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Beyond the organisational accident: the need for "error wisdom" on the frontline

Complex, well defended, high technology systems are subject to rare but usually catastrophic organisational accidents in which a variety of contributing factors combine to breach the many barriers and safeguards. To the extent that healthcare institutions share these properties, they too are subject...

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Detalhes bibliográficos
Autor principal: Reason, J
Formato: Artigo
Idioma:Inglês
Publicado em: BMJ Group 2004
Assuntos:
Acesso em linha:https://ncbi.nlm.nih.gov/pmc/articles/PMC1765802/
https://ncbi.nlm.nih.gov/pubmed/15576688
https://ncbi.nlm.nih.govhttp://dx.doi.org/10.1136/qshc.2003.009548
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