A forthcoming chapter on how sharp end practice bridges gaps to create resilience focused on health care.
What research is needed to advance patient safety? Research to help tame complexity. See a forthcoming handbook chapter to appear in Handbook of Human Factors in Health Care: Taming Complexity pdf
Analysis of a medication misadministration and how it reveals generic patterns in collaborative distributed work. In particular the study highlights the role of cross checks in resilience and safety. The study appeared in a special issue of IEEE SMC Part A in November 2004. analysis of a misadministration pdf
Co-editor of a special issue of IEEE SMC on Using Field Studies to Understand Technical Work in Healthcare. The studies will appear in IEEE SMC Part A in November 2004 edited by Chris Nemeth, Richard Cook and David Woods.
The introduction to the papers is intro to special issue pdf
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
Press items include Business First pdf press release pdf
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
9 steps to move forward if you think you have a human error problem: CTW02 pdf
What is Error? On receiving a request for help in defing error in health care, the authors respond with a "Dear Virginnia" letter that reviews some fallacies about error and points to the alternative "Resilience Engineering". "Mistaking Error" D. D. Woods and R. I. Cook. In M. J. Hatlie and B. J. Youngberg (Eds.) Patient Safety Handbook, Jones and Bartlett, 2003, in press. Mistaking error pdf
Series of papers on New Look at Error and the Patient Safety Movement in Health Care:
Future of Patient Safety pdf What is error? pdf Bridging Gaps pdf
Also see: The Pexis e-course on error, Behind the label 'Human Error', and the "The Tale of Two Stories" entries at this site.
For additional results see:
VA Gaps Center web site
Emily Patterson web site
News item on bar coding studies
Universityof Chicago Cognitive technologies Lab site
Cook news item
Electronic course, Behind Human Error -- building Performance Experts in Safety (PEXiS).
error e-course
Primer material on the 'New Look' at error and how complex systems fail:
primer text pdf primer graphics pdf Handbook1 chapter pdf
Reactions to Failure:
error as information pdf Fundamental Surprise pdf
Resilience:
Breakdowns in adaptation pdf Bridging Gaps pdf See 'Moving Forward from Error' at this site.
More on the New Look in the Patient Safety Movement in Health Care:
Future of Patient Safety pdf what is error? pdf See the "The Tale of Two Stories" entry.
Also see: The Pexis e-course on error
Behind the label 'Human Error'
all at this site.
For additional results see:
VA Gaps Center web site
Emily Patterson web site
News item on bar coding studies
Universityof Chicago Cognitive technologies Lab site
For list of papers see: error papers
The modified Unit Marking Procedure or m-UMP is described as a means to discover the events practitioners find meaningful in dynamic data streams. The method is illustrated by results from a simulation study of anesthesiologists vital signs monitoring m-UMP pdf
Woods is part of a new committee of the National Academy of Engineering aand the Institute of Medicine for a project entitled, "Engineering the Delivery of Health Care: Priorities for Application and Research."
A description of the project is at: Engineering Health Care
Final report is expected December 2003.
Woods developed HFES position on research needs to advance patient safety at the Research Summit sponsored by Agency for Healthcare Research and Quality, September 11, 2000, Washington DC. HFES Position Paper pdf
(also at: APA Human Factors)
Watch Woods Testimony mov or read Woods Testimony text pdf his oral testimony at the summit.
The monograph "A Tale of Two Stories: Contrasting Views on Patient Safety" by R. I. Cook, D. D. Woods and C. Miller resulted from a workshop on Assembing the Scientific Basis for Progress on Patient Safety held under the auspices of the National Patient Safety Foundation and sponsored by VHA and AHRQ. Tale of 2 Stories pdf
Studies of clumsy automation and near miss critical incidents in infusion devices. Infusion device papers