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17. Cook, Woods and Miller, 1998.

18. Reason, 1990.

19. Vaughan, Diane, The Challenger Launch Decision, Chicago: The University of Chicago Press, 1996.

20. Reason, 1990.

21. Reason, 1990.

22. Roberts, Karlene, 1999. See also: Gaba, David, "Risk, Regulation, Litigation and Organizational Issues in Safety in High-Hazard Industries," position paper for Workshop on Organizational Analysis in High Hazard Production Systems: An Academy/Industry Dialogue," MIT Endicott House, April 15–18, 1997, NSF Grant No. 9510883-SBR.

23. Sagan, Scott D., The Limits of Safety, Princeton, NJ: Princeton University Press, 1993.

24. Sagan, Scott D., 1993 and Robert, Karlene, 1999.

25. Reason, James, "Forward," in Human Error in Medicine, ed., Marilyn Sue Bogner, Hillsdale, NJ: Lawrence Erlbaum Associates, 1994.

26. "Agenda for Research and Development in Patient Safety," National Patient Safety Foundation at the AMA, http://www.ama-assn.org/med-sci/npsf/research/research.htm. May 24, 1999.

27. Dye, Kevin M.C.; Post, Diana; Vogt, Eleanor, "Developing a Consensus on the Accountability and Responsibility for the Safe Use of Pharmaceuticals," Preliminary White Paper prepared for the National Patient Safety Foundation, June 1, 1999.

28. Brewer, Timothy; Colditz, Graham A. Postmarketing Surveillance and Adverse Drug Reactions, Current Perspectives and Future Needs. JAMA. 281(9):824–829, 1999.

29. VHA's Patient Safety Improvement Initiative, presentation to the National Health Policy Forum by Kenneth W. Kizer, Under Secretary for Health, Department of Veterans Affairs, May 14, 1999, Washington, D.C.

30. Leape, Lucian L. Error in Medicine. JAMA. 272(23):1851–1857, 1994.

31. Perrow, 1984.

32. Cook and Woods, 1994.

33. Reason. 1990.

34. Norman, 1993.

35. Perrow, 1984.

36. Perrow, 1984.

37. Cook, Woods and Miller, 1998.

38. On the other hand, in some places, the health system may be complex, but loosely coupled. For example, during an emergency, a patient may receive services from a loosely networked set of subsystems—from the ambulance to the emergency room to the outpatient clinic to home care. See Van Cott in Bogner, 1994.

39. Cook and Woods, 1994.

40. Reason, 1990.

41. Reason, 1990.

42. Cook and Woods, 1994.

43. Reason, 1990.

44. Van Cott, 1994.

45. Reason, 1990.

46. Norman, 1993.



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