Shaping Systems for Better Behavioral Choices: Lessons Learned from a Fatal Medication Error

Author:

Smetzer Judy,Baker Christine,Byrne Frank D.,Cohen Michael R.

Publisher

Elsevier BV

Subject

Leadership and Management

Reference6 articles.

1. Green M.: “Inattention blindness” & Conspicuity. 2009. http://www.visualexpert.com/Resources/inattentionalblindness.html (last accessed Feb. 10, 2010).

2. Angier N.: Blind to change, even as it stares us in the face. New York Times, Apr. 1, 2008. http://www.nytimes.com/2008/04/01/science/01angi.htm?_r=2&ex=1207713600&en=204&oref=slogin (last accessed Feb. 10, 2010).

3. USP Safe Medication Use Expert Committee: Erroravoidance recommendations for tubing misconnections when using Luer-tip connectors: A Statement by the USP Safe Medication Use Expert Committee;Simmons;Jt Comm J Qual Patient Saf,2008

4. Institute for Safe Medication Practices (ISMP): Epidural-IV route mix-ups: Reducing the risk of deadly errors;ISMP Medication Safety Alert! Acute Care,2008

5. The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA;Vaughan,1996

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