Safety & Quality References

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Nancy Leveson MIT Systems Safety Website includes:

Archetypes for Organisational Safety Karen Marais and Nancy G. Leveson http://sunnyday.mit.edu

A Systems Theoretic Approach to Safety Engineering Nancy Leveson, Mirna Daouk, Nicolas Dulac, Karen Marais Aeronautics and Astronautics Dept. Massachusetts Institute of Technology October 30, 2003 http://sunnyday.mit.edu

Using System Dynamics for Safety and Risk Management in Complex Engineering Systems WinterSim2005 Nicolas Dulac, Nancy Leveson, David Zipkin, Stephen Friedenthal, and Joel Cutcher-Gershenfeld (Massachusetts Institute of Technology)

Crossing the Quality Chasm : A New Health System for the 21st Century Committee on Quality of Health Care in America 2001 ISBN 0-309-07280-8 http://www.nap.edu/catalog/10027.html

Learning from Incidents David L Cooke ISDC 2003 New York

Please note that this paper is published in Gonzalez, J.J., (Ed.) 2003 From Modeling to Managing Security - A System Dynamics Approach, pp. 75-108. Kristiansand, Norway:Norwegian Academic Press.

Organizational Silence and Hidden Threats to Patient Safety. Kerm Henriksen and Elizabeth Dayton Health Services Research 41:4, Part II (August 2006) p.1539-54

Institutional Medical Incident Reporting Systems: A Review Alberta Heritage Foundation for Medical Research Aug 2005

System Dynamics Approach for Error and Change Management in Concurrent Design and Construction WinterSim2005 SangHyun Lee (MIT) and Feniosky Pena-mora (UIUC)

"Going solid": a model of system dynamics and consequences for patient safety R Cook and J Rasmussen Qual Saf Health Care 2005;14;130-134 Abstract

Overcoming the Improvement Paradox Nelson Repenning and John Sterman http://web.mit.edu/jsterman/www/EMJPaper.html

Nobody Ever Gets Credit for Fixing Problems that Never Happened: Creating and Sustaining Process Improvement Nelson Repenning and John Sterman MIT Website http://web.mit.edu/nelsonr/www/CMR_Getting_Quality_v1.0.html

Self Confirming Attribution Errors in the Dynamics of Process Improvement Nelson Repenning and John Sterman http://web.mit.edu/nelsonr/www/SelfConfAttErrors_v1.0.html

A System Dynamics Analysis of the Westray Mine Disaster David L Cooke ISDC2002 Palermo and Syst. Dyn. Rev. 19,(2),139–166, (2003)

Evaluating the Capability of Information Technology to Prevent Adverse Drug Events: A Computer Simulation Approach JAMES G. ANDERSON et al J Am Med Inform Assoc. 2002;9:479–490.

Drivers of quality in health services: Different worldviews of clinicians and policy managers revealed Robert Y. Cavana, Philip K. Davies, Rachel M. Robson and Kenneth J. Wilson Syst. Dyn. Rev. 15,(3) p331-340, (1999)

Modeling….Best Practice Implementation in a Small Health Care Private Practice Martinez-Moyano and Wadhwa ISDC2002 Palermo

The Dynamics of Hospital Medication Errors: A Systems Simulator Testbed for Patient Safety Interventions Geoff McDonnell, Mark Heffernan ISDC2005 Boston Website Model

Can simulation be used to reduce errors in health care delivery? The hospital drug distribution system. Dean, B., N. Barber, et al. Journal of Health Services & Research Policy (2001). 6(1): 32-7.

Questions & Comments to Geoff McDonnell
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