The System Safety Group and Safer Healthcare, LLC
Examples of past roles, projects:

Patient Care Ombudsman: for communities served by Calais Regional Hospital (CRH), a Maine Critical Access Hospital (CAH) on Maine’s eastern border with Canada. This was a position appointed by the United States Trustee, U.S. Department of Justice, per order of the Federal Bankruptcy Court, District of Maine. Our role entailed monitoring the safety and quality of care provided by the hospital between 09 April 2020 and 15 October 2020, following a patient safety event in the hospital’s emergency department. CRH was subsequently liquidated, and it assets acquired by the remaining Critical Access Hospital in Washington County, Maine. 

The Schmidt Institute, Bangor, Maine: Assessment of key structural and process attributes of the Penobscot Community Health Care Controlled Substance Stewardship (CSS) program. 2018

The Maine Primary Care Association (MPCA) Patient Safety Organization. Developed and listed an Agency for Healthcare Research and Quality (AHRQ) designated Patient Safety Organization (PSO), Augusta Maine. Established on behalf of MPCA while serving as Director of Continuous Quality Improvement in support of Maine’s Federally Qualified Health Centers, 2015-2018

Massachusetts Health Policy Commission: A project with Safe and Reliable Healthcare, LLC that collected interview and safety culture survey data from personnel serving in roles that ranged from housekeeping to senior leadership across 28 community hospitals. Interview data was analyzed to characterize the current state of care coordination, integration, and delivery transformations within each organization and with primary care services. These data supported the development of requirements for a grant program supporting community hospitals in anticipation of their transition to an accountable care environment, 2014.

Federal Aviation Administration Research and Development Human Factors Laboratory. Senior Human Factors Contractor and Technical Task Lead. Management of a research team with projects supporting identification and mitigation of risks associated with integrating remotely piloted aircraft into the National Airspace System, and development NextGen air traffic control technologies. William J. Hughes Technical Center, Atlantic City International Airport, New Jersey. A collaborative intiative with TG O’Brien and Associates, a human factors engineering firm under contract with the Federal Aviation Administration in partnership with Applied Research Associates Transportation Division, 2011-2013.

University of Kansas College of Medicine: An evaluation of diagnostic methods for understanding social process factors in significantly reduced morbidity and mortality in the post-surgical care of open heart surgery patients. Wesley Medical Center, Wichita, Kansas. An interdisciplinary research initiative. 2009-2011

The U.S. Naval Expeditionary Combat Command (NECC): A study to develop design requirements for a new command and control interface for Riverine and Maritime Expeditionary Security Force forward operating units. With Applied Research Associates, 2010-2011

Patient Safety Solutions Center, Department of Defense Patient Safety Program: A Knowledge Audit of TeamSTEPPS Coaching Practices in Military Treatment Facilities. With Health Care Team Training, LLC, 2010-2011

Children’s Hospital of Los Angles: A study to identify and mitigate the risk associated with the transition of a Pediatric Intensive Care Unit and Cardiothoracic Intensive Care Unit to a new building. With Applied Research Associates, 2010-2011

Fatigue and Vigilance Decrement in Border Security and Public Safety: A study to identify and mitigate factors in vigilance decrement associated with fatigue and stress among homeland security and public safety personnel for a Southeast Asian government. With Applied Research Associates, 2008-2009

University of Wisconsin Department of General Surgery, Madison, Wisconsin. Analysis of communication and decision making challenges among patients, nursing professionals, and medical personnel for the University of Wisconsin Department Of General Surgery. With Applied Research Associates, 2008-2009


Right Care, Right Place, Right Time in Maine, 2020-2021 Co-developer and co-principal investigator with Susan Haas, MD, MSc for a qualitative study to identify systemic risk to provider and patient safety stemming from the erosion of rural healthcare infrastructure in Washington County, Maine. Findings represent frontline provider and patient understanding of leverage points for risk mitigation and improvement of health and healthcare. Funded by the Maine Health Access Foundation, ( ) this was a joint research initiative of the Schmidt Institute, Bangor, Maine and Ariadne Labs, Boston, Massachusetts. The full report and journal publication describing findings are found on the Services page of this website. 

Cooperative Communication System for the Advancement of Safe, Effective, and Efficient Patient Care W81XWH-12-C-0126 8/15/2012 – 11/29/2016
United States Army Institute of Surgical Research (USAIR), 
Principal Investigator LTC Jeremy Pamplin, MC HRPO Log Number A-17058. 
Phase One (2013-2015). The goal of this research was to utilize cognitive systems engineering methods to develop design requirements for an interprofessional clinical decision aid. Project was undertaken on the Burn Intensive Care Unit (BICU) at San Antonio Military Medical Center, San Antonio, Texas. Role: Senior team member for observational study and cognitive work analysis.

Human Factors Evaluation of a Smart Intravenous Infusion Pump System Implementation
Prime Grant Number W81XWH-08-1-0-389
United States Army Telemedicine and Advanced Technology Research Center Program
This research assessed the implementation of the Sigma Spectrum Smart Intravenous Pump (SIVP) Infusion System at Memorial Medical Center, Springfield, Illinois. The study utilized quantitative and qualitative methods to evaluate user adoption of the SIVP and the impact of the SIVP system on medication errors. Role: researcher and project manager for a cognitive task analysis study to identify both intended and unintended effects on individual and team performance and patient care during and following implementation of the SIVP.  

AHRQ Health Information Technology Program
UC1 HS15270

Improving Healthcare Quality via Information Technology, Southwestern Vermont Health, Bennington, Vermont. The goal of this initiative was to implement an integrated electronic patient medical record, electronic medication administration record, computerized physician order entry, and clinical decision support software. that will be accessible at all participating facilities which include an acute care hospital, home health care agency, ambulatory clinics, a rehab facility, and to patients/residents from home. Role: Consultant for improvement of technology supporting patient care transitions.

Computer Support of Collaborative Work
Partners Healthcare Information Systems Research Council

Care Process Innovation Laboratory, Massachusetts General Hospital, Boston, Massachusetts. 
A study conducted for the Department of Biomedical Engineering's Care Process Innovation Laboratory. Collaborative care processes were studied by a multidisciplinary research team in simulated and real clinical settings to generate insight for the advancement of computer support of collaborative work. Role: Research Consultant conducting observation of, and interviews with, members of clinical teams to develop design requirements for computer support of collaborative practice.

Midcoast Maine Patient Safety with IT Integration 
AHRQ Health Information Technology Program
P20 HS15170

Northeast Health Foundation, Rockland, Maine. The goal of this initiative was to develop “a high level of integration and cooperation in four significant areas: medication management, patient discharge, high-level integration of information, and the development of a new paradigm for evaluating, selecting, and implementing new technologies.” Role: Consultant for development of a new paradigm for evaluating, selecting, and implementing new technologies.


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. October 11, 2017

Maine Quality Counts Conference: Patients, Families, Providers, and Communities--the heart of High Reliability Healthcare. With Holly Gartmayer-deYoung. 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.  

Society of Thoracic Surgeons
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 Patient Safety Research Committee. May 06, 2000. San Diego, California. 


Reviewer for “Seed Grant” proposals to the Society to Improve Diagnosis in Medicine. This program funded by the Gordon and Betty Moore Foundation with a focus on catalyzing improvement in diagnostic safety and reliability. A three year appointment, effective June 2020. 

The Maine Rural Health Action Network (RHAN): Founding member of this group of non-partisan rural health experts and stakeholders from business, philanthropy, education, health, and social services. RHAN was formed to monitor and highlight the critical challenges to rural health and rural health care in Maine and recommend state legislative and executive actions to address them. 2018--current

The Schmidt Institute, Bangor, Maine: Advisory Board member to the Schmidt Institute, an applied research organization focused on rural health and primary care. Co-founded by Penobscot Community Health Care and St. Joseph Health Care in Bangor, Maine. 2017-Current

The American College of Surgeons (ACS): Advisor to the Division of Education, Interdisciplinary Committee on the Development of High Performance Teamwork in Surgery through Education. The Committee was charged with establishing educational standards and guidance for the development of high performing surgical teams. 2008-2010.

The Safety Across High Consequence Industries (SAHI) Conference, St. Louis University, St. Louis, Missouri. Co-founder and Organizer. A conference founded to advance safety research and practice across industries where there is high consequence for failure. An initiative of the St. Louis University National Center for Aviation Safety Research. 2003-2013. 

[email protected]  603-674-0687 (USA)