High Reliability Organization Research: A Literature Review for Health Care

References

• Alahmadi, H. A. (2010). Assessment of patient safety culture in Saudi Arabian hospitals. Quality and Safety in Health Care, 19(5), 1–5.
   Google Scholar
• Amalberti, R., Auroy, Y., Berwick, D., & Barach, P. (2005). Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine, 142(9), 756–764.
   PubMed Web of Science ®Google Scholar
• Bagnara, S., Parlangeli, O., & Tartagli, R. (2010). Are hospitals becoming high reliability organizations? Applied Ergonomics, 41(5), 713–718.
   PubMed Web of Science ®Google Scholar
• Baker, D. P., Day, R., & Salas, E. (2006). Teamwork as an essential component of high-reliability organizations. Health Services Research, 41(4), 1576–1598.
   PubMed Web of Science ®Google Scholar
• Barnsteiner, J. (2011). Teaching the culture of safety. Online Journal of Issues in Nursing, 16(3). doi:10.3912/OJIN.Vol16No03Man05
   PubMedGoogle Scholar
• Benn, J., Healey, A. N., & Hollnagel, E. (2008). Improving performance reliability in surgical systems. Cognition, Technology & Work, 10(4), 323–333.
   Google Scholar
• Beruvides, M., Cantu, J., Simonton, J., Tolk, J., Bromley, M., & McElwain, K. (2012). Comprehensive systems modeling approach to high reliability organizations. Paper presented at the 2012 American Society of Engineering Management International Annual Conference, American Society of Engineering Management, Virginia Beach, VA.
   Google Scholar
• Biles, M. M., Geary, M., Ries, R. J., Needy, K. L., & Cashion, M. K. (2010). A method for quantifying the benefits of greening a healthcare facility. Engineering Management Journal, 22(3), 3–11.
   Google Scholar
• Blouin, A. S., & McDonagh, K. J. (2011). Framework for patient safety, Part 1: Culture as an imperative. The Journal of Nursing Administration, 41(10), 397–400.
   PubMed Web of Science ®Google Scholar
• Bonner, A. F., Castle, N. G., Perera, S., & Handler, S. M. (2008). Patient safety culture? A review of the nursing home literature and recommendations for practice. Annals of Long-Term Care, 16(3), 18–22.
   Google Scholar
• Bourrier, M. (2011). The legacy of the high reliability organization project. Journal of Contingencies and Crisis Management, 19(1), 9–13.
   Web of Science ®Google Scholar
• Brady, P. W., Meuthing, S., Kotagal, U., Gallagher, R., Hall, D., Goodfriend, M. … Wheeler, D. S. (2005). Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics, 131(1), 298–308.
   Web of Science ®Google Scholar
• Brilli, R. J., McClead Jr., R. E., Crandall, W. V., Stoverock, L., Berry, J. C., Wheeler, T. A., & Davis, J. T. (2013). A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. Journal of Pediatrics, 163(6), 1638–1645.
   PubMed Web of Science ®Google Scholar
• Brusoni, M., Deriu, P. L., Panzeri, C., & Trinchero, E. (2009). A research method in safety culture for the safety of health services in Italy [Un metodo di indagine sulla safety culture per la sicurezza dei servizi sanitari in Italia]. Mecosan, 18(69), 63, 85.
   Google Scholar
• Callender, C., & Grasman, S. E. (2010). Barriers and best practices for material management in the healthcare sector. Engineering Management Journal, 22(4), 11–19.
   Web of Science ®Google Scholar
• Carroll, J. S., & Rudolph, J. W. (2006). Design of high reliability organizations in health care. Quality & Safety in Health Care, 15(Suppl 1), i4–i9.
   PubMedGoogle Scholar
• Chassin, M. R., & Loeb, J. M. (2013). High-reliability health care: Getting there from here. Milbank Quarterly, 91(3), 459–490.
   PubMed Web of Science ®Google Scholar
• Christianson, M. K., Sutcliffe, K. M., Miller, M. A., & Iwashyna, T. J. (2011). Becoming a high reliability organization. Critical Care (London, England), 15(6), 314.
   PubMed Web of Science ®Google Scholar
• Clarke, J. R., Lerner, J. C., & Marella, W. (2007). The role for leaders of health care organizations in patient safety. American Journal of Medical Quality: The Official Journal of the American College of Medical Quality, 22(5), 311–318.
   PubMed Web of Science ®Google Scholar
• Colla, J. B., Bracken, A. C., Kinney, L. M., & Weeks, W. B. (2005). Measuring patient safety climate: A review of surveys. Quality and Safety in Health Care, 14(5), 364–366.
   PubMed Web of Science ®Google Scholar
• Collmann, J., Coleman, J., Sostrom, K., & Wright, W. (2004). Organizing safety: Conditions for successful information assurance programs. Telemedicine Journal and E-Health, 10(3), 311–320.
   PubMed Web of Science ®Google Scholar
• Cooke, D. L., Dunscombe, P. B., & Lee, R. C. (2007). Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centre. Quality and Safety in Health Care, 16(5), 342–348.
   PubMed Web of Science ®Google Scholar
• Cooke, H. (2009). Theories of risk and safety: What is their relevance to nursing? Journal of Nursing Management, 17(2), 256–264.
   PubMed Web of Science ®Google Scholar
• Cooren, F. (2004). The communicative achievement of collective minding: Analysis of Board meeting excerpts. Management Communication Quarterly, 17(4), 517–551.
   Google Scholar
• Dalton, G. D., Samaropoulos, X. F., & Dalton, A. C. (2008). Quality improvement training: Experiences of frontline staff. Health Policy, 86, 153–162.
   PubMed Web of Science ®Google Scholar
• Denyer, D., & Tranfield, D. (2006). Using qualitative research synthesis to build an actionable knowledge base. Management Decision, 44(2), 213–227.
   Google Scholar
• Denyer, D., Tranfield, D., & Van Aken, J. E. (2008). Developing design propositions through research synthesis. Organization Studies, 29(3), 393–413.
   Web of Science ®Google Scholar
• Despins, L. A., Scott-Cawiezell, J., & Rouder, J. N. (2010). Detection of patient risk by nurses: A theoretical framework. Journal of Advanced Nursing, 66(2), 465–474.
   PubMed Web of Science ®Google Scholar
• Dixon, N. M., & Shofer, M. (2006). Struggling to invent high-reliability organizations in health care setting: Insights from the field. Health Services Research, 41(2), 1618–1632.
   PubMed Web of Science ®Google Scholar
• Dupree, E., O’Neill, L., & Anderson, R. M. (2005). Achieving a safety culture in obstetrics. Mount Sinai Journal of Medicine, 76(6), 529–538.
   Google Scholar
• Dupree, W. B., & Lin, F. (2008). Patient safety: A macrosystems perspective. Clinics in Laboratory Medicine, 28(2), 189–205.
   PubMed Web of Science ®Google Scholar
• Eisenlohr, A., Render, M. L., & Patterson, E. S. (2002). Creating patient safety with organizational learning: A case-based learning intervention at a public and private hospital. Paper presented at the Human Factors and Ergonomics Society 46th Annual Meeting, Baltimore, MD.
   Google Scholar
• Frederickson, H. G., & La Porte, T. R. (2002). Airport security, high reliability, and the problem of rationality. Public Administration Review, 62, 33–43. [Special Issue: Democratic Governance in the Aftermath of September 11, 2001].
   Web of Science ®Google Scholar
• Freeth, D., Sandall, J., Allan, T., Warburton, F., Berridge, E. J., Mackintosh, N. … Abbott, S. (2012). A methodological study to compare survey-based and observation-based evaluations of organisational and safety cultures and then compare both approaches with markers of the quality of care. Health Technology Assessment, 16(25), 1–183.
   Web of Science ®Google Scholar
• Gaba, D. M., Singer, S. J., Sinaiko, A. D., Bowen, J. D., & Ciavarelli, A. P. (2003). Differences in safety climate between hospital personnel and naval aviators. Human Factors: The Journal of the Human Factors and Ergonomics Society, 45(2), 175–185.
   Google Scholar
• Glover, W. J., Farris, J. A., & Van Aken, E. M. (2014). Kaizen events: Assessing the existing literature and convergence of practices. Engineering Management Journal, 26(1), 39–61.
   Web of Science ®Google Scholar
• Goldenhar, L. M., Brady, P. W., Sutcliffe, K. M., & Muething, S. E. (2013). Huddling for high reliability and situation awareness. BMJ Quality & Safety, 22(11), 899–906.
   PubMed Web of Science ®Google Scholar
• Gough, D., Oliver, S., & Thomas, J. (2012). An introduction to systematic reviews. Thousand Oaks, CA: Sage Publications, Inc.
   Google Scholar
• Groves, P. S., Meisenbach, R. J., & Scott-Cawiezell, J. (2011). Keeping patients safe in healthcare organizations: A structuration theory of safety culture. Journal of Advanced Nursing, 67(8), 1846–1855.
   PubMed Web of Science ®Google Scholar
• Hamdan, M. (2013). Measuring safety culture in Palestinian neonatal intensive care units using the Safety Attitudes Questionnaire. Journal of Critical Care, 28(5), 886.e7–14.
   PubMed Web of Science ®Google Scholar
• Hansen, L. O., Williams, M. V., & Singer, S. J. (2011). Perceptions of hospital safety climate and incidence of readmission. Health Services Research, 46(2), 596–616.
   PubMed Web of Science ®Google Scholar
• Hartmann, C. W., Meterko, M., Rosen, A. K., Zhao, S., Shokeen, P., Singer, S., & Gaba, D. M. (2009). Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration. Medical Care Research and Review, 66(3), 320–338.
   PubMed Web of Science ®Google Scholar
• Hartmann, C. W., Rosen, A. K., Meterko, M., Shokeen, P., Zhao, S., Singer, S., & Gaba, D. M. (2008). An overview of patient safety climate in the VA. Health Services Research, 43(4), 1263–1284.
   PubMed Web of Science ®Google Scholar
• Haugen, A. S., Softeland, E., Eide, G. E., Nortvedt, M. W., Aase, K., & Harthug, S. (2010). Patient safety in surgical environments: Cross-countries comparison of psychometric properties and results of the Norwegian version of the hospital survey on patient safety. BMC Health Services Research, 10(1), 279.
   PubMed Web of Science ®Google Scholar
• Health and Safety Laboratory for the Health and Safety Executive (HSE). (2011). High reliability organisations: A review of the literature. London, UK: Crown.
   Google Scholar
• Heightman, A. J. (2013). A win for HROs: Employing high-reliability organization characteristics in EMS. JEMS, A Journal of Emergency Medical Services, 38(6), 12–13.
   Google Scholar
• Historical View of Health Care IT. (2006). ADVANCE for health information executives, 10, 40. King of Prussia, PA: Advance Healthcare Network.
   Google Scholar
• Hobgood, C., Hevia, A., & Hinchey, P. (2004). Profiles in patient safety: When an error occurs. Academic Emergency Medicine, 11(7), 766–770.
   PubMed Web of Science ®Google Scholar
• Hobgood, C., Xie, J., Weiner, B., & Hooker, J. (2004). Error identification, disclosure, and reporting: Practice patterns of three emergency medicine provider types. Academic Emergency Medicine, 11(2), 196–199.
   PubMed Web of Science ®Google Scholar
• Hudson, P. (2003). Applying the lessons of high risk industries to health care. Quality and Safety in Health Care, 12(Suppl 1), 7i–12.
   PubMed Web of Science ®Google Scholar
• Iedema, R., Sorensen, R., Braithwaite, J., Flabouris, A., & Turnbull, L. (2005). The teleo-affective limits of end-of-life care in the intensive care unit. Social Science and Medicine, 60(4), 845–857.
   PubMed Web of Science ®Google Scholar
• Institute of Medicine (IOM) Committee on Quality of Health Care in America. (1999). To err is human: Building a safer health system. Washington, DC: National Academies Press.
   Google Scholar
• Jeffcott, S. A., Ibrahim, J. E., & Cameron, P. A. (2009). Resilience in healthcare and clinical handover. Quality and Safety in Health Care, 18(4), 256–260.
   PubMed Web of Science ®Google Scholar
• Joint Commission Center for Transforming Healthcare. (2009). Joint Commission Center for Transforming Healthcare takes aim at patient safety failures [News Release]. Retrieved from http://www.centerfortransforminghealthcare.org/
   Google Scholar
• Jones, D. N., Thomas, M. J., Mandel, C. J., Grimm, J., Hannaford, N., Schultz, T. J., & Runciman, W. (2010). Where failures occur in the imaging care cycle: Lessons from the radiology events register. Journal of the American College of Radiology, 7(8), 593–602.
   PubMed Web of Science ®Google Scholar
• Kane, R. L., & Mosser, G. (2006). The challenge of explaining why quality improvement has not done better. International Journal for Quality in Health Care, 19(1), 8–10.
   PubMed Web of Science ®Google Scholar
• Katz-Navon, T., Naveh, E., & Stern, Z. (2005). Safety climate in health care organizations: A multidimensional approach. Academy of Management Journal, 48(6), 1075–1089.
   Web of Science ®Google Scholar
• Keenan, G., Yakel, E., & Marriott, D. (2006). HANDS: A revitalized technology supported care planning method to improve nursing handoffs. Studies Health Technology Information Journal, 122, 580–584.
   PubMedGoogle Scholar
• Kemper, C., & Boyle, K. (2009). Leading your organization to high reliability. Nursing Management, 40(4), 18.
   Google Scholar
• Khatri, N., Brown, G. D., & Hicks, L. L. (2009). From a blame culture to a just culture in health care. Health Care Management Review, 34(4), 312–322.
   PubMed Web of Science ®Google Scholar
• Klemets, J., Evjemo, T. E., & Kristiansen, L. (2013). Designing for redundancy: Nurses experiences with the wireless nurse call system. Studies of Health Technology and Informatics, 192, 328–332.
   PubMedGoogle Scholar
• Kliger, A. S. (2006). Patient safety in the dialysis facility. Blood Purification, 24(1), 19–21.
   PubMed Web of Science ®Google Scholar
• Knox, G. E., & Simpson, K. R. (2011). Perinatal high reliability. American Journal of Obstetrics and Gynecology, 204(5), 373–377.
   PubMed Web of Science ®Google Scholar
• Kruke, B. I., & Olsen, O. E. (2005). Reliability-seeking networks in complex emergencies. International Journal of Emergency Management, 2(4), 275–291.
   Google Scholar
• LaPorte, T. R. (1996). High reliability organization: Unlikely, demanding and at risk. Journal of Contingencies and Crisis Management, 4(2), 60–71.
   Google Scholar
• Lasaki, O., Makin, A. M., & Winder, C. (2011). Applying the Safe Place, Safe Person, Safe Systems framework to the healthcare industry. In C. Berenguer, A. Grall, & C. Guedes Soares (Eds.), Advances in safety, reliability, and risk management (pp. 1175–1183). New York, NY: CRC Press..
   Google Scholar
• Leape, L. L., Shore, M. F., Dienstag, J. L., Mayer, R. J., Edgman-Levitan, S., Meyer, G. S., & Healy, G. B. (2012). A culture of respect, Part 2: Creating a culture of respect. Academic Medicine: Journal of the Association of American Medical Colleges, 87(7), 853–858.
   PubMed Web of Science ®Google Scholar
• Ludwig, P. E. (1971). Dollars and sense. Battle Creek, MI: W. K. Kellogg Foundation.
   Google Scholar
• Lyndon, A., & Kennedy, H. P. (2010). Perinatal safety: From concept to nursing practice. The Journal of Perinatal & Neonatal Nursing, 24(1), 22–31.
   PubMed Web of Science ®Google Scholar
• Maamoun, J. (2009). An introduction to patient safety. Journal of Medical Imaging and Radiation Sciences, 40(3), 123–133.
   Google Scholar
• Mallak, L. A., & Lyth, D. M. (2009). Using desired culture analysis to manage decentralized operations. Engineering Management Journal, 21(2), 27–32.
   Web of Science ®Google Scholar
• Matlow, A. (2013). Front-line ownership: Imagine. Healthcare Papers, 13(1), 69–74.
   PubMedGoogle Scholar
• May, E. L. (2013). The power of zero: Steps toward a high reliability health care. Healthcare Executive, 28(2), 16–24.
   PubMedGoogle Scholar
• Mazur, L., McCreery, J., & Rothenberg, L. (2012). Facilitating lean learning and behaviors in hospitals during the early stages of lean implementation. Engineering Management Journal, 24(1), 11–22.
   Web of Science ®Google Scholar
• McCabe, E. R. (2014). Newborn screening: A complex system that requires a culture of safety. Molecular Genetics and Metabolism, 113(1–2), 6–7.
   PubMed Web of Science ®Google Scholar
• McCarthy, D., & Blumenthal, D. (2006). Stories from the sharp end: Case studies in safety improvement. Milbank Quarterly, 84(1), 165–200.
   PubMed Web of Science ®Google Scholar
• McFadden, K. L., Henagan, S. C., & Gowen, C. R. (2009). The patient safety chain: Transformational leadership’s effect on patient safety culture, initiatives, and outcomes. Journal of Operations Management, 27(5), 390–404.
   Web of Science ®Google Scholar
• McFerran, S., Nunes, J., Pucci, D., & Zuniga, A. (2005). Perinatal patient safety project: A multicenter approach to improve performance reliability at Kaiser Permanente. Journal of Perinatal and Neonatal Nursing, 19(1), 37–45.
   PubMed Web of Science ®Google Scholar
• McKeon, L. M., Oswaks, J. D., & Cunningham, P. D. (2006). Safeguarding patients: Complexity science, high reliability organizations, and implications for team training in health care. Clinical Nurse Specialist, 20(6), 298–304.
   PubMed Web of Science ®Google Scholar
• Melnyk, B. M. (2012). Achieving a high reliability organization through implementation of the ARCC model for systemwide sustainability of evident-based practice. Nurse Administrator Quarterly, 36(2), 127–135.
   PubMedGoogle Scholar
• Miller, B. M., & Horsley, J. S. (2009). Digging deeper: Crisis management in the coal industry. Journal of Applied Communication Research, 37(3), 298–316.
   Web of Science ®Google Scholar
• Miller, M. R., Takata, G., Stucky, E. R., Neuspiel, D. R., Sevilla, X., Dillon, P. … Mirkinson, L. J. (2011). Principles of pediatric patient safety: Reducing harm due to medical care. Pediatrics, 127(6), 1199–1210.
   PubMed Web of Science ®Google Scholar
• Milne, J. K. (2002). Managing risk, clinical error, and quality care. Journal of Obstetrics and Gynaecology Canada, 24(9), 717–720.
   PubMedGoogle Scholar
• Milne, J. K., & Lalonde, A. B. (2007). Patient safety in women’s health-care: Professional colleges can make a difference. Best Practices Research Clinical Obstetrics Gynaecology, 21(4), 565–579.
   PubMed Web of Science ®Google Scholar
• Moller, J. L. (2013). Leadership, accountability, and patient safety. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42(5), 506–507.
   PubMed Web of Science ®Google Scholar
• Moody, R. F., Pesut, D. J., & Harrington, C. F. (2006). Creating safety culture on nursing units. Journal of Patient Safety, 2(4), 198–206.
   Google Scholar
• Morath, J. (2011). Nurses create a culture of patient safety: It takes more than projects. Online Journal of Issues in Nursing, 16(3). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No3-Sept-2011/Nurses-Create-a-Culture-of-Patient-Safety.html
   Google Scholar
• National Nuclear Security Agency. (2004). NNSA lessons learned and recommendations from the review of NASA’s Columbia Accident Investigation Boars. NNSA’s CAIB Lessons Learned Report. Washington, DC: U.S. Department of Energy.
   Google Scholar
• Naveh, E., Katz-Navon, T., & Stern, Z. (2005). Treatment errors in healthcare: A safety climate approach. Management Science, 51(6), 948–960.
   Web of Science ®Google Scholar
• Naveh, E., Katz-Navon, T., & Stern, Z. (2006). Readiness to report medical treatment errors: The effects of safety procedures, safety information, and priority of safety. Medical Care, 44(2), 117–123.
   PubMed Web of Science ®Google Scholar
• Nemeth, C., & Cook, R. (2007a). Reliability versus resilience: What does healthcare need? Paper presented at the Proceedings of the Human Factors and Ergonomics Society, San Francisco, CA.
   Google Scholar
• Nemeth, C., & Cook, R. (2007b). Healthcare IT as a source of resilience. Paper presented at the IEEE International Conference on Systems, Man and Cybernetics, Montreal, Canada.
   Google Scholar
• Ng, E. H., Beruvides, M. G., Simonton, J. L., Peimbert-Garcia, R. E., Winder, C. F., & Guadalupe, L. J. (2012). Public transportation vehicle maintenance and regional maintenance center: An analysis of existing literature. Engineering Management Journal, 24(3), 43–52.
   Web of Science ®Google Scholar
• Ng, E. H., Beruvides, M. G., Tolk, J. N., & Hartley, R. (2011). High reliability organization: A literature review. Paper presented at the American Society of Engineering Management International Annual Conference, American Society for Engineering Management, Lubbock, TX.
   Google Scholar
• Norden-Hagg, A., Sexton, J. B., Kalvemark-Sporrong, S., Ring, L., & Kettis-Lindblad, T. (2010). Assessing safety culture in pharmacies: The psychometric validation of the Safety Attitudes Questionnaire (SAQ) in a national sample of community pharmacies in Sweden. BMC Clinical Pharmacology, 10(1), 8.
   PubMedGoogle Scholar
• O’Byrne III, W. T., Weavind, L., & Selby, J. (2008). The science and economics of improving clinical communication. Anesthesiology Clinics, 26(4), 729–744.
   PubMedGoogle Scholar
• Olsen, E. (2010). Exploring the possibility of a common structural model measuring associations between safety climate factors and safety behaviour in health care and the petroleum sectors. Accident Analysis and Prevention, 42(5), 1507–1516.
   PubMed Web of Science ®Google Scholar
• Paige, J. T. (2010). Surgical team training: Promoting high reliability with nontechnical skills. The Surgical Clinics of North America, 90(3), 569–581.
   PubMed Web of Science ®Google Scholar
• Palmieri, P. A., DeLucia, P. R., Peterson, L. T., Ott, T. E., & Green, A. (2008). The anatomy and physiology of error in adverse health care events. Advances in Health Care Management, 7, 33–68.
   Google Scholar
• Perrow, C. (1999). Normal accidents, living with high-risk technologies. Princeton, NJ: Princeton University Press.
   Google Scholar
• Phelan, J. P., & Korst, L. M. (2011). Establishing a culture of perinatal safety in a community hospital. Journal of Healthcare Risk Management, 31(1), 12–18.
   PubMedGoogle Scholar
• Philibert, I. (2009). Use of strategies from high-reliability organizations to the patient hand-off by resident physicians: Practical implications. Quality and Safety in Health Care, 18(4), 261–266.
   PubMed Web of Science ®Google Scholar
• Rall, M., & Dieckmann, P. (2005a). Safety culture and crisis resource management in airway management: General principles to enhance patient safety in critical airway situations. Best Practice & Research Clinical Anaesthesiology, 19(4), 539–557.
   PubMedGoogle Scholar
• Rall, M., & Dieckmann, P. (2005). Simulation and patient safety: The use of simulation to enhance patient safety on a systems level. Current Anaesthesia and Critical Care, 16(5), 273–281.
   Google Scholar
• Redman, R. W. (2008). High reliability organizations: Implications for nursing knowledge development. Research and Theory for Nursing Practice: An International Journal, 22(3), 165–167.
   PubMedGoogle Scholar
• Riley, W. (2009). High reliability and implications for nursing leaders. Journal of Nursing Management, 17(2), 238–246.
   PubMed Web of Science ®Google Scholar
• Riley, W., Davis, S. E., Miller, K. K., & McCullough, M. (2010). A model for developing high-reliability teams. Journal of Nursing Management, 18(5), 556–563.
   PubMed Web of Science ®Google Scholar
• Roberts, K. H. (1989). New challenges in organizational research: High reliability organizations. Organization & Environment, 3(2), 111–125.
   Google Scholar
• Roberts, K. H. (2009). Managing the unexpected: Six years of HRO-literature reviewed. Journal of Contingencies and Crisis Management, 17(1), 50–54.
   Google Scholar
• Roberts, K. H., Madsen, P., Desai, V., & Van Stralen, D. (2005). A case of birth and death of a high reliability healthcare organization. Quality and Safety in Health Care, 14(3), 216–220.
   PubMed Web of Science ®Google Scholar
• Roberts, K. H., & Rousseau, D. M. (1989). Research in nearly failure free, high reliability organizations: Having the bubble. IEEE Transactions on Engineering Management, 36(2), 132–139.
   Web of Science ®Google Scholar
• Roberts, K. H., Rousseau, D. M., & La Porte, T. R. (1994). The culture of high reliability: Quantitative and qualitative assessment aboard nuclear-powered aircraft carriers. The Journal of High Technology Management Research, 5(1), 141–161.
   Google Scholar
• Rochlin, G. I. (1996). Reliable organizations: Present research and future directions. Journal of Contingencies and Crisis Management, 2(4), 55–59.
   Google Scholar
• Rosenthal, C., Balzer, F., Boemke, W., & Spies, C. (2013). Patient safety in anesthesiology and intensive care medicine: Measures for improvement [Patientensicherheit in der Anästhesie und Intensivmedizin: Maßnahmen zur Verbesserung]. Medizinische Klinik—Intensivmedizin und Notfallmedizin, 108(8), 657–665.
   PubMed Web of Science ®Google Scholar
• Ruchlin, H. S., Dubbs, N. L., & Callahan, M. A. (2004). The role of leadership in instilling a culture of safety: Lessons from the literature. Journal of Healthcare Management, 49(1), 47.
   PubMed Web of Science ®Google Scholar
• Sagan, S. D. (1993). The limits of safety. Princeton, NJ: Princeton University Press.
   Google Scholar
• Sagan, S. D. (1994). Toward a political theory of organizational reliability. Journal of Contingencies and Crisis Management, 2(4), 228–240.
   Google Scholar
• Schell, W. J., & Kuntz, S. W. (2013). Driving change from the middle: An exploration of the complementary roles and leadership behaviors of clinical nurse leaders and engineers in healthcare process improvement. Engineering Management Journal, 25(4), 33–43.
   Web of Science ®Google Scholar
• Schulz, R., & Rose, J. (1973). Can hospitals be expected to control costs? Inquiry, 10(2), 3–8.
   PubMedGoogle Scholar
• Sebastian, I. M., & Bui, T. X. (2012). The influence of IS affordances on work practices in health care: A relational coordination approach. International Conference on Information Systems, ICIS 2012, 5, 4270–4280.
   Google Scholar
• Shabot, M. M., Monroe, D., Inurria, J., Garbade, D., & France, A. C. (2013). Memorial Hermann: High reliability from board to bedside. Joint Commission Journal on Quality and Patient Safety, 39(6), 253–257.
   PubMedGoogle Scholar
• Shostek, K. (2007). Developing a culture of safety in ambulatory care settings. Journal of Ambulatory Care Management, 30(2), 105–113.
   PubMedGoogle Scholar
• Silvey, A. B., & Warrick, L. H. (2008). Linking quality assurance to performance improvement to produce a high reliability organization. International Journal of Radiation Oncology Biology Physics, 71(1), S195–S199.
   PubMed Web of Science ®Google Scholar
• Singer, S., Lin, S., Falwell, A., Gaba, D., & Baker, L. (2009). Relationship of safety climate and safety performance in hospitals. Health Services Research, 44(2p1), 399–421.
   PubMed Web of Science ®Google Scholar
• Singer, S., Meterko, M., Baker, L., Gaba, D., Falwell, A., & Rosen, A. (2007). Workforce perceptions of hospital safety culture: Development and validation of the patient safety climate in healthcare organizations survey. Health Services Research, 42(5), 1999–2021.
   PubMed Web of Science ®Google Scholar
• Singer, S. B., Gaba, D. M., Geppert, J. J., Sinaiko, A. D., Howard, S. K., & Park, K. C. (2003). The culture of safety: Results of an organization-wide survey in 15 California hospitals. Health Care, 12(2), 112–118.
   Google Scholar
• Singer, S. J., Falwell, A., Gaba, D. M., & Baker, L. C. (2008). Patient safety climate in US hospitals: Variation by management level. Medical Care, 46(11), 1149–1156.
   PubMed Web of Science ®Google Scholar
• Singer, S. J., Falwell, A., Gaba, D. M., Meterko, M., Rosen, A., Hartmann, C. W., & Baker, L. (2009). Identifying organizational cultures that promote patient safety. Health Care Management Review, 34(4), 300–311.
   PubMed Web of Science ®Google Scholar
• Singer, S. J., Gaba, D. M., Falwell, A., Lin, S., Hayes, J., & Baker, L. (2007). Patient safety climate in 92 US hospitals: Differences by work area and discipline. Medical Care, 47(1), 23–31.
   Web of Science ®Google Scholar
• Singer, S. J., Rosen, A., Zhao, S., Ciavarelli, A. P., & Gaba, D. M. (2010). Comparing safety climate in naval aviation and hospitals: Implications for improving patient safety. Health Care Management Review, 35(2), 134–146.
   PubMed Web of Science ®Google Scholar
• Singer, S. J., & Vogus, T. J. (2013). Reducing hospital errors: Interventions that build safety culture. Annual Review of Public Health, 34, 373–396.
   PubMed Web of Science ®Google Scholar
• Smith, B. K., Nachtmann, H., & Pohl, E. H. (2012). Improving healthcare supply chain processes via data standardization. Engineering Management Journal, 24(1), 3–10.
   Web of Science ®Google Scholar
• Sostrom, K., & Collman, J. R. (2003). Policy revision in health enterprise information security: P3WG final report. In Proceedings of SPIE – The International Society for Optical Engineering 5033 (pp. 232–239). Bellingham, WA: SPIE.
   Google Scholar
• Squires, M., Tourangeau, A., Spence Laschinger, H. K., & Doran, D. (2010). The link between leadership and safety outcomes in hospitals. Journal of Nursing Management, 18(8), 914–925.
   PubMed Web of Science ®Google Scholar
• Stock, G. N., McFadden, K. L., & Gowen, C. R. (2007). Organizational culture, critical success factors, and the reduction of hospital errors. International Journal of Production Economics, 106(2), 368–392.
   Web of Science ®Google Scholar
• Sullivan, J., & Beach, R. (2009). Improving project outcomes through operational reliability: A conceptual model. International Journal of Project Management, 27(8), 765–775.
   Web of Science ®Google Scholar
• Sutton, G. (2009). Evaluating multidisciplinary health care teams: Taking the crisis out of CRM. Australian Health Review, 33(3), 445–452.
   PubMed Web of Science ®Google Scholar
• Tolk, J. N., Cantu, J., & Beruvides, M. G. (2013). High reliability organization research: Transforming theory into practice, A literature review for healthcare. Paper presented at the American Society for Engineering Management International Annual Conference, Minneapolis, MN.
   Google Scholar
• Tranfield, D., Denyer, D., & Smart, P. (2003). Towards a methodology for developing evidence-informed management knowledge by means of systematic review. British Journal of Management, 14, 207–222.
   Web of Science ®Google Scholar
• Uhlig, P. N., Brown, J., Nason, A. K., Camelio, A., & Kendall, E. (2002). System innovation: Concord Hospital. Joint Commission Journal on Quality and Patient Safety, 28(12), 666–672.
   Google Scholar
• Undre, S., Koutantji, M., Sevdalix, N., Gautama, S., Selvapatt, N., Williams, S. … Vincent, C. (2007). Multidisciplinary crisis simulations: The way forward for training surgical teams. World Journal of Surgery, 31(9), 1843–1853.
   PubMed Web of Science ®Google Scholar
• Van Beuzekom, M., Boer, F., Akerboom, S., & Hudson, P. (2010). Patient safety: Latent risk factors. British Journal of Anaesthesia, 105(1), 52–59.
   PubMed Web of Science ®Google Scholar
• Van De Walle, B., & Turoff, M. (2008). Decision support for emergency situations. Information Systems and E-Business Management, 6(3), 295–316.
   Web of Science ®Google Scholar
• van den Bos, J., Bustag, K., Gray, T., Halford, M., Zienkiewicz, E., & Shreve, J. (2011). The $17.1 billion problem: The annual cost of measurable medical errors. Health Affairs, 30(4), 596–603.
   PubMed Web of Science ®Google Scholar
• Van Rite, E. (2009). Safety culture from the flight deck to the hospital: Aviation safety reporting as a model for patient safety. Law & Society Annual Meeting, 1, 1–29.
   Google Scholar
• Vogus, T., & Sutcliffe, K. (2007a). The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Medical Care, 45(10), 997–1002.
   PubMed Web of Science ®Google Scholar
• Vogus, T., & Sutcliffe, K. (2007b). The safety organizing scale: Development and validation of a behavioral measure of safety culture in hospital nursing units. Medical Care, 45(1), 46–54.
   PubMed Web of Science ®Google Scholar
• Vogus, T., Sutcliffe, K., & Weick, K. E. (2010). Doing no harm: Enabling, enacting, and elaborating a culture of safety in health care. The Academy of Management Perspectives, 24(4), 60–77.
   Web of Science ®Google Scholar
• Walston, S. L., Al-Omar, B. A., & Al-Mutari, F. A. (2010). Factors affecting the climate of hospital patient safety: A study of hospitals in Saudi Arabia. International Journal of Health Care Quality Assurance, 23(1), 35–50.
   PubMedGoogle Scholar
• Waring, J., McDonald, R., & Harrison, S. (2006). Safety and complexity: Inter-departmental relationships as a threat to patient safety in the operating department. Journal of Health Organization and Management, 20(3), 227–242.
   PubMedGoogle Scholar
• Weaver, R. R. (2015). Seeking high reliability in primary care: Leadership, tools, and organization. Health Care Management Review, 40(3), 183–192.
   PubMed Web of Science ®Google Scholar
• Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., & Dy, S. M. (2013). Promoting a culture of safety as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158(5p2), 369–374.
   PubMed Web of Science ®Google Scholar
• Weick, K. E. (1989). Mental models of high reliability systems. Industrial Crisis Quarterly, 3, 127–142.
   Google Scholar
• Weick, K., & Roberts, K. (1993). Collective mind in organizations: Heedful interrelating on flight decks. Administrative Science Quarterly, 38(3), 357–381.
   Web of Science ®Google Scholar
• Weick, K. E., & Sutcliffe, K. M. (1999). Organizing for high reliability: Processes of collective mindfulness. Research in Organizational Behavior, 21, 81–124.
   Web of Science ®Google Scholar
• Weick, K. E., & Sutcliffe, K. M. (2001). Managing the unexpected: Assuring high performance in an age of complexity. San Francisco, CA: Jossey-Bass, a John Wiley & Sons, Inc. Company.
   Google Scholar
• White, C. M., Schoettker, P. J., Conway, P. H., Geiser, M., Olivea, J., Pruett, R., & Kotagal, U. R. (2011). Utilising improvement science methods to optimise medication reconciliation. BMJ Quality & Safety, 20(4), 372–380.
   PubMed Web of Science ®Google Scholar
• Whitney, D. E. (2003). Normal accidents by Charles Perrow, Working Paper Series, Short Takes on the Literature, ESD-WP-LIT-2003-01. Cambridge, MA: Massachusetts Institute of Technology.
   Google Scholar
• Williams, M. D. (2010). Exploring “system resilience” in the context of a hospital bed crisis. In M. Anderson (Ed.), Proceedings of the International Conference on Contemprary Ergonomics and Human Factors (pp. 605–613). New York, NY: Taylor & Francis.
   Google Scholar
• Wilson, D. S. (2013). Registered nurses’ collective safety organising behaviours: The association with perceptions of patient safety culture. Journal of Research in Nursing, 18(4), 320–333.
   Google Scholar
• Wilson, K. A. (2005). Does safety culture predict clinical outcomes? ( Dissertation). University of Central Florida, Orlando, FL.
   Google Scholar
• Wilson, K. A., Burke, C. S., Priest, H. A., & Salas, E. (2005). Promoting health care safety through training high reliability teams. Quality and Safety in Health Care, 14(4), 303–309.
   PubMed Web of Science ®Google Scholar
• Xiao, Y., Plasters, C., Seagull, J., & Moss, J. (2004). Cultural and institutional conditions for high reliability teams. In IEEE International Conference on Systems, Man, and Cybernetics, 3, 2580–2585.
   Google Scholar
• Xiao, Y., Seagull, F. J., Nieves-Khouw, F., Barczak, N., & Perkins, S. (2004). Organizational-historical analysis of the “failure to respond to alarm” problems. IEEE Transactions on System, Man & Cybernetics: Part A, 34(6), 772–778.
   Web of Science ®Google Scholar
• Zeeman, G. G. (2006). Patient safety in obstetrics. European Clinics in Obstetrics and Gynaecology, 2(2), 51–61.
   Google Scholar