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Cook, Richard MD


1971 Neil Avenue
Columbus, OH 43210

Email: cook.16@osu.edu

 

Current OSU Appointments

Senior Researcher, Integrated Systems Engineering

Professor - Practice, Anesthesiology

Physician, FGP-Anesthesiology

 

Books

Behind human error

 

Licenses

1995 - present American Board of Anesthesiology: American Board of Anesthesiology
2016 - present Ohio: State Medical Board of Ohio
2016 - present US DEA: Drug Enforcement Administration
2016 - present Illinois: Illinois Medical Licensing Board
 

Chapters in Books

Human-computer interaction in context: physician interaction with automated intravenous controllers in the heart room.

Operating at the sharp end: the complexity of human error.

Perspectives on human error: hindsight biases and local rationality

A Tale of Two Stories: Contrasting Views of Patient Safety.

From counting failures to anticipating risks: possible futures for patient safety.

Operating at the sharp end: The human factors of complex technical work and its implication for patient safety

Mistaking error

Thinking about accidents and systems

Cognitive artifacts' implications for health care information technology: Revealing how practitioners create and share their understanding of daily work.

Making information technology a team player in safety: The case of infusion devices

Hobson’s choices: Matching and mismatching in transplantation work processes.

Distancing through differencing: An obstacle to Organizational learning following accidents.

Incidents – markers of resilience or brittleness?

Taking things in stride: Cognitive features of two resilient performances.

Taking things in stride: Cognitive features of two resilient performances.

Being Bumpable: Consequences of Resource Saturation and Near-Saturation for Cognitive Demands on ICU Patients.

RePresenting reality: The human factors of healthcare information.

Behind human error: taming complexity to improve patient safety

What went wrong at the Beatson Oncology Centre

Between shifts: Healthcare Communication in the PICU

How Complex Systems Fail

Systemperspektivet på säkerhet. [A systems view of safety].

Utvärdering av tkniken påverkan på patientsäkerheen. [Assessing the Impact of Technology on Patient Safety.]

Resilience, the second story, and progress on patient safety

The Stockholm blizzard of 2012

Gaps in resilience

 

Conferences

The natural history of introducing new information technology into a dynamic high-risk environment.

The role of human factors guidelines in designing usable systems: a case study of operating room equipment.

NOSOCOMIAL AUTOMATION - TECHNOLOGY-INDUCED COMPLEXITY AND HUMAN-PERFORMANCE

COGNITIVE CONSEQUENCES OF CLUMSY AUTOMATION ON HIGH WORKLOAD, HIGH CONSEQUENCE HUMAN-PERFORMANCE

Adapting to ‘clumsy’ automation: what system and task tailoring by cardiac anesthesiologists reveals about cognitive tasks.

The link between design errors in human-computer interaction, latent failures, and system disaster.

Cooperative Communications in Dynamic Fault Management

Verite, abstraction, and ordinateur systems in the evolution of complex process control

The cognitive systems engineering of automated medical evacuation scheduling and its implications

Being Bumpable

The impact of new technology on patient safety

The natural history of technology change: How introducing bar coding changes medication administration

Human performance theory-based approach to patient safety and the clinical nurse specialist

New arctic air crash aftermath role-play simulation™: Orchestrating a fundamental surprise

Medication Administration Error and BCMA: Preliminary Findings

Two Years Before the Mast: Learning to Learn About Patient Safety.

Who’s Sorry Now?

Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work Analysis.

Using cognitive artifacts to understand distributed cognition. In Y Xiao, Special session on distributed planning

The messy details: Insights from technical work studies in health care.

Lessons from the war on cancer: The need for basic research on safety.

Afterwords: The Quality of Medical Accident Investigations and Analyses.

How cognitive artifact support of acute care distributed cognition affects patient safety

Discovering and supporting temporal cognition in complex environments.

Panel: The roles of human factors in healthcare – 2020.

Above Board: Issues in Medical Accident Investigation and Analysis.

Towards a Theory of Patient Safety – Lessons from the First Decade.

Mapping cognitive work: The way out of healthcare IT system failure.

Brave New World: Medical Devices, Clinical Information Systems, Networks, and Patient Safety.

Automation, Interaction, Complexity, and Failure: A Case Study. In

Temporal cognitive work: Discovering requirements for digital artifacts.

Making Sense of Risks: A field study in an Intensive Care Unit.

Learning from investigation: Experience with understanding healthcare adverse events.

Before I forget: How clinicians cope with uncertainty through sign-outs.

Creating resilient IT: How the signout sheet shows clinicians make healthcare work.

Reliability versus resilience: What does health care Need?

Collaborative cross-checking to enhance resilience

For resilient IT: Don’t mimic the past, leverage the future.

Medical Event Data Collection and Analysis Towards an NTSB for Healthcare.

 

Degrees

1975 B.A., Lawrence University

1986 M.D., University Of Cincinnati

 

Edited Books

Behind Human Error: Cognitive Systems, Computers and Hindsight

 

Editorial Activities

1996 Sources of Power: How People Make Decisions
1998 Image and Logic: A Material Culture of Microphysics
1999 Textbook of Regional Anesthesia and Acute Pain Management
2013 - 2014 Patient Safety
 

Honors

1999 - present Peter Kiewit Memorial Award Lectureship. Eisenhower Medical Center and The Annenberg Foundation.
2001 - present McGovern Medal for Medical Writing. American Medical Writers Association.
 

Journal Articles

 

Presentations

Cognitive consequences of 'clumsy' automation on high workload, high consequence human performance

Adapting to 'clumsy' automation: what system and task tailoring by cardiac anesthesiologists reveals about cognitive tasks

How to do that voodoo that you do so well: human factors engineering of medical devices

Dynamic problem solving in anesthesiology: expertise and error; Same scene, different views: research on anesthesiologist performance

Medical disasters and latent system errors: blame, guilt, and causality

A cognitive science approach to analyzing anesthesia cases

Human performance in anesthesia: a cognitive systems manifesto

Shifting the burden to users: Clever tricks of the design masters

Rituals, Habits, and Expertise in a Changing World

Expert Performance and Evaluations of Medical Care Quality

Disaster Management: It’s Time for a National Medical Safety Board

Complex system failures and their relationship to adverse drug events

Complex system failures

Operating at the Sharp End

Operating at the Sharp End

Using Adverse Event Data to Improve Quality of Care

Two Years Before the Mast: Learning to Learn About Patient Safety

New Arctic Aircrash Accident Investigation Simulation

How Complex Systems Fail

Functions a’la mode: Sources of Operating Failures in Microprocessor Based Medical Devices

Celebrated Cases of Medical Accidents: Hindsight Bias

Being Bumpable

A New Approach for Accident Analysis

A Case of Being Bumpable

Useful Insights in Error Reduction in Health Care

Things Fall Apart:How Complex Systems Fail.

Things Fall Apart: Complexity, Failure and Safety in Healthcare in the Year 2000

Things Fall Apart: Accidents in Healthcare and Other Domains

Things Fall Apart. Human Error in Medicine

Safety, Technology, and Medical Accidents: Lessons for New System Design

Planning for Work on the Role of Pharmacists in Pharmaceutical Safety

Operating at the Sharp End

Operating at the Sharp End

Learning to Learn about Patient Safety

Inferences, Investigations and Insight: Presentation for CODA and FDA on Incident Reporting and Analysis.

How Complex Systems Fail; Characteristics of Patient Safety

Doing the right thing – technologically

Deus ex machina: Technology, Accidents, and Human Performance

Complex Systems Failures

Characteristics of Patient Safety in an Era of Challenge and Risk

Adoption of New Technology and Patient Safety

Complex System Failures and Patient Safety

The Impact of Transesophageal Echocardiography on Expert Performance

Resolving the Dilemma of Medical Errors

Preventing Errors Using Medical Products

Patient Safety at the Clinical Interface, Quality Interagency Coordinating Committee Task Force Meeting

Operating at the Sharp End; How Complex Systems Fail

Operating at the Sharp End; Gaps in the Continuity of Care

Operating at the Sharp End

Operating at the Sharp End

Operating at the Sharp End

Operating at the Sharp End

How Complex Systems Fail

GAPS: Making Safety in a Hazardous World

GAPS: Making Safety in a Hazardous World

GAPS: Making Safety in a Hazardous World

Gaps in the Continuity of Care: Making Safety at the Sharp End

Gaps in the Continuity of Care

Cooperative Cognitive Technologies and Patient Safety

Anatomy of an Accident

Complex System Failures

Operating at the Sharp End: Explaining Technical Work in Healthcare

Operating at the Sharp End

Making Safety and Gaps in the Continuity of Care

Complex systems Failures and Gaps in the Continuity of Care

Communicating in the Midst of Complexity

Choosing Paths to Safety: Understanding the Natures of Hazard and Opportunity

What do you want to be when you grow up?

The Role of the Infection Control Professional in Patient Safety & Improving Patient Care

Preventing Medical Errors: Patient Safety in a New Age of Accountability.

Operating at the Sharp End: Doing What Matters to Improve Patient Safety

How Complex Systems Fail

Safety in Anesthesia

Patient Safety and Infusion Device; Technical Work Coordination in Healthcare

Patient Safety and Medical Errors

Operating at the Sharp End: The complexity of human error; Leverage points: how do we choose targets for work on safety?

Operating at the Sharp End: Accidents and Human Error in Complex Systems.

Observational and Ethnographic Studies: Insights on Medical Error and Patient Safety

Human Factors Engineering: The Cognitive Approach

Hobson’s Choices; Notes on Matching and Mismatching in Transplantation Work Processes

Going Solid: Tight Coupling and Accidents

Flirting with the Margins: Reflections on Patient Safety Ten Years on

Analysis of Performance Errors

The Promise of New Anesthesia Technologies…Technofantasy vs. Tangible Improvements

The forgetting curve and risk homeostasis; Perinatal leadership roles and action for next steps

System Model of Patient Safety

Reacting to Accidents in the ICU: Trying to Learn While Trying to Recover

Patient Safety: Today and Tomorrow

Patient Safety: Today and Tomorrow

Patient Safety: National Imperatives and Progress

Other People's Problems: Estimating the Risk of Human Organ Transplantation Miss-Match (Duke-like) Events

Operating at the Sharp End

Operating at the Sharp End

Going Solid: Tight Coupling and Medical Accidents; Operating at the Sharp End: The Complexity of Human Error

Clinical Health Information Technology Systems and the MEDCAS Project

Challenges in Integrating Medical Devices into Hospital Networks

Analysis of unintentional ABO incompatible transplantation accidents

The Future of Medical Accident Investigation

Some Comments on the History of the Patient Safety Movement in the United States

Pumps and Infusion Devices

Operating at the Sharp End: Safety, Error, and Resilience in the Hospital; What do I do now? Post-accident recover and accident investigation

Operating at the Sharp End: Error and Safety and the Future of the Patient Safety Movement

Operating at the Sharp End

How in the world did we get into that mode?: Issues in the design and operation of infusion devices and other computer-based technologies

Crucial Conversations in Patient Safety

Anatomy of Medical Errors in Critical Care

Patient Safety and Accidents

Operating at the Sharp End: Resilience, safety and why we don’t seem to be getting anywhere

Green Gas Lecture

Con: Clinical Simulation is Not Required for Credentialing of All New Privileges

Replacing Hindsight with Insight: Understanding Adverse Events

Pumps / Infusion Devices

Why Accidents Happen; Sentinal Event/Recognition and Analysis

What’s missing? Why has patient safety been so elusive and the application of programmatic techniques for safety analysis so unproductive?

What’s missing from medical accident investigation?; Adapting to new technology in the operating room

What Are We Missing? Results of MEDCAS, the National Healthcare Safety Board Demonstration Project

Safety and the Competition for Resources

Operating at the Sharp End

Medical Event Data Collection and Analysis Towards an NTSB for Healthcare

Persistence of Accidents in Healthcare Despite Efforts to Improve Safety

Infusion devices and their role in medical accidents

Medical Accidents and Their Investigation: Learning, Forgetting and Remembering

EMR, EHR, and other CHIT: Not what we ordered!

Early Second Phase Medical Relief in Haiti

Be careful what you wish for! The “Meaningful Use� of Clinical Healthcare Information Technology

Who's Learning Now?

Patient Safety in 2011

Medical Relief Efforts in Haiti

Handoffs of Care

Healthcare Information Technology: The American Experience

Going Solid

Going Beyond Accident Prevention: Application of Resilience in Complex

50.000 incidents: how many is enough?

50.000 incidents: how many is enough?

Understanding adverse events

The Forgetting Curve

The Dynamics of Safety

The Dynamics of Safety

The Dynamics of Safety

The Dynamics of Safety

The Big Challenge: Making CHIT a Team Player

Strategy and tactics for moving forward: what to do until the doctor comes

Some thoughts on the nature of resilience

Planning research on patient safety and resilience

Patient Safety in 2011

Operating at the Sharp End and Relief Operations in Haiti

Operating at the Sharp End

Naturally occurring experiments

Is it Safe? Managing the tension between production and hazard

Introducing patient safety

How Complex Systems Don’t Fail

What we need to do to make it safer...

The safety of future technology

The conflict between quality and safety.

The conflict between quality and safety

The conflict between quality and safety

The conflict between quality and safety

Strategy and tactics for moving forward: what to do until the doctor comes

Safety Dynamics

Safety Dynamics

Safety 2

Safety 2

Patient safety talk

Safety 2

Safety 2

Safety 2

Safety 2

Safety 2

Safety 2

Resilience in healthcare

Resilience in complex adaptive systems: operating at the edge of failure

Resilience in Air Traffic Control systems.

Real Safety

Patient safety in Sweden and around the World

Operating at the Sharp End.

Oh, the places you’ll go

Leading Responses to Medical Accidents In and Out of the Operating Room: Priorities and Approaches.

Have I got this right?

Gaps in the continuity of care

Gaps in the continuity of care

Gaps in the continuity of care

Föreläsning om drivkrafter för förbättrad patientsäkerhet

Complex system failures and patient safety

Briefing on issues related to High Quality, Independent, Accident Investigation in healthcare and other industries.

Winter is coming!

The New Look and Safety 2

System Safety: why is it so difficult? Missing the system when looking at the system.

Sweden 2030

Safety is not quality: stop reporting incidents!

Rasmussen and Indicator Diagrams at Risø

Patient safety: What is happening and what is not happening.

Medication safety in context.

Checklists are magic beans.

An introduction to patient safety: Winter is coming!

Patient safety.

Gaps in the continuity of care and progress on patient safety.

Safety in the OR.

Things fall apart.

Patient safety.

Resilience and resilience engineering in health care.

 

Technical Reports

Human error in the operating room: identifying cognitive lockup

Human performance in anesthesia: a corpus of cases

Reducing the Potential for Error Through Device Design: Infusion Controllers in Cardiac Surgery

Clumsy automation, practitioner tailoring and system failures

Being bumpable: The complexity of ICU operation and their consequences

How Complex Systems Fail