Also see my Google Scholar and ResearchGate profiles.

A. Peer-Reviewed Journal Publications

  1. Francis T, de Vries M, Fan M, Pinkney S, Yousefi-Nooraie R, Ouimet M, Rac V, Trbovich P. Understanding the social networks that contribute to diversion in hospital inpatient pharmacies: A social network analysis. Exploratory Research in Clinical and Social Pharmacy. October 2024. Available from: https://doi.org/10.1016/j.rcsop.2024.100530

  2. de Vries M, Fan M, Tscheng D, Hamilton M, Trbovich, P. Critical vulnerabilities for diversion of controlled substances in the emergency department: Observations and healthcare failure mode and effect analysis. Journal of Patient Safety and Risk Management. May 2023. Available from: https://doi.org/10.1177/25160435231174309

  3. Fan M, Yang D, Ng, B, Jackson J, Bouris K, Eng S, Rolko E, Trbovich P. Impact of technology-assisted versus manual sterile compounding on safety and efficiency in a Canadian community hospital. American Journal of Health-System Pharmacy. 2022. Available from: https://doi.org/10.1093/ajhp/zxac167

  4. Petrosoniak A, Fan M, Hicks C, White K, McGowan M, Campbell D, Trbovich P. Trauma resuscitation using in situ simulation team training (TRUST) study: latent safety threat evaluation using framework analysis and video review. BMJ Quality and Safety. October 2020. Available from: https://doi.org/10.1136/bmjqs-2020-011363

  5. de Vries M, Fan M, Tscheng D, Hamilton M, Trbovich P. Vulnerabilities for Drug Diversion in the Handling, Data Entry, and Verification Tasks of 2 Inpatient Hospital Pharmacies: Clinical Observations and Healthcare Failure Mode and Effect Analysis. Journal of Patient Safety. July 2020. Available from: http://doi.org/10.1097/PTS.0000000000000744

  6. Fan M, Tscheng D, Hamilton M, Trbovich P. Opioid losses in terms of dosage and cost: a retrospective analysis of Health Canada data. CMAJ Open. Feb 2020. Available from: http://cmajopen.ca/content/8/1/E113.full

  7. Agnihotri T, Fan M, McLeod S, Borgundvaag B, Ovens H, McCarron J, Trbovich P. Impact of an Electronic Decision-Support System on Nursing Triage Process: A Usability and Workflow Analysis. Canadian Journal of Nursing Research. Jan 2020. Available from: https://doi.org/10.1177/0844562119893514.

  8. Tomasi J, Hamilton M, Fan M, Pinkney S, Middaugh K, Parshuram C, Trbovich P. Assessing the Electronic Bedside Paediatric Early Warning System: A simulation study on decision-making and usability. International Journal of Medical Informatics. 2019. Available from: https://doi.org/10.1016/j.ijmedinf.2019.103969

  9. deVries M, Fan M, Tscheng D, Hamilton M, Trbovich P. Clinical observations and a healthcare failure mode and effect analysis to identify vulnerabilities in the security and accounting of medications in Ontario hospitals: a study protocol. BMJ Open. 2019. Available from: https://bmjopen.bmj.com/content/9/6/e027629

  10. Fan M, Tscheng D, Hamilton M, Hyland B, Reding R, Trbovich P. Diversion of controlled drugs in hospitals: a scoping review of contributors and safeguards. Journal of Hospital Medicine. July 2019. Volume 14, No 7. Available from: https://www.journalofhospitalmedicine.com/jhospmed/article/202732/hospital-medicine/diversion-controlled-drugs-hospitals-scoping-review

  11. Pinkney S, Fan M, Koczmara C, Trbovich P. Untangling Infusion Confusion: A Comparative Evaluation of Interventions in a Simulated Intensive Care Setting. Critical Care Medicine. May 3 2019. Available from: https://bit.ly/mivilabel

  12. Petrosoniak A, Almeida R, Pozzobon LD, Hicks C, Fan M, White K, McGowan M, Trbovich P. Tracking workflow during high-stakes resuscitation: the application of a novel clinician movement tracing tool during in situ trauma simulation. BMJ Simulation and Technology Enhanced Learning. March 2018. Available from: http://stel.bmj.com/content/early/2018/03/16/bmjstel-2017-000300

  13. Fan M, Petrosoniak A, Pinkney S, Hicks C, White K, Almeida APSS, Campbell D, McGowan M, Gray A, Trbovich P. Study protocol for a framework analysis using video review to identify latent safety threats: Trauma Resuscitation Using in-situ Simulation Team Training (TRUST). BMJ Open. 2016 November. Volume 6, Issue 11. Available from: http://bmjopen.bmj.com/content/6/11/e013683.full

  14. Pinkney, S., Trbovich, P., Fan, M., Rothwell, S., Cafazzo, J., Easty, A. (2010). Do Smart Pumps Actually Reduce Medication Errors? Human Factors Horizons, Biomedical Instrumentation & Technology 1(1).

B. Editorials

  1. Fan M, Trbovich P. Simulation: A key tool for refining guidelines and demonstrating they produce the desired behavioural change. BMJ Quality & Safety. July 30 2020. Available from: https://qualitysafety.bmj.com/content/early/2020/07/29/bmjqs-2020-011999.full

C. Media Citations

  1. MedCentral. July 17, 2024. When drug diversion occurs in-house. Access here: https://www.medcentral.com/ai/when-drug-diversion-occurs-in-house

  2. CBC Investigates. June 27, 2024. $4M worth of prescription opioids disappeared from an Ontario pharmacy. No one can say where they went. Access here: https://www.cbc.ca/news/canada/unexplained-losses-prescription-drugs-1.7247602

  3. The Walrus. October 7, 2021. Design for Survival: How to Build a Better Trauma Bay. Access here: https://thewalrus.ca/design-for-survival-how-to-build-a-better-trauma-bay/

  4. Research Features. February 25, 2021. Investigating the causes of Canada’s drug diversion crisis. Access here: https://researchfeatures.com/investigating-cause-canadas-drug-diversion-crisis

  5. NPR. All things considered. October 5, 2020. Some Health Workers Suffering from Addiction Steal Drugs Meant for Patients. Access here: https://www.npr.org/2020/10/05/918279481/some-health-workers-suffering-from-addiction-steal-drugs-meant-for-patients

  6. Vancouver Sun. June 27 2019. Access here: https://vancouversun.com/news/local-news/thousands-of-tabs-of-addictive-opioids-stolen-from-vgh-last-year

D. Research Reports

  1. Safer Decisions Save Lives: Functional Specifications for Clinical Decision Support Systems to Enhance Opioid Prescribing. May 2017. Co-author. Access here.

  2. Safer Decisions Save Lives: Usability, Functionality, and Utility Testing of a Prototype Clinical Decision Support System to Enhance Opioid Prescribing. May 2017. Co-author. Access here.

  3. Pinkney S, Fan M, Chan K, Koczmara C, Colvin C, Sasangohar F, Masino C, Easty A, Trbovich P. Multiple intravenous infusions phase 2b: laboratory study. Ont Health Technol Assess Ser [Internet]. 2014 May;14(5):1-163. Available from: http://www.hqontario.ca/evidence/publicantions-and-ohtac-recommendations/ontario-health-technology-assessment-series/MIVI-phase2b.

  4. Fan M, Koczmara C, Masino C, Cassano-Piché A, Trbovich P, Easty A. Multiple intravenous infusions phase 2a: Ontario survey. Ont Health Technol Assess Ser [Internet]. 2014 May;14(4):1-141. Available from: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/MIVI-phase2a.

  5. Cassano-Piche, A., Fan, M., Sabovitch, S., Masino, C., Easty, A.C., Health Technology Safety Research Team, Institute for Safe Medication Practices Canada (May 2012). Multiple Intravenous Infusions Phase 1b: Practice and Training Scan. Ontario Health Technology Assessment Series 12(16). Access here.

  6. Fan, M., Cassano-Piche', A., Cheng, R., Colvin, C., Koczmara, C., Pinkney, S., Sabovitch, S., Trbovich, P., White, R., Easty, A. (2010). Multiple Intravenous Infusions Phase 1a: Situation Scan Summary Report.

  7. Fan, M., Pinkney, S., Easty, A.C. (2010). “Smart Medication Delivery Systems: Infusion Pumps. Supplementary Report: Evaluation of Effective Smart Pump Design and Education Strategies”. (February 2010). Report commissioned by the Ontario Health Technology Advisory Committee, sponsored by the Ontario Ministry of Health and Long Term Care.

E. Oral Presentations

  1. Invited Talk: Talk with HIROC: Drug Diversion in Healthcare – A Path to Safety (Part 2). Live webinar on the LinkedIn page of the Healthcare Insurance Reciprocal of Canada (HIROC). March 9, 2023. Co-presentation with Michael Hamilton. Recorded and available here: https://youtu.be/vsW8TItwbOQ

  2. Invited Talk: Talk with HIROC: Drug Diversion in Healthcare – A Path to Safety (Part 1). Live webinar on the LinkedIn page of the Healthcare Insurance Reciprocal of Canada (HIROC). Feb 1, 2023. Co-presentation with Michael Hamilton and Patricia Trbovich. Recorded and available here: https://youtu.be/_qHdYhAqYUY

  3. Invited Talk: Management of Controlled Substances in Canadian Hospitals: A human factors approach. Live Webinar. Toronto Health Economics Technology Assessment (THETA) Collaborative Rounds. May 21, 2021. Co-presentation with Maaike deVries.

  4. Invited Talk: Controlled Substance Management in Canadian Hospitals: Live Webinar. May 12, 2021. Online event sponsored by BD Canada Inc. Co-presentation with Maaike deVries.

  5. Invited Talk: 2019 Summit on Controlled Substances Management in Canadian Hospitals. September 23, 2019. William Osler Health System, Brampton, Ontario. Addressing Drug Diversion in Canada Using a System-Based Approach.

  6. Invited Talk: Institute for Safe Medication Practices Canada Medication Safety Exchange. July 17, 2019. Online Webinar. Recording available: https://youtu.be/6p7cceb0XYM

  7. Invited Talk: Ontario Hospital Pharmacy Management Seminar, May 26-27 2019. Huntsville, Ontario. Co-presentation with Maaike DeVries. A human factors approach to the management of controlled substances in hospitals.

  8. Invited Talk: Professional Practice Conference at the Canadian Society of Hospital Pharmacists, February 4, 2019. Toronto, Ontario. Co-presentation with Patricia Trbovich and Maaike DeVries. A risk-assessment on the management of controlled substances in Ontario hospitals. The event was sponsored by Becton Dickinson Canada.

  9. Invited Talk: Ontario College of Pharmacists Partnered Table on Controlled Substance Management in Hospitals, Jan 23, 2019. Toronto, Ontario. Co-presentation with Patricia Trbovich. The security and accounting of controlled substances in hospitals.

  10. Invited Talk: 10th Annual Trillium Health Partners Hospital Pharmacy Technician Conference (November 10, 2018). Toronto, Ontario. Identifying vulnerabilities in hospital medication processes that facilitate diversion.

  11. Invited Talk: Education Events to Alberta Health Services in Calgary (May 15, 2018) and Edmonton (May 17, 2018). Co-presentation with Patricia Trbovich. Identifying Vulnerabilities in Hospital Medication Processes that Facilitate Diversion. The presentation was accredited by the Canadian Council on Continuing Education in Pharmacy. The events were sponsored by Becton Dickinson Canada.

  12. International Symposium on Human Factors and Ergonomics in Health Care. March 27, 2018. Boston, MA. Trauma resuscitation using in situ simulation team training (TRUST): Identifying latent safety threats via a human factors informed framework analysis of video recordings.

  13. Invited Talk: Professional Practice Conference at the Canadian Society of Hospital Pharmacists, February 6, 2018. Toronto, Ontario. Co-presentation with Patricia Trbovich. Identifying Vulnerabilities in Hospital Medication Processes that Facilitate Diversion. The event was sponsored by Becton Dickinson Canada.

  14. National Coalition for Infusion Therapy Safety March 2015. Co-presentation with Andrea Cassano-Piché and Sonia Pinkney. Multiple IV Infusions: Research and Recommendations.

  15. Hong Kong Health Authority November 2014. Co-presentation with Dr. Tony Easty. Introduction to Human Factors, equipment procurement and equipment troubleshooting.

  16. Canadian Association of Medical Surgical Nurses, Calgary, Alberta. June 2014. Multiple Intravenous Infusions.

  17. AAMI Annual Conference May/June 2014 Philadelphia, PA. Multiple Intravenous Infusions

  18. AAMI Annual Conference May/June 2014 Philadelphia, PA. The philosophy behind human factors.

  19. Oral abstract presentation at the Infusion Nurses Society, Phoenix, Arizona, May 2014. Multiple Infusions: Using human factors to crate evidence-based safety improvements.

  20. Presentation to Canadian Vascular Access Association, London Ontario Chapter in November 2013. Introduction to human factors and case study on smart infusion pumps. Winnipeg, Manitoba. Risks associated with administering multiple intravenous infusions.

  21. Canadian Association of Critical Care Nurses Dynamics Conference September 2013. Strategies to reduce risk when administering multiple intravenous infusions: Research and recommendations from a provincial study. September 2013.

  22. Webinar conducted for the Canadian Medical and Biological Engineering Society regarding the findings of the Multiple Intravenous Infusions Study in May 2013. Co-presented with Sonia Pinkney and Tony Easty.

  23. Association for the Advancement of Medical Instrumentation (AAMI) Annual Conference on June 2-4, 2012. Co-presented with Chris Colvin to share findings from the Mulltiple Intravenous Infusions Study.

  24. Webinar conducted for the AAMI Foundation's Health Technology Safety Institute regarding the findings of the Multiple Intravenous Infusions Study, Phase 1b in May 2012. Co-presented with Andrea Cassano-Piche' and Christine Koczmara. Webinar recording and text responses to Q&A found at the bottom of the page here.

  25. Presentation to Canadian Vascular Access Association, during their 36th annual conference in October 2011. Presentation titled: Human Factors, a Strategy for Safer Systems Design. Toronto, Ontario.

  26. Presentation to Canadian Vascular Access Association, Winnipeg Chapter in May 2011. Introduction to human factors and case study on smart infusion pumps. Winnipeg, Manitoba.

  27. Ontario Hospital Association Webcast. July 27, 2010. “Medication Safety Workshop (Part II)”. One of three presenters discussing technology for medications safety. My role was to discuss the benefits and limitations of smart pumps and the key requirements for implementation. Details of past event found here.

F. Research Poster Presentations

  1. Fan, M., Tung, A., Armstrong, B., Pinkney, S., Evangelista, V., Trbovich, P. (2023). Improving the surgical safety checklist through focus groups. Poster presented at the Annual CQuIPS Symposium, Toronto, Ontario. November 1, 2023.

  2. Fan, M., Pinkney, S., Cassano-Piché, A., White, R., Trbovich, P., Easty, A., (2014). Designing impactful human factors research programs in healthcare. Poster presented at the HFES Healthcare Symposium, Chicago, Illinois, March 17, 2014.

  3. Fan, M., Pinkney, S., Trbovich, P., Woods, N., Easty, A. (2010). The impact of human factors and education science on infusion pump training. Poster presented at The University of Toronto Centre for Patient Safety Symposium, Toronto, Ontario, September 30, 2010.

  4. Fan, M., Pinkney, S., Trbovich, P., Woods, N., Easty, A. (2010). The impact of human factors and education science on infusion pump training. Poster presented at The 2010 Royal College Simulation Summit, Toronto, Ontario, September 27-29, 2010.

  5. Fan, M., Woods, N., Easty, A. (2009). Can human factors evaluation and education science improve the effects of training on safety and efficiency? Poster presented at The Canadian Healthcare Symposium (Halifax 9), Montreal, Quebec, October 22-24, 2009.

  6. Fan, M., Woods, N., Easty, A. (2009). Measuring the impact of human factors informed training on the safety and efficiency of smart infusion technology. Poster presented at IBBME Scientific Day (University of Toronto), Toronto, Ontario, May 14, 2009.

G. Conference Proceedings

  1. Arthur Tung, Mark Fan, Sonia Pinkney, Bonnie Armstrong, Ken Catchpole, Patricia Trbovich (June 2023). Amplifiers and dampeners of patient safety risk in the operating room: Interim analysis of surgical video recorded with the Operating Room Black Box. Proceedings of the International Symposium of Human Factors and Ergonomics in Healthcare. Access at: https://journals.sagepub.com/doi/10.1177/2327857923121031

  2. Jeunice Vianca Evangelista, Cherryl Li, Kimberley-Dale Ng, Mark Fan, Patricia Trbovich (October 6 2022). Characterizing and Contextualizing the Use of the Surgical Safety Checklist in General Surgery. Proceedings of the International Symposium of Human Factors and Ergonomics in Healthcare. Oct 2022. Access at: https://journals.sagepub.com/doi/abs/10.1177/2327857922111016

  3. Taylor Incze, Sonia Pinkney, Mark Fan, Patricia Trbovich (July 2021). Assessing Surgical Teamwork Competencies During Moments of Uncertainty Using OR Black Box. Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care. July 2021. Access at: https://journals.sagepub.com/doi/abs/10.1177/2327857921101246

  4. Anne Li, Mark Fan, Tony Easty (June 2015). Evaluation of the comparative effectiveness of Various Jurisdictional Computed Tomography Radiation Dose Reduction Models. World Congress on Medical Physics and Biomedical Engineering. June 7-12, 2015, Toronto, Canada.

  5. Mark Fan, Sonia Pinkney, Andrea Cassano-Piché, Rachel White, Patricia Trbovich and Anthony Easty (June 2014). Designing Impactful Human Factors Research Programs in Healthcare. Proceedings of the International Symposium of Human Factors and Ergonomics in Healthcare 2014. Access at: http://hcs.sagepub.com/content/3/1/102.abstract

  6. Chan, K., Pinkney, S., Fan, M., Colvin, C., Easty, AC., Trbovich, P. (May 2013). Proceedings of the 36th Annual Canadian Medical and Biological Engineering Conference (CMBEC36).

  7. Colvin, C., Fan, M., Cheng, R., Pinkney, S., Sabovitch, S., Shier, A., Trbovich, P., Easty, A. (June 2011). Proceedings of the Festival of International Conferences on Caregiving, Disability, Aging and Technology (FICCDAT)'s 34th Canadian Medical and Biological Engineering Conference (CMBEC34), [CD-ROM].

H. Peer Reviewed Student Oriented Publications

  1. Fan, M. (2010). Systema and leadership: One tool to enhance foundational leadership competencies. Engineering Leadership Review. 1(1), 45-56. Access at: http://lot.utoronto.ca/download/elr-v01n01.pdf

I. Theses

  1. “Measuring the impact of human factors and education informed training on the safety and efficiency of smart infusion technology,” MHSc. Thesis, 2009. Primary supervisor: Dr. Tony Easty, Co-supervisor: Dr. Nicole Woods. University of Toronto: Institute of Biomaterials and Biomedical Engineering.

  2. “The evaluation of an ecological interface design for strategy based games,” BASc. Thesis (co-authored with Megan Mekitiak), 2007. Supervisor: Dr. Greg Jamieson. University of Toronto.

J. Acknowledgements

  1. Acknowledged in: Controlled Drugs and Substances in Hospitals and Healthcare Facilities: Guidelines on Secure Management and Diversion Prevention. 2019. Canadian Society of Hospital Pharmacists. Available here: https://cshp.in1touch.org/uploaded/web/site/cshp/content/Controlled-Drugs-and-Substances-in-Hospitals-and-Healthcare-Facilities_2019_02-28.pdf

  2. Acknowledged in: Pezone, Matthew J., Robert A. Peterfreund, Mikhail Y. Maslov, Radhika R. Govindaswamy, and Mark A. Lovich. 2016. "Infusion System Architecture Impacts the Ability of Intensive Care Nurses to Maintain Hemodynamic Stability in a Living Swine Simulator." Anesthesiology 124 (5). anesthesiology.pubs.asahq.org: 1077-85.

  3. Acknowledged in: Institute for Safe Medication Practices Canada. 2016. "Understanding Human Over-reliance on Technology". Volume 16, Issue 5. ISMP Canada Safety Bulletin. August 11, 2016.

  4. Acknowledged in: Chan, A., Islam, M., Rosewall, T., Jaffray D., Easty A., Cafazzo, J. 2011. "Applying usability heuristics to radiotherapy systems." Radiotherapy & Oncology 102 (1). 

  5. Acknowledged in: Trbovich, P., Pinkney, S., Cafazzo, J., Easty, A. 2010. "The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit." Quality & Safety in Health Care 19(5).

K. STUDENT ORIENTED PRESENTATIONS

  1. Presented an overview of human factors work to third year undergraduate engineering science students at the University of Toronto. October 5, 2010. Professor Craig Simmons hosted a series of speakers for a class of students on the biomedical engineering stream.

  2. Hosted the inaugural event for the Institute for Health Improvement (IHI) University of Toronto Student Chapter. April 13, 2009. Provided a brief overview of the human factors lab at the University Health Network and provided a tour of the facilities to a mix of approximately 15 students, researchers and health care professionals.