Time to take a breath: Rebalancing the human and technical aspects of patient safety

IOM Committee on Identifying an Preventing Medication Errors, Aspden P Wolcott J Bootman JL et al . (eds). Preventing medication errors. Washington, DC: The National Academies Press, 2007.

Trist E Bamforth W. Some social and psychological consequences of the Long Wall Method of coal-getting. Hum Relat 1951; 4: 3–38.

Carayon P. Human factors of complex sociotechnical systems. Appl Ergon 2006; 37: 525–535.

Pittet D Allegranzi B Storr J et al . ‘ Clean care is safer care’: the global patient safety challenge 2005–2006. Int J Infect Dis 2006; 10: 419–424.

Haynes AB Weiser TG Berry WR et al .; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491–499.

Urbach DR Govindarajan A Saskin R et al . Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med 2014; 370: 1029–1038.

Leape LL. The checklist conundrum. N Engl J Med 2014; 370: 1063–1064.

Poon EG Keohane CA Yoon CS et al . Effect of bar-code technology on the safety of medication administration. N Engl J Med 2010; 362: 1698–1707.

Koppel R Wetterneck T Telles JL et al . Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc 2008; 15: 408–423.

van der Veen W van den Bemt PMLA Wouters H et al . Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals. J Am Med Inform Assoc 2018; 25: 385–392.

Yin S Lim PK Chan YH. Improving hand hygiene compliance with Patient Zone Demarcation: more than just lines on the floor. J Patient Saf Risk Manag 2019; 24: 100–107.

Swoboda SM Earsing K Strauss K et al . Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit. Crit Care Med 2004; 32: 358–363.

Levchenko AI Boscart VM Fernie GR. Automated monitoring: a potential solution for achieving sustainable improvement in hand hygiene practices. Comput Inform Nurs 2014; 32: 397–403.

Miller C Scott S Beck M. Second victims and mindfulness: a systematic review. J Patient Saf Risk Manag 2019; 24: 108–117.

Adams K Kim T Fong A et al . Responding to health IT reported safety events: Insights from patient safety event reports. J Patient Saf Risk Manag 2019; 24: 118–124.

Guttman O Keebler J Lazzarra E et al. Rethinking high reliability in healthcare: the role of error management theory towards advancing high reliability organizing. J Patient Saf Risk Manag 2019; 24: 127–133.