High Reliability Organization Reference List

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network. (2012). Patient Safety Primers - Systems Approach. Retrieved from https://psnet.ahrq.gov/primers/primer/21

AHRQ Morbidity and Mortality Rounds https://www.ahrq.gov/cpi/about/otherwebsites/webmm.ahrq.gov/index.html

Air Florida Flight 90. (2014, November 25). In Wikipedia, the Free Encyclopedia online. Retrieved from http://en.wikipedia.org/wiki/Air_Florida_Flight_90#Cockpit_crew

Air France Flight 296. (n.d.). In Wikipedia, the free encyclopedia. Retrieved from http://en.wikipedia.org/wiki/Air_France_Flight_296

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. https://www.acpjournals.org/doi/pdf/10.7326/0003-4819-142-9-200505030-00012

Ambrose, K. (2012, January 13). The 30 year anniversary of the crash of Air Florida Flight 90. The Washington Post. Retrieved from http://www.washingtonpost.com/blogs/capital-weather- gang/post/the-30-year-anniversary-of-the-crash-of-air-florida-flight- 90/2012/01/11/gIQAEVH4tP_blog.html

Arriaga, A. F., Bader, A. M., Wong, J. M., Lipsitz, S. R., Berry, W. R., Ziewacz, J. E., . . . Gawande, A. A. (2013). Simulation-Based Trial of Surgical-Crisis Checklists. New England Journal of Medicine, 368, 246- 253. https://www.nejm.org/doi/pdf/10.1056/NEJMsa1204720

Ayers, Keith E. (2014, January 29). Are you leading like a dictator? Six signs your management style is toxic. Corporate Wellness Magazine. The official magazine of Corporate Health and Wellness Association. Retrieved from (page not found) https://www.corporatewellnessmagazine.com/article/six-signs-your-management-style-is-toxic

Beck, J. (Interviewer) & Sculli, G. L. (Interviewee). (2011). Ask the expert: Task load division for nursing care [Nurse Leader Insider, Interview Question and Answer]. Retrieved from http://www.hcpro.com/NRS-266207-868/Ask-the-expert-Task-load-division-for-nursing-care.html

Blake, R. R., & Mouton, J. S. (1978). The new managerial grid. Houston, TX: Gulf Publishing Co. https://www.amazon.com/New-Managerial-Grid-Robert-Blake/dp/0872014738

Brady, A. M., Malone, A. M., & Fleming, S. (2009). A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of Nursing Management, 17(6), 679-697. https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2834.2009.00995.x

Bush, G., Whalen, P. J., Rosen, B. R., Jenike, M. A., McInerney, S. C., & Rauch, S. L. (1998). The counting stroop: An interference task specialized for functional neuroimaging—validation study with functional MRI. Human Brain Mapping, 6, 270–282. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6873370/

Carney, B. T., West, P., Neily, J., Mills, P. D., & Bagian, J. P. (2010). Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR. Association of Perioperative Registered Nurses (AORN) Journal, 91(6), 722-729. https://aornjournal.onlinelibrary.wiley.com/doi/epdf/10.1016/j.aorn.2009.11.066

Cherry, K. (n.d.). The Kanizsa triangle illusion: understanding the Kanizsa triangle. About.com Psychology. Retrieved from http://psychology.about.com/od/sensationandperception/ig/Optical- Illusions/Kanizsa-Triangle-Illusion.htm#step-heading

Chidester, T.R., Kenki, B.G., Foushes, H. C., Dickenson, C.L., & Bowles, S. B. (1990) Personality factors in flight operations. Volume I. Leader characteristics and crew performance in a full mission. (Air Transport Simulation). Moffett Field, CA: NASA Ames Research Center. https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19900014054.pdf

Chidester, T. R., Helmreich, R. L., Gregorich, S. E., & Geis, C. E. (1991). Pilot personality and crew coordination: implications for training and selection. International Journal of Aviation Psychology, 1(1), 25-44. http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=7367577&site=ehost-live

Cohen, J. D., Dunbar, K., & McClelland, J. L. (1990). On the control of automatic processes: a parallel distributed processing account of the Stroop effect. Psychological Review, 97(3), 332-361. http://search.ebscohost.com/login.aspx?direct=true&db=pdh&AN=1990-27437-001&site=ehost-live

De Young, R. (2014). Using the Stroop effect to test our capacity to direct attention: A tool for navigating urgent transitions. Retrieved from http://www.snre.umich.edu/eplab/demos/st0/stroopdesc.html

Dekker, S. W. (2002). Reconstructing human contributions to accidents: the new view on error and performance. Journal of Safety Research, 33(3), 371-385 http://sidneydekker.com/wp- content/uploads/2013/01/SafetyResearch.pdf

Dekker, S. W. (2017). Just Culture. Restoring Trust and Accountability in Your Organization. 3rd Edition. CRC Press. Boca Raton, FL. http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=1062212&site=ehost-live

Delta Airlines. Rules of the Road. [pdf file] Retrieved from http://www.delta.com/content/dam/delta- www/pdfs/policy/delta-rules-of-the-road.pdf

Deziel, D. J., Millikan, K. W., Economou, S. G., Doolas, A., Ko, S. T., & Airan, M. C. (1993). Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. American Journal of Surgery, 165(1), 9-14. https://reader.elsevier.com/reader/sd/pii/S1015958411600183?token=0B5E7D50A7DFB1733A059A14E 847E00DCE1BA90A4F4E2E88970168D86E64DB50AAA450BF16468C65CD855C3E1FBA5A56

Dr. Robert. C. Ginnett – Dissertation work Yale University “First Encounters of the Close Kind” https://apps.dtic.mil/dtic/tr/fulltext/u2/a187977.pdf

Endsley, M. R. (2013). Situation awareness. In J. D. Lee & A. Kirlik (Eds.), The Oxford Handbook of Cognitive Engineering (pp. 88-108). New York, NY: Oxford University Press. http://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780199757183.001.0001/oxfordhb- 9780199757183-e-5

Endsley, M.R.: Toward a Theory of Situation Awareness in Dynamic Systems. Human Factors Journal 37(1), 32-64.

F-16 Fighting Falcon News (2004, January 22). Thunderbird accident report released. [Web log report by jetech] Retrieved from http://www.f-16.net/f-16-news-article968.html

Fielkow, B. (2014, August 4). War and other crises: how companies can build a culture of safety and prevention. Chief Executive. Retrieved from http://chiefexecutive.net/war-and-other-crises-how- companies-can-build-a-culture-of-safety-and-prevention

Fore, A. M., & Sculli, G. L. (2013). A concept analysis of situational awareness in nursing. Journal of Advanced Nursing, 69(12), 2613-2621. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jan.12130

Fore, A. M., Sculli, G. L., Albee, D., & Neily, J. (2013). Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project. Journal of Nursing Management, 21(1), 106-111. https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2834.2012.01410.x

Forrester, J. W. “The Beginning of System Dynamics.” International Meeting of the System Dynamics Society, Stuttgart, Germany. 13 July 1989. Speech. Retrieved from http://web.mit.edu/sysdyn/sd- intro/D-4165-1.pdf

Forrester, J. W. (1991). System dynamics and the lessons of 35 years. In K. B. Wainrib (Ed.), The Systemic Basis of Policy Making in the 1990s. Retrieved from http://clexchange.org/ftp/documents/system- dynamics/SD1991-04SDandLessonsof35Years.pdf

Fruhen, L.S., Flin, R. & McLeod, R. (2014). Chronic unease for safety in managers - a conceptualisation. Journal of Risk Research, 11, 969-979L.s. https://www.tandfonline.com/doi/abs/10.1080/13669877.2013.822924

Gaffney, A., Gaffney, F. A., Harden, S. W, & Seddon, R. (2005). Crew resource management: the flight plan for lasting change in patient safety. Danvers, MA: HCPro, Inc. https://books.google.com/books/about/Crew_Resource_Management.html?id=NJMb4_HmewUC

Gordon D. Schiff, MD; Omar Hasan, MD; Seijeoung Kim, RN, PhD; et al, Diagnostic Error in Medicine, Analysis of 583 Physician-Reported Errors, Arch Intern Med .1887- 1881:)20(169;2009 . doi:10.1001/archinternmed.2009.333 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108559

Halsey, A. III (2012, January 12). 30 years after Air Florida crash, skies safer than ever. The Washington Post. Retrieved from http://www.washingtonpost.com/local/30-years-after-air-florida-crash-skies-safer- than-ever/2012/01/05/gIQAW0GwtP_story.html

Hartgerink, J. M., Cramm, J.M., de Vos, A. J., Bakker, T. J., Steyerberg, E. W., Mackenbach, J. P., & Nieboer, A. P. (2014). Situational awareness, relational coordination and integrated care delivery to hospitalized elderly in the Netherlands: a comparison between hospitals. BMC Geriatrics, 14(3). Retrieved from http://www.biomedcentral.com/content/pdf/1471-2318-14-3.pdf

Health and Safety Executive in United Kingdom. (n.d.). [Health and Safety Diagnostic Tool (HSDT) Kit]. The seven steps of leadership and worker involvement. Step 6: how your team can carry it out. Retrieved from http://www.hse.gov.uk/construction/lwit/step6.htm

Helmreich, R. L., Chidester, T. R., Foushee, H. C., Gregorich, S., & Wilhelm, J. A. (1990). How effective is cockpit resource management training? Exploring issues in evaluating the impact of programs to enhance crew coordination. Flight Safety Digest, 9(5), 1-17. https://www.researchgate.net/publication/11808765_How_effective_is_cockpit_resource_managemen t_training_Exploring_issues_in_evaluating_the_impact_of_programs_to_enhance_crew_coordination

Helmreich, R. L., Klinect, J. R., & Wilhelm, J. A. (1999). Models of Threat, Error, and CRM in flight operations. University of Texas Team Research Project: University of Texas; Austin, TX. https://flightsafety.org/files/models_of_threat_error.pdf

Helmreich, R. L., & Wilhelm, J. A. (1991). Outcomes of crew resource management training. International Journal of Aviation Psychology, 1(4), 287-300. http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=7369189&site=ehost-live

Helmreich, R. L., Wilhelm, J. A., Gregorich, S. E., & Chidester, T. R. (1990). Preliminary results from the evaluation of cockpit resource management training: performance ratings of flightcrews. Aviation, Space, and Environmental Medicine, 61(6), 576-579. https://www.safetylit.org/citations/ild_request_form.php?article_id=citjournalarticle_139160_19

Herzog, T. R., Hayes, L. J., Applin, R. C., & Weatherly, A. M. (2011) Incompatibility and Mental Fatigue. Environment and Behavior, 43(6), 827-847. https://journals.sagepub.com/doi/pdf/10.1177/0013916510383242

Hu, Y.Y., et al. (2016). Surgeons’ leadership styles and team behavior in the operating room. J Amer Coll Surg, 222 (1), 41-51. https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1072751515016191

Ikkersheim, D.E., and Berg, M., How reliable is your hospital? A qualitative framework for analyzing reliability levels - BMJ Qual and Saf 2011; 20: 785-790 https://qualitysafety.bmj.com/content/qhc/20/9/785.full.pdf

Institute for Safe Medication Practices (ISMP). (2004, March 11). Intimidation: practitioners speak up about this unresolved problem (part I). ISMP Medication Safety Alert!, 9(5), 1-3. Retrieved from https://www.ismp.org/resources/intimidation-practitioners-speak-about-unresolved-problem-part-i

Institute for Safe Medication Practices (ISMP). (2004, March 25). Intimidation: Mapping a plan for cultural change in healthcare (part II). ISMP Medication Safety Alert!, 9(6), 1-3. Retrieved from https://www.ismp.org/resources/intimidation-mapping-plan-cultural-change-healthcare-part-ii

Johnson, J. L. (2014, July 29). Tips for success from Delta Air Lines CEO Richard Anderson. Airline Reporter. Retrieved from http://www.airlinereporter.com/2014/07/tips-for-success-from-delta-air- lines-ceo-richard-anderson

Kanizsa, G. (1955). Margini quasi-percettivi in campi con stimolazione omogenea. Rivista di Psicologia 49(1): 7–30. https://www.researchgate.net/publication/290470422_Quasi- Perceptual_Margins_in_Homogeneously_Stimulated_Fields

Kanki, B. G., Helmreich, R. L., & Anca, J. (Eds.). (2010). Crew resource management (3rd ed.). San Diego, CA: Elsevier. https://www.elsevier.com/books/crew-resource-management/kanki/978-0-08-095900-9

Kaplan, S. (2001). Meditation, restoration, and the management of mental fatigue. Environment and Behavior, 33(4), 480-506. https://www.nrs.fs.fed.us/pubs/jrnl/2001/nc_2001_kaplan_005.pdf

Kaye, K. (1992, December 29). Flight 401 1972 Jumbo-jet Crash Was Worst Aviation Disaster In State History. Sun Sentinel. Retrieved from http://articles.sun-sentinel.com/1992-12- 29/news/9203090325_1_landing-gear-jumbo-jet-plane

Kelley, R. E. (1988). In praise of followers. Harvard Business Review, 66(6), 142-148. https://hbr.org/1988/11/in-praise-of-followers

Kelley, R. E. (1992). The power of followership. New York, NY: Doubleday Business. https://www.amazon.com/Power-Followership-Robert-Kelley/dp/0385413068

Kern, A. T. (2001). Controlling Pilot Error: Culture, Environment, and CRM (Crew Resource Management). New York, NY: McGraw-Hill Professional https://www.amazon.com/Controlling-Pilot-Error-Environment-Management/dp/0071373624

Knowles, M. (1984). The Adult Learner: A Neglected Species (3rd Ed.). Houston: Gulf Publishing

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press. http://pm9cs6fz5g.search.serialssolutions.com/log?L=PM9CS6FZ5G&D=N87&J=TC0000746524&P=EJP& H=90fd30fd60&U=https%3A%2F%2Fwww.nap.edu%2Fopenbook.php%3Frecord_id%3D9728

Leadership Grid https://www.mindtools.com/pages/article/newLDR_73.htm

Leape, L. L., Shore, M. F., Dienstag, J. L., Mayer, R. J., Edgman-Levitan, S., Meyer, G. S., & Healy, G. B. (2012). Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Academic Medicine, 87(7), 845-852. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=ovft&AN=00001888-201207000- 00010&PDF=y

Leape, L. L., Shore, M. F., Dienstag, J. L., Mayer, R. J., Edgman-Levitan, S., Meyer, G. S., & Healy, G. B. (2012). Perspective: a culture of respect, part 2: creating a culture of respect. Academic Medicine, 87(7), 853-858. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=ovft&AN=00001888-201207000- 00011&PDF=y

Lee, J. H., Kim, S. J., Lam, J., Kim, S., Nakagawa, S., & Yoo, J. W. (2014). The effects of shared situational awareness on functional and hospital outcomes of hospitalized older adults with heart failure. Journal of Multidisciplinary Healthcare, 7, 259-265. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085298/pdf/jmdh-7-259.pdf

Leonard, M.W., Frankel, A., The path to safe and reliable healthcare. Patient Educ Couns. 2010 Sep;80(3):288-292. https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0- S0738399110004027.pdf?locale=en_US&searchIndex=

Leonard, M., Graham, S., & Bonacum, D. (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(Suppl 1), i85–i90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765783/pdf/v013p00i85.pdf

Makary, M.A., Sexton, J.B., Freischlag, J. A., Holzmueller, C.G., Millman, E. A., Rowen, L., & Pronovost, P. J. (2006) Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. Journal of the American College of Surgeons, 202(5), 746-752. https://reader.elsevier.com/reader/sd/pii/S1072751502015971?token=A4A9EB744D8E52D262DDF3EE0 F018B786F1F91381F42D3FCF3CB64EDD3E191E1C6DB817CC15EB1D5508A181DBFAF4928

Marco J. Barzallo Salazar, MD Howard Minkoff, MD Jyothshna Bayya, MD Brian Gillett, MD Helen Onoriode, MD Jeremy Weedon, PhD Lisa Altshuler, PhD Nelli Fisher, MD. (2014) Influence of Surgeon Behavior on Trainee Willingness to Speak Up: A Randomized Controlled Trial. Journal of the American College of Surgeons., 219(5), 1001-1007 https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0- S1072751514014690.pdf?locale=en_US&searchIndex=

Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzler, A. (2005). Silence kills: the seven crucial conversations in healthcare. Retrieved from http://www.silenttreatmentstudy.com/silencekills/SilenceKills.pdf

Maxfield, D., Grenny, J., Ramón Lavandero, R., & Groah, L. (2010). The silent treatment: why safety tools and checklists aren’t enough to save lives. Retrieved from http://www.aacn.org/WD/hwe/docs/the- silent-treatment.pdf

McVicar, A. (2003). Workplace stress in nursing: a literature review. Journal of Advanced Nursing, 44(6), 633-642. https://onlinelibrary.wiley.com/doi/epdf/10.1046/j.0309-2402.2003.02853.x

National Institutes of Health. National Institute on Drug Abuse. (n.d.). [The NIH Curriculum Supplement Series ]. The Brain: Understanding Neurobiology Through the Study of Addiction. Retrieved from https://www.drugabuse.gov/publications/brain-understanding-neurobiology-through-study- addiction#:~:text=The%20Brain%3A%20Understanding%20Neurobiology%20Through%20the%20Study% 20of,and%20addiction%2C%20including%20neurobiology%2C%20behavioral%20components%2C%20an d%20treatment.

National Transportation Safety Board. (1973). Aircraft Accident Report. (Report Number NTSB-AAR-73- 14, Eastern Airlines, Inc., L-1011, N310EA, Miami, Florida, December 29, 1972. Adopted: June 14, 1973). Washington, DC 20591. Retrieved from http://libraryonline.erau.edu/online-full-text/ntsb/aircraft- accident-reports/AAR73-14.pdf

National Transportation Safety Board. (1988). Aircraft Accident Report. (Report Number NTSB/AAR- 88/05, Northwest Airlines, Inc., McDonnell Douglas DC-9-82, N312RC, Detroit Metropolitan Wayne County Airport, Romulus, Michigan August 16, 1987). Washington, DC 20594. Retrieved from http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR88-05.pdf

Neily, J., Mills, P. D., Young-Xu, Y., Carney, B. T., West, P., Berger, D. H., Mazzia, L. M., Paull, D. E., & Bagian, J. P. (2010). Association between implementation of a medical team training program and surgical mortality. Journal of the American Medical Association (JAMA), 304(15), 1693-1700. https://jamanetwork.com/journals/jama/fullarticle/186748

Neuroscience for Kids. (n.d.). [Interactive Game December 5, 2014]. Colors, Colors. Stroop Effect. Retrieved from https://faculty.washington.edu/chudler/words.html#seffect

Neuroscience for Kids. (n.d.). [Interactive Game December 5, 2014]. Interactive "Animal Stroop" Effect Experiment. Retrieved from https://faculty.washington.edu/chudler/java/readya.html

Nuzzo, G., Giuliante, F., Giovannini, I., Ardito, F., D'Acapito, F., Vellone, M., Murazio, M., & Capelli, G. (2005). Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Archives of Surgery, 140(10), 986-992. https://jamanetwork.com/journals/jamasurgery/fullarticle/509003

Pape, T. M. (2003). Applying airline safety practices to medication administration. MEDSURG Nursing, 12(2), 77-93. https://interruptions.net/literature/Pape-MEDSURG_Nursing03.pdf

Reader, T., Flin, R., & Cuthberson, B. (2008). Factors affecting team communication in the intensive care unit. In C. P. Nemeth (Ed.), Improving healthcare team communication: building on lessons from aviation and aerospace (pp. 117-134). . Aldershot, Hampshire,UK: Ashgate. http://eprints.lse.ac.uk/29084/

Reason, J. (1990). Human Error. Cambridge, UK: Cambridge University Press.

Reason, J. (2008). The human contribution: unsafe acts, accidents, and heroic recoveries. Bodmin, Cornwall, UK: Ashgate. https://www.researchgate.net/publication/245130738_The_Human_Contribution_Unsafe_Acts_Accide nts_and_Heroic_Recoveries_James_Reason_Ashgate_Farnham_Surrey_UK_2008_295_pp_L1995

Response to Zhang et al. (2005): loss-of-function mutation in tryptophan hydroxylase-2 identified in unipolar major depression. Neuron 45, 11-16., Neuron. 2005 Dec 8;48(5):702-3; author reply 705-6 These seem to be 3 different citations. https://reader.elsevier.com/reader/sd/pii/S0896627304008086?token=01B5A551A80F42B3E4E14D343 EEAA62181C38116FC1818D50C1715F52E75F9F93DE323039259D1C5C50A06B1980502C9 https://www.sciencedirect.com/science/article/pii/S0896627305009979 https://www.sciencedirect.com/science/article/pii/S0896627305010007

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. https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2834.2010.01121.x Salas, E., Sims, D.E., & Burke, S.C. (2005). Is there a “Big Five” in teamwork? Small Group Research, 36, 555-599. https://www.uio.no/studier/emner/matnat/ifi/INF5181/h14/artikler- teamarbeid/salas_etal_2005_is_there_a_big_five_in_teamwork---copy.pdf

Sculli, G. L., & Sine, D. M. (2011). Soaring to success: taking crew resource management from the cockpit to the nursing unit. Danvers, MA: HCPro, Inc. https://books.google.com/books/about/Soaring_to_Success.html?id=MHgh-a2ZfUoC

Smetzer, J., Baker, C., Byrne, F. D., & Cohen, M. R. (2010). Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf., 36(4),152-163. https://www.sciencedirect.com/science/article/pii/S1553725010360272?via%3Dihub

Smetzer, J. L., & Cohen, M. R. (2005). Intimidation: practitioners speak up about this unresolved problem. Joint Commission Journal on Quality and Patient Safety, 31(10), 594-599. https://www.sciencedirect.com/science/article/pii/S1553725005310774?via%3Dihub

Smith, P. (2014, march 27). How a tiny island runway became the site of the deadliest plane crash ever. Retrieved from http://www.businessinsider.com/deadliest-plane-crash-in-history-2014-3

Szczerba, R. (2013, September 17). Silence kills: can technology drive meaningful cultural change in healthcare. Forbes. Retrieved from http://www.forbes.com/sites/robertszczerba/2013/09/17/silence- kills-can-technology-drive-meaningful-cultural-change-in-healthcare/

The Herald of Free Enterprise, Read more: http://www.dailymail.co.uk/news/article-4283156/Survivors- relive-Zeebrugge-ferry-disaster-30-years-later.html#ixzz5Bj7WZs9f

Thomas, E.J., Sexton, J.B., & Helmreich R. L. (2003). Discrepant attitudes about teamwork among critical care nurses and physicians. Critical Care Medicine, 31(3), 956-959. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=ovft&AN=00003246-200303000- 00047&PDF=y

Thunderbird crash video 2 [Video file]. Retrieved from https://www.youtube.com/watch?v=alo_XWCqNUQ

Thunderbirds crash with cockpit view [Video file]. Retrieved from http://www.military.com/video/military-aircraft-operations/crash-landings/thunderbirds-crash-with- cockpit-view/2809863066001/

United States Department of Veterans Affairs. (2014). Root Cause Analysis [Data file]. Available from the Veterans Health Administration National Center for Patient Safety.

United States Food and Drug Administration. (2013). Oxygen tubing erroneously connected to a needleless IV port. Retrieved from https://www.fda.gov/medical-devices/medical-device- connectors/examples-medical-device-misconnections

Van Beuzekom, M., Akerboom, S. P., & Boer, F. (2007). Assessing system failures in operating rooms and intensive care units. Quality and Safety in Health Care, 16(1): 45–50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464926/

Way, L. W., Stewart, L., Gantert, W., Liu, K., Lee, C. M., Whang, K. & Hunter, J. G. (2003). Causes and Prevention of Laparoscopic Bile Duct Injuries. Annals of Surgery, 237(4), 460-469. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464926/pdf/45.pdf

Weick, K.E., & Sutcliffe, K. M. (2001). Managing the unexpected: assuring high performance in an age of complexity. San Francisco, CA: Jossey-Basse. https://books.google.com/books/about/Managing_the_Unexpected.html?id=Q94OAQAAMAAJ

Wiegmann, D. A., ElBardissi, A.W., Dearani, J. A., Daly, R.C., & Sundt, T. M. III. (2007). Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery, 142(5), 658- 665. https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0- S0039606007005168.pdf?locale=en_US&searchIndex=

Zaidan, H. The Blake Mouton managerial grid: identifying five different leadership styles [PDF document]. Retrieved from http://www.dcookacademic.com/uploads/1/0/8/8/10887248/blake_mouton_managerial_grid.pdf