238 .
   PubMed Web of Science ®Google Scholar
• Flanagan , J. C. 1954 . The critical incident technique . Psychological Bulletin , 51 : 327 – 358 .
   PubMed Web of Science ®Google Scholar
• Fleishman , E. and Quaintance , M. 1984 . Taxonomies of Human Performance: The Description of Human Tasks , Orlando, FL : Academic Press, Inc. .
   Google Scholar
• Isaac , A. , Shorrock , S. and Kirwan , B. 2002 . Human error in European air traffic management: the HERA project . Reliability Engineering & System Safety , 75 : 257 – 272 .
   Web of Science ®Google Scholar
• Kaplan , H. and Rabin Fastman , B. 2003 . Organization of event reporting data for sense making and system improvement . Quality and Safety in Health Care , 12 ( supp. 2 ) : 68 – 72 .
   Google Scholar
• Kirwan , B. 1994 . A Guide to Practical Human Reliability Assessment , London : Taylor & Francis .
   Google Scholar
• Kirwan , B. 1998 . Human error identification techniques for risk assessment of high risk systems – Part 1: Review and evaluation of techniques . Applied Ergonomics , 29 : 157 – 177 .
   PubMed Web of Science ®Google Scholar
• Kostopoulou , O. and Shepherd , A. 2000 . Fragmentation of care and the potential for human error in neonatal intensive care . Topics in Health Information Management (special edition of Human Error in Clinical Information Systems) , 20 : 78 – 92 .
   Google Scholar
• Luchins , A. 1942 . Mechanization in problem solving. The effect of Einstellung . Psychological Monographs , 54 : 248
   Google Scholar
• Moray , N. 1994 . “ Error reduction as a systems problem ” . In Human Error in Medicine , Edited by: Bogner , M. 67 – 91 . Hillsdale, NJ : Lawrence Erlbaum Associates .
   Google Scholar
• Nickerson , R. 1998 . Confirmation bias: a ubiquitous phenomenon in many guises . Review of General Psychology , 2 : 175 – 220 .
   Google Scholar
• Norman , D. 1988 . The Psychology of Everyday Things , New York : Basic Books .
   Google Scholar
• O'Hare , D. 2000 . The ‘Wheel of Misfortune’: a taxonomic approach to human factors in accident investigation and analysis in aviation and other complex systems . Ergonomics , 43 : 2001 – 2019 .
   PubMed Web of Science ®Google Scholar
• Rasmussen , J. 1982 . Human errors: a taxonomy for describing human malfunction in industrial installations . Journal of Occupational Accidents , 4 : 311 – 333 .
   Google Scholar
• Rasmussen , J. 1994 . “ Afterword ” . In Human Error in Medicine , Edited by: Bogner , M. 385 – 393 . Hillsdale, NJ : Lawrence Erlbaum Associates .
   Google Scholar
• Rasmussen , J. , Pedersen , O. , Carnino , A. , Griffon , M. , Mancini , G. and Gagnolet , P. 1981 . Classification System for Reporting Events Involving Human Malfunctions , Luxemburg : Commission of the European Communities . EUR 7444 EN
   Google Scholar
• Rasmussen , J. , Pejtersen , A. and Schmidt , K. 1990 . Taxonomy for Cognitive Work Analysis , Roskilde, , Denmark : Riso National Laboratory . Riso-M-2871
   Google Scholar
• Reason , J. 1987 . “ A framework for classifying errors ” . In New technology and Human Error , Edited by: Rasmussen , J. , Duncan , K. and Leplat , J. Chichester : Wiley .
   Google Scholar
• Reason , J. 1990 . Human Error , Cambridge : Cambridge University Press .
   Google Scholar
• Reason , J. 1997 . Managing the Risks of Organizational Accidents , Aldershot : Ashgate .
   Google Scholar
• Rubin , G. , George , A. , Chinn , D. and Richardson , C. 2003 . Errors in general practice: development of an error classification and pilot study of a method for detecting errors . Quality and Safety in Health Care , 12 : 443 – 447 .
   PubMed Web of Science ®Google Scholar
• Sellen , A. 1994 . Detection of everyday errors . Applied Psychology: An International Review , 43 : 475 – 498 .
   Web of Science ®Google Scholar
• Senders , J. W. and Moray , N. 1991 . Human Error: Cause, Prediction, and Reduction , 89 Hove : Lawrence Erlbaum Associates .
   Google Scholar
• Shen , S. -H. , Smidts , C. and Mosleh , A. 1997 . A methodology for collection and analysis of human error data based on a cognitive model: IDA . Nuclear Engineering and Design , 172 : 157 – 186 .
   Web of Science ®Google Scholar
• Shepherd , A. 2001 . Hierarchical Task Analysis , London : Taylor & Francis .
   Google Scholar
• Shorrock , S. and Kirwan , B. 2002 . Development and application of a human error identification tool for air traffic control . Applied Ergonomics , 33 : 319 – 336 .
   PubMed Web of Science ®Google Scholar
• Silk , N. 2000 . What went wrong in 1000 negligence claims . Health Care Risk Report , 7 : 13 – 15 .
   Google Scholar
• Tversky , A. and Kahneman , D. 1982 . “ Availability: a heuristic for judging frequency and probability ” . In Judgment Under Uncertainty: Heuristics and Biases , Edited by: Kahneman , D. , Slovic , P. and Tversky , A. 163 – 178 . New York : Cambridge University Press .
   Google Scholar
• van der Schaaf , T. 1992 . “ Near miss reporting in the chemical process industry ” . Nederlands : Technische Universiteit Eindhoven . PhD thesis
   Google Scholar
• van der Schaaf , T. and Kanse , L. 2004 . Biases in incident reporting databases: an empirical study in the chemical process industry . Safety Science , 42 : 57 – 67 .
   Web of Science ®Google Scholar
• Wallace , B. , Ross , A. , Davies , J. , Wright , L. and White , M. 2002 . The creation of a new minor event coding system . Cognition, Technology & Work , 4 : 1 – 8 .
   Google Scholar
• Wickens , C. 1992 . Engineering Psychology and Human Performance , 2nd ed. , New York : Harper-Collins .
   Google Scholar
• Wickens , C. and Hollands , J. 2000 . Engineering Psychology and Human Performance , 3rd ed. , New Jersey : Prentice Hall .
   Google Scholar
• Wolf , F. , Gruppen , L. and Billi , J. 1985 . Differential diagnosis and the competing hypotheses heuristic: A practical approach to judgment under uncertainty and Bayesian probability . The Journal of the American Medical Association , 253 : 2858 – 2862 .
   Web of Science ®Google Scholar
• Zhang , J. , Patel , V. , Johnson , T. and Shortliffe , E. 2004 . A cognitive taxonomy of medical errors . Journal of Biomedical Informatics , 37 : 193 – 204 .
   PubMed Web of Science ®Google Scholar