| 期刊論文1. | Benn, J.、Koutantji, M.、Wallace, L.、Spurgeon, P.、Rejman, M.、Healey, A.、Vincent, C.(2009)。Feedback from incident reporting: information and action to improve patient safety。Quality and Safety in Health Care,18(1),11-21。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 2. | Hutchinson, A.、Young, T. A.、Cooper, K. L.、McIntosh, A.、Karnon, J. D.、Scobie, S.、Thomson, R. G.(2009)。Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System。Quality and Safety in Health Care,18(1),5-10。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 3. | 石崇良、侯勝茂、薛亞聖、鍾國彪、蘇喜、廖熏香(20050100)。異常事件通報系統與通報障礙。臺灣醫學,9(1),63-70。 延伸查詢![new window](/gs32/images/newin.png) | 4. | Diller, Thomas、Helmrich, George、Dunning, Sharon、Cox, Stephanie、Buchanan, April、Shappell, Scott(2014)。The Human Factors Analysis Classification System (HFACS) Applied to Health Care。American Journal of Medical Quality,29(3),181-190。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 5. | Wang, Chen-hsu、Shih, Chung-liang、Chen, Wen-jing、Hung, Sheng-hui、Jhang, Wei-jia、Chuang, Li-ju、Wang, Pa-chun(20160600)。Epidemiology of Medical Adverse Events: Perspectives from a Single Institute in Taiwan。Journal of the Formosan Medical Association,115(6),434-439。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 6. | Bowie, P.、Skinner, J.、Wet, C.(2013)。Training health care professionals in root cause analysis: a crosssectional study of post-training experience, benefits and attitudes。BMC Health Services Research,13(50)。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 7. | Peerally, M. F.、Carr, S.、Waring, J.、Dixon-Woods, M.(2017)。The problem with root cause analysis。BMJ Quality & Safety,26(5),417-422。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 8. | Rabøl, L. I.、Andersen, M. L.、Østergaard, D.、Bjørn, B.、Lilja, B.、Mogensen, T.(2011)。Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals。BMJ Quality & Safety,20(3),268-274。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 9. | Khorsandi, M.、Skouras, C.、Beatson, K.、Alijani, A.(2012)。Quality review of an adverse incident reporting system and root cause analysis of serious adverse surgical incidents in a teaching hospital of Scotland。Patient Safety in Surgery,6(1)。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 10. | Kellogg, K. M.、Hettinger, Z.、Shah, M.(2017)。Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?。BMJ Quality & Safety,26(5),381-387。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 11. | Farley, D. O.、Haviland, A.、Champagne, S.(2008)。Adverse-event-reporting practices by US hospitals: results of a national survey。BMJ Quality & Safety,17(6),416-423。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 12. | Kim, J.、Kim, S.、Jung, Y.、Kim, E. K.(2010)。Status and Problems of Adverse Event Reporting Systems in Korean Hospitals。Healthcare Informatics Research,16(3),166-176。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 13. | Hanskamp-Sebregts, M.、Zegers, M.、Vincent, C.、Van Gurp, P. J.、De Vet, H. C. W.、Wollersheim, H.(2016)。Measurement of patient safety: a systematic review of the reliability and validity of adverse event detection with record review。BMJ Open,6(8)。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 14. | Mitchell, R. J.、Williamson, A. M.、Molesworth, B.、Chung, A. Z. O.(2014)。A review of the use of human factors classification frameworks that identify causal factors for adverse events in the hospital setting。Ergonomics,57(10),1443-1472。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 15. | Gurses, A. P.、Ozok, A. A.、Pronovost, P. J.(2012)。Time to accelerate integration of human factors and ergonomics in patient safety。BMJ Quality & Safety,21(4),347-351。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 16. | Taylor-Adams, S.、Vincent, C.(2004)。Systems Analysis of Clinical Incidents: The London Protocol。Clinical Risk,10(6),211-220。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 17. | Mire, J. J.、Lorenzo, S.、Carrillo, Irene、Ferrús, Lena、Scott, Susan D.(2017)。Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations。International Journal for Quality in Health Care,29(4),450-460。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 18. | Reason, J.(1995)。Understanding Adverse Events: Human Factors。Quality in Health Care,4(2),80-89。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 圖書1. | Institute of Medicine、Kohn, Linda T.、Corrigan, Janet M.、Donaldson, Molla S.(2000)。To Err Is Human: Building a Safer Health System。Washington, D.C.:National Academies Press。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 2. | 財團法人醫療品質暨醫院評鑑策進會(2006)。根本原因分析法教師版手冊。行政院衛生署。 延伸查詢![new window](/gs32/images/newin.png) | 3. | Kahneman, Daniel、洪蘭(2020)。快思慢想。天下文化。 延伸查詢![new window](/gs32/images/newin.png) | 其他1. | Wiegmann, D. A.,Shappell, S. A.(2016)。Human Factors Analysis and Classification System,https://www.hfacs.com/hfacs-framework.html。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 2. | Human Factors Analysis Classification System。Human factors definition,https://www.hfacs.com/。 ![](/gs32/thssjcncl/image/nclsfx.gif) ![new window](/gs32/images/newin.png) | 3. | 財團法人醫療品質暨醫院評鑑策進會。台灣病人安全通報系統2019年年報,https://www.patientsafety.mohw.gov.tw/Content/Downloads/List01.aspx?SiteID=l&MmmID=621273303702500244。 延伸查詢![new window](/gs32/images/newin.png) | |