Wiener EL, Nagle DC
San Diego, California, USA: Academic Press; 1988

Wiener is "Mr. Human Factors" for the aviation community. In this book he reviews the art and science of aviation safety.

Perrow C
New York, New York, USA: Basic Books; 1984

A delightful book that opens the world of complex systems and introduces the reader to concepts of coupling and opaque systems. The contrasts between the effectiveness of error prevention in aviation and the merchant marine are striking.

Bogner MS
Hillsdale, New Jersey, USA: Lawrence Erlbaum; 1994

This collection of (expanded) presentations from an American Association for the Advancement of Science (AAAS) symposium on error in medicine provides a good overview of many aspects of health care errors. A number of the key contributors to current thought concerning error in medicine are represented.

Reason J
Hampshire, England: Ashgate Publishing Limited; 1997

Human factors expert James Reason provides a comprehensive review of the causes and consequences of a wide variety of accidents. Strategies for accident prevention and mitigation come in frameworks that organizations can easily adopt.

Cohen MR
Washington, DC, USA: The American Pharmaceutical Association Foundation; 1999

This book provides an overview of types of medication errors, processes that lead to errors, research on medication errors, and suggestions for minimizing the potential for future errors. The suggestions for minimizing the occurrence of medication errors focus on improving existing systems.

McNally KM, Page MA, Sunderland VB. Failure mode and effects analysis in improving a drug distribution system. American Journal of Health System Pharmacists. 1997;54:171-177.

Description of use of Failure Modes and Effects Analysis (FMEA) in pharmacy practice.

Lesar, TS, Briceland LL, Delcoure K, Parmalee, JC, Masta-Gornic V, Pohl H. Medication prescribing errors in a teaching hospital. The Journal of the American Medical Association (JAMA). 1990;263:2329-2334.

One of the first descriptions of prescribing errors in hospitals.

Useem M
New York, New York: Three Rivers Press; 1998

Leaders of groups are often thrust into situations where their skills and actions can make the difference between success and failure. These nine true stories of both successes and failures are fascinating accounts of how leaders — mountaineers, NASA mission controllers, US Civil War generals, and more — changed everything for the people they led.

Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. Quality Review Bulletin. 1993;144-149.

Description of the extent to which iatrogenic injuries reported in the medical practice study were due to errors and were, therefore, preventable.

Leape LL. Error in Medicine. Journal of the American Medical Association. 1994;272:1851-1857.

An overview of the problems of detection and management of errors in health care. It explores the effects of errors on those who make them and reviews the cognitive basis for human error. The concept of systems failures as the cause of errors is introduced, and suggestions are made as to how hospitals can use human factors principles to redesign their systems for safety. For those new to the subject of error prevention, this is the best place to start.