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Richard Cook

  • Senior Researcher, Integrated Systems Engineering
  • Physician, FGP-Anesthesiology
  • Professor - Practice, Anesthesiology
  • 210 Baker Systems
    1971 Neil Avenue
    Columbus, OH 43210

About

Physician, researcher, and educator Richard Cook is presently a research scientist in the Department of Integrated Systems Engineering at the Ohio State University in Columbus, Ohio, and emeritus professor of healthcare systems safety at Sweden’s KTH. Richard is an internationally recognized expert on safety, accidents, and human performance at the sharp end of complex, adaptive systems. His most often cited publication is “Going Solid: A Model of System Dynamics and Consequences for Patient Safety.”

Honors

  • January, 2001

    McGovern Medal for Medical Writing.

  • January, 1999

    Peter Kiewit Memorial Award Lectureship.

Books

2010

  • Woods DD, Dekker S, Cook R, Johannesen L, Sarter N. 2010. "Behind human error." Ashgate.

Edited Books

1994

  • Woods DD, Johannesen L, Cook RI, Sarter N.. 1994. "Behind Human Error: Cognitive Systems, Computers and Hindsight." Wright-Patterson Air Force Base.

Chapters

2013

  • 2013. "Resilience, the second story, and progress on patient safety." In Resilient Health Care, edited by Hollnagel E, Braithwaite J, Wears R.,
  • 2013. "Systemperspektivet pÃ¥ säkerhet. [A systems view of safety].." In Patiensakerhet: Teori ock praktik. [Safety: theory and practice].,
  • 2013. "Utvärdering av tkniken pÃ¥verkan pÃ¥ patientsäkerheen. [Assessing the Impact of Technology on Patient Safety.]." In Patiensakerhet: Teori ock praktik. [Safety: theory and practice].,

2010

  • 2010. "How Complex Systems Fail." In Web Operations: Keeping the Data On Time., edited by J Allspaw & J Robbins,

2008

  • 2008. "What went wrong at the Beatson Oncology Centre." In Resilience Engineering Perspective, Volume 1: Remaining Sensitive to the Possibility of Failure, edited by E Hollnagel, CP Nemeth, S Dekker,

2007

  • 2007. "Behind human error: taming complexity to improve patient safety." In Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, edited by P Carayon,
  • 2007. "RePresenting reality: The human factors of healthcare information.." In The Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety., edited by P Carayon,

2006

  • 2006. "Taking things in stride: Cognitive features of two resilient performances.." In Resilience engineering: concepts and precepts,
  • 2006. "Hobson’s choices: Matching and mismatching in transplantation work processes.." In A death retold: Jesica Santillan, the bungled transplant, and paradoxes of medical citizenship,
  • 2006. "Being Bumpable: Consequences of Resource Saturation and Near-Saturation for Cognitive Demands on ICU Patients.." In Joint cognitive systems: patterns in cognitive systems engineering,

2005

  • 2005. "Cognitive artifacts' implications for health care information technology: Revealing how practitioners create and share their understanding of daily work.." In Advances in Patient Safety: From Research to Implementation. Vol. 2., edited by K Henricksen, JB Battles, E Marks & DI Lewin,
  • 2005. "Making information technology a team player in safety: The case of infusion devices." In Advances in Patient Safety: from research to implementation. Vol. 1., edited by K Henricksen, JB Battles, E Marks & DI Lewin,
  • 2005. "Thinking about accidents and systems." In Medication Safety: A Guide for Health Care Facilities, edited by HR Manasse & KK Thompson,

2004

  • 2004. "Operating at the sharp end: The human factors of complex technical work and its implication for patient safety." In Surgical Patient Safety: Essential Information for Surgeons in Today's Environment, edited by BM Manuel & PF Nora,
  • 2004. "Mistaking error." In The Patient Safety Handbook,

2001

  • 2001. "From counting failures to anticipating risks: possible futures for patient safety.." In Lessons in Patient Safety, edited by L Zipperer, S Cushman,

1998

  • 1998. "A Tale of Two Stories: Contrasting Views of Patient Safety.." In (Report from a Workshop on Assembling the Scientific Basis for Progress on Patient Safety,
  • 1998. "Perspectives on human error: hindsight biases and local rationality." In Handbook of Applied Cognition, edited by RS Durso et al.,

Unknown

  • "Gaps in resilience." In Human Error in Medicine, 2nd ed.,

Journal Articles

2014

  • Fairbanks,Rollin,J; Wears,Robert,L; Woods,David,D; Hollnagel,Erik; Plsek,Paul; Cook,Richard,I, 2014, "Resilience and resilience engineering in health care.." Joint Commission journal on quality and patient safety / Joint Commission Resources 40, no. 8, 376-383 - 376-383.

2013

  • Cook RI., 2013, "Seeing is believing (Editorial)." Annals of Surgery 237, no. 4, 472-3 - 472-3.

2011

  • Nemeth,Christopher; Wears,Robert,L; Patel,Sachin; Rosen,Greg; Cook,Richard, 2011, "Resilience is not control: healthcare, crisis management, and ICT." COGNITION TECHNOLOGY & WORK 13, no. 3, 189-202 - 189-202.

2007

  • Albolino S, Cook R, & O'Connor M., 2007, "Sensemaking, safety, and cooperative work in the intensive care unit.." Cognition, Technology & Work 9, no. 3, 131-7 - 131-7.

2006

  • Cook RI., 2006, "To Err Is Not Always Human." Medicine on the Midway 60, no. 1, 40-1 - 40-1.
  • Nemeth C, O’Connor M, Klock PA, Cook RI., 2006, "Discovering Healthcare cognition: The use of cognitive artifacts to reveal cognitive work." ORGANIZATION STUDIES 27, no. 7, 1011-1035 - 1011-1035.

2005

  • Bates D, Clark NG, Cook RI, Garber JR, Hellman R, Jellinger PS, Kukora JS, Petal SM, Reason JT, Tourtelot JB., 2005, "Writing committee on patient safety and medical system errors in diabetes and endocrinology.." Endocrine Practice 11, no. 3, 197-202 - 197-202.
  • Nemeth,C; Nunnally,M; O'Connor,M; Klock,P,A; Cook,R, 2005, "Getting to the point: developing IT for the sharp end of healthcare." Journal of Biomedical Informatics 38, no. 1, 18-25 - 18-25.
  • Cook,R; Rasmussen,J, 2005, "Going solid: A model of system dynamics and consequences for patient safety.." Quality & Safety in Health Care 14, no. 2, 130-134 - 130-134.
  • Nemeth C, Cook R., 2005, "Hiding in plain sight: What Koppel et al. tell us about healthcare IT.." Journal of Biomedical Informatics 38, no. 4, 262-3 - 262-3.
  • Perry SJ, Wears RL, Cook RI., 2005, "The role of automation in complex system failures." Journal of Patient Safety 1, no. 1, 56-61 - 56-61.
  • Albolino S, Cook R., 2005, "Medici in terapia intensive: sensemaking, sicurezza e lavoro quotidiano." Studi Organizzativi 2, 7-28 - 7-28.
  • Cook RI., 2005, "Lessons from the war on cancer: The need for basic research on safety.." Journal of Patient Safety 1, no. 1, 7-8 - 7-8.

2004

  • O’Connor MF, Nunnally M, Cook RI, 2004, "Deriving the most benefit from bar coded medication administration. Letter to the Editor (Editorial)." IEEE Transactions on Systems, Man, and Cybernetics Par A: Systems and Humans.Anesthesia Patient Safety Foundation Newsletter 19, no. 3, 24 - 24.
  • Patterson,E,S; Cook,R,I; Woods,D,D; Render,M,L, 2004, "Examining the complexity behind a medication error: Generic patterns in communication." IEEE TRANSACTIONS ON SYSTEMS MAN AND CYBERNETICS PART A-SYSTEMS AND HUMANS 34, no. 6, 749-756 - 749-756.
  • Nemeth C, Cook R, O'Connor M, Wears R, & Perry S., 2004, "Crafting information technology solutions, not experiments for the ED.." Academic Emergency Medicine 11, no. 11, 1114-7 - 1114-7.
  • Weber SG, Bottei E, Cook R, O’Connor M., 2004, "SARS, emerging infections, and bioterrorism preparedness." LANCET INFECTIOUS DISEASES 4, no. 8, 483-484 - 483-484.
  • Rogers ML, Cook RI, Bower R, Molloy M, Render ML., 2004, "Barriers to implementing wrong site surgery guidelines: A cognitive work analysis." IEEE TRANSACTIONS ON SYSTEMS MAN AND CYBERNETICS PART A-SYSTEMS AND HUMANS 34, no. 6, 757-763 - 757-763.

2002

  • Woods DD, Cook RI., 2002, "Nine steps to move forward from error." Cognition, Technology & Work 4, 137-44 - 137-44.
  • Cook RI, 2002, "Safety technology: solutions or experiments? (Editorial)." Nursing Economics 20, 80-83 - 80-83.

2000

  • Cook RI, Render M, Woods DD., 2000, "Gaps in the continuity of care and progress on patient safety." BRITISH MEDICAL JOURNAL 320, 791-4 - 791-4.
  • Cook RI, 2000, "Combating medical errors (Editorial)." Lancet 356, no. 9224, 167 - 167.

1998

  • Aronson S, Cook R, 1998, "Vigilance-A main component of clinical quality (Editorial)." Anesthesiology 88, no. 4, 1122-3 - 1122-3.

1992

  • Cook RI, Woods DD., 1992, "Blood pressure monitoring (Editorial)." J Clinical Monitoring 8, no. 1, 95 - 95.
  • Cook RI, Woods DD, Howie MB, Harrow JC, Gaba DM., 1992, "Case 2-1992. Unintentional delivery of vasoactive drugs with an electromechanical infusion device.." Journal of cardiothoracic and vascular anesthesia 6, no. 2, 238-244 - 238-244.

1991

  • Woods DD, Cook RI, 1991, "Effects of outcome on physicians' judgment of appropriateness of care. (Editorial)." JAMA 72, no. 3, 578 - 578.

1988

  • Cook RI., 1988, "Scenarios for bedside medical data communication.." SIGBIO 10, 8-14 - 8-14.

1983

  • Cook RI, 1983, "Letters of recommendation. (Editorial)." N Engl J Med 309, 736 - 736.

Unknown

  • Wears RL, Cook RI, "Getting Better at being worse (Editorial)." Ann Emerg Med

Presentations

  • "Operating at the Sharp End." 1997, Presented at Pediatric Grand Rounds. University of Chicago,
  • "Patient Safety and Accidents." 2007, Presented at HIMSS 2007 Conference and Exhibition,
  • "Operating at the Sharp End: Resilience, safety and why we don’t seem to be getting anywhere." 2007, Presented at 2007 Spring Meeting of The Michigan Association of Nurse Anesthetists,
  • "Green Gas Lecture." 2007, Presented at Anesthesia & Critical Care Special Topics in Surgery/Medicine,
  • "Con: Clinical Simulation is Not Required for Credentialing of All New Privileges." 2007, Presented at Point-Counterpoint, American Society of Anesthesiologists Annual Meeting,
  • "Shifting the burden to users: Clever tricks of the design masters." 1994, Presented at Food and Drug Administration Staff College,
  • "Useful Insights in Error Reduction in Health Care." 1999, Presented at VHA Physician Leaders Forum,
  • "Things Fall Apart:How Complex Systems Fail.." 1999, Presented at Challenges for Clinicians in the New Millennium,
  • "Human performance in anesthesia: a cognitive systems manifesto." 1993, Presented at Danish Society of Anesthesiologists Annual Meeting,
  • "Things Fall Apart: Complexity, Failure and Safety in Healthcare in the Year 2000." 1999, Presented at VHA Inc., Third Annual Risk Management and Captive Development Symposium,
  • "Things Fall Apart: Accidents in Healthcare and Other Domains." 1999, Presented at Twentieth Annual Peter Kiewit Memorial Lectureship in Medicine. Annenberg Center for Health Sciences,
  • "What do you want to be when you grow up?." 2002, Presented at CSEC Site Meeting,
  • "The Role of the Infection Control Professional in Patient Safety & Improving Patient Care." 2002, Presented at Ontario Hospital Association,
  • "Preventing Medical Errors: Patient Safety in a New Age of Accountability.." 2002, Presented at Southern California Association for Healthcare Risk Management,
  • "Operating at the Sharp End: Doing What Matters to Improve Patient Safety." 2002, Presented at WSMA Leadership Conference,
  • "How Complex Systems Fail." 2002, Presented at Pierce County Medical Society 2002 Annual Meeting,
  • "Medical Accidents and Their Investigation: Learning, Forgetting and Remembering." 2010, Presented at University of Chicago, Department of Anesthesia and Critical Care,
  • "EMR, EHR, and other CHIT: Not what we ordered!." 2010, Presented at Annual MIDAS+ User Symposium,
  • "Early Second Phase Medical Relief in Haiti." 2010, Presented at University of Chicago Medical Center,
  • "Be careful what you wish for! The “Meaningful Useâ€� of Clinical Healthcare Information Technology." 2010, Presented at University of Chicago, Department of Anesthesia and Critical Care,
  • "Who's Learning Now?." 2011, Presented at Finnish Patient Safety Conference,
  • "Patient Safety in 2011." 2011, Presented at University of Pennsylvania Department of Anesthesiology,
  • "Medical Relief Efforts in Haiti." 2011, Presented at Rotary Club of Oak Park,
  • "Handoffs of Care." 2011, Presented at Scandinavian Society of Anaesthesia and Intensive Care Annual Meeting,
  • "Healthcare Information Technology: The American Experience." 2012, Presented at Vitalis Conference,
  • "Going Solid." 2012, Presented at American Dental Anesthesia Society Annual Meeting,
  • "Going Beyond Accident Prevention: Application of Resilience in Complex." 2012, Presented at High-Risk Settings Workshop,
  • "50.000 incidents: how many is enough?." 2012, Presented at LÖF Chief Medical Officer day,
  • "50.000 incidents: how many is enough?." 2012, Presented at Patient safety seminar,
  • "Complex System Failures." 2001, Presented at Medical/Legal Risk Management Education Module, University of Chicago Hospitals,
  • "Cognitive consequences of 'clumsy' automation on high workload, high consequence human performance." 1990, Presented at Fourth Annual Workshop on Space Operations,
  • "Adapting to 'clumsy' automation: what system and task tailoring by cardiac anesthesiologists reveals about cognitive tasks." 1990, Presented at Computer Support and Cognitive Simulation Meeting,
  • "Replacing Hindsight with Insight: Understanding Adverse Events." 2007, Presented at Society for Academic Emergency Medicine Annual Meeting,
  • "How to do that voodoo that you do so well: human factors engineering of medical devices." 1991, Presented at Human Factors Society 36th Annual Meeting,
  • "Dynamic problem solving in anesthesiology: expertise and error; Same scene, different views: research on anesthesiologist performance." 1991, Presented at Anesthesia Patient Safety Foundation, Conference on Human Error in Anesthesia,
  • "Medical disasters and latent system errors: blame, guilt, and causality." 1992, Presented at American Association for Advancement of Science Annual Meeting,
  • "A cognitive science approach to analyzing anesthesia cases." 1992, Presented at International Anesthesia Research Society Annual Meeting,
  • "Two Years Before the Mast: Learning to Learn About Patient Safety." 1998, Presented at Enhancing Patient Safety and Reducing Errors in Healthcare (Annenberg II),
  • "New Arctic Aircrash Accident Investigation Simulation." 1998, Presented at MMI Companies,
  • "How Complex Systems Fail." 1998, Presented at American Society of Health- Systems Pharmacists Leadership Conference,
  • "Functions a’la mode: Sources of Operating Failures in Microprocessor Based Medical Devices." 1998, Presented at FDA conference on “Minimizing Medical Product Errors: A Systems Approachâ€�,
  • "Celebrated Cases of Medical Accidents: Hindsight Bias." 1998, Presented at 42nd Annual Meeting of the Human Factors and Ergonomics Society,
  • "Being Bumpable." 1998, Presented at NetWork Workshop on Risk and Safety in Medicine,
  • "A New Approach for Accident Analysis." 1998, Presented at National Institutes of Health, Frontline Healthcare Worker’s Conference,
  • "A Case of Being Bumpable." 1998, Presented at Fourth Naturalistic Decision Making Conference,
  • "Operating at the Sharp End: Explaining Technical Work in Healthcare." 2001, Presented at McGovern Medal Lecture, American Medical Writers Association Annual Meeting,
  • "Operating at the Sharp End." 2001, Presented at Northwest Center for Patient Safety Education and Research Conference Bell Harbor Conference Center,
  • "Making Safety and Gaps in the Continuity of Care." 2001, Presented at National Pediatric Emergency Fellows’ Conference,
  • "Complex systems Failures and Gaps in the Continuity of Care." 2001, Presented at Annual Meeting of American College of Surgeons,
  • "Communicating in the Midst of Complexity." 2001, Presented at 3rd Annenberg Conference “Let's Talk: Communicating Risk and Safety in Health Careâ€�,
  • "Choosing Paths to Safety: Understanding the Natures of Hazard and Opportunity." 2001, Presented at Society for Technology in Anesthesia,
  • "Safety in Anesthesia." 2003, Presented at Illinois Society of Anesthesiologists Fall Meeting,
  • "Patient Safety and Infusion Device; Technical Work Coordination in Healthcare." 2003, Presented at Challenges for Clinicians in the New Millennium, Inaugural European Conference,
  • "Pumps / Infusion Devices." 2007, Presented at Anesthesia & Critical Care Special Topics in Surgery/Medicine,
  • "Why Accidents Happen; Sentinal Event/Recognition and Analysis." 2007, Presented at California Dreamin’ 2007 Annual Meeting of the American Dental Society of Anesthesiology,
  • "Persistence of Accidents in Healthcare Despite Efforts to Improve Safety." 2009, Presented at MIEC Defense Counsel Seminar,
  • "Infusion devices and their role in medical accidents." 2009, Presented at Human Factors in High-risk Health Care Symposium,
  • "Understanding adverse events." 2012, Presented at Karolinska Solna,
  • "The Forgetting Curve." 2012, Presented at Red Cross Nurses College,
  • "The Dynamics of Safety." 2012, Presented at Healthcare Management Society,
  • "The Dynamics of Safety." 2012, Presented at St. Eriks Eye hospital staff meeting,
  • "The Dynamics of Safety." 2012, Presented at Hospital anesthesiologists seminar,
  • "The Dynamics of Safety." 2012, Presented at Patient safety seminar,
  • "The Big Challenge: Making CHIT a Team Player." 2012, Presented at 7th Forum on Risk Management in Healthcare,
  • "Strategy and tactics for moving forward: what to do until the doctor comes." 2012, Presented at Patientsäkerhet Teori och praktik Seminarium 6,
  • "Some thoughts on the nature of resilience." 2012, Presented at Resilience Healthcare Network (RCHN) Meeting,
  • "Planning research on patient safety and resilience." 2012, Presented at Nordic Patient Safety Network Conference,
  • "Patient Safety in 2011." 2012, Presented at installation of Erik Hollnagel as Professor, University of South Demark,
  • "Operating at the Sharp End and Relief Operations in Haiti." 2012, Presented at Department of Anaesthesia, Basel University Hospital,
  • "Operating at the Sharp End." 2012, Presented at KTH patient safety course,
  • "Naturally occurring experiments." 2012, Presented at Swedish Patient Safety Network,
  • "Is it Safe? Managing the tension between production and hazard." 2012, Presented at Swedish Anesthesia and Intensive Care Society,
  • "Introducing patient safety." 2012, Presented at Dagens Medicin Conference,
  • "How Complex Systems Don’t Fail." 2012, Presented at Velocity Conference,
  • "Operating at the Sharp End." 1997, Presented at Medical Grand Rounds. University of Chicago,
  • "Using Adverse Event Data to Improve Quality of Care." 1997, Presented at Agency for Health Care Policy and Research (AHCPR),
  • "Things Fall Apart. Human Error in Medicine." 1999, Presented at Loyola University Medical Center, Stritch School of Medicine,
  • "Safety, Technology, and Medical Accidents: Lessons for New System Design." 1999, Presented at (IFCC – WorldLab),
  • "Planning for Work on the Role of Pharmacists in Pharmaceutical Safety." 1999, Presented at Discussion of Medication Misadventures,
  • "Operating at the Sharp End." 1999, Presented at Society for Airway Management Annual Scientific Meeting,
  • "Operating at the Sharp End." 1999, Presented at Professional Liability Committee,
  • "Learning to Learn about Patient Safety." 1999, Presented at Patient Safety Forum. Descano Gardens,
  • "Inferences, Investigations and Insight: Presentation for CODA and FDA on Incident Reporting and Analysis.." 1999, Presented at Seminar on Design of Medical Device Surveillance Network, Center for Devices and Radiological Health,
  • "How Complex Systems Fail; Characteristics of Patient Safety." 1999, Presented at American College of Surgeons Postgraduate Course,
  • "Doing the right thing – technologically." 1999, Presented at Daughters of Charity National Health System Annual Meeting,
  • "Deus ex machina: Technology, Accidents, and Human Performance." 1999, Presented at Academy of Managed Care Pharmacy Annual Educational Conference,
  • "Complex Systems Failures." 1999, Presented at CAN HealthPro / University of Chicago Hospitals Academy Conference,
  • "Characteristics of Patient Safety in an Era of Challenge and Risk." 1999, Presented at Surgery and Anesthesia Services: Enhancing Quality and Managing Risk,
  • "Adoption of New Technology and Patient Safety." 1999, Presented at 12th ATACCS meeting of the International Trauma Anesthesia and Critical Care Society,
  • "Complex System Failures and Patient Safety." 2000, Presented at Pediatric Grand Rounds, Cincinnati Children’s Hospital Medical Center,
  • "The Promise of New Anesthesia Technologies…Technofantasy vs. Tangible Improvements." 2005, Presented at Keynote Debate, STA 2005,
  • "The forgetting curve and risk homeostasis; Perinatal leadership roles and action for next steps." 2005, Presented at Perinatal Collaborative – Providence Health System,
  • "System Model of Patient Safety." 2005, Presented at PSLF Leadership Retreat,
  • "Reacting to Accidents in the ICU: Trying to Learn While Trying to Recover." 2005, Presented at SCCM Critical Care Summit,
  • "Patient Safety: Today and Tomorrow." 2005, Presented at Medical Liability Executive Summit,
  • "Patient Safety: Today and Tomorrow." 2005, Presented at Benfield’s 2005 Medical Liability Executive Summit,
  • "Patient Safety: National Imperatives and Progress." 2005, Presented at Evidence- Based Strategies for Patient Falls and Wandering,
  • "Other People's Problems: Estimating the Risk of Human Organ Transplantation Miss-Match (Duke-like) Events." 2005, Presented at NASA Risk Management Conference 2005 (RMC VI),
  • "Operating at the Sharp End." 2005, Presented at The 2nd Richard M. Smith, MD Symposium on Quality and Patient Safety,
  • "Operating at the Sharp End." 2005, Presented at Consensus Conference on Patient Safety and Medical System Errors in Diabetes & Endocrinology,
  • "Going Solid: Tight Coupling and Medical Accidents; Operating at the Sharp End: The Complexity of Human Error." 2005, Presented at University of Wisconsin,
  • "Clinical Health Information Technology Systems and the MEDCAS Project." 2005, Presented at 4th Annual Conference for MedSun Representatives 2005,
  • "Challenges in Integrating Medical Devices into Hospital Networks." 2005, Presented at AAMI Conference & Expo.,
  • "Analysis of unintentional ABO incompatible transplantation accidents." 2005, Presented at Health Systems, Ergonomics and Patient Safety 2005,
  • "What’s missing? Why has patient safety been so elusive and the application of programmatic techniques for safety analysis so unproductive?." 2008, Presented at 26th International System Safety Conference,
  • "What’s missing from medical accident investigation?; Adapting to new technology in the operating room." 2008, Presented at Nurse Anesthesia: Senior Seminar,
  • "What Are We Missing? Results of MEDCAS, the National Healthcare Safety Board Demonstration Project." 2008, Presented at Healthcare Systems Ergonomics and Patient Safety 2008,
  • "Safety and the Competition for Resources." 2008, Presented at Post Graduate Course in General Surgery,
  • "Operating at the Sharp End." 2008, Presented at University of British Columbia,
  • "Medical Event Data Collection and Analysis Towards an NTSB for Healthcare." 2008, Presented at Medical Accidents and Patient Safety in Israel – Legal and Interdisciplinary Perspectives (International Conference),
  • "What we need to do to make it safer...." 2013, Presented at Quality Forum 2013,
  • "The safety of future technology." 2013, Presented at SAMTIT,
  • "The conflict between quality and safety.." 2013, Presented at Göteborg medical society meeting,
  • "The conflict between quality and safety." 2013, Presented at Swedish Quality Assoc.,
  • "The conflict between quality and safety." 2013, Presented at Kvalitetsmässan (Quality Conference),
  • "The conflict between quality and safety." 2013, Presented at Swedish Intensive Care Registry meeting,
  • "Strategy and tactics for moving forward: what to do until the doctor comes." 2013, Presented at KTH executive patient safety course,
  • "Safety Dynamics." 2013, Presented at Patient Safety Workshop,
  • "Safety Dynamics." 2013, Presented at VargÃ¥rd lecture,
  • "Safety 2." 2013, Presented at Karolinska Institutet,
  • "Safety 2." 2013, Presented at Karolinska Thorax,
  • "Winter is coming!." 2014, Presented at Association Européenne des Médecins des Hôpitaux (European Association of Senior Hospital Physicians),
  • "The New Look and Safety 2." 2014, Presented at Lund University Centre for Risk Assessment and Management,
  • "System Safety: why is it so difficult? Missing the system when looking at the system.." 2014, Presented at IAEA Technical Meeting on Systemic Approach to Safety J8-TM-47706,
  • "Sweden 2030." 2014, Presented at Riksrevisionen (National Auditor),
  • "Safety is not quality: stop reporting incidents!." 2014, Presented at Uppsala University Hospital,
  • "Rasmussen and Indicator Diagrams at Risø." 2014, Presented at The Legacy of Jens Rasmussen ODAM 2014,
  • "Patient safety: What is happening and what is not happening.." 2014, Presented at VÃ¥rdförbundet avd SkÃ¥ne,
  • "Medication safety in context.." 2014, Presented at Västernorrland County Council Drug Days,
  • "Checklists are magic beans.." 2014, Presented at Department of Surgery, Ersta Diakoni Hospital,
  • "An introduction to patient safety: Winter is coming!." 2014, Presented at Västra Götalandsregionen Patient Safety course,
  • "Patient safety talk." 2013, Presented at Annual meeting of the Avancerad SjukvÃ¥rd i Hemmet,
  • "Rituals, Habits, and Expertise in a Changing World." 1996, Presented at 10th Annual “Challenges to Clinicians for The New Millenium Conferenceâ€�,
  • "Expert Performance and Evaluations of Medical Care Quality." 1996, Presented at Swiss Society of Anesthesiology,
  • "Disaster Management: It’s Time for a National Medical Safety Board." 1996, Presented at 11th Annual “Challenges to Clinicians for The New Millennium Conferenceâ€�,
  • "Complex system failures and their relationship to adverse drug events." 1996, Presented at Institute for Healthcare Improvement Symposium on Reducing Adverse Drug Events and Medical Errors,
  • "Complex system failures." 1996, Presented at American Medical Association National 1996 Leadership Council,
  • "The Impact of Transesophageal Echocardiography on Expert Performance." 2000, Presented at Society of Cardiovascular Anesthesiologists Annual Meeting,
  • "Resolving the Dilemma of Medical Errors." 2000, Presented at exas Medical Association 2000 Winter Conference,
  • "Preventing Errors Using Medical Products." 2000, Presented at FDA/ASHRM Cosponsored Satellite Teleconference,
  • "Patient Safety at the Clinical Interface, Quality Interagency Coordinating Committee Task Force Meeting." 2000, Presented at Quality Interagency Coordinating Committee Task Force Meeting,
  • "Operating at the Sharp End; How Complex Systems Fail." 2000, Presented at Health Care Ethics Consortium of Georgia Seventh Annual Conference,
  • "Operating at the Sharp End; Gaps in the Continuity of Care." 2000, Presented at National Conference on Patient Safety,
  • "Operating at the Sharp End." 2000, Presented at American College of Surgeons Clinical Congress,
  • "Operating at the Sharp End." 2000, Presented at DC Association of Nurse Anesthetists,
  • "Operating at the Sharp End." 2000, Presented at United States Air Force Quality Systems Program Assessment Review Conference,
  • "Operating at the Sharp End." 2000, Presented at American College of Surgeons, Louisiana Chapter, Annual Meeting,
  • "How Complex Systems Fail." 2000, Presented at National Committee for Quality Health Care Annual Conference,
  • "GAPS: Making Safety in a Hazardous World." 2000, Presented at Illinois Society of Anesthesiologists Annual Meeting,
  • "GAPS: Making Safety in a Hazardous World." 2000, Presented at 14th Annual “Challenges to Clinicians for The New Millennium Conferenceâ€�,
  • "GAPS: Making Safety in a Hazardous World." 2000, Presented at Southern California Forum on Patient Safety,
  • "Gaps in the Continuity of Care: Making Safety at the Sharp End." 2000, Presented at Academic Orthopedic Society Annual Meeting,
  • "Gaps in the Continuity of Care." 2000, Presented at Department of Veterans Affairs Eighteenth Annual HSR&D Meeting,
  • "Cooperative Cognitive Technologies and Patient Safety." 2000, Presented at World Congress on Medical Physics and Biomedical Engineering,
  • "Anatomy of an Accident." 2000, Presented at Children’s Hospitals and Clinics Patient Safety Mini-Course,
  • "Patient Safety and Medical Errors." 2004, Presented at American Medical Association’s 2004 Presidents’ Forum,
  • "Operating at the Sharp End: The complexity of human error; Leverage points: how do we choose targets for work on safety?." 2004, Presented at Inspiration Conference on Patient Safety,
  • "Operating at the Sharp End: Accidents and Human Error in Complex Systems.." 2004, Presented at Colloquium, Fermi National Accelerator Laboratory,
  • "Observational and Ethnographic Studies: Insights on Medical Error and Patient Safety." 2004, Presented at 6th Annual NPSF Patient Safety Congress,
  • "Human Factors Engineering: The Cognitive Approach." 2004, Presented at 5th National Conference Evidence-Based Fall Prevention,
  • "Hobson’s Choices; Notes on Matching and Mismatching in Transplantation Work Processes." 2004, Presented at Rutgers University, New Brunswick Conference,
  • "Going Solid: Tight Coupling and Accidents." 2004, Presented at Perinatal Collaborative – Providence Health System,
  • "Flirting with the Margins: Reflections on Patient Safety Ten Years on." 2004, Presented at National Patient Safety Board of Directors Meeting,
  • "Analysis of Performance Errors." 2004, Presented at Conference on Surgical Errors (COSE),
  • "The Future of Medical Accident Investigation." 2006, Presented at American Society of Critical Care Anesthesiologists Annual Meeting,
  • "Some Comments on the History of the Patient Safety Movement in the United States." 2006, Presented at Patient Safety Seminar,
  • "Pumps and Infusion Devices." 2006, Presented at Anesthesia & Critical Care Special Topics in Surgery/Medicine,
  • "Operating at the Sharp End: Safety, Error, and Resilience in the Hospital; What do I do now? Post-accident recover and accident investigation." 2006, Presented at Edwards Hospital and Health Systems,
  • "Operating at the Sharp End: Error and Safety and the Future of the Patient Safety Movement." 2006, Presented at Michigan Health & Safety Coalition Patient Safety Conference,
  • "Operating at the Sharp End." 2006, Presented at Medical Error Day,
  • "How in the world did we get into that mode?: Issues in the design and operation of infusion devices and other computer-based technologies." 2006, Presented at AVA Preconference,
  • "Crucial Conversations in Patient Safety." 2006, Presented at MHA 2006 Health Care Leadership Forum,
  • "Anatomy of Medical Errors in Critical Care." 2006, Presented at SCCM Excellence in Quality & Safety Critical Care Conference,
  • "Safety 2." 2013, Presented at Patient Safety Seminar,
  • "Safety 2." 2013, Presented at National Patient Safety conference,
  • "Safety 2." 2013, Presented at VinnvÃ¥rd breakfast lecture,
  • "Safety 2." 2013, Presented at VÃ¥rdförbundet (Nurses union) Örebro,
  • "Safety 2." 2013, Presented at Swedish Senior Hospital Physicians Association,
  • "Safety 2." 2013, Presented at Swedish Association of Midwives annual Conference of Reproductive Health,
  • "Resilience in healthcare." 2013, Presented at Patientsäkerhetsdagarna (Patient safety day),
  • "Resilience in complex adaptive systems: operating at the edge of failure." 2013, Presented at Velocity Conference,
  • "Resilience in Air Traffic Control systems.." 2013, Presented at DFS Deutsche Flugsicherung (German Flight Safety),
  • "Real Safety." 2013, Presented at Health Care Resource Management meeting,
  • "Patient safety in Sweden and around the World." 2013, Presented at Svensk Förening för Anestesi och IntensivvÃ¥rd,
  • "Operating at the Sharp End.." 2013, Presented at Swedish Auditors Association,
  • "Oh, the places you’ll go." 2013, Presented at AT-Forum 2013,
  • "Leading Responses to Medical Accidents In and Out of the Operating Room: Priorities and Approaches.." 2013, Presented at American Society of Anesthesiologists Annual Meeting, Refresher Course,
  • "Have I got this right?." 2013, Presented at Swedish Emergency Medicine Conference,
  • "Gaps in the continuity of care." 2013, Presented at Astrid Lindgrens Childrens Hospital,
  • "Gaps in the continuity of care." 2013, Presented at NOKIAS - Nordic Congress in Anesthesia and Intensive Care Nurses,
  • "Gaps in the continuity of care." 2013, Presented at Department of Surgery, Danderyds Hospital,
  • "Föreläsning om drivkrafter för förbättrad patientsäkerhet." 2013, Presented at Föreläsning om drivkrafter för förbättrad patientsäkerhet,
  • "Complex system failures and patient safety." 2013, Presented at Red Cross Nursing College,
  • "Briefing on issues related to High Quality, Independent, Accident Investigation in healthcare and other industries.." 2013, Presented at Anesthesia Patient Safety Foundation Workshop, , American Society of Anesthesiologists Annual Meeting,

Papers in Proceedings

2008

  • Cook RI. "Medical Event Data Collection and Analysis Towards an NTSB for Healthcare.." in Medical Accidents and Patient Safety in Israel – Legal and Interdisciplinary Perspectives,. (5 2008).
  • Nemeth C, Nunnally M, O’Connor M & Cook R. "For resilient IT: Don’t mimic the past, leverage the future.." in Conference on Systems Engineering Research. (4 2008).

2007

  • Nemeth CP & Cook R. "Reliability versus resilience: What does health care Need?." in Human Factors and Ergonomics Society 51st Annual Meeting. (10 2007).

2006

  • Nemeth C, Nunnally M, O'Connor M, & Cook R. "Creating resilient IT: How the signout sheet shows clinicians make healthcare work.." in AMIA Annual Symposium. (11 2006).

2005

  • Albolino S, Cook R. "Making Sense of Risks: A field study in an Intensive Care Unit.." in International Conference of HEPS 2005. (1 2005).
  • Nemeth CP, Cook RI, Crowley J, Ragan M, Battles J, Smithson K, & Bruley M. "Above Board: Issues in Medical Accident Investigation and Analysis.." in Human Factors and Ergonomics Society 49th Annual Meeting. (9 2005).
  • Nemeth C, O’Connor M, Klock PA, Cook R. "Mapping cognitive work: The way out of healthcare IT system failure.." in AMIA Annual Symposium. (10 2005).
  • Nemeth, CP, Nunnally M, Cook RI, Crowley J, Weinger M, & Woods DD. "Brave New World: Medical Devices, Clinical Information Systems, Networks, and Patient Safety.." in Human Factors and Ergonomics Society 49th Annual Meeting. (9 2005).
  • Nemeth C, O’Connor M, Klock PA, Cook RI. "Temporal cognitive work: Discovering requirements for digital artifacts.." in Eleventh International Conference on Human-Computer Interaction,. (7 2005).

2004

  • Nemeth C, Cook RI, Patterson E, Donchin Y, Rogers M, and Ebright, P. "Afterwords: The Quality of Medical Accident Investigations and Analyses.." in Proceedings of the Human Factors and Ergonomics Society 48th Annual Meeting,. (9 2004).
  • Alvarado C, Cao C, Klein G, Weinger M, Patterson ES, Cook R, Carayon P. "Panel: The roles of human factors in healthcare – 2020.." in Human Factors and Ergonomics Society 47th annual meeting.. (9 2004).
  • Nemeth CP & Cook RI. "Discovering and supporting temporal cognition in complex environments.." in Twenty-Sixth Annual Conference of the Cognitive Science Society. (1 2004).

2003

  • Cook RI, Woods DD "The messy details: Insights from technical work studies in health care.." in Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting,. (10 2003).
  • Cook, RI. "Lessons from the war on cancer: The need for basic research on safety.." (11 2003).
  • Nemeth C, Cook RI. "Using cognitive artifacts to understand distributed cognition. In Y Xiao, Special session on distributed planning." in IEEE International Conference on Systems, Man & Cybernetics,. (10 2003).

2002

  • Cook, RI. "Who’s Sorry Now?." (10 2002).

2001

  • Ebright P, Render ML, Cook RI, Woods DD, Patterson ES, Eisenlohr A. "Human performance theory-based approach to patient safety and the clinical nurse specialist." in National Association of Clinical Nurse Specialists National Conference. (3 2001).
  • Patterson ES, Render ML, Coyle G, Woods DD, Cook RI "Medication Administration Error and BCMA: Preliminary Findings." in 19th Annual Meeting VA Health Services Research: Improving Access and Outcomes.. (2 2001).
  • Cook RI. "Two Years Before the Mast: Learning to Learn About Patient Safety.." in Enhancing Patient Safety and Reducing Error in Health Care. (1 2001).

2000

  • Patterson ES, Coelho DA, Woods DD, Cook RI, Render ML. "The natural history of technology change: How introducing bar coding changes medication administration." in Fifth Conference on Naturalistic Decision Making. (5 2000).

1998

  • Cook RI. "Being Bumpable." in Fourth Conference on Naturalistic Decision Making. (5 1998).

1996

  • Cook,R; Woods,D; Walters,M; Christoffersen,K "The cognitive systems engineering of automated medical evacuation scheduling and its implications." in 3rd Annual Symposium on Human Interaction with Complex Systems (HICS 96). (1 1996).

1992

  • Woods DD, Cook RI. "The link between design errors in human-computer interaction, latent failures, and system disaster.." in Human Factors Society 36th Annual Meeting. (1 1992).

1991

  • Cook RI, Woods DD, Howie MB. "Adapting to ‘clumsy’ automation: what system and task tailoring by cardiac anesthesiologists reveals about cognitive tasks.." in Computer Support & Cognitive Simulations Meeting. (1 1991).

1990

  • Potter SS, Cook RI, Woods DD, McDonald JS. "The role of human factors guidelines in designing usable systems: a case study of operating room equipment.." in Human Factors Society, 34th Annual Meeting. (1 1990).