As hospitals across the United States develop policies to prevent worker fatigue and ensure patient safety, a study at Ohio State University has identified key strategies that might make the job easier. Culled from high-risk environments as diverse as a railroad dispatch center and the NASA Johnson Space Center, the strategies address the most critical time during any workday -- the shift change -- when incoming and outgoing workers have to exchange information and hand-off important duties. handoffs in health care pdf

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Invited talk Conflicts between Learning and Accountability in Patient Safety.
Presented at the 10th Annual Clifford Symposium on Tort Law and Social Policy. "Starting Over?: Redesigning the Medical Malpractice System." DePaul Law School, Chicago IL, April 15-16, 2004.
Examines how blame-based systems of accountability block information flow and learning, exacerbate double binds and goal conflicts, and degrade cooperation. beyond blame pdf

A study of how a concept for representing order of magnitude aids comprhension of the decibel scale. decibel scale pdf