Human Error: Cause, Prediction and Reduction.

Book/Report

Classic

Human Error: Cause, Prediction and Reduction.

March 6, 2005

Senders JW, Morey NP. Hillsdale NJ: L. Erlbaum Associates; 1991. ISBN: 9780898595987.

View more articles from the same authors.

Information

Related commentary

Related Resources From the Same Author(s)

Human Error in Medicine.

March 27, 2005

Operating at the sharp end: the complexity of human error.

March 6, 2005

Using Human Factors Engineering to Improve Patient Safety, Second edition.

June 29, 2005

How Professionals Make Decisions.

May 4, 2005

8 ways to prevent medication errors in kids.

May 12, 2010

Sorry Works! 2.0: Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims.

March 12, 2008

Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice.

March 6, 2005

Taking the Lead in Patient Safety: How Healthcare Leaders Influence Behavior and Create Culture.

April 22, 2009

The Limits of Safety: Organizations, Accidents and Nuclear Weapons.

March 6, 2005

The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth.

December 5, 2018

Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition.

May 17, 2017

Health Care Errors and Patient Safety.

May 13, 2009

Advances in Human Factors and Ergonomics in Healthcare and Medical Devices.

September 11, 2019

On the Edge: Nursing in the Age of Complexity.

October 29, 2008

SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience.

May 13, 2015

The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed.

March 6, 2005

ACR White Paper on Magnetic Resonance (MR) Safety: Combined Papers of 2002 and 2004.

November 16, 2005

Teaching smart people how to learn.

March 6, 2005

Preventing catheter-related bloodstream infections outside the intensive care unit: expanding prevention to new settings.

July 21, 2010

Safety Climate: New Developments in Conceptualization, Theory, and Research.

October 6, 2010

Quality, Safety, and Noninterpretive Skills.

November 11, 2015

Health care management during Covid-19: insights from complexity science.

October 21, 2020

The Transforming Care at the Bedside (TCAB) Toolkit.

June 25, 2008

Addressing the quality and safety gap—parts I-III.

August 12, 2009

Normal Accidents: Living with High-Risk Technologies.

March 6, 2005

Medication safety: reducing anesthesia medication errors and adverse drug events in dentistry part I and II.

May 6, 2020

Safety by Design.

December 20, 2006

Drug, Healthcare and Patient Safety.

November 7, 2012

Hospital Performance Report.

October 28, 2021

Patient perception of fall risk and fall risk screening scores.

March 15, 2023

Engaging Patients in Improving Ambulatory Care.

April 3, 2013

Do you hear what I hear? Communication practices about medications between physicians and clients with chronic illness in Canada.

April 2, 2014

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

February 3, 2016

Intravenous smart pumps at the point of care: a descriptive, observational study.

October 12, 2022

Three perspectives on changes in resident work environment and duty hours.

July 26, 2017

Health Information Technology in the United States: The Information Base for Progress.

October 25, 2006

Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System.

November 4, 2009

Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III.

December 17, 2008

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.

June 8, 2022

Placing Diagnosis Errors on the Policy Agenda.

May 21, 2014

Failure of crisis leadership in a global pandemic: some reflections on COVID-19 and future recommendations.

November 16, 2022

A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia preoperative evaluation associates with increased length of stay and mortality.

October 20, 2021

Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed?

April 2, 2014

Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.

May 30, 2012

Assessment of the AHRQ Patient Safety Initiative: Final Report Evaluation Report IV.

December 17, 2008

Inpatient telemedicine and new models of care during COVID-19: hospital design strategies to enhance patient and staff safety.

September 15, 2021

Use of administrative data to find substandard care: validation of the complications screening program.

October 26, 2005

Telehealth in the COVID-19 era: a balancing act to avoid harm.

February 17, 2021

Diagnostic errors in pediatric critical care: a systematic review.

April 28, 2021

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Adverse events among emergency department patients with cardiovascular conditions: a multicenter study.

March 10, 2021

Development and validation of a brief culture-of-safety survey.

June 22, 2022

Medication safety incidents associated with the remote delivery of primary care: a rapid review.

January 18, 2023

Using smart IV infusion pumps outside of patient rooms.

February 2, 2022

Cause and effect analysis of closed claims in obstetrics and gynecology.

May 18, 2005

Persisting high rates of omissions during anesthesia induction are decreased by utilization of a pre- & post-induction checklist.

February 1, 2023

Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review.

September 29, 2021

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings.

October 6, 2021

Functional decline associated with polypharmacy and potentially inappropriate medications in community-dwelling older adults with dementia.

February 22, 2012

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.

August 24, 2005

Errors during resuscitation: the impact of perceived authority on delivery of care.

March 25, 2020

Acceptability and feasibility of the Leapfrog computerized physician order entry evaluation tool for hospitals outside the United States.

July 22, 2015

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

May 12, 2021

The role of organizational and professional cultures in medication safety: a scoping review of the literature.

January 15, 2020

Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults.

March 30, 2022

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

November 2, 2022

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017.

March 24, 2021

Global Patient Safety Action Plan 2021-2030: Towards Eliminating Avoidable Harm in Health Care.

August 18, 2021

Getting the Board on Board: What Your Board Needs to Know About Quality and Safety, Third Edition.

December 7, 2016

The Joint Commission Big Book of Checklists. 2nd Edition.

September 7, 2016

Communicating Radiation Risks in Paediatric Imaging: Information to Support Healthcare Discussions About Benefit and Risk.

July 13, 2016

Using Safety Cases in Industry and Healthcare.

February 13, 2013

Ethical Issues in Patient Safety Research: Interpreting Existing Guidance.

August 7, 2013

Medical Team Training.

January 7, 2009

Defusing Disruptive Behavior. A Workbook for Health Care Leaders.

January 7, 2009

Safety Culture: Theory, Method and Improvement.

March 31, 2010

Front Line of Defense: The Role of Nurses in Preventing Sentinel Events. Third Edition.

November 29, 2006

Critical Care Safety: Essentials for ICU Patient Care and Technology.

August 8, 2007

Assessment of the National Patient Safety Initiative: Context and Baseline Evaluation Report 1.

October 19, 2005

Global Report on the Epidemiology and Burden of Sepsis: Current Evidence, Identifying Gaps and Future Directions.

October 7, 2020

A Guide to Patient Safety Improvement: Integrating Knowledge Translation & Quality Improvement Approaches.

September 23, 2020

Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.

January 13, 2021

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

December 9, 2020

Sway: Unravelling Unconscious Bias

July 8, 2020

When We Do Harm: A Doctor Confronts Medical Error.

April 22, 2020

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.

July 22, 2020

Delivering Quality Health Services: A Global Imperative for Universal Health Coverage.

July 18, 2018

Guidance on Safe Medical Staffing: Report of a Working Party.

August 1, 2018

Doing Harm.

April 11, 2018

Patient Safety Culture: Theory, Methods and Application.

January 21, 2015

Black Box Thinking: Why Most People Never Learn From Their Mistakes—But Some Do.

January 13, 2016

How Doctors Think.

March 28, 2007

Safety-I and Safety-II: The Past and Future of Safety Management.

August 20, 2014

Review of Patient Safety for Children and Young People.

July 1, 2009

Strategies for Addressing Health Care Worker Fatigue.

December 17, 2008

Safety in Doses.

September 16, 2009

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

June 23, 2021

Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation.

June 29, 2022

Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS.

June 22, 2022

Final Report of the Ockenden Review.

April 27, 2022

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment.

April 26, 2023

Your Safety in our Hands in Hospital.

April 20, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Interview

In conversation with Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

December 14, 2022

Perspective

Resilient Healthcare and the Safety-I and Safety-II Frameworks

December 14, 2022

Adverse Health Events in Minnesota: Annual Reports.

August 9, 2022

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Health information technology-related wrong-patient errors: context is critical.

January 27, 2021

Racism as a Root Cause approach: a new framework.

January 1, 2021

National Patient Safety Syllabus 1.0 Training for all NHS Staff.

March 4, 2020

Ambulatory safety nets to reduce missed and delayed diagnoses of cancer.

August 14, 2019

Doing Harm.

April 11, 2018

Patient Deaths at Arbour Health Systems—Westwood Lodge Hospital and Pembroke Hospital.

March 21, 2018

Behind Human Error, Second Edition.

November 10, 2017

The Field Guide to Human Error Investigations, Third Edition.

August 24, 2017

Applied use of safety event occurrence control charts of harm and non-harm events: a case study.

July 20, 2016

Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition.

June 22, 2016

Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Final Report.

May 4, 2016

Consumer Guide to Adverse Health Events.

February 28, 2015

Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews.

December 17, 2014

Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance Centres.

November 19, 2014

Assessing distractors and teamwork during surgery: developing an event-based method for direct observation.

October 29, 2014

Safety-I and Safety-II: The Past and Future of Safety Management.

August 20, 2014

Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.

August 13, 2014

An Avoidable Death of a Three-year-old Child from Sepsis.

July 16, 2014

Medication safety and the administration of intravenous vincristine: international survey of oncology pharmacists.

February 26, 2014

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Non-Health Care Professionals

Safety Scientists

Active Errors