Managing the Unexpected

High Reliability develops an organization’s strengths through individual actions.
Shared attitudes fill the gap between organization and the individual to determine High Reliability.


Titles are alphabetized below:

>>Are the Eyes Better Than the Gas? Use of a Five-Point Respiratory Exam, Daved van Stralen, MD, Presented at: Making the Desert Bloom: Creating Excellence in LTC Medicine, AMDA’s 27th Annual Symposium, March 4-7, 2004, Phoenix, Arizona

>>Bill Corr, Obituary. We have witnessed the passing of another legend who served with honor and distinction as a loving husband, father, professional firefighter and union leader. Jim Perry, Editor November/December 2005 Los Angeles Firefighter Page 7

>>Build a Healthy Safety Culture Using Organizational Learning and High Reliability Organizing, David Christenson, MA, A paper presented at the Wildfire2007 international conference of wild land firefighters in Seville, Spain, May 2007 and the Bridging the Gap Between Theory and Practice, European HRO Conference, April/May 2007. Deauville, Normandy, France

>>Changing a Pediatric Sub-Acute Facility to Increase Safety and Reliability, David W. van Stralen, Racquel M. Calderon, Jeff F, Lewis and Karlene H. Roberts, Patient Safety and Health Care Management, Vol. 7, 259-282, 2008

>>Circle of Fear: Cultivating A Healthy Respect for Unexpected Failures, Major Randy E. Cadieux, USMC, 8/16/2010

>>C Libuser's Dissertation
Part 1 Introduction & Literature Review
Part 2 Case Reports & Model
Part 3 Results
Part 4 Summary
Part 5 Methods & Material

>>Creating Resilience on a Fire Assignment Managers that lead crews and teams into high risk environments want to believe the group they are leading is skilled, capable, strong...resilient even. Do we know what we mean when we are talking about having resilience or behaving resiliently? JT Holt, 5/12/2009

>>CRITICAL THINKING: PLUGGING (OR MOVING) A HOLE IN OUR SWISS CHEESE The purpose of this and previous papers is to 1) improve decision quality or avoid decision error consequences, 2) improve the judging of decision quality by those with outcome knowledge and 3) protect decision makers from inappropriate second-guessing by non-experts, in hindsight. Michael A. Johns, Assistant U.S. Attorney, January, 2010

>>Dynamic Resilience: High Reliability Organizing from the Ground Up, Daved van Stralen, MD

>>Differences in Safety Climate Between Hospital Personnel and Naval Aviators, David Gaba, MD; Sara Singer, MBA; Anna Sinaiko, BA; Jennie Bowen, BS; Anthony Ciavarelli, Ed.D

>>Full-Spectrum Analysis: A New Way of Thinking for a New World, Adrian Wolfberg, Military Review, July-August, 2006

>>Introduction: Design and Organizational Change, Richard Buchanan, Design Issues: Vol. 24, Number 1, Winter 2008

>>Hanford Human Improvement Performance Lessons Learned 2007, This document provides the lessons learned and results of a pilot initiative to implement Human Performance Improvement (HPI) tools and techniques by U.S. Department of Energy (DOE) Office of River Protection (ORP), DOE Richland Operations Office (RL), and their respective Prime Contractors.

>>High-Reliability Organizations: Changing the Culture of Care in Two Medical Units, Daved van Stralen, M.D., Design Issues: Vol. 24, Number 1, Winter 2008

>>High Reliability Organizing to develop managers and organizational capabilities, Dr. Annette Gebauer, Beratung für Corporate Learning, Berlin, a presentation at the 2010 International HRO Conference in New Orleans, Download Abstract, and Paper in German

>>HRO, Daved van Stralen, MD

>>HRO Before We Knew It Was Called HRO, David A. Christenson on HRO implementation in a jet fighter squadron's quick reaction alert force operations in 1980

>>HRO Hypotheses, Karlene Roberts, Ph.D; Carolyn Libuser

>>Implementation. How I do it. Daved van Stralen, MD, FAAP December 2011

>>Managing the Unexpected, Karl Weick,Ph.D; Kathleen Sutcliffe, University of Michigan, Ross School of Business, Presented at: MTU in Wildland Prescribed Fire Workshop, February 28, 2005, Jacksonville, Florida

>>Managing The Unpredictable, "What can we learn from the Seattle Symphony and hospital pediatric emergency wards? For starters, they can teach us how to handle a crisis." March 2008, Engineering Management Feature Article, Bobert Bea

>>Mindfulness: Are We Managing Our Expectations?, By the Wildland Fire Lessons Learned Center's Staff Writer Jonetta T. Holt

>>Mitigating risks, visible hands, inevitable disasters, and soft variables: Management research that matters to managers, Eric Ford; W. Jack Duncan; Arthur Bedeian; Peter Ginter; Matthew Rousculp; Alice Adams

>>Morning Briefings Reinforce Deference to Expertise Briefing crew leaders about the potential hazards they face and actions to take when they become realities. JT Holt, 9/14/2008

>>On Error Management: Lessons From Aviation, Robert Helmreich

>>Organizational Factors in Accident Risk Assessment, Anthony Ciavarelli, Ed.D; Jeffrey Crowson, Presented at: Safety Across High-Consequence Industries Conference, March 9 & 10, 2004, St. Louis, MO

>>Organizing for Mindfulness: Eastern Wisdom and Western Knowledge, Karl E. Weick and Ted Putnam, JOURNAL OF MANAGEMENT INQUIRY, Vol. 15 No. 3, pp. 275-287, September 2006

>>Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials, Gordon C S Smith and Jill P Pell, Hazardous Journeys, BMJ, December 2003;327;1459-1461

>>Patient Safety is an Organizational Systems Issue: Lessons from a Variety of Industries,
Karlene Roberts Ph.D; Daved van Stralen, MD; Kuo Yu, Prepared for B. Youngblood and M. Hatlie (Eds.), Handbook on Patient Safety. Aspen Publications

>>Practical Applications of Reliability Theory, Roger Resar, M.D., Senior Fellow, Institute for Health Care Improvement, Health Research and Educational Trust, DOI: 10.1111/j.1475-6773.2006.00571.x

>>Risk Center Releases Findings of Two-Year Study: “Managing Large-Scale Risks in a New Era of Catastrophes,” Howard Kunreuther and Erwann Michel-Kerjan, Risk Management Review, Wharton Risk Center, University of Pennsylvania, Spring 2008

>>Safety Climate and Risk Culture: How Does Your Organization Measure Up? Anthony Ciavarelli, PhD, Copyright © 2007, Human Factors Associates, Inc. All rights reserved.

>>Shooting an Elephant. George Orwell (1903-1950)

>>The Emotionally Intelligent Firefighter: An unspoken human dimension of wild land firefighting, George Solverson, Safety Officer, Boise, ID, August, 13, 2007

>>The Incident Command System, Gregory Bigley, Ph.D; Karlene Roberts, Ph.D

>>The French Connection: France's wild land fire service finds success through high-reliability concepts, Daved van Stralen, MD; Gary Provansal

>>The Origins of EMS in Military Medicine: How Combat Medicine Influenced the Advent of Today's EMS Model, Daved van Stralen, M.D., War on Trauma, Journal of Emergency Medical Services

>>Tracking and Responding to Small Errors in High Risk Environments Responding to small system failures before they become big problems, even deadly catastrophes, without being able to pinpoint the actual cause is confusing and often creates hesitation. JT Holt, 7/25/2008

>>Transferring Wildland Fire Knowledge Using A National Lessons Learned Center, David Christenson, MA, U.S. Wildland Fire Lessons Learned Center, A paper presented at the Wildfire2007 international conference of wild land firefighters in Seville, Spain, May 2007

>>What Risk Managers Need to Know, Karlene Roberts, Ph.D, Presented at: American Society for Healthcare Risk Management, October, 17-20, 2008, Orlando, Florida

>>Why Transformation Efforts Fail, John P. Kotter, Leading Change, Harvard Business Review, The Tests of a Leader, January 2007

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