Funding for this conference was made possible (in part) by 1R13HS020139-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. This issue of Academic Emergency Medicine is funded by the Robert Wood Johnson Foundation.
Learning from Accident and Error: Avoiding the Hazards of Workload, Stress, and Routine Interruptions in the Emergency Department
Article first published online: 13 DEC 2011
© 2011 by the Society for Academic Emergency Medicine
Academic Emergency Medicine
Special Issue: Proceedings of the 2011 AEM Consenus Conference: Interventions to Assure Quality in the Crowded Emergency Department Guest Editors: James R. Miner, MD Manish N. Shah, MD, MPH
Volume 18, Issue 12, pages 1246–1254, December 2011
How to Cite
Bradley Morrison, J. and Rudolph, J. W. (2011), Learning from Accident and Error: Avoiding the Hazards of Workload, Stress, and Routine Interruptions in the Emergency Department. Academic Emergency Medicine, 18: 1246–1254. doi: 10.1111/j.1553-2712.2011.01231.x
The authors have no potential conflicts of interest to disclose.
Supervising Editor: James Miner, MD.
- Issue published online: 13 DEC 2011
- Article first published online: 13 DEC 2011
- Received July 19, 2011; revision received August 19, 2011; accepted August 20, 2011.
- 1Operating at the sharp end: the complexity of human error. In: Bogner BS, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Earlbaum, 1994, pp 255–310., .
- 2The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chicago, IL: University of Chicago Press, 1996..
- 3The Vulnerable System: An Analysis of the Tenerife Air Disaster. In: Roberts KH, ed. New Challenges to Understanding Organizations. New York, NY: MacMillan, 1993, pp 173–98..
- 5Normal Accidents: Living with High Risk Systems. New York, NY: Basic Books, 1984..
- 8Managing the Risks of Organizational Accidents. Alsershot, England: Ashgate Publishing Limited, 1997..
- 10Emergency crews worry as hospitals say, ‘No vacancy.’ New York Times. Available at: http://www.nytimes.com/2000/12/17/us/emergency-crews-worry-as-hospitals-say-no-vacancy.html. Accessed Sep 18, 2011..
- 13U.S. General Accounting Office. Hospital Emergency Departments: Crowded Conditions Vary Among Hospitals and Communities. Washington, DC: US General Accounting Office, 2003, p 71.
- 18Kohn L, Corrigan J, Donaldson M (eds). To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press, 1999.
- 20Sea of lies. Newsweek. Available at: http://www.thedailybeast.com/newsweek/1992/07/12/sea-of-lies.html. Accessed Sep 18, 2011..
- 21Sources of Power. Cambridge, MA: MIT Press, 1998..
- 22The Vincennes incident: another player on the stage? Def Anal. 1995; 11:31–45., .
- 23U.S. Senate Committee on Armed Services. Investigation into the Downing of an Iranian Airliner by the USS Vincennes. Washington, DC: U.S. Government Printing Office, 1988.
- 24Tactical decision making under stress: history and overview. In: Cannon-Bowers JA, Salas E, eds. Making Decisions Under Stress: Implications for Individual and Team Training. Washington, DC: American Psychological Association, 1998, pp 3–15., .
- 25Stress and thought processes. In: Goldberger S, Breznitz S, eds. Handbook of Stress. New York, NY: Free Press, 1982, pp 88–164..
- 27Industrial Dynamics. Cambridge, MA: Productivity Press, 1961..
- 28Business Dynamics: Systems Thinking and Modeling for a Complex World. Chicago, IL: Irwin-McGraw Hill, 2000..
- 29The carbon bathtub. Nat Geograph. 2009; 216:26–9..
- 31The consumption concept in economic theory. Am Econ Rev. 1945; 35:1–14..
- 32Fixation errors: failures to revise situation assessment in dynamic and risky systems. In: Colombo G, de Bustamante AS, eds. Systems Reliability Assessment. Amsterdam: Kluwer, 1990, pp 231–51., .
- 33Mental Models. Hillsdale, NJ: Lawrence Erlbaum, 1983., .
- 34Confidence, Error, and Ingenuity in Diagnostic Problem Solving: Clarifying the Role of Exploration and Exploitation. In: Solomon GT (ed.). Best Paper Proceedings of the Sixty-Seventh Annual Meeting of the Academy of Management. Philadelphia, PA, 2007., , .
- 39Living Systems. New York, NY: McGraw-Hill, 1978..
- 41Stress and Strategy. London: Lawrence Erlbaum, 1986..
- 42Institute of Medicine. Hospital-based Emergency Care At the Breaking Point. Washington, DC: National Academies Press, 2006.
- 43Free fall - a case study of resilience, its degradation, and recovery, in an emergency department. In: Hollnagel E, Rigaud E, eds. 2nd International Symposium on Resilience Engineer. Juan-les-Pins, France: Mines Paris Les Presses, 2006, pp 325–32., .
- 44The Psychology of Judgment and Decision Making. New York, NY: McGraw-Hill, 1993..
- 45Organizing for high reliability: processes of collective mindfulness. In: Sutton RI, Staw BM, eds. Research in Organizational Behavior. Stamford, CT: JAI Press, 1999, pp 81–123., , .
- 46Theory in Practice: Increasing Professional Effectiveness. London: Jossey-Bass, 1974., .