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Studies of patient safety have identified gaps in current work including the need for research about communication and information sharing among health care providers. They have also encouraged the use of decision support tools to improve human performance. Distributed cog-nition is the shared awareness of goals, plans, and details that no single individual(More)
— Communication was the most frequently cited cause of medication errors reported between 1995 and 2003. More detailed models of how communication breakdowns contribute to adverse events are needed to intervene to improve communication processes. We describe in detail an incident where an oncology fellow physician erroneously substituted the medication(More)
Healthcare demonstrates the same properties of risk, complexity, uncertainty, dynamic change, and time-pressure as other high hazard sectors including aviation, nuclear power generation, the military, and transportation. Unlike those sectors, healthcare has particular traits that make it unique such as wide variability, ad hoc configuration, evanescence,(More)
Making sense of circumstances and situations is critical to coordinate cooperative work. Especially in process control domains, we may expect that effective and reliable organizations will possess processes that develop, maintain, distribute, and, when necessary, repair this social understanding (sensemak-ing). Our research has focused on collective(More)