Correlating data from different sensors to increase the positive predictive value of alarms: an empiric assessment
    (2012), F1000 Research , 1:45 , 0
Correlating data from different sensors to increase the positive predictive value of alarms: an epiric assessment
    (2012), HFES 2012 Symposium on Human Factors and Ergonomics in Health Care , Baltimore, MD

Dissenting Statement: Health IT is a Class III Medical Device
    (2011), Health IT and Patient Safety: Building Safer Systems of Better Care
How do clinicians reconcile conditions and medications? The cognitive context of medication reconciliation.
    (2011), Cognition, Techology & Work , (In Press)
Resilience is not control: healthcare, crisis management, and ICT
    (2011), Cognition, Technology & Work , 13 , 189-202
Perspective: The Safety of Medical Devices. Web M&M: Morbidity and Mortality Rounds on the Web.
    (2011), The Agency for Healthcare Research and Quality. Washington, DC.
Making sense of diseases in medication reconciliation
    (2011), Cognition, Technology & Work , 13 , 151-8

An alternative point of view: Getting by with less: What's wrong with perfection?
    (2010), Critical Care Medicine , 38(11) , 2247-9
Getting Better at Being Worse (Editorial)
    (2010), Annals of Emergency Medicine , 56(5) , 465-7
Does Telemedicine Have a Role in the Intensive Care Unit? What Is It? Does It Make a Difference?
    (2010), In Deutschman CS, Neligan PJ (Eds.) Evidence-Based Practice of Critical Care , Philadelphia, PA: Saunders , 693-7
How Complex Systems Fail
    (2010), In Allspaw J & Robbins J. Web Operations: Keeping the Data On Time
"Those found responsible have been sacked": some observations on the usefulness of error
    (2010), Cognition, Technology & Work , 12 , 87-93

Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety
    (2009), Quality and Safety in Health Care , 18(6) , 505-9
Between Choice and Chance: The Role of Human Factors in Acute Care Equipment Decisions
    (2009), Journal of Patient Safety , 5(2) , 114-121

Minding the gaps: Creating resilience in healthcare, In K Henriksen, JB Battles, MA Keyes and ML Grady (Eds.)
    (2008), Advances in patient safety: New directions and alternative approaches. Vol. 3. Performance and Tools, AHRQ Publication No. 08-0034-3 , Rockville, MD: AHRQ , 259-71
The Path to Resilience in Ambulatory Care
    (2008), AHRQ 2008 Conference: Promoting Quality...Partnering for Change
What's Missing
    (2008), Presentation at the International System Safety Conference 2008
Engaging Data, How Practitioners Resolve Complex Information
    (2008), Anesthesiology , 109 , A1635
Please Do Not Leave Your Bags Unattended!
    (2008), Anesthesiology , 109 , A1170
Anesthesia for Electroconvulsive Therapy: Does the Device Make a Difference?
    (2008), Anesthesiology , 109 , A280
Resilience Engineering Perspectives, Volume 1: Remaining Sensitive to the Possibility of Failure
    (2008), Book , Aldershot,UK: Ashgate Publishing
What went wrong at the Beatson Oncology Centre
    (2008), In Hollnagel E, Nemeth CP & Dekker S (Eds.), Resilience Engineering Perspectives, Volume 1: Remaining Sensitive to the Possibility of Failure , Aldershot: Ashgate , 225-35
The Context for Improving Healthcare Team Communications
    (2008), In Nemeth CP (Ed.), Improving Healthcare Team Communication , Aldershot: Ashgate , 1-7
A Healthcare Team Communication Research Agenda
    (2008), In Nemeth CP (Ed.), Improving Healthcare Team Communication , Aldershot: Ashgate , 245-50
Between Shifts: Healthcare Communication in the PICU
    (2008), In Nemeth CP (Ed.), Improving Healthcare Team Communication , Aldershot: Ashgate , 135-53
Resilience Engineering: The Birth of a Notion
    (2008), In Hollnagel E, Nemeth CP & Dekker S (Eds.), Resilience Engineering Perspectives, Volume 1: Remaining Sensitive to the Possibility of Failure , Aldershot: Ashgate , 3-9
Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace
    (2008), Aldershot, UK: Ashgate Publishing
For resilient IT: Don't mimic the past, leverage the future
    (2008), Conference on Systems Engineering Research , Redondo Beach, CA

Probabilistic Risk Assessment of Accidental ABO-Incompatible Thoracic Organ Transplantation Before and After 2003
    (2007), Transplantation , 84(12) , 162-9
Can a log of infusion device events be used to understand infusion accidents?
    (2007), Journal of Patient Safety , 3(4) , 208-13
Healthcare IT as a Source of Resilience
    (2007), In Nemeth, C. (chair) Symposium on Resilience in Health Systems. Proceedings of the International Conference on Systms, Man and Cybernetics , Montreal
Reliability Versus Resilience: What Does Healthcare Really Need?
    (2007), In Dominguez, C. (chair) Symposium on High Reliability in Healthcare. Proceedings of the Human Factors and Ergonomics Society Annual Meeting , Baltimore , 621-5
Studying the technical work of Emergency Care
    (2007), Annals of Emergency Medicine , 50(4) , 384-6
Medical event data collection and analysis service (MEDCAS), an NTSB for medicine
    (2007), Anesthesiology , 107 , A1789
What are they saying? Device logs don't tell us as much as they could about events
    (2007), Anesthesiology , 107 , A1598
Not a black box: infusion devices are not used like aviation data recorders in accident analysis
    (2007), Anesthesiology , 107 , A1595
Let the record show: an infusion device doesn't record critical evidence
    (2007), Anesthesiology , 107 , A1600
Healthcare groups at work: further lessons from research into large-scale coordination
    (2007), Cognition, Technology & Work , 9(3) , 127-30
Regularly irregular: how groups reconcile cross-cutting agendas and demand in healthcare
    (2007), Cognition, Technology and work , 9(3) , 139-48
Sensemaking, safety, and cooperative work in the intensive care unit
    (2007), Cognition, Technology & Work , 9(3) , 131-7
Collaborative cross-checking to enhance resilience
    (2007), Cognition, Technology & Work , 9(3) , 155-62
Self-initiated and respondent actions in a simulated control task
    (2007), Ergonomics , 50(5) , 763-88
Groups at work: lessons from research into large-scale coordination
    (2007), Cognition, Technology & Work , 9(1) , 1-4
Replacing hindsight with insight: Toward better understanding of diagnostic failures
    (2007), Annals of Emergency Medicine , 49(2) , 206-9
Gaps and resilience
    (2007), In MS Bogner (Ed). Human Error in Medicine (2nd ed.) , (in press)
Behind Human Error: Taming Complexity to Improve Patient Safety
    (2007), In Carayon P (Ed.). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ , Lawrence Erlbaum Associates , 459-76
RePresenting Reality: The Human Factors of Health Care Information
    (2007), In Carayon, P. (Ed.). The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ , Lawrence Erlbaum Associates , 439-55

To err is not always human
    (2006), Medicine on the Midway , 60(1) , 40-1
Creating resilient IT: How the sign-out sheet shows clinicans make healthcare work
    (2006), Proceedings of the American Medical Informatics Association Annual Symposium , Washington, DC , 584-8
Clinical human-centered research: Bridging social science and engineering
    (2006), Paper presented at the ABMS-ACGME: Assessing and Improving Patient Care Conference , Rosemont, IL
Learning from investigation: Experience with understanding healthcare adverse events
    (2006), Proceedings of the Human Factors and Ergonomics Society Annual Meeting , San Francisco, CA
Before I forget: How clinicians cope with uncertainty through ICU sign-outs
    (2006), Proceedings of the Human Factors and Ergonomics Society Annual Meeting , San Francisco, CA
Hobson’s choices: Matching and mismatching in transplantation work processes
    (2006), 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 , 46-69
The Ambu Bag is Superior to the Mapleson D for Hyperventilating Electroconvulsive Therapy Patients
    (2006), Anesthesiology , 105 , A1277
Don't Close the Valve! The Effect of Closing the Valve on Ventilation in Patients Undergoing ECT
    (2006), Anesthesiology , 105 , A939
Time to Get Off This Pig's Back? The Human Factors Aspects of the Mismatch Between Device and Real-World Knowledge in the Health Care Environment
    (2006), Journal of Patient Safety , 2(3) , 124-31
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work
    (2006), Organization Studies: Special issue on Naturalistic Decision Making , 27(7) , 1011-35
Case 2-2006: Catastrophic cardiovascular collapse during carotid endarterectomy
    (2006), Journal of Cardiothoracic & Vascular Anesthesia , 20(2) , 259-68
Distancing Through Differencing: An Obstacle to Organizational Learning Following Accidents
    (2006), In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts , Aldershot: Ashgate , 329-38
Incidents - Markers of Resilience or Brittleness?
    (2006), In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts , Aldershot: Ashgate , 69-76
Taking Things in One's Stride: Cognitive Features of Two Resilient Preformances
    (2006), In E Hollnagel, DD Woods & N Leveson (Eds). Resilience Engineering: Concepts and Precepts , Aldershot: Ashgate , 205-21
Three Key Levers for Achieving Resilience in Medication Delivery with Information Technology
    (2006), Journal of Patient Safety , 2(1) , 33-8
Being Bumpable: Consequences of Resource Saturation and Near-Saturation for Cognitive Demands on ICU Practitioners
    (2006), Joint Cognitive Systems: Patterns in Cognitive Systems Engineering , 23-35

Automation, interaction, complexity and failure: A case study
    (2005), Paper presented at the 2nd Workshop on Complexity in Design and Engineering , University of Glasgow, Scotland
Failure in context: linking observed behavior to cognition, tasks, and adverse events
    (2005), Anesthesiology , 103 , A1296
Discovering variability in infusion device flow rates by automated gravimetric measurement
    (2005), Anesthesiology , 103 , A885
Distributed cognition: how hand-off communication actually works
    (2005), Anesthesiology , 103 , A1289
Mapping Cognitive Work: The Way Out of Healthcare IT System Failures
    (2005), Proceedings of the American Medical Informatics Association Annual Symposium , Washington, DC , 560-4
Central Venous Oxygen Saturation Does Not Correlate with Serum Lactate in Patients with Cardiogenic Shock after Cardiac Surgery
    (2005), Anesthesiology , 103 , A293
Con: Tight Perioperative Glycemic Control: Poorly Supported and Risky
    (2005), Journal of Cardiothoracic and Vascular Anesthesia , 19(5) , 689-90
Large Scale Coordination: The Study of Groups at Work
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting , 527-8
Collaborative Cross-Checking to Enhance Resilience
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting , 512-6
Brave New World: Medical Devices, Clinical Information Systems, Networks, and Patient Safety
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting
Above Board: Issues in Medical Account Investigation and Analysis
    (2005), Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting
Hiding in plain sight: What Koppel et al. Tell Us About Healthcare IT
    (2005), Journal of Biomedical Informatics , 38 (4) , 262-3
Temporal Cognitive Work: Discovering Requirements for Digital Artifacts
    (2005), Eleventh International Conference on Human-Computer Interaction , Las Vegas
Toward a Theory of Patient Safety - Lessons From the First Decade
    (2005), In Tartaglia R, Bagnara S Bellandi T & Albolino S (Eds). Healthcare Systems Ergonomics and Patient Safety , 23-6
Going Solid: A Model of System Dynamics and Consequences for Patient Safety
    (2005), Quality & Safety in Health Care , 14(2) , 130-4
Making Sense of Risks: A Field Study in an Intensive Care Unit
    (2005), In Tartaglia R, Bagnara S Bellandi T & Albolino S (Eds). Healthcare Systems Ergonomics and Patient Safety , 208-14
The Role of Automation in Complex System Failures
    (2005), Journal of Patient Safety , 1(1) , 56-61
Lessons from the War on Cancer
    (2005), Journal of Patient Safety , 1(1) , 7-8
A brief look at Going Solid and the Dynamics of Safety
    (2005)
Cognitive Artifacts in Complex Work.
    (2005), In Cai Y (Ed.). Ambient Intelligence for Scientific Discovery: Foundations, Theories, and Systems. Lecture Notes in Computer Science , 3345 , 152-83
Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding
    (2005), Advances in Patient Safety: From Research to Implementation , Agency for Healthcare Research. Washington, DC. 2 , 279-92
Thinking About Accidents and Systems
    (2005), In Manasse HR & Thompson KK (Eds.), Medication Safety: A Guide to Health Care Facilities , Bethesda, MD:ASHP , 73-87
Making Information Technology a Team Player in Safety: The Case of Infusion Devices.
    (2005), 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
Health Care Forensics.
    (2005), In Noy, YI. and Karwowski, W. (Eds.). Handbook of Human Factors in Litigation , New York, CRC Press , 37-1 to 37-18
Getting to the Point: Developing IT for the Sharp End of Healthcare
    (2005), Journal of Biomedical Informatics , 38(1) , 18-25
A Brief Look at the New Look in Complex System Failure, Error, Safety & Resilience
    (2005)
A Brief Look at Gaps in the Continuity of Care and how Practitioners Compensate for Them
    (2005)

Operating at the sharp end: The human factors of complex technical work and its implication for patient safety
    (2004), In Manuel BM & Nora PF (eds), Surgical Patient Safety: Essential Information for Surgeons in Today's Environment , Chicago: American College of Surgeons , 19-30
Understanding Sign Outs: Conversation Analysis Reveals ICU Handoff Content and Form
    (2004), Critical Care Medicine , 32 (12) , A29
The Messy Details: Insights from Technical Work in Healthcare
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 689-92
Using Cognitive Artifacts to Understand Distributed Cognition
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 726-35
Examining the Complexity Behind a Medication Error: Generic Patterns in Communication
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 749-56
Barriers to Implementing Wrong Site Surgery Guidelines: A Cognitive Work Analysis
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 757-63
Crafting Information Technology Solutions, Not Experiments, for the Emergency Department
    (2004), Academic Emergency Medicine , 11(11) , 1114-7
Lost in Menuspace: User Interactions with Complex Medical Devices.
    (2004), IEEE Transactions on Systems, Man and Cybernetics - Part A: Systems and Humans , 34(6) , 736-42
Nurses' reactions to alarms in a neonatal intensive care unit
    (2004), Cognition, Technology & Work , 6(4) , 239-46
Fixing Drug and Pump Mismatches: How Practitioners Make Up the Difference Through Coping Strategies
    (2004), Anesthesiology , 101 , A1284
Laying Traps: How Infusion Device Interface Design Contributes to Adverse Events
    (2004), Anesthesiology , 101 , A1296
The Illusion of Explanation
    (2004), Acedemic Emergency Medicine , 11(10) , 1064-5
Afterwords: The Quality of Medical Accident Investigations and Analyses
    (2004), Human Factors and Ergonomics Society National Conference , New Orleans
Discovering and Supporting Temporal Cognition in Complex Environments
    (2004), In Proceedings of theTwenty-Sixth Annual Conference of the Cognitive Science Society , Chicago , 1005-10
SARS, emerging infections, and bioterrorism preparedness
    (2004), The Lancet infectious diseases , 4 , 483-4
Deriving the Most Benefit from Bar Coded Medication Administration
    (2004), APSF Newsletter , 19(2) , 24
Assessing Risk: The Role of Probabilistic Risk Assessment (PRA) in Patient Safety Improvement
    (2004), Quality & Safety in Health Care , 13(3) , 206-12
How Cognitive Artifact Support of Acute Care Distributed Cognition Affects Patient Safety
    (2004), International Conference on Probabilistic Safety Assessment and Management (PSAM) Conference , Berlin
Technical Work Studies: Understanding Human Work Amid Complexity, Uncertainty, and Conflict
    (2004), Administration for Healthcare Research and Quality 3rd Annual Patient Safety Research Conference , Arlington, VA
Further Thoughts on Being Forehanded
    (2004), Conference on Surgical Errors , U.S. Army Medical Command (MEDCOM) , Washington, DC
Mistaking error
    (2004), In Youngberg BJ & Hatlie MJ (eds), The Patient Safety Handbook , Sundbury, MA: Jones and Bartlett Publishers , 95-108
Human Factors Methods for Design
    (2004), Book , London , Taylor and Francis/ CRC Press

How Cognitive Artifacts Support Acute Care Distributed Cognition. In Cook R, Woods D, Insights From Technical Work Studies in Healthcare
    (2003), Symposium at Human Factors and Ergonomics Society National Conference , Denver , 381-5
Using Cognitive Artifacts to Understand Distributed Cognition (HFES)
    (2003), In Xiao Y, Special Session on Distributed Planning. IEEE International Conference on Systems, Man & Cybernetics , Washington, DC
Using Finite State Modeling To Compare and Contrast Infusion Devices in the Context of Device Specificity
    (2003), Anesthesiology , 99(3A) , A532
Seeing is Believing
    (2003), Annals of Surgery , 237(4) , 472-3
The Master Schedule: How Cognitive Artifacts Affect Distributed Cognition in Acute Care
    (2003), Dissertation Abstracts International 64/08 , 3990, (UMI No. AAT 3101124)
Determining the Weights of Scheduling and Responding in the Control of a Dynamic System
    (2003), Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting
Scheduling of Activities and Responding to Alarms in the Control of a Complex System
    (2003), Dissertation Submitted to the Senate of Ban-Gurion University of the Negev
Get Real: The Need for Effective Design Research. Special Issue: Research in Communication Design
    (2003), Visible Language , 37(1)
Being Bumpable:Consequences of Resource Saturation and Near-saturation for Cognitive Demand on ICU Practitioners
    (2003), International Anesthesia Research Society National Conference , New Orleans
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims
    (2003), SCCM , San Antonio

Who's Sorry Now?
    (2002), SEA Meeting
Lost in Menuspace: Variability among Users Programming Infusion Devices under Controlled Conditions
    (2002), Anesthesiology , 97(3A) , A521
Infusion Device Characteristics Related to User Error during Programming and Operation Determined by Finite State Modeling
    (2002), Anesthesiology , 97(3A) , A520
Features of Infusion Device Related Incidents Revealed by Systematic Analysis of an Incident Reporting Database
    (2002), Anesthesiology , 97(3A) , A1073
Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration
    (2002), Journal of the American Medical Information Association , 9(5) , 540-53
Safety Technology: Solutions or Experiments
    (2002), Nursing Economics , 20(2) , 80-2
Nine Steps to Move Forward from Error
    (2002), Cognitive Technology & Work , 4(2) , 137-44
Why Better Operators Receive Worse Warnings
    (2002), Human Factors , 44(3) , 343-53
A Study of How Cognitive Artifacts Affect Distributed Cognition in Operating Room Management
    (2002), Anesthesiology , 97(3A) , A1183
Upper Bound for Performance of Incident Reporting Systems Based on Experience with Phase III Adverse Event Reporting
    (2002), Anesthesiology , 97(3A) , A1089
Return to Sender(s): More Questions Than Answers
    (2002), Third International Conference on the Nature and Source of Human Error , Chicago. Washington, DC , U.S. Food and Drug Administration

New Artic Air Crash Aftermath Role-Play Simulation: Orchestrating a Fundamental Surprise
    (2001), Proceedings of the Human Factors and Ergonomics Society 45th Annual Meeting
The End of the Beginning: Complexity and Craftsmanship and the Era of Sustained Work on Patient Safety
    (2001), The Joint Commision Journal on Quality Improvement , 27(10) , 507-8
BIS Monitoring to Prevent Awareness During General Anesthesia
    (2001), Anesthesiology , 94(3) , 520-2
From Counting Failures to Anticipating Risks: Possible Futures for Patient Safety.
    (2001), In Zipperer L & Cushman S (Eds.). Lessons in Patient Safety. A Primer , National Patient Safety Foundation. Chicago, 89-97

Syringe pump assemblies and the natural history of clinical technology
    (2000), Canadian Journal of Anesthesia , 47(10) , 929-35
How Complex Systems Fail
    (2000)
Gaps in the continuity of care and progress on patient safety
    (2000), British Medical Journal , 320(7237) , 791-4
Staff Actions and Alarms in a Neonatal Intensive Care Unit
    (2000), Proceedings of the Human Factors and Ergonomics Society 44th Annual Meeting

Scheduling of Actions and Reliance on Warnings in a Simulated Control Task
    (1999), Proceeding sof the Human Factors and Ergonomics Society 43rd Annual Meeting , 251-5
Perspectives on Human Error: Hindsight Bias and Local Rationality
    (1999), In Durso F, Nickerson R & Schvanevelt J (Eds.). Handbook of Applied Cognition , New York , John Wiley & Sons, 141-71

Two Years Before the Mast: Learning How to Learn about Patient Safety
    (1998), Enhancing Patient Safety and Reducing Errors in Health Care , Rancho Mirage, CA
Characteristics of Patient Safety
    (1998)
Potassium Administration and Drug Safety
    (1998), Proceedings of the Human Factors and Ergonomics Society National Conference , Chicago
A Tale of Two Stories: Contrasting Views of Patient Safety
    (1998), National Health Care Safety Council of the National Patient Safety Foundation at the AMA , Chicago

Observations on RISKS and Risks
    (1997), Communications of the ACM , 40(3) , 122
First Do No Harm: Expertise and Metacognition in Laparoscopic Surgery
    (1997), Ph.D. Dissertation , Wright State University

Adapting to New Technology in the Operating Room
    (1996), Human Factors , 38(4) , 593-613
The Cognitive Systems Engineering of Automated Medical Evacuation Scheduling and its Implications
    (1996), 3rd Annual Symposium of Human Interaction with Complex Systems , Dayton, OH
Verite, Abstraction, and Ordinateur Systems in the Evolution of Complex Process Control
    (1996), 3rd Annual Symposium of Human Interaction with Complex Systems , Dayton, OH
Implications of Automation Surprises in Aviation for TIVA
    (1996), Journal of Clinical Anesthesia , 8(3 Suppl) , 29S-37S

The Impact of Technology on Physician Cognition and Performance
    (1995), Journal of Clinical Monitoring , 11(1) , 5-8

Operating at the Sharp End: The Complexity of Human Error
    (1994), In Bogner MS (Ed.). Human Error in Medicine , Hillsdale, NJ , Lawrence Erlbaum Associates. 255-310

Human-Computer Interaction in Context: Physician Interaction with Automated Intravenous Controllers in the Heart Room
    (1993), In HG Stassen (Ed), Analysis, Design and Evaluation of Man-Machine Systems 1992 , New York: Pergamon Press , 263-74

Case 2-1992. Unintentional Delivery of Vasoactive Drugs with an Electromechanical Infusion Devise
    (1992), Journal of Cardiothoracic and Vascular Anesthesia , 6(2) , 238-44

Evaluating the Human Enginering of Microprocessor-Controlled Operating Room Devices
    (1991), Journal of Clinical Monitoring , 7(3) , 217-26
Human Performance in Anesthesia: A Corpus of Cases
    (1991), CSEL Report CSEL91.003

On Attributing Critical Incidents to Factors in the Environment
    (1989), Anesthesiology , 71(5) , 808
Learning Theories Implicit in Medical School Lectures
    (1989), JAMA , 261(15) , 2244-5

Scenarios for bedside medical data communication
    (1988), ACM SIGBIO Newsletter , 10(4) , 8-14