The System Safety Group and Safer Healthcare, LLC
JOURNAL ARTICLES, BOOKS and BOOK CHAPTERS, CONFERENCE PRESENTATIONS
SELECTED JOURNAL PUBLICATIONS and BLOG POSTS
Vincent, C., Irving, D., Bellandi, T., Higham, H., Michel, P., Staines, A., Adams, S., Brown, J., Hibbert, P.D., Hemmelgarn, C., Karina Pires, K., Sheridan, S., Sunol, R., Ushiro, S. Wu, A., Zambon, A. 2025. Systems analysis of clinical incidents: development of a new edition of the London Protocol. BMJ Quality & Safety.
Nesin, N., Houck, S., Brown, J., & Burger, C. (2023). The Time Is Now: The Case for Transforming Primary Care. The Journal of Ambulatory Care Management, 46(2), 97-102.
West, R. L., Margo, J., Brown, J., Dowley, A., & Haas, S. (2022). Convergence of Service Providers and Managers’ Perspectives on Strengths, Gaps, and Priorities for Rural Health System Redesign: A Whole-Systems Qualitative Study in Washington County, Maine. Journal of Primary Care & Community Health, 13, 21501319221102041.
Brown, J., Papautsky, E.L., Patterson, E.S. (2021) Integrated Primary Care in Rural America Is Urgently Needed, Psychology Today.
Patankar, M. S., & Brown, J. P. (2019). Adapting systems thinking and safety reporting in high-consequence industries to healthcare. In Seminars in perinatology. WB Saunders.
Academic Medicine: Uhlig, P., Doll, J.D., Brandon, K., Goodman, C., Medado-Ramirez, J., Barnes, M.A., Dolansky, M.A., Ratcliffe, T.A., Kornsawad, K., Raboin, E., Hitzeman, M., Brown, J. & Hall, L. (2018). Interprofessional practice and education in clinical learning environments: Frontline perspectives. An invited commentary.
Patient Safety and Quality in Healthcare: Charles Burger, MD; Paula Eaton; Kalie Hess, MPH; Ashley Mills, MHA; Maureen O’Connor, MA; Darcy Shargo, MFA; Caroline Zimmerman, MPP; Sky Vargas, MBA; and Jeff Brown, MEd (2017). A System-based Approach to Safety in Ambulatory Care and beyond.
Military Medicine: Nemeth, C., Crandall, B., Brown, J. & Fallon, C. (2014). The mixed blessings of smart infusion devices and Healthcare IT. Society of Federal Health Professionals (AMSUS). 179(8):4-10
Hospital Pharmacy. A Sociotechnical Model for Pharmacy, Classen D. and Brown, J. (2013). 48, 1–5.
Nursing Management: Kosnik, L., Brown, J., and Maund, T. (2007). Learning from the Aviation Industry. Crew Resource Management Brings Collaborative Communication to Healthcare.
Annals of Thoracic Surgery: Thor Sundt, III, Jeffrey Brown, and Paul Uhlig (2005). Focus on Patient Safety: Good News for the Practicing Surgeon. 79:11-15.
A comparative review of safety cultures. Federal Aviation Administration Technical Report,
FAA Research Grant #5-G-009 (2005). Patankar, M. S., Bigda-Peyton, T., Sabin, E., Brown, J., & Kelly, T.
Journal of Health Care Risk Management: Brown, J. (2004). Structuring Communication for Team-based Error Management, Volume 24 (4).
Joint Commission Journal on Quality and Safety: Brown, J. (2004). Closing the Communication Loop: Using Readback/Hearback to Support Patient Safety, Volume 30, Number 8.
Journal of Health Care Risk Management: Brown, J. (2004). Achieving High Reliability: Other Industries
can help health care's safety transformation. Volume 24 (2). Journal of the American Society for Healthcare Risk Management.
Joint Commission Journal on Quality and Safety: Paul Uhlig, Jeffrey Brown, Anne Nason, Addie Camelio, and Elise Kendall (2002). The Collaborative Rounds Model. Article in the December 2002 section on John M. Eisenberg Patient Safety Award Recipients.
Journal of Innovative Management: Martin D. Merry and Jeffrey P. Brown. Winter 2001/2002From a Culture of Safety To a Culture of Excellence: Quality Science, Human Factors, and the Future of Healthcare Quality. 7 (2), 29-46.
Patient Safety Beat: Five health care experts look to the future of patient safety.
Newsletter of the Betsy Lehman Center for Patient Safety (2018).
Ph 603-674-0687 USA
BOOKS & BOOK CHAPTERS
Chapter 07: Support for ICU Clinician Cognitive Work Through Cognitive Systems Engineering. Nemeth, C., Anders, S., Brown, J., Grome, A. and Crandall, B. Cognitive Systems Engineering in Health Care. Bisantz, A. M., Burns, C. M., & Fairbanks, R. J. (Eds.). (2015) CRC Press.
Chapter 08: Aviation Contexts and Evidence, Information, and Knowledge Innovation: Reliability, Teamwork, and Sensemaking. Brown, J. Thompson, S., Zipperer, L. Patient Safety: Evidence, Information, and Knowledge Transfer. Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.
Chapter 10, Using Technology to Enhance Safety. The Essential Guide for Patient Safety Officers, Second Edition. , Brown J., Tonkel, J., Classen, D. (2013) Joint Commission Resources. Oakbrook Terrace, Illinois.
Safety Culture: Building and Sustaining Cultural Change in Aviation and Healthcare Patankar, M., Brown, J., Bigda-Peyton, T., and Sabin, E. (2012). Human Factors Group, Ashgate Publishing, Farnham, England.
Complications in cardiothoracic surgery: avoidance and treatment. Preventing complications: New frontiers of safety science in cardiothoracic surgery. Uhlig, P., Berry, B., Hendrick, A., Raboin, E., Brown, J., Erskin, J., & Raemer, D. (2010).In A. G. Little & W. H. Merrill (Eds) Blackwell Synergy Press.
Chapter 10, Collaborative Cross-Checking. Brown, J. (2008). Improving healthcare team communication: building on lessons from aviation and aerospace. Ashgate Publishing, Ltd..Nemeth, C. P. (Ed.).
Safety Ethics: Cases from Aviation, Healthcare, and Occupational and Environmental Health, Patankar, M., Brown, J., Treadwell, M. (2005) Human Factors Group, Routledge Publishing.
EXAMPLE PRESENTATIONS/WORKSHOPS
The Human Factors and Ergonomics Society's International Symposium on Human Factors in Healthcare: Building Capacity for Proactive Safety in Rural Healthcare. March 27, 2024, Chicago, Illinois.
The State of Maine Sentinel Event Conference: Kicking the Should out of Healthcare. A discussion of methods to mitigate counterfactual reasoning in the investigation of patient harm events. June 29, 2023, Hallowell, Maine.
The University of Southern Maine Patient Safety Academy: Accidents as Decision Side Effects. September 17, 2018. University of Southern Maine, Portland, Maine.
Maine Health Management Coalition/Maine Medical Association Annual Symposium: Presentation on the mission, quality functions, and methods of the Maine Primary Care Association Patient Safety Organization. Hallowell, Maine. October 11, 2017
Maine Quality Counts Conference: Patients, Families, Providers, and Communities--the heart of High Reliability Healthcare. With Holly Gartmayer-deYoung. The Augusta Civic Center, Augusta, Maine. April 05, 2017.
Maine Sentinel Event Program, a case-based presentation on human factors in safety across high-risk domains. Topics included organizational accident concepts, and discussion of adverse event investigation. Hallowell, Maine, May 06, 2016.
The 2013 Culture & Adverse Event Conference, Presentation: The Role of Human Factors and Cognitive Systems Engineering in providing safe and reliable care. Pascal Metrics, an Agency for Healthcare Research and Quality accredited Patient Safety Organization. Washington, D.C., April 09-10, 2013.
The Institute of Medicine Report on Health Information Technology and Patient Safety. Webinar for the National Patient Safety Foundation. Co-presented with David Classen, MD. May 31, 2012
The American Congress of Obstetricians and Gynecologist,
Provision of a post-graduate workshop on clinical incident and accident investigation. 58th Annual Clinical Meeting. With Ken Milne, MD, May 15, 2010. San Francisco, California.
3rd Annual Duke University Medicine Patient Safety and Quality Conference.
Presentation on the findings from research for the book, Safety Ethics. Subtitled “Accidents as Decision Side Effects”. December 07, 2007. Durham, North Carolina.
American College of Clinical Engineers Symposium on Clinical Engineering
Building a Better Healthcare System: Clinical Engineering’s Role. Keynote panelist.
June 24, 2006. Washington, D.C.
National Patient Safety Foundation Congress: Initial Findings of a Study to Evaluate Role-based Information Needs and Preferences in Collaborative Clinical Practice. A panel session with Paul Uhlig, MD, Cynthia, Dominquez, PhD, and Lorri Zipperer, MA. A research initiative of the Care Process Innovation Laboratory, Department of Biomedical Engineering, Massachusetts General Hospital/Partners Healthcare, Boston, Massachusetts. May 2005.
Safety Across High Consequence Industries Conference
Similarities, Differences and Opportunities Across Flight Decks and Operating Rooms. A panel session at the 2004 Safety Across High Consequence Industries Conference. Examination of cross-domain application of safety management principles and practice. (Panelists from cardiothoracic surgery, airline, and research communities.) St. Louis, Missouri. March 10, 2004.
Oregon Medical Association Socioeconomic and Political Forum System-based approaches to Safety. Keynote address. Portland, Oregon. November 07, 2003.
Mayo Clinic: The Nature of Safety in Team-based Systems. A presentation in support of the
Mayo Clinic’s Patient Safety Education Program for clinical and administrative personnel.
With Paul Uhlig, MD, MPH. December 13, 2002, Rochester, Minnesota.
Kaiser Permanente Healthcare System: The Concord Hospital Human Factors Initiative, Post-Surgical care of Open Heart Surgery Patients. Keynote address for the Human Factors Project Leader Training Program, an initiative of the University of Texas Human Factors Research Project and Kaiser Permanente. June 24-26, 2002, Berkeley, California.
Reporting Systems: Considerations and Concerns in the Classification and Analysis of Human, Technical and Organizational Factors in Near Misses and Adverse Events. Presented to the Society of Thoracic Surgeons Patient Safety Research Committee. May 06, 2000. San Diego, California.