Abstract
In August 1922, Dr. William Stewart Halsted returned to Baltimore from his summer retreat (High Hampton, North Carolina) with symptoms of choledocholithiasis. He had had his gallbladder successfully removed at Johns Hopkins Hospital in August 1919 and had remained symptom free until this occasion. However, despite a successful reoperation and attentive care by his colleagues he developed pneumonia and pleurisy of which he died on Thursday, 7 September 1922.
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References
Adnett N, Hardy S. Reviewing the working time directive: rationale, implementation and case law. Ind Relat J. 2001;32(2):114-125.
Agency for Healthcare Research and Quality (AHRQ). National healthcare quality report. Journal. From: http://www.ahrq.gov/qual/qrdr09.htm. 2009 (accessed 19th September 2010).
Åkerstedt T, Gillberg M. A dose-response study of sleep loss and spontaneous sleep termination. Psychophysiology. 1986;23(3):293-297.
APA. NCME (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education). Standards for educational and psychological tests; Washington DC: AERA Publications Sales; 1999.
Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med. 1988;318(12):771.
Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6(4):313-321.
Berguer R. Surgery and ergonomics. Arch Surg. 1999;134(9):1011-1016.
Brazier M. Medicine, Patients and the Law. Harmondsworth: Penguin-Printed Resource; 1992.
Brennan TA, Hebert LE, Laird NM, et al. Hospital characteristics associated with adverse events and substandard care. JAMA. 1991;265(24):3265-3269.
Bristol Royal Infirmary Inquiry. Learning from Bristol: The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995. London: Stationery Office; 2001.
Burton B. Court ruling ends Patel inquiry. BMJ. 2005;331(7516):536.
Cameron JL. William Stewart Halsted: our surgical heritage. Ann Surg. 1997;225(5):445-458.
Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49(5):651-661.
Cooper JB, Taqueti VR. A brief history of the development of mannequin simulators for clinical education and training. Br Med J. 2004;13(suppl 1):i11-i18.
Crothers IR, Gallagher AG, McClure N, James DT, McGuigan J. Experienced laparoscopic surgeons are automated to the “fulcrum effect”: an ergonomic demonstration. Endoscopy. 1999;31(5):365-369.
Cuschieri A. Whither minimal access surgery: tribulations and expectations. Am J Surg. 1995;169(1):9-19.
Daan S, Beersma DG, Borbely AA. Timing of human sleep: recovery process gated by a circadian pacemaker. Am J Physiol Regul Integr Comp Physiol. 1984;246(2):R161-R183.
Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg. 1992;215(3):196-202.
Davies M. Medical Self-Regulation: Crisis and Change. Hampshire: Ashgate Publishing Company; 2007.
Dembe AE, Erickson JB, Delbos RG, Banks SM. The impact of overtime and long work hours on occupational injuries and illnesses: new evidence from the United States. Br Med J. 2005;62(9):588-597.
Elman MJ, Sugar J, Fiscella R, et al. The effect of propranolol versus placebo on resident surgical performance. Trans Am Ophthalmol Soc. 1998;96:283-294.
Fassett WE. Patient safety and quality improvement act of 2005. The Annals of pharmacotherapy 2006;40(5):917-924.
Ferguson RL, Jobe K. A quiet hand for microneurosurgery: twiddle your thumb. J Neurosurg. 2004;101(3):541-544.
Forster P. Queensland Health Systems Review Final Report. Queensland: Queensland Department of Health; 2005 http://www.health.qld.gov.au/health_sys_review/final/qhsr_final_report.pdf (accessed 5th July 2011).
Friedman RC, Bigger JT, Kornfeld DS. The intern and sleep loss. N Engl J Med. 1971;285(4):201-203.
Gaba DM. Dynamic decision-making in anesthesiology: cognitive models and training approaches. In: Evans DA, Patel VL, eds. Advanced Models of Cognition for Medical Training and Practice. Berlin: Springer; 1992:123-147.
Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology. 1988;69(3):387-394.
Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347(16):1249-1255.
Gallagher AG, Smith CD. From the operating room of the present to the operating room of the future. Human-factors lessons learned from the minimally invasive surgery revolution. Semin Laparosc Surg. 2003;10(3):127-139.
Gallagher AG, McClure N, McGuigan J, Ritchie K, Sheehy NP. An ergonomic analysis of the fulcrum effect in the acquisition of endoscopic skills. Endoscopy. 1998;30(7):617-620.
Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little, Brown & Company; 2000.
Grantcharov TP, Bardram L, Peter FJ, Rosenberg J. Laparoscopic performance after one night on call in a surgical department: prospective study. BMJ. 2001;323(7323):1222-1223.
Grillo HC. Edward D. Churchill and the “rectangular” surgical residency. Surgery. 2004;136(5):947-952.
Hallenbeck WH. Radiation Protection. Boca Raton: CRC Press; 1994.
Harding Clark M. The Lourdes Hospital Inquiry–An Inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda. Report of Judge Maureen Harding Clark SC. The Stationery Office, Dublin; 2006.
Harpwood V. Negligence in Healthcare: Clinical Claims and Risk in Context. London: Informa; 2001.
Harwell RC, Ferguson RL. Physiologic tremor and microsurgery. Microsurgery. 1983;4(3):187-192.
Haug M. Deprofessionalization: an alternative hypothesis for the future. Sociol Rev Monogr. 1973;20:195-211.
Health Committee. Working for patients. Vol. 159 cc556-9W. 1989. From: http://hansard.millbanksystems.com/written_answers/1989/nov/07/working-for-patients. Retrieved October 21, 2010.
Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-871.
Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington DC: National Academy Press; 2000:196-197.
Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003;163(17):2014-2018.
Kuhn TS. The Structure of Scientific Revolutions. International Encyclopaedia of United Science. Chicago: University of Chicago Press; 1962.
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838-1848.
Leape LL. Reporting of adverse events. N Engl J Med. 2002;347(20):1633-1638.
Leape LL, Berwick DM. Five years after to err is human: what have we learned? JAMA. 2005;293(19):2384-2390.
Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard medical practice study II. N Engl J Med. 1991;324(6):377-384.
Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282(3):267-270.
Litynski GS. Endoscopic surgery: the history, the pioneers. World J Surg. 1999;23(8):745-753.
Lowry J, Cripps J. Results of the online EWTD trainee survey. Bull R Coll Surg Engl. 2005;87(3):86-87.
Lupien SJ, Maheu F, Tu M, Fiocco A, Schramek TE. The effects of stress and stress hormones on human cognition: implications for the field of brain and cognition. Brain Cogn. 2007;65(3):209-237.
McKee M, Healy J. Hospitals in a Changing Europe. Buckingham: Open University Press; 2002.
Meumann E. Haus-und Schularbeit: Experimente an Kindern der Volkschule. [Home and schoolwork: experiments on children in school]. Die Deutsche Schule. 1904;8:278-303; 337-359; 416-431.
Millenson ML. Pushing the profession: how the news media turned patient safety into a priority. Qual Saf Health Care. 2002;11(1):57-63.
Mills DH. Medical insurance feasibility study: a technical summary. West J Med. 1978;128(4):360-365.
Moore-Ede M. Twenty-Four-Hour Society: Understanding Human Limits in a World That Never Stops. Reading: Addison Wesley Publishing Company; 1993.
NIH. Consensus development panel. Gallstones and laparoscopic cholecystectomy. (National Institutes of Health Consensus Development Panel on Gallstone and Laparoscopic Cholecystetomy). JAMA. 1993;269(8):1018-1024.
NIH. The NIH almanac – appropriations. May 14, 2010. From: http://www.nih.gov/about/almanac/appropriations/index.htm. Retrieved September 19, 2010.
Oxford English Dictionary (ed) (Vol. 24) Oxford: Oxford University Press; 2004.
Pais A. Subtle Is the Lord: The Science and the Life of Albert Einstein. Oxford: Oxford University Press; 2005.
Patkin M. Ergonomics applied to the practice of microsurgery. Aust N Z J Surg. 1977;47(3):320-329.
Patkin M, Isabel L. Ergonomics and Laparoscopic General Surgery. Laparoscopic Abdominal Surgery. New York: McGraw-Hill; 1993.
Pellegrini CA. Surgical education in the United States: navigating the white waters. Ann Surg. 2006;244(3):335-342.
Pellegrini CA, Sachdeva AK, Johnson KA. Accreditation of education institutes by the American College of Surgeons: a new program following an old tradition. Bull Am Coll Surg. 2006;91(3):8-12.
Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients. Ann Surg. 1991;213(1):3-12.
Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288(9):1112-1114.
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732
Quality Interagency Coordination Task Force (QuIC). Doing what counts for patient safety: federal actions to reduce medical errors and their impact. Journal. From: http://www.quic.gov/report/mederr2.htm. 2000 (accessed 19th September 2010).
Reason J. Human Error. Cambridge: Cambridge University Press; 1990.
Safar P, Brown TC, Holtey WJ, Wilder RJ. Ventilation and circulation with closed-chest cardiac massage in man. JAMA. 1961;176(7):574-576.
Salter B. The Politics of Change in the Health Service. Basingstoke: Macmillan; 1998.
Samkoff JS, Jacques CH. A review of studies concerning effects of sleep deprivation and fatigue on residents’ performance. Acad Med. 1991;66(11):687-693.
Satava RM. Virtual reality surgical simulator. The first steps. Surg Endosc. 1993;7(3):203-205.
Satava RM. Historical review of surgical simulation – a personal perspective. World J Surg. 2008;32(2):141-148.
Schuster M, Rhodes S. The impact of overtime work on industrial accident rates. Ind Relat J Economy Soc. 1985;24(2):234-246.
Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236(4):458-463; discussion 463-454.
Sheldon GF. Surgical workforce since the 1975 study of surgical services in the United States: an update. Ann Surg. 2007;246(4):541-545.
Slack PS, Ma X. Time dependency assessment of muscular fatigue index and hand tremor under operating conditions. IEEE. 2007:4822-4825.
Smith R. All changed, changed utterly. Br Med J. 1998;316(7149):1917-1918.
Smith C, Wise MN. Energy and Empire: A Biographical Study of Lord Kelvin. Cambridge: Cambridge University Press; 1989.
Spritz N. Oversight of physicians’ conduct by state licensing agencies. Ann Intern Med. 1991;115(3):219-222.
The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 1991;324(16):1073-1078.
Van Der Weyden MB. The Bundaberg Hospital scandal: the need for reform in Queensland and beyond. Med J Aust. 2005;183(6):284-285.
Villaneuva T. European working time directive faces challenges. Can Med Assoc J. 2010;182(1):E39-E40.
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322(7285):517-519.
Wachter RM. The end of the beginning: patient safety five years after’to err is human’. Journal, W4-534-545. From: http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.534v1. 2004.
Wallack MK, Chao L. Resident work hours: the evolution of a revolution. Arch Surg. 2001;136(12):1426-1431.
Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Qual Health Care. 2001;10(4):250-256.
Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA. 2002;287(8):955-957.
Whang EE, Mello MM, Ashley SW, Zinner MJ. Implementing resident work hour limitations: lessons from the New York State experience. Ann Surg. 2003;237(4):449-455.
Wojtczak-Jaroszowa J, Jarosz D. Time-related distribution of occupational accidents* 1. J Safety Res. 1987;18(1):33-41.
Yerkes RM, Dodson JD. The relationship of stimulus to rapidity of habit formation. J Comp Neurol Psychol. 1908;18:459-482.
Zajonc RB. Social facilitation. Science. 1965;149(3681):269-274.
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Gallagher, A.G., O’Sullivan, G.C., O’Sullivan, G.C. (2011). Agents of Change. In: Fundamentals of Surgical Simulation. Improving Medical Outcome - Zero Tolerance. Springer, London. https://doi.org/10.1007/978-0-85729-763-1_1
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