J T Reason
- Diagnosing "vulnerable system syndrome": an essential prerequisite to effective risk managementJ T Reason
Psychology Department, University of Manchester, Manchester M13 9PL, UK
Qual Health Care 10:ii21-5. 2001..Two kinds of organisational learning are discussed: "single loop" learning that fuels and sustains VSS and "double loop" learning that is necessary to start breaking free from it...
- Combating omission errors through task analysis and good remindersJ Reason
Department of Psychology, University of Manchester, Manchester M13 9PL, UK
Qual Saf Health Care 11:40-4. 2002..Such a programme is applicable to a variety of healthcare procedures...
- Beyond the organisational accident: the need for "error wisdom" on the frontlineJ Reason
Qual Saf Health Care 13:ii28-33. 2004..Some mental skills are outlined that could alert junior doctors and nurses to situations likely to promote damaging errors...