Classen, DC, Pestotnik, SL, Evans RS, Lloyd JF, Burke, JP. Adverse drug events in hospitalized patients: Excess length of stay, extra costs, and attributable mortality. The Journal of the American Medical Association (JAMA). 1997;277:301-306.

Cost study from the LDS Hospital in Salt Lake City, Utah, USA.

Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. The Journal of the American Medical Association (JAMA). 1991;266:2847-2851.

Description of the continuous monitoring system at LDS Hospital in Salt Lake City, Utah, USA. This is an impressive system that integrates clinical, laboratory, drug, and cost information to identify adverse drug events (ADEs) both prospectively and retrospectively.

Christensen JF, Levinson W, Dunn PM. The heart of darkness: The impact of perceived mistakes on physicians. Journal of General Internal Medicine. 1992;7:424-431.

Gripping account of the effect of errors on physicians and their inability to deal with them or receive support when needed.

Bedell SE, Deitz DC, Leeman D, Delbanco TL. Incidence and characteristics of preventable iatrogenic cardiac arrests. The Journal of the American Medical Association (JAMA). 1991;265:2815-2820.

Landmark study that demonstrates that most cardiac arrests that occur in hospitals are caused by misuse of drugs and are, therefore, potentially preventable.

Bates DW, O’Neil AC, Boyle D, Teich J, Chertow G, Komaroff A, et al. Potential identifiability and preventability of adverse events using information systems. Journal of the American Medical Informatics Association. 1994;1:404-411.

Description of the use of a computerized screening system that identifies potential adverse drug events by use of a logic system based on laboratory data and orders. Shows what can be done if all clinical and laboratory information is on-line.

Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape LL. Relationship between medication errors and adverse drug events. Journal of General Internal Medicine. 1995;10:199-205.

Results of a detailed study of the incidence of medication errors and their relationship to preventable adverse drug events.

Reason J
New York, New York, USA: Cambridge University Press; 1990

The "bible" of error theory, written by the leading authority. James Reason reviews the literature and establishes a theoretical framework for understanding error, based in large part on his and Jens Rasmussen’s work. A treasure trove of important concepts.

Norman DA
New York, New York, USA: Bantam Doubleday Dell Publishing Group, Inc.; 1988

Originally published as The Psychology of Everyday Things, this often humorous discussion of design principles and how humans interact with technology provides a whole new perspective about the products we use every day. It will change the way you look at the world.

Alibhai SMH, Han RK, Naglie G. Medication education of acutely hospitalized older patients. Journal of General Internal Medicine. 1999;14:610-616.

The results of this study indicate that even though patients perceive the education they receive from their physician or pharmacist to be satisfactory, many patients still make errors when they take their medications. On the other hand, the clinicians surveyed identified many barriers to providing adequate education about medicines to their patients, most notably lack of time.