One hundred and six girls with Turner's syndrome were recruited from 36 UK hospitals between 1999 and 2003, of whom 14 withdrew (four of them because of early organisational errors), leaving 92 to complete the study (fig 1).
For example, 'operating theatre' was changed to 'medical team.' The questionnaire had nine themes: leadership, confidence/assertion, information-sharing, teamwork, stress and fatigue, work values, organisational climate, error and procedural compliance and error management.
35 36 System-related interventions are those that are focused on addressing organisational process errors, and vulnerabilities, whereas cognitive interventions focus on improving physicians' perceptual and thought processes (eg, educational interventions, cognitive de-biasing strategies; see related papers in supplement).
Argyris (1977) mentions the double bind between the two organisational rules "hide errors" and "reveal errors".
In their respective working contexts, the DMOM are often involved in a sequence of events leading to an incident or accident [10] poor inspection and maintenance being only the final act of a long and complex chain of organisational and systemic errors.
To make this into a reality, external rules, regulations and policies would be necessary to make diagnostic error an organisational priority and to secure commitment from the organisational leadership.
With the increasing complexity of care in critically ill patients, organisational factors such as error reporting systems and routine checks can reduce the risk for such errors.
A side effect of this growth in complexity has been a corresponding increase in the number and type of engineering and organisational factors underlying human error.
* The items of the American factors Feedback about and communication about error and Organisational learning – Continuous improvement combined into one factor, Feedback about and learning from error, in the Dutch factor structure.
