المصادر والمراجع

References
Master Reference List - Vancouver / ICMJE Style
جميع المصادر والمراجع المستخدمة في إعداد "دليل السلامة والجودة في التخدير"
تم اتباع أسلوب Vancouver / ICMJE في التوثيق

إحصائيات المراجع

571 مصدر ومرجع علمي

  1. 1. Aasland OG, Forde R. Impact of feeling responsible for adverse events on doctors’ personal and professional lives: the importance of being open to criticism from colleagues. Qual Saf Health Care. 2005;14:13– 17.
  2. 2. Abecassis ZA, et al. Applying fault tree analysis to the prevention of wrong-site surgery. J Surg Res. 2015;193(1):88–94.
  3. 3. ACOG committee opinion no. 508: disruptive behavior. Obstet Gynecol. 2011 Oct;118(4):970– 972.
  4. 4. Agency for Healthcare Research and Quality. User comparative database report: hospital survey on patient safety culture. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
  5. 5. Aggarwal R, Grantcharov T, Moorthy K, Milland T, Darzi A. Toward feasible, valid, and reliable video- based assessments of technical surgical skills in the operating room. Ann Surg. 2008;247(2):372–9.
  6. 6. Aitkenhead AR. Anaesthetic disasters: handling the aftermath. Anaesthesia. 1997;52:477– 482.
  7. 7. Allo MD, Tedesco M. Operating room management: operative suite considerations, infection control. Surg Clin North Am. 2005;85(6):1291–7. xii.
  8. 8. American Society of Anesthesiologists Committee on Equipment and Facilities. Guidelines for Pre- Anesthesia Checkout Procedures. 2008. http:// www.asahq.org/ resources/ clinical- information/ 2008- asa- recommendations- for- pre- anesthesia- checkout. Accessed 9 April, 2016.
  9. 9. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Stan dards for Basic Anesthetic Monitoring. 2010. http:// www.asahq.org/ ~/ media/ sites/ asahq/ files/ public/.
  10. 10. American Society of Anesthesiologists Committee on Standards and Practice Parameters. Statement on Nonoperating Room Anesthetizing Locations. 2013. http:// www.asahq.org/ ~/ media/ legacy/ for% 20members/ documents/ standards%20guidelines%20stmts/ nonoperating%20room%20anesthetizing%20locations.pdf. Accessed 9 April, 2016.
  11. 11. American Society of Anesthesiologists Task Force on Operating Room Fires. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013;118:271– 290.
  12. 12. Antonsen S. Safety Culture: Theory, Measurement, and Improvement. Burlington, VT: Ashgate; 2009.
  13. 13. AORN position statement on perioperative safe staffing and on-call practices. Association of periOperative Registered Nurses, Denver; 2014.
  14. 14. AORN. Guideline for positioning the patient. In: Guidelines for perioperative practice. AORN, Inc: Denver, CO; 2015. p. 563–81.
  15. 15. Apostolakis G, Barach P. Lessons learned from nuclear power. In: Hatlie M, Tavill K, editors. Patient safety, international textbook. Faithersburg: Aspen; 2003. p. 205–25.
  16. 16. Aronson S, Mathew JP, Cheung AT, Shore- Lesserson L, Troianos CA, Reeves S. The rationale and development of an adult cardiac anesthesia module to supplement the society of thoracic surgeons national database: using data to drive quality. Anesth Analg. 2014;118:925– 932.
  17. 17. Asch DA, Weinstein DF. Innovation in medical education. N Engl J Med. 2014;371(9):794– 795.
  18. 18. Association of periOperative Registered Nurses. Recommended practices for electrosurgery. AORN J. 2005;81(3):616–8, 621–6, 629–32.
  19. 19. Australian Institute of Health and Welfare. Hospital performance: adverse events treated in hospitals. 2015. http:// www.aihw.gov.au/ haag11- 12/ adverse- events/.
  20. 20. Ayers LR, Beyea SC, Godfrey MM, Harper DC, Nelson EC, Batalden PB. Quality improvement learning collaboratives. Qual Manag Health Care. 2005;14:234–47.Table 42.1 Key components of a successful learning collaborative Component Description Mission and target populationClear and achievable mission Tangible goals Membership Strategies for membership (application, invitation, etc.) Defined roles • Clinical Leader or “Champion” (e.g., knowledgeable of improvement processes, ability to integrate spirit of collaborative learning with everyday practice, willingness to share) • Project Manager (e.g., coordinates communication, organizes and facilitates meetings, project expertise) • Data Analyst (e.g., transforms data into useful information) Technology Develop data management and communication systems across member organizations to enable collection, aggregation, and analysis of the data Funding Identify and select sources (e.g., membership dues, private organizations, research institutions) Governance Establish multidisciplinary decision-making body to guide Collaborative process Contractual issuesEstablish and articulate policies addressing confidentiality, data ownership by organization submitting data, publication/presentation process and rights, and participant responsibilities Meetings Convene regular, formal face-to- face meetings Modified from Ayers LR, Beyea SC, Godfrey MM, Harper DC, Nelson EC, Batalden PB. Quality improvement learning collaboratives. Qual Manag Health Care. 2005;14:234–47 J.K. Johnson et al.
  21. 21. Baik SH, Lim DR, Hur H, Min BS, Lee KY. Oncologic outcomes and perioperative clinicopathologic results after robot-assisted tumor-specific mesorectal excision for rectal cancer. Ann Surg Oncol. 2013;20(8):2625–32.
  22. 22. Baines R, Langelaan M, de Bruijne M, Spreeuwenberg P, Wagner C. How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time. BMJ Qual Saf. 2015;24(9):561–71. doi: 10.1136/bmjqs-2014-003702.
  23. 23. Baker D, Battles J, King H, Salas E, Barach P. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Jt Comm J Qual Saf. 2005;31(4):185–202.
  24. 24. Baker DP, Gustafson S, Beaubien JM, Salas E, Barach P. Medical teamwork and patient safety: The evidence-based relation. Washington, DC: American Institute for Research; 2003.
  25. 25. Banks J, Marmot M, Oldfield Z, Smith JP. Disease and disadvantage in the United States and in England. JAMA. 2006;295(17):2037– 2045.
  26. 26. Barach P, Cosman P. Teams, team training, and the role of simulation. In: Barach P, Jacobs J, Laussen P, Lipshultz S, editors. Outcomes analysis, quality improvement, and patient safety for pediatric and congenital cardiac disease. New York, NY: Springer Books; 2014. ISBN 978-1-4471-4618-6.
  27. 27. Barach P, Cosman P. Teams, team training, and the role of simulation. In: Barach P, Jacobs J, Laussen P, Lipshultz S, editors. Outcomes analysis, quality improvement, and patient safety for pediatric and congenital cardiac disease. New York: Springer; 2014. ISBN 978-1-4471-4618-6.
  28. 28. Barach P, Johnson J, Ahmed A, Galvan C, Bognar A, Duncan R, Starr J, Bacha E. Intraoperative adverse events and their impact on pediatric cardiac surgery: a prospective observational study. J Thorac Cardiovasc Surg. 2008;136(6):142.
  29. 29. Barach P, Phelps G. Clinical sensemaking: a systematic approach to reduce the impact of normalised deviance in the medical profession. J R Soc Med. 2013;106(10):387–90.
  30. 30. Barach P. Addressing barriers for change in clinical practice. In: Guidet B, Valentin A, Flaatten H, edi21 The Science of Delivering Safe and Reliable Anesthesia Care.
  31. 31. Barach P. Final report on the recommendations for implementation of the Florida Patient Safety Corporation, Florida Safety Network, 29 June 2004.
  32. 32. Barach P. Team based risk modification program to make health care safer. Theor Iss Ergon Sci. 2007;8:481–94.
  33. 33. Barach P. The impact of the patient safety movement on clinical care. Adv Anesth. 2003;21:51–80.
  34. 34. Barker KN, Flynn EA, Pepper GA. Observation method of detecting medication errors. Am J Health Syst Pharm. 2002;59:2314–6.
  35. 35. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199– 205.
  36. 36. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, Seger DL. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311–6.
  37. 37. Bender SP, Paganelli WC, et al. Intraoperative lung- protection ventilation trends and practice patterns: a report from the multicenter perioperative outcomes group. Anesth Analg. 2015121(5): 1231– 1239.
  38. 38. Benn J, Arnold G, Wei I, Riley C, Aleva F. Using quality indicators in anaesthesia: feeding back to improve care. Br J Anaesth. 2012;109(1):80– 91.
  39. 39. Bernstein MS. Isolated power and line isolation monitors. Biomed Instrum Technol 1990;24:221– 223.
  40. 40. Bianchi PP, Ceriani C, Locateli A, Spinoglio G, Zampino MG, Sonzogni A, Crosta C, Andreoni B. Robotic versus laparoscopic total mesorectal excision for rectal cancer: a comparative analysis of oncological safety and short-term outcomes. Surg Endosc. 2010;24(11):2888–94.
  41. 41. Bickler SW, Sanno-Duanda B. Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. Bull World Health Organ. 2000;78:1330–6.
  42. 42. Bilimoria KY, Kmiecik TE, DaRosa DA, Halverson A, Eskandari MK, Bell Jr RH, Soper NJ, Wayne JD. Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. Arch Surg. 2009;144(4):305–11. doi: 10.1001/archsurg.2009.5. discussion 311.
  43. 43. Birkmeyer JD, Finks JF, O’Reilly A, Oerline M, Carlin AM, Nunn AR, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434–42.
  44. 44. Bitter J, van Veen-Berkx E, van Amelsvoort P, Gooszen H. Preoperative cross functional teams improve OR performance. J Health Organ Manag. 2015;29(3):343–52.
  45. 45. Bognar A, Barach P, Johnson J, Duncan R, Woods D, Holl J, Birnbach D, Bacha E. Errors and the burden of errors: attitudes, perceptions and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;4:1374–81.
  46. 46. Bognar A, Barach P, Johnson J, Duncan R, Woods D, Holl J, Birnbach D, Bacha E. Errors and the burden of errors: attitudes, perceptions and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;4:1374–81. S. Moffatt-Bruce and R.S.D. Higgins.
  47. 47. Bognar A, Barach P, Johnson J, Duncan R, Woods D, Holl J, et al. Errors and the burden of errors: attitudes, perceptions and the culture of safety in pediatric cardiac surgical teams. Ann Thoracic Surg. 2008;4:1374–81.
  48. 48. Bognár A, Barach P, Johnson JK, Duncan RC, Birnbach D, Woods D, Holl JL, Bacha EA. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;85(4):1374–81.
  49. 49. Bokar V, Perry DG. Different roles, same goal: risk and quality management partnering for patient safety. By the ASHRM Monographs Task Force. J Healthc Risk Manag. 2007;27(2):17–23. 25.
  50. 50. Bonmati- Carrion MA, Arguelles- Prieto R, Martinez- Madrid MJ, et al. Protecting the melatonin rhythm through circadian healthy light exposure. Int J Mol Sci. 2014 Dec 17;15(12): 23448– 23500.
  51. 51. Bordyugov G, Abraham U, Granada A, et al. Tuning the phase of circadian entrainment. J R Soc Interface. 2015;12:20150282; DOI: 10.1098/ rsif.2015.0282.
  52. 52. Bould MD, Naik VN, Hamstra SJ. Review article: new directions in medical education related to anesthesiology and perioperative medicine. Can J Anaesth. 2012;59(2):136– 150. doi: 10.1007/ s12630- 011- 9633-.
  53. 53. Branch WT, Frankel R, Gracey CF, Haidet PM, Weissmann PF, Cantey P, et al. A good clinician and a caring person: longitudinal faculty development and the enhancement of the human dimensions of care. Acad Med. 2009;84(1):117– 125. doi: 10.1097/ ACM.0b013e3181900f8a. PubMed PMID: 19116489.
  54. 54. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322–30.
  55. 55. Brewer CS, Kovner CT, Obeidat RF, Budin WC. Positive work environments of early- career registered nurses and the correlation with physician verbal abuse. Nurs Outlook. 2013 Nov- Dec;61(6): 408– 416.
  56. 56. Broadbent DE. The current state of noise research: reply to Poulton. Psychol Bull. 1978;85(C):1052– 1067. doi:10.1037/ 0033- 2909.85.5.1052.
  57. 57. Brookhuis KA, de Waard D. The use of psychophysiology to assess driver status. Ergonomics. 1993;36(9):1099– 1110. doi:10.1080/ 00140139308967981.
  58. 58. Brue G. Six Sigma for managers. New York: McGraw Hill; 2002.
  59. 59. Bruley ME. Surgical fires: perioperative communication is essential to prevent this rare but devastating complication. Qual Saf Health Care. 2004;13(6): 467–71.
  60. 60. Buchel TL, Edwards FD. Characteristics of effective clinical teachers. Fam Med. 2005;37(1):30–.
  61. 61. Burden A, et al. Situational Awareness Errors in Malpractice Claims. ASA Abstract. New Orleans: ASA, 2014.
  62. 62. Campbell EG, Singer S, Kitch BT, Iezzoni LI, Meyer GS. Patient safety climates in hospitals: act locally on variations across units. Jt Comm J Qual Patient Saf. 2010;36(7):319–26.
  63. 63. Capers PL, Fobian AD, Kaiser KA, Borah R, Allison DB. A systemic review and meta- analysis of randomized controlled trials of the impact of sleep duration on adiposity and components of energy balance. Obes Rev. 2015;16(9):771– 782.
  64. 64. Cappuccio FP, Cooper D, D’Elia L, Strazzullo P, Miller MA. Sleep duration predicts cardiovascular outcomes: a systematic review and meta- analysis of prospective studies. Eur Heart J. 2011;32(12):1484– 1492.
  65. 65. Carayon P, Hundt AS, Karsh BT, Gurses AP, Alvarado CJ, Smith M, Brennan PF. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15(Suppl 1):i50– i58.
  66. 66. Carayon P, Schoofs Hundt A, Karsh B, Gurses AP, Alvarado CJ, Smith M, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care. 2006;15(1):150–8.
  67. 67. Casale AS, Paulus RA, Selna MJ, Doll MC, Bothe Jr AE, McKinley KE, et al. “ProvenCareSM”: a provider-driven pay-for-performance program for acute episodic cardiac surgical care. Ann Surg. 2007;246(4):613–21. discussion 21–3.
  68. 68. Cassera MA, Zheng B, Martinec DV, Dunst CM, Swanström LL. Surgical time independently affected by surgical team size. Am J Surg. 2009;198(2):216– 22. doi: 10.1016/j.amjsurg.2008.10.016.
  69. 69. Cassin B, Barach P. Balancing clinical team perceptions of the workplace: applying ‘work domain analysis’ to pediatric cardiac care. Prog Pediatr Cardiol. doi:10.1016/j.ppedcard.2011.12.005.
  70. 70. Cassin B, Barach P. Balancing clinical team perceptions of the workplace: applying ‘work domain analysis’ to pediatric cardiac care. Prog Pediatr Cardiol. 2011. doi:10.1016/j.ppedcard.2011.12.005.
  71. 71. Cassin B, Barach P. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin N Am. 2012, 1–15. doi: 10.1016/j. suc.2011.12.008.
  72. 72. Cassin B, Barach P. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin North Am. 2012;1–15. doi: 10.1016/j. suc.2011.12.008.
  73. 73. Cassin B, Barach P. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin North Am. 2012;92:101–15. doi: 10.1016/j. suc.2011.12.008.
  74. 74. Cassin B, Barach P. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin North Am. 2012;92(1):101–15. doi:10.1016/j.suc.2011.12.008.
  75. 75. Cassin B, Barach P. Making Sense of Root Cause Analysis Investigations of Surgery-Related Adverse Events. Surg Clin North America 2012, 1–15, doi:10.1016/j.suc.2011.12.008.
  76. 76. Cassin BR, Barach PR. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin North Am. 2012;92(1):101–15.
  77. 77. Catchpole K, Mishra A, Handa A, McCulloch P. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699–706. 16. van Veen-Berkx E, Bitter J, Kazemier G, Scheffer GJ, Gooszen HG. Multidisciplinary teamwork improves use of the operating room: a multicenter study. J Am Coll Surg. 2015;220(6):1070–6.
  78. 78. Causer J, Barach P, Williams M. Expertise in medicine: using the expert performance approach to improve simulation training. Med Educ. 2014;48:115– 23. doi: 10.1111/medu.12306.
  79. 79. Causer J, Barach P. Williams M. Expertise in Medicine: Using the expert performance approach to improve simulation training. Med Educ 2014;48: 115–123. doi:10.1111/medu.12306.
  80. 80. Center for Disease Control and Prevention, Healthcare Safety Network (“NHSN”). NHSN@cdc.gov include HPS Flu Summary-ASC in subject line. Accessed May 2016.
  81. 81. Centers for Disease Control and Prevention. Inpatient Surgery. Atlanta; 2015.
  82. 82. Centers for Medicare and Medicaid Services. http:// innovation.cms.gov/ initiatives/ Pioneer- ACO- Model/. Accessed June 2015.
  83. 83. Chajut E, Algom D. Selective attention improves under stress: implications for theories of social cognition. J Pers Soc Psychol. 2003;85(2):231– 248. doi:10.1037/ 0022- 3514.85.2.231.
  84. 84. Chang B, Kaye AD, Diaz JH, Westlake B, Dutton RP, Urman RD. Complications of non- operating room procedures: outcomes from the National Anesthesia Clinical Outcomes Registry. J Patient Safety. 2015; epub ahead of print.
  85. 85. Chang B, Kaye AD, et al. Complication of non- operating room procedures: outcomes from the National Anesthesia Clinical Outcomes Registry. J Patient Saf. 2015, http:// journals.lww.com/ journalpatientsafety/ Abstract/ publishahead/ Complications_ of_ Non_ Operating_ Room_ Procedures_ _.99676.aspx, Apr 7. Accessed May 31, 2016.
  86. 86. Chappy S. Perioperative patient safety: a multisite qualitative analysis. AORN J. 2006;83(4):871–97.
  87. 87. Charpiat B, Goutelle S, Schoeffler M, et al. Prescriptions analysis by clinical pharmacists in the post- operative period: a 4- year prospective study. Acta Anaesthesiol Scand. 2012;56(8): 1047– 1051.
  88. 88. Chellali A, Schwaitberg SD, Jones DB, Romanelli J, Miller A, Rattner D, Roberts KE, Cao CGL. Towards scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES. Surg Endosc. 2014;28(11):3119–33.
  89. 89. Chenoweth CE, Saint S. Urinary tract infections. Infect Dis Clin North Am. 2011;25(1):103–15.
  90. 90. Cherns A. The principles of sociotechnical design. Hum Relat. 1976;29(8):783– 792.
  91. 91. Chopra V, Bovill JG, Spierdijk J. Accidents, near accidents and complications during anaesthesia. Anaesthesia. 1990;45:3– 6.
  92. 92. Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K, Zinner MJ, Dierks MM. A prospective study of patient safety in the operating room. Surgery. 2006 Feb;139(2):159– 173.
  93. 93. Cima RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80–7.
  94. 94. Cnattingius S, Ericson A, Gunnarskog J, Kallen B. A quality study of a medical birth registry. Scand J Public Health. 1990;18(2):143– 148. http:// sjp.sagepub.com/ content/ 18/ 2/ 143. short.
  95. 95. Cohen AT, Tapson VF, Bergmann J, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet. 2008;371(9610):387–94.
  96. 96. Cohen S, Doyle WJ, Alper CM, Janicki- Deverts D, Turner RB. Sleep habits and susceptibility to the common cold. Arch Intern Med. 2009;169(1):62– 67.
  97. 97. Collins SJ, Newhouse R, Porter J, Talsma A. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason’s Swiss cheese model. AORN J. 2014; 100(1):65–79.
  98. 98. Collinson F, Jayne D, Pigazzi A, Tsang C, Barrie J, et al. An International, multicentre, prospective, randomized, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparoscopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis. 2012;27:233–41.
  99. 99. Conceptual Framework for the international classification for patient safety. WHO/ IER/ PSP/ 2010.2. January 2009, pp. 21– 24. http:// www.who.int/ pa- tientsafety/ taxonomy/ icps_ full_ report.pdf.
  100. 100. Cook JK, Green M, Topp RV. Exploring the impact of physician verbal abuse on perioperative nurses. AORN J. 2001 Sep;74(3):317, 320, 322– 327, 329– 331.
  101. 101. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984;60(1):34– 42.
  102. 102. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984;60:34–42.
  103. 103. Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49(6):399– 406.
  104. 104. Cooper JB. Toward prevention of anesthetic mishaps. Int Anesthesiol Clin. 1984;22:167–83.
  105. 105. Cooper RL, Merry A. Medication management. In: Stonemetz J, Ruskin K, eds. Anesthesia Informatics. London: Springer; 2008:209– 226.
  106. 106. Cottrell D, Kilminster S, Jolly B, Grant J. What is effective supervision and how does it happen? A critical incident study. Med Educ. 2002;36(11):1042– 1049. Epub 2002/ 10/.
  107. 107. Coughlin LD, Patel VL. Processing of critical information by physicians and medical students. J Med Educ. 1987;62(10):818–28.
  108. 108. Council of Economic Advisors. The economic case for health care reform. 2009. https:// www. whitehouse.gov/ administration/ eop/ cea/ TheEconomicCaseforHealthCareReform/. Accessed June 2015.
  109. 109. Creating clear project requirements— differen- tiating “what” from “how.” http:// www.pmi.org/ ~/ media/ PDF/ Publications/ ADV06NA08.ashx. Accessed January 29, 2016.
  110. 110. Cullati S, Le Du S, Rae AC, et al. Is the Surgical Safety Checklist successfully conducted? An observational study of social interactions in the operating rooms of a tertiary hospital. BMJ Qual Saf. 2013;22:639–46.
  111. 111. Currie M, Mackay P, Morgan C, et al. The “wrong drug” problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21(5):596– 601.
  112. 112. Currie M, Mackay P, Morgan C, et al. The “wrong drug” problem in anesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:596–601.
  113. 113. Cushing H, Bovie W. Electrosurgery as an aid to the removal of intracranial tumors. Surg Gynecol Obstet. 1928;47:751–84.
  114. 114. Czeisler CA, Duffy JF, Shanahan TL. Stability, precision, and near- 24- hour period of the human circadian pacemaker. Science. 1999;284(5423): 2177– 2181.
  115. 115. Datta V, Chang A, Mackay S, et al. The relationship between motion analysis and surgical technical assessments. Am J Surg. 2002;184(1):70–3.
  116. 116. Davis K, Stremikis K, Schoen C, Squires D. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. The Commonwealth Fund. 2014: 1– 32.
  117. 117. Davis R, Barach P. Increasing patient safety and reducing medical error: the role of preventive medicine. Am J Prev Health. 2000;19(3):202–5.
  118. 118. Dawe SR, Pena GN, Windsor JA, et al. Systematic review of skills transfer after surgical simulation- based training. Br J Surg. 2014;101(9):1063–76.
  119. 119. Dekker S, Cilliers P, Hofmeyr J-H. The complexity of failure: implications of complexity theory for safety investigations. Saf Sci. 2011;49:939–45.
  120. 120. Dekker S. Patient safety: a human factors approach. Boca Raton: CRC Press Taylor & Francis Group; 2011.
  121. 121. Dekker S. Safety differently: human factors for a new era. Boca Raton: CRC Press; 2014.
  122. 122. Delbanco T, Bell SK. Guilty, afraid, and alone: struggling with medical error. N Engl J Med. 2007;357:1682– 1683.
  123. 123. DeNavas- Walt C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2007. US Census Bureau. Washington, DC: US Government Printing Office; 2008.
  124. 124. DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure mode and effect analysis™: the V A National Center for Patient Safety’s prospective risk analysis system. Jt Comm J Qual Patient Saf. 2002;28(5):248–67.
  125. 125. Designing patient safety into the microsystem. Jt Comm J Qual Patient Saf. 2003;29:401–8.
  126. 126. Dexter F, Epstein R, Traub R, Xiao Y. Making management decisions on the day of surgery based on operating room efficiency and patient waiting times. Anesthesiology. 2004;101(6):1444–53.
  127. 127. Dexter F, Ledolter J. Bayesian prediction bounds and comparisons of operating room times even for procedures with few or no historic data. Anesthesiology. 2005;103(6):1259–67.
  128. 128. Dexter F, Macario A, Traub R, Hopwood M, Lubarsky D. An operating room scheduling strategy to maximize the use of operating room block time. Anesth Analg. 1999;89(1):7–20.
  129. 129. Dexter F, Traub R. How to schedule elective surgical cases into specific operating rooms to maximize the efficiency of use of operating room time. Anesth Analg. 2002;94(4):933–42.
  130. 130. Dijk D, Lockley SW. Invited review: Integration of human sleep- wake regulation and circadian rhythmicity. J Appl Physiol. 2002;92(2):852– 862.
  131. 131. Dillon A. Group dynamics meet cognition: combining socio- technical concepts and usability engineering in the design of information systems. In: Coakes E, ed. The New Socio Tech: Graffiti on the Long Wall. London: Springer; 2000:119– 126.
  132. 132. Dimick JB, Chen SL, Taheri PA, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531–7.
  133. 133. Domain NEPS. Standardise, educate, harmonise: commissioning the conditions for safer surgery. England: NHS England Never Events Taskforce; 2014.
  134. 134. Duffy GL, Farmer E, Moran JW. Applying lean Six Sigma in public health. In: Bialek R, Duffy GL, Moran JW, editors. The public health quality improvement handbook. Milwaukee: ASQ Quality Press; 2009.
  135. 135. Dunn EJ, et al. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Sat. 2007;33:317–25.
  136. 136. Dutton RP, Cohen JA. Medication shortages: are we the Iron Chefs or our own worst enemies? Anesth Analg. 2011;113(6):1298– 1299.
  137. 137. Dutton RP, Dukatz A. Quality improvement using automated data sources: the anesthesia quality institute. Anesthesiol Clin. 2011;29:439– 454.
  138. 138. Dutton RP. Why have a quality management program? Int Anesthesiol Clin. 2013;51(4):1– 9.
  139. 139. Dyer C. Public inquiry hears how Shipman killed patients with diamorphine. BMJ. 2001; 322(7302):1566.
  140. 140. Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309(15):1599–606.
  141. 141. Eastridge BJ, Hamilton EC, O’Keefe GE, Rege RV, Valentine RJ, Jones DJ, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg. 2003;186:169–74.
  142. 142. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2): 350–83.
  143. 143. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350.
  144. 144. Ehrenwerth J, Seifert HA. Electrical and fire safety. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical Anesthesia. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2006:149– 174.
  145. 145. Eichhorn J. Organized response to major anesthesia accident will help limit damage. APSF Newsl. 2006;21:11– 13.
  146. 146. Eijkemans M, van Houdenhoven M, Nguyen T, Boersma E, Steyerberg E, Kazemier G. Predicting the unpredictable. Anesthesiology. 2010;112:41–9.
  147. 147. Electrical Safety Foundation International. Five easy steps to a safer home. Electrical Safety Foundation International Newsletter, March 2014.
  148. 148. Emergency Care Research Institute (ECRI). New clinical guidance for surgical fire prevention. Health Devices 2009;38:1067– 1075.
  149. 149. Encinosa WE, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. Health Serv Res. 2008;43(6):2067–85.
  150. 150. Endsley MR, Bolstad CA. Individual differences in pilot situation awareness. Int J Aviat Psychol. 1994;3(4):241– 264.
  151. 151. Endsley MR, Garland DJ, eds. Situation awareness analysis and measurement. Mahwah, NJ: Lawrence Erlbaum Associates; 2000.
  152. 152. Endsley MR, Jones DG. Designing for situation awareness: An Approach to User- Centered Design. 2nd ed. London: CRC Press; 2011:147– 168.
  153. 153. Endsley MR. Direct measurement of situation awareness: validity and use of SAGAT. In: Endsley MR, Garland DJ, eds. Situation Awareness Analysis and Measurement. Mahwah, NJ: Lawrence Erlbaum Associates; 2000.
  154. 154. Endsley MR. Expertise and situation awareness. In: Ericsson KA, et al., eds. The Cambridge Handbook of Expertise and Expert Performance. New York: Cambridge Universitiy Press; 2006:633– 651.
  155. 155. Endsley MR. The role of situation awareness in naturalistic decision making. In: Zsambok CE, Klein G, eds. Naturalistic Decision Making. Mahwah, NJ: Lawrence Erlbaum Associates; 1997:269– 283.
  156. 156. Endsley MR. Towards a theory of situation awareness in dynamic systems. Hum Factors. 1995;37:32– 64.
  157. 157. Engel KG, Rosenthal M, Sutcliffe KM. Residents’ responses to medical error: coping, learning, and change. Acad Med. 2006;81:86– 93.
  158. 158. Epub 2002/ 08/ 24. doi: 10.1080/ 0142159021000000834. PubMed PMID: 12193321.
  159. 159. Epub 2007/ 06/ 01. doi: 10.1080/ 01421590701210907. PubMed PMID: 17538823.
  160. 160. Epub 2013/ 10/ 16. doi: 10.1097/ aco.0000000000000004. PubMed PMID: 24126692.
  161. 161. Erlandson RF, Sant D. Poka-yoke process controller: designed for individuals with cognitive impairments. Assist Technol. 1998;10(2):102–12.
  162. 162. Espin S, Lingard L, Baker GR, Regehr G. Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Qual Saf Health Care. 2006;15:165–70.
  163. 163. Federal Aviation Administration; 14 CFR Parts 117, 119, and 121; Docket No.: FAA- 2009- 1093; Amdt. Nos. 117- 1, 119- 16, 121- 357; RIN 2120– AJ58; Flightcrew Member Duty and Rest Requirements. https:// www.faa.gov/ regulations_ policies/ rulemaking/ recently_ published/ media/ 2120- AJ58- FinalRule.pdf, accessed January 2016.
  164. 164. Fiore S, Jentsch F, Oser R, et al. Perceptual and conceptual processing in expert/novice cue pattern recognition. Int J Cognitive Technol. 2001;5(1):17–26.
  165. 165. Fitts P. Human engineering for an effective air navigation and traffic control system. Washington, DC: National Research Council; 1951. 11. de Winter JCF, Dodo D. Why the Fitts list has persisted throughout the history of function allocation. Cogn Tech Work. 2014;16(1):11.
  166. 166. Fixler T, Wright J. Identification and use of operating room efficiency indicators: the problem of definition. Can J Surg. 2013;56(5):E104.
  167. 167. Flaatten H, Hevroy O. Errors in the intensive care unit (ICU): experiences with an anonymous registration. Acta Anaesthesiol Scand. 1999;43(6): 614– 617.
  168. 168. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/ AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/ American Heart Association task force on practice guidelines. Circulation. 2014;130(24):e278– e333.
  169. 169. Fletcher G, et al. Anaesthetists’ Non- Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth. 2003;90(5):580– 588.
  170. 170. Flin R, et al. Anaesthetists’ non- technical skills. Br J Anaesth. 2010;105(1):38– 44.
  171. 171. Flin R, et al. Leadership for safety: industrial experience. Qual Saf Health Care. 2004;13 suppl 2:ii45–51.
  172. 172. Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. Health Serv Res. 2006;41(4 Pt 2):1690–709.
  173. 173. Friedberg MW, Chen PG, Van Busum KR, Aunon F, Pham C, Caloyeras J, Mattke S, Pitchforth E, Quigley DD, Brook RH, Crosson FJ. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Santa Monica: Rand Corporation; 2013.
  174. 174. Gaba DM, Howard SK, Small SD. Situation awareness in anesthesiology. Hum Factors. 1995;37:20– 31.
  175. 175. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347(16):1249–55.
  176. 176. Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987;66:670–6.
  177. 177. Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ. 2000:320:785– 788.
  178. 178. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001– 1007.
  179. 179. Galvan C, Bacha B, Mohr J, Barach P. A human factors approach to understanding patient safety during pediatric cardiac surgery. Prog Pediat Cardiol. 2005;20:13–20.
  180. 180. Galvan C, Bacha B, Mohr J, Barach P. A human factors approach to understanding patient safety during pediatric cardiac surgery. Prog Pediatr Cardiol. 2005;20:13–20.
  181. 181. Galvan C, Bacha EA, Mohr J, Barach P. A human factors approach to understanding patient safety during pediatric cardiac surgery. Progr Pediatr Cardiol. 2005;20(1):13–20.
  182. 182. Galvan C, et al. A human factors approach to understanding patient safety during pediatric cardiac surgery. Prog Pediatr Cardiol. 2005;20(1):13–20.
  183. 183. Garber AM, Skinner J. Is American health care uniquely inefficient? J Econ Perspect. Fall 2008;22(4):27– 50.
  184. 184. Garg AX, Adhikari NK, McDonald H, Rosas- Arellano MP, Devereaux PJ, Beyene J, … Haynes RB. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293(10):1223– 1238.
  185. 185. Gawande A. The checklist manifesto. New York: Metropolitan Books; 2009.
  186. 186. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229–35.
  187. 187. Gawande AA, Thomas EJ, Zinner MJ, et al. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126:66–75.
  188. 188. Gazoni FM, Amato PE, Malik ZM, Durieux ME. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg. 2012;114:596– 603.
  189. 189. Geary DC. An evolutionarily informed education science. Educ Psychol. 2008;43(February 2014):179– 195. doi:10.1080/ 00461520802392133.
  190. 190. Geary DC. The Origin of Mind: Evolution of Brain, Cognition, and General Intelligence. 2005:307– 337. doi:10.1037/ 10871- 009.
  191. 191. Gennis VM, Gennis MA. Supervision in the outpatient clinic: effects on teaching and patient care. J Gen Intern Med. 1993;8(7):378–.
  192. 192. Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care. 2011;49:1076–81.
  193. 193. Gibbs N, Borton CL. Safety of anaesthesia in Australia: a review of anaesthesia related mortality 2000– 2002. Australian and New Zealand College of Anaesthetists: 2006.
  194. 194. Gilbreth F, Gilbreth L. Fatigue study: the elimination of humanity’s greatest unnecessary waste, a first step in motion study. New York: The MacMillan Company; 1919.
  195. 195. Gillespie BM, Charboyer W, Murray P. Enhancing communication in surgery through team training interventions: a systematic literature review. AORN J. 2010;92(6):642–57.
  196. 196. Gillespie BM, Charboyer W. Interruptions and miscommunications in surgery: an observational study. AORN J. 2012;95(5):576–90.
  197. 197. Glance LG, Dick A, Kellerman A, Hannan EL, Fleisher L, Eaton M, Lustik S, Li Y, Dutton RP. Impact of anesthesiologists on CABG mortality. Anesth Analg. 2015Mar;120(3):526–533.
  198. 198. Goldhaber SZ, Tapson VF, DVT FREE Steering Committee. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. Am J Cardiol. 2004;93(2):259–62.
  199. 199. Gosden PE, et al. Importance of air quality and related factors in the prevention of infection in orthopedic implant surgery. J Hosp Infect. 1998;39:173–80.
  200. 200. Graling PR. Designing an applied model of perioperative patient safety. Clin Scholars Rev. 2011; 4(2):104–14.
  201. 201. Grantcharov TP, Bardram L, Funch-Jensen P, et al. Learning curves and impact of previous operative experience on performance on a virtual reality simulator to test laparoscopic surgical skills. Am J Surg. 2003;185(2):146–9.
  202. 202. Green BB, Cook AJ, Ralston JD, et al. Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial. JAMA. 2008;299(24):2857– 2867.
  203. 203. Greig PR, Higham H, Nobre AC. Failure to perceive clinical events: an under- recognised source of error. Resuscitation, 2014;85(7):952– 956.
  204. 204. Grover FL, Johnson RR, Shroyer AL, Marshall G, Hammermeister KE. The veterans affairs continuous improvement in cardiac surgery study. Ann Thorac Surg. 1994;58(6):1845–51.
  205. 205. Guidebook for Managing Disruptive Physician Behavior. Toronto: College of Physicians and Surgeons of Ontario; 2008.
  206. 206. Hadley J, Holahan J, Coughlin T, Miller D. Covering the uninsured in 2008: current costs, sources of payment, and incremental costs. Health Aff (Millwood). 2008;27(5):399– 415.
  207. 207. Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, Haut ER, Stevens KA, Cornwell EE3rd, MacKenzie EJ, Efron DT. Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact? J Am Coll Surg. 2012;214:756– 768.
  208. 208. Hall RE, Plant JR, Bands CJ, Wall AR, Kang J, Hall CA. Human patient simulation is effective for teaching paramedic students endotracheal intubation. Acad Emerg Med. 2005;12(9):850– 855. doi: 10.1197/ j.aem.2005.04.007. PubMed PMID: 16141019.
  209. 209. Haller G, Myles PS, Taffé P, Perneger TV, Wu CL. Rate of undesirable events at beginning of academic year: retrospective cohort study. BMJ. 2009;339:b3974. PubMed PMID: 19826176; PubMed Central PMCID: PMCPMC2762036.
  210. 210. Haller G, Stoelwinder J, Myles PS, McNeil J. Quality & safety indicators in anesthesia: a systematic review. Anesthesiology. 2009;110:1158– 1175.
  211. 211. Halligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. BMJ Qual Saf. 2011;20(4):338–43.
  212. 212. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137(6):511–20.
  213. 213. Hameleers PA, et al. Habitual caffeine consumption and its relation to memory, attention, planning capacity and psychomotor performance across multiple age groups. Hum Psychopharmacol. 2000; 15(8):573– 581.
  214. 214. Hamilton, V, Warburton DM, Mandler G. Human stress and cognition: an information processing approach. In: Hamilton, Warburton DM, eds. Thought Processes, Consciousness, and Stress. New York: John Wiley & Sons; 1979:179– 201.
  215. 215. Hanson C, Barach P. Improving cardiac care quality and safety through partnerships with patients and their families. Prog Pediatr Cardiol. 2012;33:73–9.
  216. 216. Harrison MI, Koppel R, Bar- Lev S. Unintended consequences of information technologies in health care: an interactive sociotechnical analysis. J Am Med Inform Assn. 2007;14(5):542– 549.
  217. 217. Harrison Y, Horne JA. The impact of sleep deprivation on decision making: a review. J Exp Psychol Appl. 2000;6(3):236– 249.
  218. 218. Hart CN, Carskadon MA, Considine RV, et al. Changes in children’s sleep duration on food intake, weight, and leptin. Pediatrics. 2013;132(6): e1473– 1480.
  219. 219. Haynes AB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2010;360:12–21.
  220. 220. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491– 499.
  221. 221. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–9.
  222. 222. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.
  223. 223. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.
  224. 224. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286(4):415– 420.
  225. 225. Healey MA, Shackford SR, Osler TM, Rogers FB, Burns E. Complications in surgical patients. Arch Surg. 2002;137(5):611–7; discussion 617–8.
  226. 226. Health and Safety Commission. Third Report: Organizing for Safety: Advisory Committee on the Safety of Nuclear Installations. London: HSE Books; 1993.
  227. 227. Heard G. Errors in medicine: a human factors perspective. Australas Anesth. 2005;5:1–11.
  228. 228. Heinrich HW. Industrial Accident Prevention: A Scientific Approach. New York: McGraw- Hill; 1950.
  229. 229. Helfman S. Electrical service. In: Block FE, Helfman S, eds. Operating Room Design Manual. American Society of Anesthesiologists; 2010:69– 74.
  230. 230. Helmreich R. On error management: lessons from aviation. BMJ. 2000;320(7237):781– 785.
  231. 231. Helmreich RL, Schaefer HG. Team performance in the operating room. In: Bogner MS, editor. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates, Inc.; 1994. p. 225–54.
  232. 232. Hempel S, Maggard-Gibbons M, Nguyen DK, Dawes AJ, et al. Wrong-site surgery, retained surgical items, and surgical fires: a systemic review of surgical never events. JAMA Surg. 2015;150(8):796– 805. doi: 10.1001/jamasurg.2015.0301.
  233. 233. Hempel S, Maggard-Gibbons M, Nguyen DK, Dawes AJ, Miake-Lye I, Beroes JM, Booth MJ, Miles JN, Shanman R, Shekelle PG. Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA Surg. 2015;150(8):796–805.
  234. 234. Hicks RW, Becker SC, Krenzischeck D, Beyea SC. Medication errors in the PACU: a secondary analysis of MEDMARX findings. J Perianesth Nurs. 2004;19(1):18– 28.
  235. 235. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007 Nov;82(11):1040– 1048.
  236. 236. Hirsh S. GM plant a sign of decline. The Baltimore Sun. May 9, 2005. http:// articles.baltimoresun.com/ 2005- 05- 09/ news/ 0505090070_ 1_ general- motors- gm- baltimore- workers. Accessed April 2016.
  237. 237. Hogan MF. The President’s New Freedom Commission: recommendations to transform mental health care in America. Psychiatr Serv. 2003;54(11):1467–74.
  238. 238. Hogan MP, et al. Use of human patient simulation and the situation awareness global assessment technique in practical trauma skills assessment. J Trauma. 2006;61(5):1047– 1052.
  239. 239. Hollnagel E. Safety-I and safety-II: the past and future of safety management. Farnham: Ashgate Publishing; 2014.
  240. 240. Holweg M. The genealogy of lean production. J Oper Manag. 2007;25(2):420–37.
  241. 241. Howard S, Gaba D, Fish K, Yang G, Sarnquist F. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med. 1992;63:763– 770.
  242. 242. Howard SK, Rosekind MR, Katz JD, Berry AJ; Fatigue in anesthesia implications and strategies for patient and provider safety. Anesthesiology. 2002;97:1281– 1294.
  243. 243. Hoyler M, Finlayson SR, McClain CD, Meara JG, Hagander L. Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature. World J Surg. 2014;38(2):269–80.
  244. 244. Hull CJ. Electrocution hazards in the operating theatre. Br J Anaesth. 1978;50:647– 657.
  245. 245. Hänsel M, et al. Impact of simulator training and crew resource management training on final- year medical students’ performance in sepsis resuscitation: a randomised trial. Minerva Anesthesiol. 2012;78(8):901– 909.
  246. 246. Ingraham AM, Richards KE, Hall BL, Ko CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg. 2010;44:251– 267.
  247. 247. Institute ECRI. Electrosurgical safety: conducting a safety audit. Health Devices. 2005;34(12):414–20.
  248. 248. Institute ECRI. Fires during surgery of the head and neck area [update]. Health Devices. 1980;9(3):82.
  249. 249. Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
  250. 250. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.Measurement Policy/Hospital Fa ctors Caregi ver Factors Patient-Rela ted Fa ctorsEquipment/Ma terialsC are Fa ctors Need to measur e urine v olume Dif/f_icult to g et patients to restroom Catheter -Related Urinary Tract Infection Problem Statement Little de vice utilization dataSeveral types of catheters a vailabl e May need to change out catheter type Need for mor e education on indications Provider fatigue GenderEducational gap s Inability to conv ey symptoms Age MobilityLack of a wareness of infection risk Inconsistent use of securing de vices Dif/f_icult to pr edict needNot all infections being documented and captur ed Unclear polic y for catheter documentation No incentives to remove early FIGURE 10.2: Sample cause- and- effect (fishbone) diagram.
  251. 251. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.
  252. 252. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
  253. 253. Jacobs JP. Databases for assessing the outcomes of the treatment of patients with congenital and pediatric cardiac disease—the perspective of cardiac surgery. In: Barach P, Jacobs JP, Lipshultz SE, Laussen P, editors. Pediatric and Congenital Cardiac CareV olume 1: Outcomes Analysis. Springer-Verlag London. Pages 1 –.
  254. 254. Jalote A, Badke P. Workflow integration matrix: a framework to support the development of surgical information systems. Des Stud. 2008;29:338–68.
  255. 255. James JT. A new, evidence- based estimate of patient harms associated with hospital care. J Patient Safety 2013;9(3):122– 128.
  256. 256. Jarman B. Quality of care and patient safety in the UK: the way forward after Mid Staffordshire. Lancet. 2013;382(9892):573– 575.
  257. 257. Jensen PF, Barach P. The role of human factors in the intensive care unit. Qual Saf Health Care. 2003; 12(2):147–8.
  258. 258. Jha AK, Joynt KE, Orav EJ, Epstein AM. The long- term effect of premier pay for performance on patient outcomes. N Engl J Med. 2012;366(17):1606– 1615.
  259. 259. Johnson J, Barach P. Quality improvement methods to study and improve the process and outcomes of pediatric cardiac surgery. Prog Pediatr Cardiol. 2011;32(2):147–53.
  260. 260. Johnson J, Barach P. Quality improvement methods to study and improve the process and outcomes of pediatric cardiac surgery. Prog Pediatr Cardiol. 2011;32:147–53.
  261. 261. Johnson J, Barach P. Quality improvement methods to study and improve the process and outcomes of pediatric cardiac surgery. Progr Pediatr Cardiol. 2011;32:147–53.
  262. 262. Johnson- Kozlow M, et al. Coffee consumption and cognitive function among older adults. Am J Epidemiol. 2002;156(9):842– 850.
  263. 263. Joint Commission on Accreditation of Healthcare Organizations. Disclosing medical error: a guide to an effective explanation and apology. Joint Commission Resources. Oakbridge Terrace, IL; 2007, 36p.
  264. 264. Jones DG, Endsley MR. Sources of situation awareness errors in aviation. Aviat Space Environ Med. 1996;67(6):507– 512.
  265. 265. Kahneman D. Attention and effort. The American Journal of Psychology 1973;88. doi:10.2307/ 1421603.
  266. 266. Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, et al. The perioperative surgical home as a future perioperative practice model. Anesth Analg. 2014;118(5):1126–30.
  267. 267. Kannan J, Kurup V. Blended learning in anesthesia education: current state and future model. Curr Opin Anaesthesiol. 2012;25(6):692– 698. doi: 10.1097/ ACO.0b013e32835a1c2a. PubMed PMID: 23147669.
  268. 268. Kao LS, Thomas EJ. Navigating towards improved surgical safety using aviation based strategies. J Surg Res. 2007;145:327–35.
  269. 269. Kaplan H, Barach P. Incident reporting: science or protoscience? Ten years later. Qual Saf Health Care. 2002;11(2):144–5.
  270. 270. Kaplan J. Kaplan’s cardiac anesthesia. Philadelphia, PA: Elsevier Saunders; 2006.
  271. 271. Karamichalis J, Barach P, Henaine R, del Nido P, Bacha E. Assessment of surgical competency in pediatric cardiac surgery. Prog Pediatr Cardiol. 2012;33(1):15–20. doi:10.1016/j.ppedcard.2011.12.003.
  272. 272. Kaysis E, Wang H, Patel M, Gonzalez T, Jain S, Ramamurthi R, et al. Improving prediction of surgery duration using operational and temporal factors. AMIA Annu Symp Proc. 2012;2012:456–62.
  273. 273. Keijzer H, Smits MG, Duffy JF, Curfs LM. Why the dim light melatonin onset (DLMO) should be measured before treatment of patients with circadian rhythm sleep disorders. Sleep Med Rev. 2014 Aug;18(4):333– 339.
  274. 274. Kheterpal S, Healy D, et al. Incidence, predictors, and outcomes of difficult mask ventilation combined with difficult laryngoscopy: a report from the Multicenter Perioperative Outcomes Group. Anesthesiology. 2013:119(6):1360– 1369.
  275. 275. Khuri SF, Daley J, Henderson W, Hur K, Demakis J, Aust JB, Chong V, Fabri PJ, Gibbs JO, Grover F, Hammermeister K, Irvin 3rd G, McDonald G, Passaro Jr E, Phillips L, Scamman F, Spencer J, Stremple JF. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National V A Surgical Quality Improvement Program. Ann Surg. 1998;228(4):491–507.
  276. 276. Kiefer H, Hoeft A. Display of information in the operating room. Curr Opin Anaesthesiol. 2010;23(6):772– 777.
  277. 277. Kilminster S, Cottrell D, Grant J, Jolly B. AMEE Guide No. 27: Effective educational and clinical supervision. Med Teach. 2007;29(1):2–.
  278. 278. Kilminster S, Jolly B, van der Vleuten CP. A framework for effective training for supervisors. Med Teach. 2002;24(4):385–.
  279. 279. Kingham TP, Kamara TB, Cherian MN, Gosselin RA, Simkins M, Meissner C, et al. Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care. Arch Surg. 2009;144(2):122–7. discussion 8.
  280. 280. Kirkpatrick AW, Vis C, Dube M, Biesbroek S, Ball CG, Laberge J, Shultz J, Rea K, Sadler D, Holcomb JB, Kortbeek J. The evolution of a purpose designed hybrid trauma operating room from the service perspective: The RAPTOR (resuscitation with angiogra -phy percutaneous treatments and operative resuscitations). Injury. 2014;45:1413–21.
  281. 281. Kirkpatrick DL, Kirkpatrick JD. Evaluating Training Programs. 3rd ed. San Francisco: Berrett- Koehler; 1998.
  282. 282. Klein G. Streetlights and shadows: searching for the keys to adaptive decision making. Cambridge, MA: MIT Press; 2009. Fig. 41.2 The desire to pursue system stability is compelling in health care organizations ( arrow #1). What can be known about the perioperative suite exists on a continuum between stable predictions about the system on the left and significant breakdowns in the system on the right B.R. Cassin and P. Barach.
  283. 283. Klevens RM, Edwards JR, Richards CL, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Rep. 2007;122(2):160–6.
  284. 284. Kluger MT, Bullock MF. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia. 2002;57(11):1060– 1066.
  285. 285. Koeneke S, Lutz K, Wustenberg T, et al. Long-term training affects cerebellar processing in skilled keyboard players. Neuroreport. 2004;15(8):1279–82.
  286. 286. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
  287. 287. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
  288. 288. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197– 1203.
  289. 289. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10): 1197– 1203.
  290. 290. Kreideit A, Kalkman C, Barach P. Role of handwashing and perioperative infections. Br J Anesth. 2011. doi:10.1093/bja/aer162.
  291. 291. Kringos DS, Sunol R, Wagner C, Mannion R, Michel P, Klazinga NS, Groene O, DUQuE Consortium. The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. BMC Health Serv Res. 2015;15:277.
  292. 292. Krupka DC, Sandberg WS. Operating room design and its impact on operating room economics. Curr Opin Anaesthesiol. 2006;19(2):185–91.
  293. 293. Kurup V, Hersey D. The changing landscape of anesthesia education: is Flipped Classroom the answer? Curr Opin Anaesthesiol. 2013;26(6):726–.
  294. 294. Kwok AC, Funk LM, Baltaga R, Lipsitz SR, Merry AF, Dziekan G, et al. Implementation of the World Health Organization surgical safety checklist, including introduction of pulse oximetry, in a resource- limited setting. Ann Surg. 2012;257:633–9.
  295. 295. Langelaan M, et al. Monitor health care related harm in Dutch hospitals 2008 [in Dutch]. Utrecht: Nivel; 2010.
  296. 296. Larson JA, Johnson MH, Bhayani SB. Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence. J Am Coll Surg. 2014;218(2):290–3.
  297. 297. Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009;144(10):961–9.
  298. 298. Laufman H. The control of operating room infection: discipline, defence, mechanisms, drugs, design and devices. Bull N Y Acad Med. 1978;54(5):465–83.
  299. 299. Leape L, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18:424–8.
  300. 300. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377– 384.
  301. 301. Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman- Levitan S, Meyer GS, Healy GB. Perspective: A culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012 Jul;87(7):845– 852.
  302. 302. Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman- Levitan S, Meyer GS, Healy GB. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012 Jul;87 (7):853– 858.
  303. 303. Leape LL. Error in medicine. JAMA. 1994; 272(23):1851– 1857.
  304. 304. Lebak K, Springman S, Lee J. designing safety and engineering standards for the non- operating room anesthesia procedure site. In: Weiss MS, Fleisher LA, eds. Non- Operating Room Anesthesia. Philadelphia: Elsevier Saunders; 2015:8– 10.
  305. 305. Lederer W, Kinzl JF, Trefalt E, Traweger C, Benzer A. Significance of working conditions on burnout in anesthetists. Acta Anaesthesiol Scand. 2006;50(1):58–63.
  306. 306. Leiker M. Sentinel events, disruptive behavior, and medical staff codes of conduct. WMJ. 2009 Sep;108(6):333– 334.
  307. 307. Leonard PF. Characteristics of electrical hazards. Anesth Analg. 1972;51:797– 809.
  308. 308. Liao JM, Etchegaray JM, WIliams ST, Berger DH, Bell SK, Thomas EJ. Assessing medical students’ perception of patient safety: the medical student safety attitudes and professionalism survey. Acad Med. 2014;89:343–51.
  309. 309. Lienhart A, Auroy Y, Pequignot F, Benhamou D, Warszawski J, Bovet M, Jougla E. Survey of anesthesia- related mortality in France. Anesthesiology. 2006;105:1087– 1097.
  310. 310. Lingard L, Garwood S, Poenaru D. Tensions influencing operating room team function: does institutional context make a difference? Med Educ. 2004 Jul;38(7):691– 699.
  311. 311. Lingard L, Reger G, Orser B, Reznick R, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1):12–7.
  312. 312. Lingard L, Reznick R, Espin S, Regehr G, DeVito I. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med. 2002 Mar;77(3):232– 237.
  313. 313. Lohr KN, Schroeder SA. A strategy for quality assurance in Medicare. N Engl J Med. 1990;322:1161– 1171 [p. 1161].
  314. 314. Longo DR, Hewett JE, Ge B, Schubert S. The long road to patient safety: a status report on patient safety systems. JAMA. 2005;294(22):2858– 2865.
  315. 315. Loren DJ, Garbutt J, Dunagan WC, Bommarito KM, Ebers AG, Levinson W, Waterman AD, Fraser VJ, Summy EA, Gallagher TH. Risk managers, physicians, and disclosure of harmful medical errors. Jt Comm J Qual Patient Saf. 2010;36:101– 108.
  316. 316. Love- Jones S, Magee P. Medical gases, their storage and delivery. Anaesth Intensive Care Med. 2007;8(1):2– 6.
  317. 317. Luca F, Valvo M, Ghezzi T, Zuccaro M, Cenciarelli S, Trovato C, et al. Impact of robotic surgery on sexual and urinary functions after fully robotic nerve-sparing total mesorectal excision for rectal cancer. Ann Surg. 2013;257(4):672–8.
  318. 318. Ludwick DA, Doucette J. Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries. Int J Med Inform. 2009;78(1):22– 31.
  319. 319. Lunn JN, Devlin HB. Lessons from the confidential enquiry into perioperative deaths in three NHS regions. Lancet. 1987;12:1384–6.
  320. 320. Lypson ML, Stephens S, Colletti L. Preventing surgical fires: who needs to be educated? Jt Comm J Qual Patient Saf. 2005;31(9):522–7.
  321. 321. Macario A, Dexter F, Traub R. Hospital profitability per hour of operating room time can vary among surgeons. Anesth Analg. 2001;93(3):669–75.
  322. 322. Macario A. Are your hospital operating rooms efficient? A scoring system with eight performance indicators. Anesthesiology. 2006;105(2):237–40.
  323. 323. Macario A. Truth in scheduling: is it possible to accurately predict how long a surgical case will last? Anesth Analg. 2009;108(3):681–5.
  324. 324. Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22:233–6.
  325. 325. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, Lynfield R, Maloney M, McAllister-Hollod L, Nadle J, Ray SM, Thompson DL, Wilson LE, Fridkin SK, Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care- associated infections. N Engl J Med. 2014;370(13):1198–208.
  326. 326. Mangram AJ, et al. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20:247–78.
  327. 327. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20:250–78.
  328. 328. Manser T, Staender S. Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure. Acta Anaesthesiol Scand. 2005; 49: 728– 734.
  329. 329. Marjamaa R, Vakkuri A, Kirvela O. Operating room management: why, how and by whom? Acta Anaesthesiol Scand. 2008;52(5):596–600.
  330. 330. Martinez EA, Marsteller JA, Thompson DA, et al. The Society of Cardiovascular Anesthesiologists’ FOCUS initiative: locating errors through networked surveillance (LENS) project vision. Anesth Analg. 2010;110:307–311. http://journals.lww.com/anes- thesiaanalgesia/pages/results.aspx?txtkeywords= Martinez. Accessed 2 May 2016.
  331. 331. Masoudi FA, Ponirakis A, Yeh RW, Maddox TM, Beachy J, Casale PN, Curtis JP, De Lemos J, Fonarow G, Heidenreich P, Koutras C, Kremers M, Messenger J, Moussa I, Oetgen WJ, Roe MT, Rosenfield K, Shields TPJr, Spertus JA, Wei J, White C, Young CH, Rumsfeld JS. Cardiovascular care facts: a report from the national cardiovascular data registry: 2011. J Am Coll Cardiol. 2013;62:1931– 1947.
  332. 332. Mathieu J, et al. The influence of shared mental models on team process and performance. J Appl Psychol. 2000;85(2):273– 283.
  333. 333. Mavis B, Sousa A, Lipscomb W, Rappley MD. Learning about medical student mistreatment from responses to the medical school graduation questionnaire. Acad Med. 2014 May;89(5):705– 711.
  334. 334. Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, Gurwitz JH. Health plan members’ views on forgiving medical errors. Am J Manag Care. 2005; 11: 49– 52.
  335. 335. Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197(5):678–85.
  336. 336. McAlearney AS, Robbins J, Garman AN, Song PH. Implementing high-performance work practices in healthcare organizations: qualitative and conceptual evidence. J Healthc Manag. 2013;58(6):446–62. discussion 463–444.
  337. 337. McCormick BA, Eltringham RJ. Anaesthesia equipment for resource- poor environments. Anaesthesia. 2007;62:54– 60.
  338. 338. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635– 2645.
  339. 339. McIntosh C, Dexter F, Epstein R. The impact of service-specific staffing, case scheduling, turnovers, and first-case starts on anesthesia group and operating room productivity: a tutorial using data from an Australian hospital. Anesth Analg. 2006;103(6):1499–516.
  340. 340. McKibben L, Horan T, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control. 2005;33:217–26. 51 International Perspectives on Safety, Quality, and Reliability of Surgical Care.
  341. 341. McKibben L, Horan TC, Tokars JI, Fowler G, Cardo DM, Pearson ML, Brennan PJ, Healthcare Infection Control Practices Advisory Committee. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 2005;26(6):580–7.
  342. 342. McManus RJ, Mant J, Haque MS, et al. Effect of self- monitoring and medication self- titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN- SR randomized clinical trial. JAMA. 2014;312(8):799– 808.
  343. 343. McMillan WJ. “Then you get a teacher”: guidelines for excellence in teaching. Med Teach. 2007;29(8):e209– 218. doi: 10.1080/ 01421590701478264. PubMed PMID: 18236265.
  344. 344. McPherson K, Wennberg JE, Hovind OB, Clifford P. Small area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med. 1982;307:1310–4.
  345. 345. McPherson K, Wennberg JE, Hovind OB, Clifford P. Small- area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med. Nov 18 1982;307(21):1310– 1314.
  346. 346. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: 34 Managing the Complex High-Risk Surgical Patient.
  347. 347. Mede/ Analytics, Analytics versus reporting: the salient differences. www.medeanalytics.com. Accessed April 13, 2012.
  348. 348. Medication Safety in the Operating Room: Time for a New Paradigm. Indianapolis, IN: Anesthesia Patient Safety Foundation; 2010.
  349. 349. Meguid RA, Bronsert MR, Juarez-Colunga E, Hammermeister KE, Henderson WG. Surgical risk preoperative assessment system (SURPAS): II. Parsimonious risk models for postoperative adverse outcomes addressing need for laboratory variables and surgeon specialty-specific models. Ann Surg. 2016;264(1):10–22.
  350. 350. Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: a closed claims analysis. Anesthesiology 2013;118:1133– 1139.
  351. 351. Meister D. The history of human factors and ergonomics. Mahwah: Lawrence Erlbaum Associates; 1999.
  352. 352. Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47– 55.
  353. 353. Menachery EP, Wright SM, Howell EE, Knight AM. Physician- teacher characteristics associated with learner- centered teaching skills. Med Teach. 2008;30(5):e137– 144. doi: 10.1080/ 01421590801942094. PubMed PMID: 18576184.
  354. 354. Merry AF, Anderson BJ. Medication errors: new approaches to prevention. Paediatr Anaesth. 2011;21(7):743– 753.
  355. 355. Merry AF, Webster CS, Hannam J, et al. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. BMJ. 2011;343:d5543.
  356. 356. Merry AF, Webster CS, Holland RL, et al. Clinical tolerability of perioperative tenoxicam in 1001 patients: a prospective, controlled, double- blind, multi- centre study. Pain. 2004;111(3):313– 322.
  357. 357. Merry AF, Weller JM, Robinson BJ, et al. A simulation design for research evaluating safety innovations in anaesthesia. Anaesthesia. 2008;63(12): 1349– 1357.
  358. 358. Merseburger AS, Herrmann TR, Shariat SF, Kyriazis I, Nagele U, Traxer O, et al. EAU guidelines on robotic and single-site surgery in urology. Eur Urol. 2013;64(2):277–91.
  359. 359. Metzner J, Domino KB. Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider. Curr Opin Anaesthesiol. 2010;23(4):523– 531.
  360. 360. Metzner J, et al. Closed claim’s analysis. Best Pract Res Clin Anaesthesiol. 2011 Jun;25(2):263– 276.
  361. 361. Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol. 2009;22(4):502– 508.
  362. 362. Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS system: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care. 2009;18(2):104–8.
  363. 363. Mohr J, Abelson H, Barach P. Leadership strategies in patient safety. J Qual Manag Health Care. 2003;11(1):69–78.
  364. 364. Mohr J, Batalden P, Barach P. Integrating patient safety into the clinical microsystem. Qual Saf Healthcare. 2004;13:34–8.
  365. 365. Moris DN, Bramis KJ, Mantonakis EI, Papalampros EL, Petrou AS, Paplampros AE. Surgery via natural orifices in human beings: yesterday, today, tomorrow. Am J Surg. 2012;204:93–102.
  366. 366. Moskowitz AJ, Kuipers BJ, Kassirer JP. Dealing with uncertainty, risks, and tradeoffs in clinical decisions. A cognitive science approach. Ann Intern Med. 1988;108(3):435–49.
  367. 367. Munday GS, Deveaux P, Roberts H, Fry DE, Polk HC. Impact of implementation of the Surgical Care Improvement Project and future strategies for improving quality in surgery. Am J Surg. 2014;208:835– 840.
  368. 368. Möckel T, Beste C, Wascher E. The effects of time on task in response selection: an ERP study of mental fatigue. Scientific Reports. 2015;5:10113. doi:10.1038/ srep10113.
  369. 369. Nagelhout JJ, Plaus KL. Nurse anesthesia. St. Louis, MO.: Saunders/Elsevier; 2010.
  370. 370. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124(1):25– 34. doi: 10.1097/ALN.0000000000000904.
  371. 371. Nasca TJ, Day SH, Amis ES, Force ADHT. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi: NEJMsb1005800 [pii] 10.1056/ NEJMsb1005800. PubMed PMID: 20573917.
  372. 372. National Association of Insurance Commissioners. Medical malpractice closed claims, 1975–1978. Brookfield, WI: National Association of Insurance Commissioners; 1980.
  373. 373. National Quality Measures Clearinghouse. Measure regarding normothermia. http:// www.qualitymeasures.ahrq.gov/ content.aspx?id=27987. Accessed January 20, 2015.
  374. 374. National Transportation Safety Board. Incident Report CHI08IA292. Washington, DC: National Transportation Safety Board; 2010.
  375. 375. New York, NY: Marcel Dekker, Inc.; 2007. p. 101–13. ISBN 100-8247-2916-6.Profiles in Surgical Patient Safety Dr. Lucian L. Leape: The First Study of Iatrogenesis In his 1991 landmark paper, Dr. Leap and his colleagues described the Harvard Medical Practice Study, a sample of 30,195 randomly selected hospital records which identified 3.7 % with disabling injuries caused by medical treatment [ 94]. Leape’s publication, Error in Medicine, in JAMA in 1994, called for the application of systems theory to prevent medical errors. His work led ultimately to the Institute of Medicine’s landmark publications, To Err is Human and Crossing the Quality Chasm, Dr. Leape has devoted his entire career to the cause of preventing medical errors and protecting patient safety. Professor Leape has testified before a subcommittee of the US Senate on improving patient safety. The Lucian Leape Institute at the National Patient Safety Foundation was founded in 2007 to further strategic thinking in patient safety. J.A. Sanchez and K.W. Lobdell.
  376. 376. Nilsson UG. Intraoperative positioning of patients under general anesthesia and the risk of postoperative pain and pressure ulcers. J Perianesth Nurs. 2013;28(3):137–43.
  377. 377. Nygren J, Hausel J, Kehlet H, Revhaug A, Lassen K, Dejong C, et al. A comparison in five European Centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Clin Nutr. 2005;24(3):455–61.Table 22.2 Research issues related to ERAS Short term Recovery Hospital stay Clinical outcomes Cost-effectiveness Medium term QoL Postdischarge recovery Need for assistance at home Time off work Cost-effectiveness Long term QoL Long-term functional outcome Survival Cost-effectiveness J. Nygren et al.
  378. 378. O'Hara NN. Is safe surgery possible when resources are scarce? BMJ Qual Saf. 2015;24(7):432–4.
  379. 379. Olympio MA, Goldstein MM, Mathes DD. Instructional review improves performance of anesthesia apparatus checkout procedures. Anesth Analg. 1996;83(3):618– 622.
  380. 380. Opinion 9.045— Physicians with disruptive behavior; c2000. http:// www.ama- assn.org/ ama/ pub/ physician- resources/ medical- ethics/ code- medical- ethics/ opinion9045.page#. Accessed October 31, 2014.
  381. 381. Organisation for Economic Co- operation and Development. https:// data.oecd.org/ searchresults/ ?hf=20&b=0&r=%2Bf%2Fdata_ portal_ v2_ topics_ en%2Fhealth&l=en&s=score. Accessed June 2015.
  382. 382. O’Connell M. Positioning impact on the surgical patient. Nurs Clin N Am. 2006;41(2):173–92.
  383. 383. Pariser JJ, Diamond AJ, Christianson LW, Mitchell BA, Langerman A. Operating room inefficiencies attributable to errors in surgical case scheduling and surgeon procedure heterogeneity. Am J Med Qual. 2015. doi: 1062860615606517.
  384. 384. Parsons HM. What happened at Hawthorne? Science. 1974;183:922– 932.
  385. 385. Pash J, Kadry B, Bugrara S, Macario A. Scheduling of procedures and staff in an ambulatory surgery center. Anesthesiol Clin. 2014;32(2):517–27.
  386. 386. Pasquarella C, et al. A mobile laminar airflow unit to reduce air bacterial contamination at surgical area in a conventionally ventilated operating theatre. J Hosp Infect. 2007;66:313–9.
  387. 387. Patrick PK. Burnout: job hazard for health workers. Hospitals. 1979;53(22):87–8.
  388. 388. Pearse RM, et al. EuSOS: European surgical outcomes study. Eur J Anaesth. 2011;28(6): 454– 456.
  389. 389. Perrow C. Normal Accidents: Living With High Risk Technologies. 2nd ed. Princeton, NJ: Princeton University Press; 1999.
  390. 390. Perrow C. Normal Accidents: Living With High Risk Technologies. New York: Basic Books; 1984.
  391. 391. Pham HH, Cohen M, Conway PH. The Pioneer accountable care organization model: improving quality and lowering costs. JAMA. 2014;312(16):1635– 1636.
  392. 392. Phelps G, Barach P. Why the safety and quality movement has been slow to improve care? Int J Clin Pract. 2014;68(8):932–5.
  393. 393. Pierce EC, Jr. The 34th Rovenstine Lecture: 40 years behind the mask: safety revisited. Anesthesiology. 1996;84:965– 975.
  394. 394. Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003;290:2838– 2842.
  395. 395. Pilcher JJ, Huffcutt A. Effects of sleep deprivation on performance: a meta- analysis. Sleep. 1996;19(4):318– 326.
  396. 396. Piquette D, Reeves S, LeBlanc VR. Stressful intensive care unit medical crises: How individual responses impact on team performance. Crit Care Med. 2009 Apr;37(4):1251– 1255.
  397. 397. Poon EG, Cina JL, Churchill W, Patel N, Featherstone E, Rothschild JM, Keohane CA, Whittemore AD, Bates DW, Gandhi TK. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med. 2006;145:426–34.
  398. 398. Poon SJ, Zuckerman SL, Mainthia R, et al. Methodology and bias in assessing compliance with a surgical safety checklist. Jt Comm J Qual Patient Saf. 2013;39:77–82.
  399. 399. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522– 538.
  400. 400. Prevention and treatment of surgical site infection. NICE guideline CG74. London (UK): National Institute for Health and Clinical Excellence, London, UK, 28 October 2008 infection: prevention and treatment of surgical site infection. www.nice.org.uk/ CG74.
  401. 401. Primiano M et al. Pressure ulcer prevalence and risk factors during prolonged surgical procedures. AORN J. 2011;94(6):555–66.
  402. 402. Prober CG, Khan S. Medical education reimagined: a call to action. Acad Med. 2013;88(10):1407– 1410. doi: 10.1097/ ACM.0b013e3182a368bd. PubMed PMID: 23969367.
  403. 403. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter- related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725– 2732.
  404. 404. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–32.
  405. 405. Pronovost P, V ohr E. Safe patients, smart hospitals: how one doctor’s checklist can help us change health care from the inside out. New York: Hudson Street Press, Penguin Group; 2010.
  406. 406. Pronovost PJ, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff. 2009;28:w479–89.
  407. 407. Prunuske AJ, Batzli J, Howell E, Miller S. Using online lectures to make time for active learning. Genetics. 2012;192(1):67– 72; quiz 1Sl- 3SL. Epub 2012/ 06/ 21. doi: 10.1534/ genetics.112.141754. PubMed PMID: 22714412; PubMed Central PMCID: PMCPmc- 3430546.
  408. 408. Pryor F, Messmer PR. The effect of traffic patterns in the OR on surgical site infections. AORN J. 1998;68(4):649–60.
  409. 409. PSO AHRQ Program Brief Network of Patient Safety Databases [Internet]. https://pso.ahrq.gov/sites/default/ files/wysiwyg/npsd_data_brief_0715.pdf.
  410. 410. PubMed PMID: 24044727; PubMed Central PMCID: PMCPMC3848658. 12. van Roermund TC, Tromp F, Scherpbier AJ, Bottema BJ, Bueving HJ. Teachers’ ideas versus experts’ descriptions of “the good teacher” in postgraduate medical education: implications for implementation. A qualitative study. BMC Med Educ. 2011;11:42. doi: 10.1186/ 1472- 6920- 11-.
  411. 411. Ray DC, Drummond GB. Halothane hepatitis. Br J Anaesth. 1991;67(1):84– 99.
  412. 412. Reason J. Human Error. New York: Cambridge University Press; 1990.
  413. 413. Reason J. Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate; 1997.
  414. 414. Reason J. Safety in the operating theatre—part 2: human error and organisational failure. Curr Anaesth Crit Care. 1995;6:121–6.
  415. 415. Reichman DE, Greenberg JA. Reducing surgical site infections: a review. Rev Obstet Gynecol. 2009;2(4): 212–21.
  416. 416. Report prepared for the Agency for Healthcare Research and Quality, Contract No. 290-97-0013. Prepared by: University of California at San Francisco (UCSF)-Stanford University Evidence-based Practice Center. http://archive.ahrq.gov/clinic/ptsafety/.
  417. 417. Rettner R. US ranks behind 25 other countries in infant mortality. Accessed June 2015.
  418. 418. Reznick RK, MacRae H. Teaching surgical skills: changes in the wind. N Engl J Med. 2006;355(25):2664– 2669. doi: 10.1056/ NEJMra- 054785. PubMed PMID: 17182991.
  419. 419. Rochlin, GI. Trapped in the Net: The Unanticipated Consequences of Computerization Princeton: MA: Princeton University Press. 1997.
  420. 420. Roff S, McAleer S. What is educational climate? Med Teach. 2001;23(4):333– 334. doi: 10.1080/ 01421590120063312. PubMed PMID: 12098377.
  421. 421. Rogers DA, Lingard L, Boehler ML, Espin S, Mellinger JD, Schindler N, Klingensmith M. Surgeons managing conflict in the operating room: defining the educational need and identifying effective behaviors. Am J Surg. 2013 Feb;205(2):125– 130.
  422. 422. Rogers SO, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25–33.
  423. 423. Rosenstein AH, O’Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006 Jul;203(1):96– 105.
  424. 424. Ross SD. Drug-related adverse events: a readers’ guide to assessing literature reviews and meta- analyses. Arch Intern Med. 2001;161:1041–6.
  425. 425. Rostenberg B, Barach P. Design of cardiac surgery operating rooms and the impact of the built environment. In: Barach P, Jacobs J, Laussen P, Lipshultz S, editors. Outcomes analysis, quality improvement, and patient safety for pediatric and congenital cardiac disease. New York, NY: Springer Books; 2014. ISBN 978-1-4471-4618-6.
  426. 426. Rostenberg B, Barach P. Design of cardiac surgery operating rooms and the impact of the built environment. In: Barach P, Jacobs J, Laussen P, Lipshultz S, editors. Outcomes analysis, quality improvement, and patient safety for pediatric and congenital cardiac disease. New York: Springer Books; 2014. ISBN 978-1-4471-4618-6.
  427. 427. Rostenberg B, Barach P. Desperately seeking safety. Asian Healthcare Manage. 2007;14:54–6.
  428. 428. Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, Stone PH, Lilly CM, Katz JT, Czeisler CA, Bates DW. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694– 1700.
  429. 429. Rowlands J, Yeager MP, Beach M, Patel HM, Huysman BC, Loftus RW. Video observation to map hand contact and bacterial transmission in operating rooms. Am J Infect Control. 2014;42(7):698–701.
  430. 430. Runciman B, Merry A, Walton M. Safety and Ethics in Healthcare: A Guide to Getting it Right. Aldershot, UK: Ashgate; 2007.
  431. 431. Runciman WB, Merry AF. A brief history of the patient safety movement in anaesthesia. In: Eger EI, Saidman LJ, Westhorpe RN, eds. The Wondrous Story of Anesthesia. New York: Springer; 2014:541– 556.
  432. 432. Runciman WB, Webb RK, Helps SC, et al. A comparison of iatrogenic injury studies in Australia and the USA. II: reviewer behaviour and quality of care. Int J Qual Health Care. 2000;12(5):379– 388.
  433. 433. Runciman WB, Williamson JA, Deakin A, Benveniste KA, Bannon K, Hibbert PD. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Qual Saf Health Care. 2006;15 Suppl 1:i82–90.
  434. 434. Runciman WB. Shared meanings: preferred terms and definitions for safety and quality concepts. Med J Aust. 2006;184(10 Suppl):S41–3.
  435. 435. Runciman WB. Shared meanings: preferred terms and definitions for safety and quality concepts. Med J Aust. 2006;184(10 Suppl):S41–3. 17. de Feijter JM, de Grave WS, Muijtjens AM, Scherpbier AJ, Koopmans RP. A comprehensive overview of medical error in hospitals using incident- reporting systems, patient complaints and chart review of inpatient deaths. PLoS One. 2012;7(2), e31125.
  436. 436. Ruskin KJ, Caldwell JA, Caldwell JL, Boudreau EA. Screening for sleep apnea in morbidly obese pilots. Aerosp Med Hum Perform. 2015 Sep;86(9): 835– 841.
  437. 437. Russ S, Sevdalis N, Moorthy K, et al. Barriers and facilitators towards implementation of the WHO Surgical Safety Checklist across hospitals in England: lessons from the national ‘Surgical Checklist Implementation Project.’ Ann Surg. (2014 July 28).
  438. 438. Russell WJ. Getting in the red: a strategic step for safety. Qual Saf Health Care. 2002;11:107.
  439. 439. Sack RL, Auckley D, Auger RR, et al. Circadian rhythm sleep disorders: Part I, basic principles, shift work and jet lag disorders: an American Academy of Sleep Medicine review. Sleep. 2007;30(11): 1460– 1483.
  440. 440. Sacks GD, Lawson EH, Dawes AJ, Russell MM, Maggard-Gibbons M, Zingmond DS, Ko CY. Relationship Between Hospital Performance on a Patient Satisfaction Survey and Surgical Quality. JAMA Surg. 2015 Sep;150(9):858–64.
  441. 441. Safety WAfP, Organization WH. The second global patient safety challenge: safe surgery saves lives: World Health Organization; 2008.
  442. 442. Salas E, et al. Toward an understanding of team performance and training. In: Swezey RW, Salas E, eds. Teams: Their Training and Peformance. Norwood, NJ: Ablex; 1992:3– 29.
  443. 443. Sanchez J, Barach P. High reliability organizations and surgical microsystems: re-engineering surgical care. Surg Clin N Am. 2012;92(1):1–14. doi: 10.1016/j. suc.2011.12.005.
  444. 444. Sanchez J, Barach P. High reliability organizations and surgical microsystems: re-engineering surgical care. Surg Clin North Am. 2012;92(1):1–14. doi:10.1016/j.suc.2011.12.005.
  445. 445. Sanchez J, Barach P. High Reliability Organizations and Surgical Microsystems: Re-engineering Surgical Care. Surgical Clinics of North America, 02/2012; 92(1):1–14. DOI: 10.1016/j.suc.2011.12.005.
  446. 446. Sanchez JA, Barach PR. High reliability organizations and surgical microsystems: re-engineering surgical care. Surg Clin N Am. 2012;92(1):1–4.
  447. 447. Saul J, Duffy J, Noonan R, Lubell K, Wandersman A, Flaspohler P, et al. Bridging science and practice in violence prevention: addressing ten key challenges. Am J Community Psychol. 2008;41(3-4):197–205.
  448. 448. Saxton R, Hines T, Enriquez M. The negative impact of nurse- physician disruptive behavior on patient safety: a review of the literature. J Patient Saf. 2009 Sep;5(3):180– 183.
  449. 449. Scacci W. Socio- technical design. In: Bainbridge WS, ed. The Berkshire Encyclopedia of Human Computer Interaction. Great Barrington, MA: Berkshire Publishing; 2004:656– 659.
  450. 450. Schraagen JM, Schouten A, Smit M, van der Beek D, Van de Ven J, Barach P. A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. BMJ Qual Saf. 2011. doi:10.1136/bmjqs.2010.048983.
  451. 451. Schraagen JM, Schouten T, Smit M, Haas F, van der Beek D, Barach P. Assessing and improving teamwork in cardiac surgery. Qual Saf Health Care. 2010;19(6):e29.
  452. 452. Schraagen JM, Schouten T, Smit M, Haas F, van der Beek D. Assessing and improving teamwork in cardiac surgery. Qual Saf Health Care. 2009;19(6):e29.
  453. 453. Schulz CM et al. Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. BMC Anesthesiology 2016;16(4).
  454. 454. Schulz CM, et al. Situation awareness in anesthesia: concept and research. Anesthesiology. 2013; 118(3):729– 742.
  455. 455. Schulz CM, et al. Visual attention of anaesthetists during simulated critical incidents. Br J Anaesth. 2011;106(6):807– 813.
  456. 456. Schupp M, Hanning CD. Physiology of sleep. BJA CEPD Rev. 2003;3:69– 74.
  457. 457. Schwappach D, Hochreutener MA, von Laue N, Frank O. Täter als Opfer. Schriftenreihe 3. January 10, 2010. Zürich: Stiftung für Patientensicherheit Schweiz.
  458. 458. Secanell M, Groene O, Arah OA, Lopez MA, Kutryba B, Pfaff H, Klazinga N, Wagner C, Kristensen S, Bartels PD, Garel P, Bruneau C, Escoval A, França M, Mora N, Suñol R, DUQuE Project Consortium. Deepening our understanding of quality improvement in Europe (DUQuE): overview of a study of hospital quality management in seven countries. Int J Qual Health Care. 2014;26 Suppl 1:5–15.
  459. 459. Seddon ME, Hocking CJ, Bryce EA, Hillman J, McCoubrie V. From ICU to hospital- wide: extending central line associated bacteraemia (CLAB) prevention. N Z Med J. 2014;127(1394):60– 71.
  460. 460. Seddon ME, Jackson A, Cameron C, et al. The Adverse Drug Event Collaborative: a joint venture to measure medication- related patient harm. N Z Med J. 2013;126(1368):9– 20.
  461. 461. Seiden S, Barach P. The risk management handbook for health professionals, review. Risk Manag. 2003;3(5):59–61.
  462. 462. Seiden, S., Barach, P. Wrong-side, wrong procedure, and wrong patient adverse events: Are they preventable? Archives of Surgery, 2006;141:1–9.
  463. 463. Seifert BC. Surgeons’ attitudes to intraoperative death: anaesthetic departments need action plans to deal with such catastrophes. BMJ. 2001;323:342.
  464. 464. Sharma A, Sharp DM, Walker LG, Monson JRT. Stress and burnout among colorectal surgeons and colorectal nurse specialists working in the National Health Service. Colorectal Dis. 2008;10(4):397–406.
  465. 465. Shaw J, Calder K. Aviation is not the only industry: health care could look wider for lessons on patient safety. Health Care Manage Rev. 2008;35:134–46. 6. van der Schraaf TW. Medical applications of industrial safety science. Qual Saf Health Care. 2002;11:205–6.
  466. 466. Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158:365–8.
  467. 467. Shojania KG, Duncan BW, McDonald KM, Wachter RM. Safe but sound: patient safety meets evidence- based medicine [Editorial]. JAMA. 2002;288:508–13.
  468. 468. Shojania KG, McDonald KM, Wachter RM, et al. Closing the quality gap: a critical analysis of quality improvement strategies. V olume 1–Series Overview and Methodology Technical Review 9 (Contract No 290-02-0017 to the Stanford University–UCSF Evidence-based Practice Center) Rockville: Agency for Healthcare Research and Quality; 2004. AHRQ Publication No. 04-0051–1.
  469. 469. Shubin S. Burnout: the professional hazard you face in nursing. Nursing. 1978;8(7):22–7.
  470. 470. Simon RW. Surgical scheduling: a lean approach to process improvement. AORN J. 2014;99(1):147–59.
  471. 471. Simorov A, Bills N, Shostrom V, Boilesen E, Oleynikov D. Can surgical performance benchmarking be generalized across multiple outcomes databases: a comparison of University Health System Consortium and National Surgical Quality Improvement Program. Am J Surg. 2014;208(6): 942– 948.
  472. 472. Singer SJ, V ogus TJ. Reducing hospital errors: interventions that build safety culture. Ann Rev Public Health. 2013;34:373–96.
  473. 473. Singer SJ, V ogus TJ. Safety climate research: taking stock and looking forward. Qual Saf Health Care. 2013;22:1–4.
  474. 474. Singh H, et al. Comparing safety climate in naval aviation and hospitals: implications for improving patient safety. Health Care Manage Rev. 2006;35:134–46.
  475. 475. Singh S, Pai DR, Sinha NK, Kaur A, Soe HH, Barua A. Qualities of an effective teacher: what do medical teachers think? BMC Med Educ. 2013;13:128. doi: 10.1186/ 1472- 6920- 13-.
  476. 476. Skegg PDG. Criminal prosecutions of negligent health professionals: the New Zealand experience. Med Law Rev. 1998;6:220– 246.
  477. 477. Slight SP, Seger DL, Nanji KC, et al. Are we heeding the warning signs? Examining providers’ overrides of computerized drug- drug interaction alerts in primary care. PLoS One. 2013;8(12):e85071.
  478. 478. Sloate S, Popovitch E, Wiggins H, Barach P. Report on the development of an overarching strategy to create alignment, drive clinician and staff engagement for continuous quality improvement and document value to all stakeholders. North Carolina AccessCare Network; July 2014.
  479. 479. Small DS, Barach P. Patient safety and health policy: a history and review. Hematol Oncol Clin N Am. 2002;16(6):1463–82.
  480. 480. Small DS, Barach P. Patient safety and health policy: a history and review. Hematol Oncol Clin North Am. 2002;16(6):1463–82.
  481. 481. Small SD, Barach P. Statewide survey of Massachusetts physician attitudes towards policy and workplace issues of patient safety. Am Soc Anesthesiol. 2000;93:A-1188.
  482. 482. Smith IC, Jones MW. Surgeons’ attitudes to intraoperative death: questionnaire survey. BMJ. 2001;322:896– 897.
  483. 483. Sofield L, Salmond SW. Workplace violence: a focus on verbal abuse and intent to leave the organization. Orthop Nurs. 2003 Jul– Aug;22(4):274– 283.
  484. 484. Sollecito W, Johnson J, editors. Continuous quality improvement in health care. Burlington: Jones and Bartlett Learning; 2011.
  485. 485. Spick M. The Ace Factor: Air Combat and the Role of Situational Awareness. Annapolis: US Naval Institute Press; 1988.
  486. 486. Spiess BD, Wahr JA, Nussmeier NA. Bring your life into FOCUS! Anesth Analg. 2010;110(2):283–7.
  487. 487. Splettes M. “Burnout” problem in helping professionals. Dent Dimens. 1977;11:17–24.
  488. 488. Staal MA. Stress, cognition, and human performance: a literature review and conceptual framework [Internet]. NASA Technical Memorandum. 2004. http:// human- factors. arc.nasa.gov/ flightcognition/ Publications/ IH_ 054_ Staal.pdf \npapers3:// publication/ uuid/ E92DA994- B825- 40CA- 9E74- A94101F33496.
  489. 489. Staender SE, Manser T. Taking care of patients, relatives and staff after critical incidents and accidents. Eur J Anaesthesiol. 2012;29:303– 306.
  490. 490. Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety issues identified by perioperative nurses. AORN J. 2013;97(4):402–18.
  491. 491. Stefanidis D, et al. Redefining simulator proficiency using automaticity theory. Am J Surg. 2007;193(4):502– 506.
  492. 492. Stefanidis D, et al. Simulator training to automaticity leads to improved skill transfer compared with traditional proficiency- based training: a randomized controlled trial. Ann Surg. 2012;255(1):30– 37.
  493. 493. Stewart DE, Tlusty SM, Taylor KH, Brown RS, Neil HN, Klassen DK, et al. Trends and patterns in reporting of patient safety situations in transplantation. Am J Transplant. 2015;15(12):3123–33.
  494. 494. Stewart RM, Liao LF, West M, Sirinek KR. The general surgery workforce shortage is worse when assessed at county level. Am J Surg. 2013;206(6):1016– 22. discussion 22-3.
  495. 495. Stockert EW, Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. J Am Coll Surg. 2014;219:646–55.
  496. 496. Strum D, May J, Vargas L. Modeling the uncertainty of surgical procedure times. Anesthesiology. 2000;92(4):1160–7.
  497. 497. Strum D, Vargas L, May J. Surgical subspecialty block utilization and capacity planning. Anesthesiology. 1999;90(4):1176–85.
  498. 498. Suliman A, Klaber RE, Warren OJ. Exploiting opportunities for leadership development of surgeons within the operating theatre. Int J Surg. 2013;11(1):6– 11.
  499. 499. Sunol R, Wagner C, Arah OA, Kristensen S, Pfaff H, Klazinga N, Thompson CA, Wang A, DerSarkissian M, Bartels P, Michel P, Groene O, DUQuE Project Consortium. Implementation of departmental quality strategies is positively associated with clinical practice: results of a multicenter study in 73 hospitals in 7 European countries. PLoS One. 2015;10(11):e0141157.
  500. 500. Swanson SP, Roberts LJ, Chapman MD. Are anaesthetists prone to suicide? A review of rates and risk factors. Anaesth Intensive Care. 2003;31(4):434– 445.
  501. 501. Sweller J, Ayres P, Kalyuga S. Cognitive Load Theory. 2011;1. doi:10.1007/ 978- 1- 4419- 8126- 4.
  502. 502. Sweller J, Sweller S. Natural information processing systems. Evol Psychol. 2006;4:434– 458.
  503. 503. Sweller J. Cognitive load theory. In: Ross B, Mestre J, eds. The Psychology of Learning and Motivation: Cognition in Education. Oxford: Academic Press; 2011:37– 76.
  504. 504. Sweller J. Element interactivity and intrinsic, extraneous, and germane cognitive load. Educ Psychol Rev. 2010;22(2):123– 138. doi:10.1007/ s10648- 010- 9128- 5.
  505. 505. Sweller J. Human cognitive architecture: why some instructional procedures work and others do not. In: APA Educational Psychology Handbook, Vol 1: Theories, Constructs, and Critical Issues.; 2012:295– 325. doi:10.1037/ 13273- 011.
  506. 506. Tenner, E. Why Things Bite Back: Technology and the Revenge of Unintended Consequences. New York: Knopf; 1997.
  507. 507. The Joint Commission on Accreditation of Healthcare Organizations. What every healthcare organization should know about sentinel events. Oakbrook: Joint Commission Resources; 2005.
  508. 508. The Joint Commission. Accreditation essentials: tips for addressing the “rights” of medication administration. Joint Commission Resources. http:// www.jcrinc.com/ 6840/. Accessed April 7, 2015.
  509. 509. The Joint Commission. Sentinel Event Data: Root Causes by Event Type. Oakbrook Terrace, IL; 2015.
  510. 510. The Patient Safety and Quality Improvement Act of 2005. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
  511. 511. Thiels CA, Lal TM, Nienow JM, Pasupathy KS, et al. Surgical never events and contributing human factors. Surgery. 2015;158(2):515–21. doi: 10.1016/j. surg.2015.03.053.
  512. 512. Thomas L. The Medusa and the Snail: More Notes of a Biology Watcher. New York: Viking Press; 1974.
  513. 513. Thompson CL, Larkin EK, Patel S, Berger NA, Redline S, Li L. Short duration of sleep increases risk of colorectal adenoma. Cancer. 2011 Feb 15;117(4): 841– 847.
  514. 514. Tissot E, Cornettte C, Demoly P, et al. Medication errors at the administration stage in an intensive care unit. Intensive Care Med. 1999;25:353–9.
  515. 515. Tokars JI, Richards C, Andrus M, Klevens M, Curtis A, Horan T, et al. The changing face of surveillance for health care-associated infections. Clin Infect Dis. 2004;39:1347–52.
  516. 516. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. 2014;23(4):299–318.
  517. 517. Trist E. The evolution of sociotechnical systems as a conceptual framework and as an action research program. In: Van de Ven A, Joyce W, eds. Perspectives on Organization Design and Behavior. New York: Wiley; 1981:19– 75.
  518. 518. Tucker RD, Platz CE, Landas SK. Histologic characteristics of electrosurgical injuries. J Am Assoc Gynecol Laparosc. 1997;4(2):201–6.
  519. 519. Turner B. Man- Made Disasters. London: Wykeham; 1978.
  520. 520. Tyler D, Pasquariello C, Chen C. Determining optimum operating room utilization. Anesth Analg. 2003;96(4):1114–21.
  521. 521. US Agency for Health Research and Quality. Patient Safety Primers: Safety Culture. October 2012. http:// psnet.ahrq.gov/ primer.aspx?primerID=5.
  522. 522. V ogus TJ, Sutcliffe KM, Weick KE. Doing no harm: enabling, enacting, and elaborating a culture of safety in health care. Acad Manage Perspect. 2010;24(4): 60–78.
  523. 523. Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: the annual cost of measurable medical errors. Health Aff. 2011;30(4);596- 603.
  524. 524. Veltman LL. Disruptive behavior in obstetrics: a hidden threat to patient safety. Am J Obstet Gynecol. 2007 Jun;196(6):587.e1, 4; discussion 587. e4– 5.
  525. 525. Veninga R. Administrator burnout—causes and cures. Hosp Prog. 1979;60(2):45–52.
  526. 526. Vetter TR, Boudreaux AM, Jones KA, Hunter Jr JM, Pittet JF. The perioperative surgical home: how anesthesiology can collaboratively achieve and leverage the triple aim in health care. Anesth Analg. 2014;118(5):1131–6.
  527. 527. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol. 2013;13:6.
  528. 528. Vetter TR, Ivankova NV, Goeddel LA, McGwin Jr G, Pittet JF. An analysis of methodologies that can be used to validate if a perioperative surgical home improves the patient-centeredness, evidence-based practice, quality, safety, and value of patient care. Anesthesiology. 2013;119(6):1261–74.
  529. 529. Vetter TR, Jones KA. Perioperative Surgical Home: perspective II. Anesthesiol Clin. 2015;33(4):771–84. doi:10.1016/j.anclin.2015.07.002. Review. PubMed PMID: 26610629.
  530. 530. Vickers MD. Fire and explosion hazards in operating theatres. Br J Anaesth. 1978;50(7):659–64.
  531. 531. Vienna: International Atomic Energy Agency; 1986.
  532. 532. Vienna: International Atomic Energy Agency; 1993.
  533. 533. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg. 2004;239(4):475–82.
  534. 534. Vincent C, Moorthy K, Sarker SK, et al. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg. 2004;239:475–82.
  535. 535. Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet. 1994;343:1609– 1613.
  536. 536. Wachtel R, Dexter F. Tactical increases in operating room block time for capacity planning should not be based on utilization. Anesth Analg. 2008;106(1): 215–26.
  537. 537. Walrath JM, Dang D, Nyberg D. An organizational assessment of disruptive clinician behavior: Findings and implications. J Nurs Care Qual. 2013 Apr– Jun;28(2):110– 121.
  538. 538. Walsh-Sukys M, Reitenbach A, Hudson-Barr D, DePompei P. Reducing light and sound in the neonatal intensive care unit: an evaluation of patient safety, staff satisfaction and costs. J Perinatol. 2001;21:230–5.
  539. 539. Waring J, Harrison S, McDonald R. A culture of safety or coping: ritualistic behaviours in the operating department. J Health Serv Res Policy. 2007;12 Suppl 1:s1–3–9.
  540. 540. Washington, DC: National Academies Press; 1999.
  541. 541. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, Gallagher TH. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33:467– 476.
  542. 542. Wears RL, Wu AW. Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med. 2002;39(3):344– 346.
  543. 543. Weber DJ, Sickbert-Bennett EE, Gould CV, Brown VM, Huslage K, Rutala WA. Incidence of catheter- associated and non-catheter-associated urinary tract infections in a healthcare system. Infect Control Hosp Epidemiol. 2011;32:822–3.
  544. 544. Weber DO. Poll results: doctors’ disruptive behavior disturbs physician leaders. Physician Exec. 2004 Sep– Oct;30(5):6– 14.
  545. 545. Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001;29(5):494– 500.
  546. 546. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372:139–44.
  547. 547. Weller J, Henderson R, Webster CS, et al. Building the evidence on simulation validity: comparison of anesthesiologists’ communication patterns in real and simulated cases. Anesthesiology. 2014;120(1): 142– 148.
  548. 548. Wennberg J, Gittelsohn. Small area variations in health care delivery. Science. Dec 14 1973;182(4117):1102– 1108.
  549. 549. West N, Eng T. Monitoring and reporting hospital- acquired conditions: a federalist approach. Medicare Medicaid Res Rev. 2014;4(4):E1–E16.
  550. 550. Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170:683–90.
  551. 551. Wetzel CM, Kneebone RL, Woloshynowych M, Nestel D, Moorthy K, Kidd J, et al. The effects of stress on surgical performance. Am J Surg. 2006;191:5–10.
  552. 552. Wheeler SJ, Wheeler DW. Medication errors in anaesthesia and critical care. Anaesthesia. 2005;60(3):257– 273.
  553. 553. White SM, Akerele O. Anaesthetists’ attitudes to intraoperative death. Eur J Anaesthesiol. 2005; 22:938– 941.
  554. 554. Whitlock EL, Feiner JR, Chen LL. Perioperative mortality, 2010 to 2014: a retrospective cohort study using the National Anesthesia Clinical Outcomes Registry. Anesthesiology. 2015; 123(6): 1312– 1321.
  555. 555. Wiegmann DA, ElBardissi AW, Dearani JA, Daly RC, Sundt TM. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658–65.
  556. 556. Wiegmann DA, ElBardissi AW, Dearani JA, Daly RC, Sundt TM. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142:658–65.
  557. 557. Wilf-Miron R, et al. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care. Qual Saf Health Care. 2003;12:35–9.
  558. 558. Williamson JA, et al. The Australian Incident Monitoring Study. Human failure: an analysis of 2000 incident reports. Anaesth Intens Care. 1993;21(5):678– 683.
  559. 559. Woods D, Sarter N, Billings C. Automation surprises. The handbook of human factors. 2nd edn. 1997.
  560. 560. World Alliance For Patient Safety Drafting Group, Sherman H, Castro G, Fletcher M; World Alliance for Patient Safety, Hatlie M, Hibbert P, Jakob R, Koss R, Lewalle P, Loeb J, Perneger T, Runciman W, Thomson R, Van Der Schaaf T, Virtanen M. Towards an International Classification for Patient Safety: the conceptual framework. Int J Qual Health Care. 2009;21(1):2–8.
  561. 561. World Alliance for Patient Safety. WHO guidelines for safe surgery. Geneva: World Health Organization; 2008.
  562. 562. World Health Organization. Guidelines for community noise. Geneva: WHO; 1999.
  563. 563. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? Qual Saf Health Care. 2003;12:221– 226.
  564. 564. Xie A, Carayon P. A systematic review of human factors and ergonomics (HFE)- based healthcare system redesign for quality of care and patient safety. Ergonomics. 2014;58(1):33– 49.
  565. 565. Young JS, Smith RL, Guerlain S, et al. How residents think and make medical decisions: implications for education and patient safety. Am Surg. 2007;73(6):548–53; discussion 53–4.
  566. 566. Zachariah P, Reagan J, Furuya EY, et al. The association of state legal mandates for data submission of central line-associated bloodstream infections in neonatal intensive care units with process and outcome measures. Infect Control Hosp Epidemiol. 2014;35(9):1133–9.
  567. 567. Zaremba S, Chamberlin NL, Eikermann M. Sleep Medicine. In: Miller RD, Lars I, Eriksson LI, Fleisher LA, Wiener- Kronish JP, Cohen NH, Young WL, eds. Miller’s Anesthesia. 8th ed. Philadelphia: Elsevier Saunders; 2015.
  568. 568. Zeitlin GL. History of anesthesia records. ASA Newsl. 2013;77:26–9. R. P. D u t to n.
  569. 569. Zhang Y, et al. Effects of integrated graphical displays on situation awareness in anaesthesiology. Cog Tech Work. 2002;4:82– 90.
  570. 570. Zimmerman T, Amori G. The silent organizational pathology of insidious intimidation. J Healthc Risk Manag. 2011;30(3):5,6, 8– 15.
  571. 571. Zohar D. Safety climate in industrial organizations: theoretical and applied implications. J Appl Psychol. 1980;65(1):96.
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