{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2024,9,6]],"date-time":"2024-09-06T00:37:26Z","timestamp":1725583046529},"publisher-location":"London","reference-count":54,"publisher":"Springer London","isbn-type":[{"type":"print","value":"9781852335618"},{"type":"electronic","value":"9781447101734"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2002]]},"DOI":"10.1007\/978-1-4471-0173-4_3","type":"book-chapter","created":{"date-parts":[[2011,4,29]],"date-time":"2011-04-29T23:10:58Z","timestamp":1304118658000},"page":"31-57","source":"Crossref","is-referenced-by-count":6,"title":["Reasons for the Failure of Incident Reporting in the Healthcare and Rail Industries"],"prefix":"10.1007","author":[{"given":"C. W.","family":"Johnson","sequence":"first","affiliation":[]}],"member":"297","reference":[{"key":"3_CR1","doi-asserted-by":"crossref","unstructured":"L.B. Andrews, C. Stocking, T. Krizek, L. Gottlieb, C. Krizek, and T. Vargish. An alternative strategy for studying adverse events in medical care. Lancet, (349):309313, 1997.","DOI":"10.1016\/S0140-6736(96)08268-2"},{"key":"3_CR2","volume-title":"NASA Ames Research Centre","author":"Aviation Safety Reporting System. The Aviation Safety Reporting System. Technical report","year":"2000","unstructured":"Aviation Safety Reporting System. The Aviation Safety Reporting System. Technical report, NASA Ames Research Centre, California, United States of America, 2000. http:\/\/asrs.arc.nasa.gov ."},{"key":"3_CR3","first-page":"367","volume-title":"Accident reconstruction\/simulation with event recorders","author":"K Bolte","year":"1999","unstructured":"K. Bolte, L. Jackson, V. Roberts, and S. McComb. Accident reconstruction\/simulation with event recorders. In International Symposium on Transportation Recorders, pages 367\u2013369. National Transportation Safety Board, Washington DC, USA, 1999. http:\/\/www.ntsb.gov\/publictn\/1999\/rp9901.pdf ."},{"key":"3_CR4","unstructured":"British Broadcasting Corporation. Rail summit moves forward on safety. Technical report, News Staff, BBC, London, United Kingdom, 30th November 1999. http:\/\/news.bbc.co.uk\/hi\/english\/uk\/newsid_543000\/543019.stm ."},{"key":"3_CR5","volume-title":"lan to stop dangerous doctors","author":"British Broadcasting Corporation","year":"2000","unstructured":"British Broadcasting Corporation. Plan to stop dangerous doctors. Technical report, News Staff, BBC, London, United Kingdom, 13 June 2000. http:\/\/news.bbc.co.uk\/hi\/english\/health\/newsid_788000\/788805.stm ."},{"key":"3_CR6","volume-title":"Doctors back down in whistle-blower case","author":"British Broadcasting Corporation","year":"2001","unstructured":"British Broadcasting Corporation. Doctors back down in whistle-blower case. Technical report, News Staff, BBC, London, United Kingdom, 2001. hhttp:\/\/news.bbc.co.uk\/hi\/english\/heal th\/newsid_1470000\/1470590.stm"},{"issue":"4","key":"3_CR7","first-page":"1","volume":"20","author":"DK Busse","year":"2000","unstructured":"D. K. Busse and D. J. Wright. Classification and analysis of incidents in complex, medical environments. Topics in Health Information Management, 20(4):1\u201311, 2000. Special Edition on Human Error and Clinical Systems.","journal-title":"Topics in Health Information Management"},{"key":"3_CR8","doi-asserted-by":"crossref","unstructured":"R.M.J. Byrne and S.J. Handley. Reasoning strategies for suppositional deductions. Cognition, pages 1\u201349, 1997.","DOI":"10.1016\/S0010-0277(96)00720-2"},{"issue":"4","key":"3_CR9","doi-asserted-by":"crossref","first-page":"726","DOI":"10.3758\/BF03211565","volume":"27","author":"Ruth M. J. Byrne","year":"1999","unstructured":"R.M.J. Byrne and A. Tasso. Deductive reasoning with factual, possible and counterfactual conditionals. Memory and Cognition, pages 726\u2013740, 1999.","journal-title":"Memory & Cognition"},{"key":"3_CR10","volume-title":"The Ladbroke Grove Rail Inquiry Part","author":"Cullen","year":"2001","unstructured":"Cullen. The Ladbroke Grove Rail Inquiry Part 1 Re-port. HSE\/Stationary Office, London, United Kingdom, 2001. http:\/\/www.hse.gov.uk\/railway\/paddrail\/lgril.pdf"},{"key":"3_CR11","first-page":"139","volume-title":"International Symposium on Transportation Recorders","author":"M Durkin","year":"1999","unstructured":"M. Durkin. Digital audio recorders: Life savers, educators and vindicators. In International Symposium on Transportation Recorders, pages 139\u2013144. National Transportation Safety Board, Washington DC, USA, 1999."},{"key":"3_CR12","first-page":"1997","volume-title":"Office of Safety, Federal Railroad Administration","author":"Federal Railroad Administration. Fra guide for preparing accidents\/incidents reports. Technical Report DOT\/FRA\/RRS-22 Effective","year":"1997","unstructured":"Federal Railroad Administration. Fra guide for preparing accidents\/incidents reports. Technical Report DOT\/FRA\/RRS-22 Effective: January 1997, Office of Safety, Federal Railroad Administration, Washington DC, United States of America, 1997. http:\/\/safetydata.fra.dot.gov\/Objects\/guide97.pdf ."},{"key":"3_CR13","doi-asserted-by":"publisher","DOI":"10.1002\/9780470172230","volume-title":"Modern Accident Investigation and Analysis","author":"TS Ferry","year":"1988","unstructured":"T. S. Ferry. Modern Accident Investigation and Analysis. John Wiley and Sons Inc., London, 1988."},{"key":"3_CR14","unstructured":"Food and Drug Administration. Clinical impact of adverse event reporting. Technical report, Department of Health and Human Services, Public Health Service, US Food and Drug Administration, Rockville, Maryland, USA, 1996. http:\/\/www.fda.gov\/medwatch\/articles\/medcont\/synopses.htm ."},{"key":"3_CR15","unstructured":"Food and Drug Administration: A. Morrison. Avoiding sticksfrom sharp containers. User Facility Reporting Bulletins, 1998. http:\/\/www.fda.gov\/cdrh\/fusenews\/fuse25.pdf ."},{"key":"3_CR16","unstructured":"Food and Drug Administration: D. Dwyer. Sending the wrong signals. User Facility Reporting Bulletins, 2000. http:\/\/www.fda.gov\/cdrh\/fusenews\/ufb33.html ."},{"key":"3_CR17","unstructured":"Food and Drug Administration: M. Weick-Brady. Those codes! User Facility Reporting Bulletins, 1996. http:\/\/www.fda.gov\/cdrh\/issuel8.pd\u00a3."},{"key":"3_CR18","volume-title":"A handbook of rhetorical devices. Technical report, SCC","author":"R Harris","year":"1997","unstructured":"R. Harris. A handbook of rhetorical devices. Technical report, SCC, Cosa Mesa, California, 1997. http:\/\/www.sccu.edu\/faculty\/R_Harris\/rhetoric.htm ."},{"key":"3_CR19","doi-asserted-by":"publisher","DOI":"10.1017\/CBO9780511663710","volume-title":"Causal Asymmetries. Cambridge University Press","author":"DM Hausman","year":"1998","unstructured":"D.M. Hausman. Causal Asymmetries. Cambridge University Press, Cambridge, U.K., 1998."},{"key":"3_CR20","unstructured":"Health and Safety Commission. The Southall Rail Accident Inquiry Report: HSC action plan to implement recommendations. Technical report, Health and Safety Executive, London, United Kingdom, 2000. http:\/\/www.hse.gov.uk\/hsc\/south01.htm ."},{"key":"3_CR21","unstructured":"Her Majesty\u2019s Railway Inspectorate. Report on the inspection carried out by hm railway inspectorate during 1998\/99 of the management systems in the railway industry covering signals passed at danger. Technical report, Health and Safety Executive, London, United Kingdom, 1999. http:\/\/www.hse.gov.uk\/railway\/spad01.htm ."},{"key":"3_CR22","unstructured":"Her Majesty\u2019s Railway Inspectorate. Assessment criteria for railway safety cases. Technical report, Health and Safety Executive, London, United Kingdom, 2000. http:\/\/www.hse.gov.uk\/railway\/criteria\/index.htm ."},{"key":"3_CR23","volume-title":"Internal inquiry report: Events lead-ing up to the ladbroke grove rail accident on 5 october 1999","author":"Her Majesty\u2019s Railway Inspectorate","year":"2000","unstructured":"Her Majesty\u2019s Railway Inspectorate. Internal inquiry report: Events lead-ing up to the ladbroke grove rail accident on 5 october 1999. Techni-cal report, Health and Safety Executive, London, United Kingdom, 2000. http:\/\/www.hse.gov.uk\/railway\/paddrail\/inq-03.htm ."},{"key":"3_CR24","first-page":"391","volume-title":"Human Factors in Air Traffic Control","author":"VD Hopkin","year":"1998","unstructured":"V.D. Hopkin. The impact of automation. In M.W. Smolensky and E.S. Stein, editors, Human Factors in Air Traffic Control, pages 391\u2013419. Academic Press, London, United Kingdom, 1998."},{"key":"3_CR25","volume-title":"The cognitive complexity of pilot-mode interaction","author":"D Javaux","year":"1998","unstructured":"D. Javaux. The cognitive complexity of pilot-mode interaction. In HCI-Aero\u201998: Conference on Human-machine Interaction in Aeronautics, Montreal, Canada, 1998."},{"issue":"3","key":"3_CR26","doi-asserted-by":"publisher","first-page":"305","DOI":"10.1136\/jamia.1998.0050305","volume":"5","author":"AK Jha","year":"1998","unstructured":"A.K. Jha, G.J. Kuperman, J.M. Teich, L. Leape, B. Shea, E. Rittenberg, E. Burdick, D.L. Seger, M. Vander Vliet, and D.W. Bates. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. Journal of the American Medical Informatics Association, 5(3):305\u2013314, 1998.","journal-title":"Journal of the American Medical Informatics Association"},{"key":"3_CR27","first-page":"17","volume-title":"Don\u2019t keep reminding me","author":"CW Johnson","year":"2000","unstructured":"C.W. Johnson. Don\u2019t keep reminding me: The limitations of incident reporting. In K. Abbott, J.-J. Speyer, and G.Boy, editors, HCI Aero 2000: International Conference on Human-Computer Interfaces in Aeronautics, pages 17\u201322, Toulouse, France, 2000. Cepadues-Editions."},{"key":"3_CR28","doi-asserted-by":"crossref","unstructured":"C.W. Johnson. Software support for incident reporting systems in safety-critical applications. In F. Koornneef and M. van der Meulen, editors, Computer Safety, Reliability and Security: Proceedings of 19th International Conference SAFECOMP 2000, LNCS 1943, pages 96\u2013106. Springer Verlag, 2000.","DOI":"10.1007\/3-540-40891-6_9"},{"key":"3_CR29","volume-title":"A Handbook of Incident Reporting: A Guide to the Detection","author":"CW Johnson","year":"2002","unstructured":"C.W. Johnson. A Handbook of Incident Reporting: A Guide to the Detection, Mitigation and Avoidance of Failure in Safety-Critical Systems. Springer Verlag, UK, 2002 (in press)."},{"key":"3_CR30","volume-title":"European Organisation for Air Traffic Control (EUROCONTROL)","author":"C.W. Johnson, G. Le Galo, and M. Blaine. Guidelines for the development of occurrence reporting systems in european air traffic control. Technical report","year":"2000","unstructured":"C.W. Johnson, G. Le Galo, and M. Blaine. Guidelines for the development of occurrence reporting systems in european air traffic control. Technical report, European Organisation for Air Traffic Control (EUROCONTROL), Brussels, Belgium, 2000."},{"issue":"6","key":"3_CR31","doi-asserted-by":"publisher","first-page":"1265","DOI":"10.1080\/00140139508925187","volume":"38","author":"CW Johnson","year":"1995","unstructured":"C.W. Johnson, J.C. McCarthy, and P.C. Wright. Using a formal language to support natural language in accident reports. Ergonomics, 38(6):1265\u20131283, 1995.","journal-title":"Ergonomics"},{"key":"3_CR32","volume-title":"Command Paper: CM","author":"I Kennedy","year":"2001","unstructured":"I. Kennedy. Learning from Bristol: the report of the public inquiry into children\u2019s heart surgery at the Bristol Royal Infirmary 1984\u20131995. Command Paper: CM 5207. Her Majesty\u2019s Stationary Office, London, United Kingdom, 2001. http:\/\/www.bristol-inquiry.org.uk ."},{"key":"3_CR33","doi-asserted-by":"crossref","DOI":"10.1201\/b17206","volume-title":"Prevention of Accidents Through Experience Feedback. Taylor and Francis","author":"U Kjellen","year":"2000","unstructured":"U. Kjellen. Prevention of Accidents Through Experience Feedback. Taylor and Francis, London, United Kingdom, 2000."},{"key":"3_CR34","volume-title":"Building a Safer Health System. Institute of Medicine, National Academy Press, Washington DC","author":"L Kohn","year":"1999","unstructured":"L. Kohn, J. Corrigan, and M. Donaldson. To Err Is Human: Building a Safer Health System. Institute of Medicine, National Academy Press, Washington DC, United States of America, 1999. Committee on Quality of Health Care in America."},{"key":"3_CR35","first-page":"344","volume-title":"SAFECOMP 2000, Lecture Notes in Computing Science No. 1943","author":"PB Ladkin","year":"2000","unstructured":"P.B. Ladkin. Causal reasoning about accidents. In F. Koorneef and M. van der Meulen, editors, SAFECOMP 2000, Lecture Notes in Computing Science No. 1943, pages 344\u2013355. Springer Verlag, Berlin, Germany, 2000."},{"key":"3_CR36","volume-title":"Safeware: System Safety and Computers. Addison Wesley, Reading","author":"NG Leveson","year":"1995","unstructured":"N.G. Leveson. Safeware: System Safety and Computers. Addison Wesley, Reading, MA, United States of America, 1995."},{"key":"3_CR37","volume-title":"Counterfactuals. Oxford University Press","author":"D Lewis","year":"1973","unstructured":"D. Lewis. Counterfactuals. Oxford University Press, Oxford, UK, 1973."},{"key":"3_CR38","volume-title":"Causation and Conditions","author":"JL Mackie","year":"1975","unstructured":"J.L. Mackie. Causation and conditions. In E. Sosa, editor, Causation and Conditions. Oxford University Press, Oxford, 1975."},{"key":"3_CR39","volume-title":"Technical Report NASA PG 8621","author":"NASA","year":"2001","unstructured":"NASA. NASA procedures and guidelines for mishap reporting, investigating and record-keeping. Technical Report NASA PG 8621.1, Safety and Risk Management Division, NASA Headquarters, Washington DC, USA, 2001. http:\/\/www.hq.nasa.gov\/office\/codeq\/doctree\/safeheal.htm ."},{"key":"3_CR40","volume-title":"CA March 29","author":"NASA (D. Goldin)","year":"2000","unstructured":"NASA (D. Goldin). When The Best Must Do Even Better\u201c Remarks by NASA Administrator Daniel S. Goldin At the Jet Propulsion Laboratory Pasadena, CA March 29, 2000. Technical report, NASA Headquarters, Washington DC, USA, 2000. http:\/\/www.hq.nasa.gov\/office\/pao\/ftp\/Goldin\/00text\/jpl_remarks.txt ."},{"key":"3_CR41","first-page":"1999","volume-title":"Technical Report NTSB\/RAR-99\/03, NTSB","author":"National Transportation Safety Board. Railroad Accident Report Col-lision of Northern Indiana Commuter Transportation District Train 102 with a Tractor-Trailer Portage, Indiana June 18","year":"1998","unstructured":"National Transportation Safety Board. Railroad Accident Report Col-lision of Northern Indiana Commuter Transportation District Train 102 with a Tractor-Trailer Portage, Indiana June 18, 1998. Technical Report NTSB\/RAR-99\/03, NTSB, Washington, DC United States of America, 1999. http:\/\/www.ntsb.gov\/Publictn\/1999\/RAR9903.pdf ."},{"key":"3_CR42","volume-title":"Technical Report Safety Report NTSB\/SR-99\/01 May 1999 PB99917002 Notation","author":"National Transportation Safety Board","year":"1999","unstructured":"National Transportation Safety Board. Safety Study: Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Operator Fatigue. Technical Report Safety Report NTSB\/SR-99\/01 May 1999 PB99917002 Notation 7155, NTSB, Washington, DC United States of America, 1999. http:\/\/www.ntsb.gov\/Publictn\/1999\/SR9901.pdf ."},{"key":"3_CR43","volume-title":"An organisation with a memory. Technical report, National Health Service","author":"NHS Expert Group on Learning from Adverse Events in the NHS","year":"2000","unstructured":"NHS Expert Group on Learning from Adverse Events in the NHS. An organisation with a memory. Technical report, National Health Service, London, United Kingdom, 2000. http:\/\/www.doh.gov.uk\/orgmemreport\/index.htm ."},{"key":"3_CR44","volume-title":"Normal Accidents: Living with High-Risk Technologies. Princeton University Press, Princeton","author":"C Perrow","year":"1999","unstructured":"C. Perrow. Normal Accidents: Living with High-Risk Technologies. Princeton University Press, Princeton, NJ, United States of America, 1999."},{"key":"3_CR45","unstructured":"J. Reason. Managing the Risks of Organizational Accidents. Ashgate Publishing, Aldershot, UK, 1997."},{"key":"3_CR46","doi-asserted-by":"crossref","DOI":"10.1515\/9780691213064","volume-title":"The Limits of Safety: Organisations, Accidents and Nuclear Weapons. Princeton University Press, Princeton","author":"SD Sagan","year":"1993","unstructured":"S.D. Sagan. The Limits of Safety: Organisations, Accidents and Nuclear Weapons. Princeton University Press, Princeton, NJ, United States of America, 1993."},{"key":"3_CR47","volume-title":"Special report on ladbroke grove: \u2018pass the signal - pass the blame\u2019. The Locomotive Journal","author":"A Scrivener","year":"2000","unstructured":"A. Scrivener. Special report on ladbroke grove: \u2018pass the signal - pass the blame\u2019. The Locomotive Journal, pages 8\u20139, June 2000. Quoted extracts from evidence to Lord Cullen\u2019s inquiry into the Ladbroke Grove accident, http:\/\/www.asleforg.uk\/dox\/loco_june_00.pdf ."},{"key":"3_CR48","volume-title":"Assessment of Investigations into SignalsPassed at Danger","author":"G Sitwell","year":"2001","unstructured":"G. Sitwell and S. Purcel. Assessment of Investigations into SignalsPassed at Danger (SPADs). Technical Report BL2077 004 TR06, WSAtkins Rail Limited, under contract from the HSE, London, UK, 2001. http:\/\/www.hse.gov.uk\/railway\/spad\/spadrepl.pdf ."},{"key":"3_CR49","first-page":"21","volume-title":"People in Control: An international conference on human interfaces in control rooms, cockpits and command centres, pages 258-262, Savoy Place, London, United Kingdom, 1999. The Institute of Electrical Engineers","author":"P Snowdon","year":"1999","unstructured":"P. Snowdon and C.W. Johnson. Results of a preliminary survey into the usability of accident and incident reports. In J. Noyes and M. Bransby, editors, People in Control: An international conference on human interfaces in control rooms, cockpits and command centres, pages 258\u2013262, Savoy Place, London, United Kingdom, 1999. The Institute of Electrical Engineers. Bath, UK, 21\u201323 June 1999."},{"key":"3_CR50","unstructured":"Systems Safety Society: New Mexico Chapter. System safety analysis handbook. Technical report, Systems Safety Society, Unionvile, VA, USA, 1997."},{"key":"3_CR51","volume-title":"Butterworth-Heinemann","author":"TW Schaaf van der","year":"1991","unstructured":"T.W. van der Schaaf, D.A. Lucas, and A.R. Hale. Near Miss Reporting as a Safety Tool. Butterworth-Heinemann, Oxford, United Kingdom, 1991."},{"key":"3_CR52","volume-title":"Organisational Failure: An Exploratory Study in the Steel Industry and the Medical Domain. PhD thesis, Institute for Business Engineering and Technology Application","author":"W Vuuren van","year":"2000","unstructured":"W. van Vuuren. Organisational Failure: An Exploratory Study in the Steel Industry and the Medical Domain. PhD thesis, Institute for Business Engineering and Technology Application, Technical University of Eindhoven, Eindhoven, The Netherlands, 2000."},{"key":"3_CR53","volume-title":"The Challenger Launch Decision. Chicago University Press","author":"D Vaughan","year":"1996","unstructured":"D. Vaughan. The Challenger Launch Decision. Chicago University Press, Chicago, United States of America, 1996."},{"issue":"7138","key":"3_CR54","doi-asserted-by":"crossref","first-page":"1154","DOI":"10.1136\/bmj.316.7138.1154","volume":"316","author":"C. Vincent","year":"1998","unstructured":"C. Vincent, S. Taylor-Adams, and N. Stanhope. Framework for analysing risk and safety in clinical medicine. British Medical Journal, pages 1154\u20131157, 1998.","journal-title":"BMJ"}],"container-title":["Components of System Safety"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1007\/978-1-4471-0173-4_3.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,11,18]],"date-time":"2020-11-18T00:37:31Z","timestamp":1605659851000},"score":1,"resource":{"primary":{"URL":"http:\/\/link.springer.com\/10.1007\/978-1-4471-0173-4_3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2002]]},"ISBN":["9781852335618","9781447101734"],"references-count":54,"URL":"https:\/\/doi.org\/10.1007\/978-1-4471-0173-4_3","relation":{},"subject":[],"published":{"date-parts":[[2002]]}}}