Agents of Change

  • Anthony G. Gallagher
  • Gerald C. O’Sullivan
  • Gerald C. O’Sullivan
Part of the Improving Medical Outcome - Zero Tolerance book series (IMOZT)


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.


Laparoscopic Cholecystectomy National Health Service Minimally Invasive Surgery Surgical Trainee General Medical Council 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Adnett N, Hardy S. Reviewing the working time directive: rationale, implementation and case law. Ind Relat J. 2001;32(2):114-125.CrossRefGoogle Scholar
  2. Agency for Healthcare Research and Quality (AHRQ). National healthcare quality report. Journal. From: 2009 (accessed 19th September 2010).
  3. Åkerstedt T, Gillberg M. A dose-response study of sleep loss and spontaneous sleep termination. Psychophysiology. 1986;23(3):293-297.PubMedCrossRefGoogle Scholar
  4. 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.Google Scholar
  5. Asch DA, Parker RM. The Libby Zion case. One step forward or two steps backward? N Engl J Med. 1988;318(12):771.PubMedCrossRefGoogle Scholar
  6. 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.PubMedCrossRefGoogle Scholar
  7. Berguer R. Surgery and ergonomics. Arch Surg. 1999;134(9):1011-1016.PubMedCrossRefGoogle Scholar
  8. Brazier M. Medicine, Patients and the Law. Harmondsworth: Penguin-Printed Resource; 1992.Google Scholar
  9. Brennan TA, Hebert LE, Laird NM, et al. Hospital characteristics associated with adverse events and substandard care. JAMA. 1991;265(24):3265-3269.PubMedCrossRefGoogle Scholar
  10. 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.Google Scholar
  11. Burton B. Court ruling ends Patel inquiry. BMJ. 2005;331(7516):536.PubMedCrossRefGoogle Scholar
  12. Cameron JL. William Stewart Halsted: our surgical heritage. Ann Surg. 1997;225(5):445-458.PubMedCrossRefGoogle Scholar
  13. 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.PubMedCrossRefGoogle Scholar
  14. 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.Google Scholar
  15. 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.PubMedCrossRefGoogle Scholar
  16. Cuschieri A. Whither minimal access surgery: tribulations and expectations. Am J Surg. 1995;169(1):9-19.PubMedCrossRefGoogle Scholar
  17. 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.Google Scholar
  18. Davidoff AM, Pappas TN, Murray EA, et al. Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg. 1992;215(3):196-202.PubMedCrossRefGoogle Scholar
  19. Davies M. Medical Self-Regulation: Crisis and Change. Hampshire: Ashgate Publishing Company; 2007.Google Scholar
  20. 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.Google Scholar
  21. 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.PubMedGoogle Scholar
  22. Fassett WE. Patient safety and quality improvement act of 2005. The Annals of pharmacotherapy 2006;40(5):917-924.PubMedCrossRefGoogle Scholar
  23. Ferguson RL, Jobe K. A quiet hand for microneurosurgery: twiddle your thumb. J Neurosurg. 2004;101(3):541-544.PubMedCrossRefGoogle Scholar
  24. Forster P. Queensland Health Systems Review Final Report. Queensland: Queensland Department of Health; 2005 (accessed 5th July 2011).
  25. Friedman RC, Bigger JT, Kornfeld DS. The intern and sleep loss. N Engl J Med. 1971;285(4):201-203.PubMedCrossRefGoogle Scholar
  26. 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.Google Scholar
  27. Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: re-creating the operating room for research and training. Anesthesiology. 1988;69(3):387-394.PubMedCrossRefGoogle Scholar
  28. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347(16):1249-1255.PubMedCrossRefGoogle Scholar
  29. 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.PubMedGoogle Scholar
  30. 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.PubMedCrossRefGoogle Scholar
  31. Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little, Brown & Company; 2000.Google Scholar
  32. 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.PubMedCrossRefGoogle Scholar
  33. Grillo HC. Edward D. Churchill and the “rectangular” surgical residency. Surgery. 2004;136(5):947-952.PubMedCrossRefGoogle Scholar
  34. Hallenbeck WH. Radiation Protection. Boca Raton: CRC Press; 1994.Google Scholar
  35. 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.Google Scholar
  36. Harpwood V. Negligence in Healthcare: Clinical Claims and Risk in Context. London: Informa; 2001.Google Scholar
  37. Harwell RC, Ferguson RL. Physiologic tremor and microsurgery. Microsurgery. 1983;4(3):187-192.PubMedCrossRefGoogle Scholar
  38. Haug M. Deprofessionalization: an alternative hypothesis for the future. Sociol Rev Monogr. 1973;20:195-211.Google Scholar
  39. Health Committee. Working for patients. Vol. 159 cc556-9W. 1989. From: Retrieved October 21, 2010.
  40. 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.PubMedCrossRefGoogle Scholar
  41. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington DC: National Academy Press; 2000:196-197.Google Scholar
  42. 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.PubMedCrossRefGoogle Scholar
  43. Kuhn TS. The Structure of Scientific Revolutions. International Encyclopaedia of United Science. Chicago: University of Chicago Press; 1962.Google Scholar
  44. 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.PubMedCrossRefGoogle Scholar
  45. Leape LL. Reporting of adverse events. N Engl J Med. 2002;347(20):1633-1638.PubMedCrossRefGoogle Scholar
  46. Leape LL, Berwick DM. Five years after to err is human: what have we learned? JAMA. 2005;293(19):2384-2390.PubMedCrossRefGoogle Scholar
  47. 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.PubMedCrossRefGoogle Scholar
  48. 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.PubMedCrossRefGoogle Scholar
  49. Litynski GS. Endoscopic surgery: the history, the pioneers. World J Surg. 1999;23(8):745-753.PubMedCrossRefGoogle Scholar
  50. Lowry J, Cripps J. Results of the online EWTD trainee survey. Bull R Coll Surg Engl. 2005;87(3):86-87.CrossRefGoogle Scholar
  51. 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.PubMedCrossRefGoogle Scholar
  52. McKee M, Healy J. Hospitals in a Changing Europe. Buckingham: Open University Press; 2002.Google Scholar
  53. 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.Google Scholar
  54. Millenson ML. Pushing the profession: how the news media turned patient safety into a priority. Qual Saf Health Care. 2002;11(1):57-63.PubMedCrossRefGoogle Scholar
  55. Mills DH. Medical insurance feasibility study: a technical summary. West J Med. 1978;128(4):360-365.PubMedGoogle Scholar
  56. Moore-Ede M. Twenty-Four-Hour Society: Understanding Human Limits in a World That Never Stops. Reading: Addison Wesley Publishing Company; 1993.Google Scholar
  57. 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.CrossRefGoogle Scholar
  58. NIH. The NIH almanac – appropriations. May 14, 2010. From: Retrieved September 19, 2010.
  59. Oxford English Dictionary (ed) (Vol. 24) Oxford: Oxford University Press; 2004.Google Scholar
  60. Pais A. Subtle Is the Lord: The Science and the Life of Albert Einstein. Oxford: Oxford University Press; 2005.Google Scholar
  61. Patkin M. Ergonomics applied to the practice of microsurgery. Aust N Z J Surg. 1977;47(3):320-329.PubMedCrossRefGoogle Scholar
  62. Patkin M, Isabel L. Ergonomics and Laparoscopic General Surgery. Laparoscopic Abdominal Surgery. New York: McGraw-Hill; 1993.Google Scholar
  63. Pellegrini CA. Surgical education in the United States: navigating the white waters. Ann Surg. 2006;244(3):335-342.PubMedGoogle Scholar
  64. 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.PubMedGoogle Scholar
  65. 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.PubMedCrossRefGoogle Scholar
  66. Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288(9):1112-1114.PubMedCrossRefGoogle Scholar
  67. 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):2725-2732PubMedCrossRefGoogle Scholar
  68. Quality Interagency Coordination Task Force (QuIC). Doing what counts for patient safety: ­federal actions to reduce medical errors and their impact. Journal. From: 2000 (accessed 19th September 2010).
  69. Reason J. Human Error. Cambridge: Cambridge University Press; 1990.CrossRefGoogle Scholar
  70. Safar P, Brown TC, Holtey WJ, Wilder RJ. Ventilation and circulation with closed-chest cardiac massage in man. JAMA. 1961;176(7):574-576.PubMedCrossRefGoogle Scholar
  71. Salter B. The Politics of Change in the Health Service. Basingstoke: Macmillan; 1998.Google Scholar
  72. 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.PubMedCrossRefGoogle Scholar
  73. Satava RM. Virtual reality surgical simulator. The first steps. Surg Endosc. 1993;7(3):203-205.PubMedCrossRefGoogle Scholar
  74. Satava RM. Historical review of surgical simulation – a personal perspective. World J Surg. 2008;32(2):141-148.PubMedCrossRefGoogle Scholar
  75. Schuster M, Rhodes S. The impact of overtime work on industrial accident rates. Ind Relat J Economy Soc. 1985;24(2):234-246.CrossRefGoogle Scholar
  76. 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.PubMedCrossRefGoogle Scholar
  77. Sheldon GF. Surgical workforce since the 1975 study of surgical services in the United States: an update. Ann Surg. 2007;246(4):541-545.PubMedCrossRefGoogle Scholar
  78. Slack PS, Ma X. Time dependency assessment of muscular fatigue index and hand tremor under operating conditions. IEEE. 2007:4822-4825.Google Scholar
  79. Smith R. All changed, changed utterly. Br Med J. 1998;316(7149):1917-1918.CrossRefGoogle Scholar
  80. Smith C, Wise MN. Energy and Empire: A Biographical Study of Lord Kelvin. Cambridge: Cambridge University Press; 1989.Google Scholar
  81. Spritz N. Oversight of physicians’ conduct by state licensing agencies. Ann Intern Med. 1991;115(3):219-222.PubMedGoogle Scholar
  82. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med. 1991;324(16):1073-1078.CrossRefGoogle Scholar
  83. Van Der Weyden MB. The Bundaberg Hospital scandal: the need for reform in Queensland and beyond. Med J Aust. 2005;183(6):284-285.Google Scholar
  84. Villaneuva T. European working time directive faces challenges. Can Med Assoc J. 2010;182(1):E39-E40.CrossRefGoogle Scholar
  85. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322(7285):517-519.PubMedCrossRefGoogle Scholar
  86. Wachter RM. The end of the beginning: patient safety five years after’to err is human’. Journal, W4-534-545. From: 2004.
  87. Wallack MK, Chao L. Resident work hours: the evolution of a revolution. Arch Surg. 2001;136(12):1426-1431.PubMedCrossRefGoogle Scholar
  88. 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.PubMedCrossRefGoogle Scholar
  89. Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA. 2002;287(8):955-957.PubMedCrossRefGoogle Scholar
  90. 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.PubMedGoogle Scholar
  91. Wojtczak-Jaroszowa J, Jarosz D. Time-related distribution of occupational accidents* 1. J Safety Res. 1987;18(1):33-41.CrossRefGoogle Scholar
  92. Yerkes RM, Dodson JD. The relationship of stimulus to rapidity of habit formation. J Comp Neurol Psychol. 1908;18:459-482.CrossRefGoogle Scholar
  93. Zajonc RB. Social facilitation. Science. 1965;149(3681):269-274.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2011

Authors and Affiliations

  • Anthony G. Gallagher
    • 1
  • Gerald C. O’Sullivan
    • 2
  • Gerald C. O’Sullivan
    • 3
  1. 1.School of MedicineUniversity College CorkCorkIreland
  2. 2.Mercy University HospitalCorkIreland
  3. 3.Cork Cancer Research CentreUniversity College CorkCorkIreland

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