Commentary Beyond the organisational accident: the need for "error wisdom" on the frontline. Citation Text: Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Reason J. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33. View more articles from the same authors. This commentary uses a case study involving a fatal medication error to illustrate the importance of mental skills that improve recognition of potentially adverse events. PubMed citation Available at Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Human error: models and management. March 27, 2005 Accident analysis of large-scale technological disasters applied to an anaesthetic complication. March 6, 2005 Safety paradoxes and safety culture. April 9, 2003 Human factor in cardiac surgery: errors and near misses in a high technology medical domain. March 27, 2005 Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. February 6, 2008 American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. December 7, 2005 Early cost and safety benefits of an inpatient electronic health record. February 23, 2011 The need for risk profiling in patient safety. 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Accident analysis of large-scale technological disasters applied to an anaesthetic complication. March 6, 2005
Human factor in cardiac surgery: errors and near misses in a high technology medical domain. March 27, 2005
Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. February 6, 2008
American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. December 7, 2005
Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. February 17, 2010
Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections. June 14, 2017
A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. October 30, 2013
Electronic medical record alert associated with reduced opioid and benzodiazepine coprescribing in high-risk Veteran patients. January 17, 2018
The introduction of a surgical safety checklist in a tertiary referral obstetric centre. July 27, 2011
Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995-2007. November 4, 2009
Surgical checklists: a detailed review of their emergence, development, and relevance to neurosurgical practice. March 14, 2012
Monitoring the anaesthetist in the operating theatre—professional competence and patient safety. March 1, 2017
When does quality improvement count as research? Human subject protection and theories of knowledge. March 6, 2005
Resident uncertainty in clinical decision making and impact on patient care: a qualitative study. April 16, 2008
Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008. August 31, 2011
Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives. August 23, 2017
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2017. October 31, 2018
ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2015. September 14, 2016
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2014. August 12, 2015
ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2010. June 6, 2012
ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education—2009. June 13, 2012
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011. May 9, 2012
ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2016. September 20, 2017
ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013. July 23, 2014
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008. May 20, 2009
ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2007. June 4, 2008
Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error. January 18, 2006
Using standardised patients in an objective structured clinical examination as a patient safety tool. March 6, 2005
A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. December 20, 2006
An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. March 6, 2005
A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist. February 2, 2022
A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients. December 6, 2006
Medical error disclosure among pediatricians: choosing carefully what we might say to parents. October 15, 2008
Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. October 21, 2015
Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors. September 23, 2015
Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery. December 5, 2012
The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. November 12, 2014
A comparison of voluntarily reported medication errors in intensive care and general care units. March 24, 2010
The "physician-led chart audit": engaging providers in fortifying a culture of safety. March 19, 2014
Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports. October 14, 2020
Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study. April 27, 2022
Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors. June 18, 2008
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Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior. February 3, 2010
Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety. January 30, 2005
The Institute for Safe Medication Practices and poison control centers: collaborating to prevent medication errors and unintentional poisonings. June 10, 2015
What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records. December 21, 2011
Techniques to improve patient safety in hospitals: what nurse administrators need to know. September 19, 2012
Exploring the factors that promote or diminish a psychologically safe environment: a qualitative interview study with critical care staff. September 22, 2021
Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals. May 26, 2021
Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. February 24, 2021
Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis. February 3, 2021
It’s time to consider national culture when designing team training initiatives in healthcare. January 27, 2021
Covid-19: Assessing the Risk to Public Protection Posed by a Doctor as a Result of Concerns about their Practice during the Pandemic. September 30, 2020
Impacts of operational failures on primary care physicians' work: a critical interpretive synthesis of the literature. May 13, 2020
Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service February 19, 2020
The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes. July 10, 2019
A safety evaluation of the impact of maternity-orientated human factors training on safety culture in a tertiary maternity unit. June 19, 2019
Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. December 17, 2014
Mentorship for newly appointed physicians: a strategy for enhancing patient safety? September 3, 2014
A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project." August 20, 2014
Deafening silence? Time to reconsider whether organisations are silent or deaf when things go wrong. August 6, 2014
'Even now it makes me angry': health care students' professionalism dilemma narratives. August 6, 2014