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Richard Cook:Dr. Richard Cook is the Professor of Healthcare System Safety and the chief of the patient safety division in the Skolan för teknik och hälsa  [School of Technology and Health] at KTH, the Kungliga Tekniska Hogskölan [Royal Institute of Technology ] in Stockholm, Sweden.  

Dr. Cook graduated with honors from Lawrence University where he was a Scholar of the University.  He worked in the computer industry in supercomputer system design and engineering applications.  He received the MD degree from the University of Cincinnati in 1986 where he was a General Surgery intern.  Between 1987 and 1991 he was researcher on expert human performance in Anesthesiology and Industrial and Systems Engineering at The Ohio State University.  He completed an Anesthesiology residency at The Ohio State University in 1994.  From November 1994 until March 2012 he was a practicing anesthesiologist, teacher, and researcher in the Department of Anesthesia and Intensive Care at the University of Chicago.

Dr. Cook is an internationally recognized expert on medical accidents, complex system failures, and human performance at the sharp end of these systems.  He has investigated a variety of problems in such diverse areas as urban mass transportation, semiconductor manufacturing, and military software systems.  He is often a consultant for not-for-profit organizations, government agencies, and academic groups. His most often cited publications are "Gaps in the continuity of patient care and progress in patient safety", "Operating at the Sharp End: The complexity of human error", "Adapting to New Technology in the Operating Room", and the report "A Tale of Two Stories: Contrasting Views of Patient Safety", and “Going Solid: A Model of System Dynamics and Consequences for Patient Safety”.

Dr. Cook lives in Stockholm.

Contact information:

Mailing address:

Professor Richard I Cook, MD
STH (Skolan för teknik och hälsa)
KTH (Kungliga Tekniska högskolan)
Alfred Nobels Allé 10
141 52 Huddinge, SWEDEN

personal mobile: +46 70 190 42 16

email: rcook at-sign kth.se


Most-Cited Works
- Cook RI, Render ML, Woods DD [2000] Gaps in the continuity of care and progress on patient safety British Medical Journal. 320(7237): 791-4. (226 KB)
- Cook RI, Woods DD [1994] Operating at the Sharp End: The Complexity of Human Error In Bogner MS (Ed.). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates. 255-310. (669 KB)
- Cook RI [2005] A Brief Look at the New Look in Complex System Failure, Error, Safety & Resilience (929 KB)

2006
- Nemeth CP, O'Connor MF, Nunnally ME, Cook RI [2007] RePresenting Reality: The Human Factors of Health Care Information In Carayon, P. (Ed.). The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ. Lawrence Erlbaum Associates: 439-55.
- Woods DD, Patterson ES, Cook RI [2007] Behind Human Error: Taming Complexity to Improve Patient Safety In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ. Lawrence Erlbaum Associates: 459-76. (1.9 MB)
- Cook RI [2006] Hobson’s choices: Matching and mismatching in transplantation work processes In Wailoo K, Livingston J & Guarnaccia P (Eds.). A Death Retold: Jesica Santillan, the Bungled Transplant, and Paradoxes of Medical Citizenship. University of North Carolina Press: (1.32 MB)
- Nemeth CP, O'Connor MF, Klock PA, Cook RI [2006] Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work Organization Studies: Special issue on Naturalistic Decision Making. 27(7): 1011-35.
- Cook RI, Woods DD [2006] Distancing Through Differencing: An Obstacle to Organizational Learning Following Accidents In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts. Aldershot: Ashgate: 329-38. (2.79 MB)
- Woods DD, Cook RI [2006] Incidents - Markers of Resilience or Brittleness? In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts. Aldershot: Ashgate: 69-76. (2.21 MB)
- Cook RI, Nemeth CP [2006] Taking Things in One's Stride: Cognitive Features of Two Resilient Preformances In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts. Aldershot: Ashgate: 205-21. (4.74 MB)
- Patterson ES, Woods DD, Roth EM, Cook RI, Wears RL, Render ML [2006] Three Key Levers for Achieving Resilience in Medication Delivery with Information Technology Journal of Patient Safety. 2(1): 33-8. (138 KB)
- Cook RI [2006] Being Bumpable: Consequences of Resource Saturation and Near-Saturation for Cognitive Demands on ICU Practitioners Joint Cognitive Systems: Patterns in Cognitive Systems Engineering. : 23-35. (7,702 KB)

2005
- Nunnally ME, Bitan Y, Nemeth CP, O'Connor MF, Cook RI [2005] Failure in context: linking observed behavior to cognition, tasks, and adverse events Anesthesiology. 103: A1296. (724 KB)
- Cook RI, Ghiardi G, Nemeth CP, O'Connor MF [2005] Discovering variability in infusion device flow rates by automated gravimetric measurement Anesthesiology. 103: A885. (446 KB)
- Nemeth CP, Kowalsky J, Brandwijk M, O'Connor MF, Nunnally ME, Klock PA, Cook RI [2005] Distributed cognition: how hand-off communication actually works Anesthesiology. 103: A1289. (1.01 MB)
- Nemeth CP, Cook RI [2005] Hiding in plain sight: What Koppel et al. Tell Us About Healthcare IT Journal of Biomedical Informatics. 38 (4): 262-3. (84 KB)
- Nemeth CP, O'Connor MF, Klock PA, Cook RI [2005] Temporal Cognitive Work: Discovering Requirements for Digital Artifacts Eleventh International Conference on Human-Computer Interaction. Las Vegas: (255 KB)
- Cook RI [2005] Toward a Theory of Patient Safety - Lessons From the First Decade In Tartaglia R, Bagnara S Bellandi T & Albolino S (Eds). Healthcare Systems Ergonomics and Patient Safety. : (398 KB)
- Cook RI, Rasmussen J [2005] Going Solid: A Model of System Dynamics and Consequences for Patient Safety Quality & Safety in Health Care. 14(2): 130-4. (174 KB)
- Albolino S, Cook RI [2005] Making Sense of Risks: A Field Study in an Intensive Care Unit In Tartaglia R, Bagnara S Bellandi T & Albolino S (Eds). Healthcare Systems Ergonomics and Patient Safety. 208-14. (4992 KB)
- Perry S, Wears RL, Cook RI [2005] The Role of Automation in Complex System Failures Journal of Patient Safety. 1(1): 56-61. (101 KB)
- Cook RI [2005] Lessons from the War on Cancer Journal of Patient Safety. 1(1): 7-8. (1635 KB)
- Nemeth CP, O'Connor MF, Klock PA, Cook RI [2005] Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding Advances in Patient Safety: From Research to Implementation. Agency for Healthcare Research. Washington, DC. 2: 279-92. (644 KB)
- Cook RI, O'Connor MF [2005] Thinking About Accidents and Systems In Manasse HR & Thompson KK (Eds.), Medication Safety: A Guide to Health Care Facilities. Bethesda, MD:ASHP: 73-87. (345 KB)
- Nemeth CP, Nunnally ME, O'Connor MF, Klock PA, Cook RI [2005] Making Information Technology a Team Player in Safety: The Case of Infusion Devices. In K. Henricksen & J. B. Battles & E. Marks & D. I. Lewin (Eds.). Advances in Patient Safety: From Research to Implementation. Agency for Health Care Research. Washington, DC. 1: 319-30. (361 KB)
- Nemeth CP, Nunnally ME, O'Connor MF, Klock PA, Cook RI [2005] Getting to the Point: Developing IT for the Sharp End of Healthcare Journal of Biomedical Informatics. 38(1): 18-25. (643 KB)

2004
- Nemeth CP, Cook RI, Patterson ES, Donchin Y, Rogers ML, Ebright PR [2004] Afterwords: The Quality of Medical Accident Investigations and Analyses Human Factors and Ergonomics Society National Conference. New Orleans. (173 KB)
- Rogers ML, Cook RI, Bower R, Molloy M, Render ML [2004] Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work Analysis IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans. 34(6): (451 KB)
- Nemeth CP, Wears RL, O'Connor MF, Perry S, Cook RI [2004] Crafting Information Technology Solutions, Not Experiments, for the Emergency Department Academic Emergency Medicine. 11(11): 1114-7. (128 KB)
- O'Connor MF, Nunnally ME, Cook RI [2004] Deriving the Most Benefit from Bar Coded Medication Administration APSF Newsletter. 19(2): 24.
- Nemeth CP, Cook RI [2004] Discovering and Supporting Temporal Cognition in Complex Environments In Proceedings of theTwenty-Sixth Annual Conference of the Cognitive Science Society. Chicago: 1005-10. (1.07 MB)
- Patterson ES, Cook RI, Woods DD, Render ML [2004] Examining the Complexity Behind a Medication Error: Generic Patterns in Communication IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans. 34(6): (342 KB)
- Nunnally ME, Nemeth CP, O'Connor MF, Cook RI [2004] Fixing Drug and Pump Mismatches: How Practitioners Make Up the Difference Through Coping Strategies Anesthesiology. 101: A1284. (1093 KB)
- Nemeth CP [2004] Further Thoughts on Being Forehanded Conference on Surgical Errors. U.S. Army Medical Command (MEDCOM): Washington, DC. (89.5 KB)
- Nemeth CP, Klock PA, O'Connor MF, Cook RI [2004] How Cognitive Artifact Support of Acute Care Distributed Cognition Affects Patient Safety International Conference on Probabilistic Safety Assessment and Management (PSAM) Conference. Berlin. (322 KB)
- Nemeth CP, Conran A, Nunnally ME, O'Connor MF, Cook RI [2004] Laying Traps: How Infusion Device Interface Design Contributes to Adverse Events Anesthesiology. 101: A1296. (300 KB)
- Nunnally ME, Nemeth CP, Brunetti VL, Cook RI [2004] Lost in Menuspace: User Interactions with Complex Medical Devices. IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans. 34(6): 736-42. (566 KB)
- Cook RI, Nemeth CP, Brandwijk M [2004] Technical Work Studies: Understanding Human Work Amid Complexity, Uncertainty, and Conflict Administration for Healthcare Research and Quality 3rd Annual Patient Safety Research Conference. Arlington, VA. (71 KB)
- Wears RL, Cook RI [2004] The Illusion of Explanation Acedemic Emergency Medicine. 11(10): 1064-5. (43 KB)
- Nemeth CP, Cook RI, Woods DD [2004] The Messy Details: Insights from Technical Work in Healthcare IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans. 34(6): 689-92. (442 KB)
- Nemeth CP, Cook RI, Kowalsky J, Brandwijk M [2004] Understanding Sign Outs: Conversation Analysis Reveals ICU Handoff Content and Form Critical Care Medicine. 32 (12): A29. (161 KB)
- Nemeth CP, Cook RI, O'Connor MF, Klock PA [2004] Using Cognitive Artifacts to Understand Distributed Cognition IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans. 34(6): 726-35. (1221 KB)

2003
- Cook RI, Brandwijk M, Kahana M, O'Connor MF, Brunetti VL, Nemeth CP [2003] Being Bumpable:Consequences of Resource Saturation and Near-saturation for Cognitive Demand on ICU Practitioners International Anesthesia Research Society National Conference. New Orleans: (200 KB)
- Brandwijk M, Nemeth CP, O'Connor MF, Kahana M, Cook RI [2003] Distributing Cognition: ICU Handoffs Conform to Grice's Maxims SCCM. San Antonio. (161 KB)
- Cook RI [2003] Seeing is Believing Annals of Surgery. 237(4): 472-3. (75 KB)
- Nemeth CP, Cook RI, O'Connor MF, Klock PA [2003] Using Cognitive Artifacts to Understand Distributed Cognition (HFES) In Xiao Y, Special Session on Distributed Planning. IEEE International Conference on Systems, Man & Cybernetics. Washington, DC. (54 KB)
- Nunnally ME, O'Connor MF, Cook RI [2003] Using Finite State Modeling To Compare and Contrast Infusion Devices in the Context of Device Specificity Anesthesiology. 99(3A): A532. (17 KB)

2002
- Nemeth CP, Klock PA, Daves S, Cook RI [2002] A Study of How Cognitive Artifacts Affect Distributed Cognition in Operating Room Management Anesthesiology. 97(3A): A1183. (569 KB)
- Nunnally ME, Brunetti VL, Gosbee J, Crowley J, Cook RI [2002] Features of Infusion Device Related Incidents Revealed by Systematic Analysis of an Incident Reporting Database Anesthesiology. 97(3A): A1073. (13 KB)
- Patterson ES, Cook RI, Render ML [2002] Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration Journal of the American Medical Information Association. 9(5): 540-53. (308 KB)
- Nunnally ME, Brunetti VL, Woods DD, Cook RI [2002] Infusion Device Characteristics Related to User Error during Programming and Operation Determined by Finite State Modeling Anesthesiology. 97(3A): A520. (14 KB)
- Nunnally ME, Brunetti VL, O'Connor MF, Render ML, Cook RI [2002] Lost in Menuspace: Variability among Users Programming Infusion Devices under Controlled Conditions Anesthesiology. 97(3A): (17 KB)
- Woods DD, Cook RI [2002] Nine Steps to Move Forward from Error Cognitive Technology & Work. 4(2): 137-44. (84 KB)
- Cook RI [2002] Safety Technology: Solutions or Experiments Nursing Economics. 20(2): (576 KB)
- O'Connor MF, Tung A, Nunnally ME, Daves SA, Cook RI [2002] Upper Bound for Performance of Incident Reporting Systems Based on Experience with Phase III Adverse Event Reporting Anesthesiology. 97(3A): (13.4 KB)
- Cook RI [2002] Who's Sorry Now? SEA Meeting. : (101 KB)

2001
- O'Connor MF, Daves SA, Tung A, Cook RI, Thisted R, Apfelbaum J [2001] BIS Monitoring to Prevent Awareness During General Anesthesia Anesthesiology. 94(3): 520-2. (115 KB)
- Woods DD, Cook RI [2001] From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety. In Zipperer L & Cushman S (Eds.). Lessons in Patient Safety. A Primer. : National Patient Safety Foundation. Chicago, 89-97. (3631 KB)
- Cook RI [2001] The End of the Beginning: Complexity and Craftsmanship and the Era of Sustained Work on Patient Safety The Joint Commision Journal on Quality Improvement. 27(10): 507-8. (172 KB)

2000
- Cook RI, Render ML, Woods DD [2000] Gaps in the continuity of care and progress on patient safety British Medical Journal. 320(7237): 791-4. (226 KB)
- Cook RI [2000] How Complex Systems Fail . (35 KB)
- MacReady N [2000] Second Stories, Sharp Ends: Dissecting Medical Errors The Lancet. 355: 994. (48 KB)

1999
- Woods DD, Cook RI [1999] Perspectives on Human Error: Hindsight Bias and Local Rationality In Durso F, Nickerson R & Schvanevelt J (Eds.). Handbook of Applied Cognition. New York: (17189 KB)

1998
- Cook RI, Woods DD, Miller C [1998] A Tale of Two Stories: Contrasting Views of Patient Safety National Health Care Safety Council of the National Patient Safety Foundation at the AMA. Chicago: (1068 KB)
- Woods DD, Cook RI [1998] Characteristics of Patient Safety . : (22 KB)
- Cook RI [1998] Two Years Before the Mast: Learning How to Learn about Patient Safety Enhancing Patient Safety and Reducing Errors in Health Care. : (994 KB)

1997 and earlier
- Cook RI [1997] Observations on RISKS and Risks Communications of the ACM. 40(3): 122. (158)
- Cook RI, Woods DD [1996] Adapting to New Technology in the Operating Room Human Factors. 38(4): 593-613. (11,680 KB)
- Cook RI, Woods DD [1996] Implications of Automation Surprises in Aviation for TIVA Journal of Clinical Anesthesia. 8(3 Suppl): 29S-37S. (582)
- Cook RI, Woods DD, Walters M, Christoffersen K [1996] The Cognitive Systems Engineering of Automated Medical Evacuation Scheduling and its Implications 3rd Annual Symposium of Human Interaction with Complex Systems. : (791 KB)
- Cook RI, Woods DD [1994] Operating at the Sharp End: The Complexity of Human Error In Bogner MS (Ed.). Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates. 255-310. (669 KB)
- Cook RI, Woods DD, Howie MB, Horrow JC, Gaba DM [1992] Case 2-1992. Unintentional Delivery of Vasoactive Drugs with an Electromechanical Infusion Devise Journal of Cardiothoracic and Vascular Anesthesia. 6(2): 238-44. (4849 KB)
- Cook RI, Potter SS, Woods DD, McDonald JS [1991] Evaluating the Human Enginering of Microprocessor-Controlled Operating Room Devices Journal of Clinical Monitoring. 7(3): 217-26. (6699 KB)
- Cook RI [1989] Learning Theories Implicit in Medical School Lectures JAMA. 261(15): 2244-5. (717 KB)
- Cook RI, Woods DD, McDonald JS [1989] On Attributing Critical Incidents to Factors in the Environment Anesthesiology. 71(5): 808. (604 KB)

 
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