Commentary Involuntary automaticity: a work-system induced risk to safe health care. Citation Text: Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Serv Manage Res. 2005;18(4):211-6. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL November 16, 2005 Toft B, Mascie-Taylor H. Health Serv Manage Res. 2005;18(4):211-6. View more articles from the same authors. The authors discuss the concept of automaticity, or the automation of a skilled behavior through repetition. They discuss its possible impact on patient safety and strategies to help health care managers minimize its negative effects. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Serv Manage Res. 2005;18(4):211-6. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Towards an organization with a memory: exploring the organizational generation of adverse events in health care. June 8, 2005 Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021 Health information exchange in emergency medicine. August 19, 2015 The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review. August 3, 2022 Point prevalence of surgical checklist use in Europe: relationship with hospital mortality. February 25, 2015 How would final-year medical students perform if their skill-based prescription assessment was real life? February 22, 2023 Supporting the emotional well-being of health care workers during the COVID-19 pandemic. August 5, 2020 COVID-19: the dark side and the sunny side for patient safety. October 14, 2020 Overnight stay in the emergency department and mortality in older patients. November 29, 2023 Factors influencing the perception of feeling safe in pre-hospital emergency care: a mixed-methods systematic review. August 9, 2023 Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study. October 18, 2023 The preventable proportion of healthcare-associated infections 2005-2016: systematic review and meta-analysis. October 17, 2018 Patient participation: current knowledge and applicability to patient safety. January 27, 2010 Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: a meta-analysis. January 30, 2005 HIM functions in healthcare quality and patient safety. August 10, 2011 Effect of genetic diagnosis on patients with previously undiagnosed disease. November 7, 2018 Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems. April 26, 2017 Factors influencing witnesses' perception of patient safety during pre-hospital health care from emergency medical services: a multi-center cross-sectional study. February 14, 2024 Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial. March 1, 2006 Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. March 19, 2008 CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting. September 1, 2021 Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis. March 23, 2022 Reframing and addressing horizontal violence as a workplace quality improvement concern. August 22, 2018 Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. March 8, 2023 Associations between national board exam performance and residency program emphasis on patient safety and interprofessional teamwork. September 11, 2019 Association of clinician diagnostic performance with machine learning–based decision support systems: a systematic review. April 14, 2021 Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities. January 20, 2021 Longitudinal evaluation of a programme for safety culture change in a mental health service. January 13, 2021 Hospital medication errors: a cross sectional study. December 23, 2020 Physician use of stigmatizing language in patient medical records. July 28, 2021 Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement. July 28, 2021 Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study. November 24, 2021 Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy. November 17, 2021 DEEP SCOPE: a framework for safe healthcare design. October 13, 2021 Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis. November 18, 2020 Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study. October 28, 2020 Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic. October 7, 2020 Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals September 1, 2021 Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. April 13, 2022 Complexity and challenges of the clinical diagnosis and management of Long COVID. November 30, 2022 Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities. October 26, 2022 Testimonial injustice: linguistic bias in the medical records of black patients and women. June 6, 2021 The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study. October 5, 2022 Exploring the impact of employee engagement and patient safety. September 14, 2022 Racism in health services for adolescents: a scoping review. August 2, 2023 Sociotechnical work system approach to occupational fatigue. July 26, 2023 Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023 Organisational failure: rethinking whistleblowing for tomorrow's doctors. September 7, 2022 Enhancing safety of a system-wide in situ simulation program using no-go considerations. October 4, 2023 Inpatient EHR user experience and hospital EHR safety performance. October 4, 2023 Pharmacy e-prescription dispensing before and after CancelRx implementation. September 20, 2023 The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services. May 3, 2023 Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals. June 29, 2022 Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey. May 11, 2022 Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. May 4, 2022 Patient safety concerns in COVID-19–related events: a study of 343 event reports from 71 hospitals in Pennsylvania. July 8, 2020 Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. June 10, 2020 A case-controlled study of relatives' complaints concerning patients who died in hospital: the role of treatment escalation/limitation planning. June 3, 2020 A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. September 25, 2019 Development of a pediatric adverse events terminology. March 15, 2017 Opportunities to enhance laboratory professionals' role on the diagnostic team. November 16, 2016 A method of addressing proprietary name similarity for US prescription drugs. August 19, 2015 Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications. April 29, 2015 Trends and patterns in reporting of patient safety situations in transplantation. February 10, 2016 What methods are used to apply positive deviance within healthcare organisations? A systematic review. March 2, 2016 Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. March 9, 2016 Exploring the causes of junior doctors' prescribing mistakes: a qualitative study. October 22, 2014 Positive deviance: a different approach to achieving patient safety. August 20, 2014 Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. August 26, 2015 An analysis of electronic health record–related patient safety concerns. July 2, 2014 Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. May 21, 2014 Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. May 14, 2014 A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. April 10, 2019 Why are patients not more involved in their own safety? A questionnaire-based survey in a multi-ethnic North London hospital population. June 26, 2019 Patient safety in dermatology: a review of the literature. February 17, 2010 Review of patient safety incidents submitted from critical care units in England & Wales to the UK National Patient Safety Agency. December 2, 2009 Time to listen: a review of methods to solicit patient reports of adverse events. April 14, 2010 Bringing patients' own medications into an emergency department by ambulance: effect on prescribing accuracy when these patients are admitted to hospital. October 14, 2009 Therapeutic errors involving adults in the community setting: nature, causes and outcomes. September 9, 2009 Diagnostic errors in pediatric radiology. March 30, 2011 The role of theory in research to develop and evaluate the implementation of patient safety practices. January 30, 2005 Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011 What context features might be important determinants of the effectiveness of patient safety practice interventions? June 29, 2011 A framework for classifying patient safety practices: results from an expert consensus process. January 30, 2005 Advancing the science of patient safety. May 25, 2011 How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research. May 4, 2011 Introducing new technology safely. September 1, 2010 Ethics, oversight and quality improvement initiatives. August 25, 2010 Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis. June 29, 2016 Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial. June 1, 2016 We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication. March 19, 2014 A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. March 26, 2014 Framework for analysing risk and safety in clinical medicine. July 17, 2013 Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. October 16, 2013 Diagnostic errors with inserted tubes, lines and catheters in children. December 5, 2012 Using inpatient hospital discharge data to monitor patient safety events. May 8, 2013 Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017 Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. August 21, 2013 Framework for analysing risk and safety in clinical medicine. July 17, 2013 Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the Academic Hospitalist Taskforce. July 17, 2013 View More Related Resources Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care. October 11, 2023 Anesthesia Risk Alert program: a proactive safety initiative. August 30, 2023 Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 National Safety Standards for Invasive Procedures (NatSSIPs2). February 7, 2023 Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors. October 12, 2022 ASHP Standard for Certification as a Center of Excellence in Medication-Use Safety and Pharmacy Practice. April 20, 2022 Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care. October 27, 2021 The problem with 'My Five Moments for Hand Hygiene'. August 25, 2021 WebM&M Cases Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review. May 12, 2021 Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system. October 28, 2020 COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought. August 19, 2020 Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. May 13, 2020 Diagnostic error in the emergency department: learning from national patient safety incident report analysis. January 15, 2020 Improving the quality of insulin prescribing for people with diabetes being discharged from hospital October 16, 2019 Is WHO's surgical safety checklist being hyped? August 21, 2019 Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. May 8, 2019 Recommendations from a national panel on quality improvement in obstetrics. April 24, 2019 Emergency department checklist: an innovation to improve safety in emergency care. October 31, 2018 Making the journey safe: recognising and responding to severe sepsis in accident and emergency. November 2, 2016 The WakeWings journey: creating a patient safety program. July 13, 2016 The impact of surgical safety checklists on theatre departments: a critical review of the literature. June 22, 2016 Towards international consensus on patient harm: perspectives on pressure injury policy. June 8, 2016 Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward. May 18, 2016 Combining systems and teamwork approaches to enhance the effectiveness of safety improvement interventions in surgery: the Safer Delivery of Surgical Services (S3) program. January 20, 2016 Guideline for prevention of retained surgical items. January 20, 2016 Safety first! Using a checklist for intrafacility transport of adult intensive care patients. October 21, 2015 The problem with checklists. July 15, 2015 Effectiveness of interventions to improve patient handover in surgery: a systematic review. June 17, 2015 Back to basics: checklists in aviation and healthcare. June 17, 2015 View More See More About The Topic Health Care Executives and Administrators Practice Guidelines Checklists
Towards an organization with a memory: exploring the organizational generation of adverse events in health care. June 8, 2005
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021
The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review. August 3, 2022
Point prevalence of surgical checklist use in Europe: relationship with hospital mortality. February 25, 2015
How would final-year medical students perform if their skill-based prescription assessment was real life? February 22, 2023
Supporting the emotional well-being of health care workers during the COVID-19 pandemic. August 5, 2020
Factors influencing the perception of feeling safe in pre-hospital emergency care: a mixed-methods systematic review. August 9, 2023
Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study. October 18, 2023
The preventable proportion of healthcare-associated infections 2005-2016: systematic review and meta-analysis. October 17, 2018
Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: a meta-analysis. January 30, 2005
Inpatient Notes: human factors engineering and inpatient care—new ways to solve old problems. April 26, 2017
Factors influencing witnesses' perception of patient safety during pre-hospital health care from emergency medical services: a multi-center cross-sectional study. February 14, 2024
Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial. March 1, 2006
Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. March 19, 2008
CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting. September 1, 2021
Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis. March 23, 2022
Reframing and addressing horizontal violence as a workplace quality improvement concern. August 22, 2018
Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. March 8, 2023
Associations between national board exam performance and residency program emphasis on patient safety and interprofessional teamwork. September 11, 2019
Association of clinician diagnostic performance with machine learning–based decision support systems: a systematic review. April 14, 2021
Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities. January 20, 2021
Longitudinal evaluation of a programme for safety culture change in a mental health service. January 13, 2021
Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement. July 28, 2021
Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study. November 24, 2021
Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy. November 17, 2021
Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis. November 18, 2020
Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study. October 28, 2020
Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic. October 7, 2020
Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals September 1, 2021
Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. April 13, 2022
Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities. October 26, 2022
Testimonial injustice: linguistic bias in the medical records of black patients and women. June 6, 2021
The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study. October 5, 2022
Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023
Enhancing safety of a system-wide in situ simulation program using no-go considerations. October 4, 2023
The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services. May 3, 2023
Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals. June 29, 2022
Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey. May 11, 2022
Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. May 4, 2022
Patient safety concerns in COVID-19–related events: a study of 343 event reports from 71 hospitals in Pennsylvania. July 8, 2020
Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. June 10, 2020
A case-controlled study of relatives' complaints concerning patients who died in hospital: the role of treatment escalation/limitation planning. June 3, 2020
A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers. September 25, 2019
Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications. April 29, 2015
What methods are used to apply positive deviance within healthcare organisations? A systematic review. March 2, 2016
Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. March 9, 2016
Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals. August 26, 2015
Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature. May 21, 2014
Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. May 14, 2014
A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. April 10, 2019
Why are patients not more involved in their own safety? A questionnaire-based survey in a multi-ethnic North London hospital population. June 26, 2019
Review of patient safety incidents submitted from critical care units in England & Wales to the UK National Patient Safety Agency. December 2, 2009
Bringing patients' own medications into an emergency department by ambulance: effect on prescribing accuracy when these patients are admitted to hospital. October 14, 2009
Therapeutic errors involving adults in the community setting: nature, causes and outcomes. September 9, 2009
The role of theory in research to develop and evaluate the implementation of patient safety practices. January 30, 2005
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011
What context features might be important determinants of the effectiveness of patient safety practice interventions? June 29, 2011
A framework for classifying patient safety practices: results from an expert consensus process. January 30, 2005
How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research. May 4, 2011
Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis. June 29, 2016
Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial. June 1, 2016
We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication. March 19, 2014
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. March 26, 2014
Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. October 16, 2013
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws. August 21, 2013
Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the Academic Hospitalist Taskforce. July 17, 2013
Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care. October 11, 2023
Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023
Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors. October 12, 2022
ASHP Standard for Certification as a Center of Excellence in Medication-Use Safety and Pharmacy Practice. April 20, 2022
Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review. May 12, 2021
Reducing nosocomial transmission of COVID-19: implementation of a COVID-19 triage system. October 28, 2020
COVID-19 crisis, safe reopening of simulation centres and the new normal: food for thought. August 19, 2020
Barriers and facilitators to healthcare workers' adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. May 13, 2020
Diagnostic error in the emergency department: learning from national patient safety incident report analysis. January 15, 2020
Improving the quality of insulin prescribing for people with diabetes being discharged from hospital October 16, 2019
Making the journey safe: recognising and responding to severe sepsis in accident and emergency. November 2, 2016
The impact of surgical safety checklists on theatre departments: a critical review of the literature. June 22, 2016
Towards international consensus on patient harm: perspectives on pressure injury policy. June 8, 2016
Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward. May 18, 2016
Combining systems and teamwork approaches to enhance the effectiveness of safety improvement interventions in surgery: the Safer Delivery of Surgical Services (S3) program. January 20, 2016
Safety first! Using a checklist for intrafacility transport of adult intensive care patients. October 21, 2015
Effectiveness of interventions to improve patient handover in surgery: a systematic review. June 17, 2015