Reason J, Hobbs A
Aldershot, Hampshire, England: Ashgate Publishing Company; 2003

Though this book relates to maintenance error primarily in the aviation industry, it contains a wealth of information from one of the world's foremost experts on human factors and errors, James Reason. The concept of a "just culture" is particularly relevant to health care and the book contains tips on how to create an organizational culture that reports errors.

Berwick DM. Invisible injuries. Washington Post. July 29, 2003.

Dr. Donald Berwick (President and CEO of the Institute for Healthcare Improvement) identifies three essential pre-conditions for improvement: will, ideas, and execution.

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Berwick DM. Not again! Preventing errors lies in redesign — not exhortation. British Medical Journal. 2001;322:247-248.

This editorial suggests that the remedy for improving patient safety and reducing medical errors lies in redesign and changing systems of work using modern principles from human factors engineering, reliability sciences, research on group dynamics, communication theory, and semiotics (to name but a few relevant disciplines).

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Thomas EJ, Studdart DM, Newhouse JP, et al. Cost of medical injuries in Utah and Colorado. Inquiry. 1999;36(3):255-264.

The authors estimate the direct and indirect costs of adverse events from a review of hospital admissions data. Extrapolation to all hospital admissions in the U.S. indicates national costs for preventable adverse events of $17 billion.

Peery CL, Chendrasekhar A, Paradise NF, Moorman DW, Timberlake GA. Missed injuries in pediatric trauma. American Surgeon. 1999;65:1067-1069.

Missed injuries are presented as an opportunity to learn. It concludes that pediatric emergency care can be made safer through devising methods to avoid such instances.

Melmon KL. Preventable drug reactions: Causes and cures.

One of the earliest papers on preventable adverse drug events. A classic.

McDonald CJ. Protocol-based computer remedies, the quality of care and the non-perfectibility of man. New England Journal of Medicine. 1976;295:1351-1355.

Pioneering paper on the potential use of computerized reminders to aid medical decision-making.

Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. Journal of the American Medical Association. 1997;277(4):312-317.

This study quantified the type and frequency of identifiable factors associated with medication prescribing errors. Systematic evaluation of every third prescribing error between July 1, 1994, and June 30, 1995 at a tertiary care teaching hospital revealed total errors of 2,103, with 696 errors meeting study criteria. These 696 were evaluated and the likely related factor was identified. The article ends with call for redesigning medication systems through standardization, reduction of complexity and computerization, and by integrating pharmacists with health care teams.

Brennan TA, Leape LL, Laird NM, et al. The nature of adverse events in hospitalized patients: Results of the Harvard Medical Practice Study II. New England Journal of Medicine. 1991;324(6):377-384.

Analysis of the types of injuries reported in the medical practice study together with analysis of causative errors.

Leape LL, Bates DW, Cullen DJ, Cooper J, et al. Systems analysis of adverse drug events. Journal of the American Medical Association. 1995;274:35-43.

The landmark article on systems analysis of adverse drug events. The authors define the underlying problems and identify the "proximal causes" of medication errors.