Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: HMSO; 2000.

McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45.PubMed

Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.

Classen DC, Resar R, Griffin F, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581–9.

Kreckler S, Catchpole KR, New SJ, Handa A, McCulloch PG. Quality and safety on an acute surgical ward an exploratory cohort study of process and outcome. Ann Surg. 2009;250(6):1035–40.PubMed

Andel C, Davidow SL, Hollander M, Moreno DA. The economics of health care quality and medical errors. J Health Care Finance. 2012;39(1):39–50.PubMed

Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med. 2001;94(7):322–30.PubMedCentralPubMed

Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614–21.PubMed

Davidson TM. Anatomy of a medical accident. West J Med. 2000;172(4):267–70.PubMedCentralPubMed

Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137(5):327–33.PubMed

Woolf SH, Kuzel AJ, Dovey SM, Phillips RL. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med. 2004;2:317–26.PubMedCentralPubMed

Reason J. Human error: models and management. Br Med J. 2000;320(7237):768–70.

Reason JT. Human error. Cambridge: University Press; 1990.

Reason J. Managing the risks of organisational accidents. Aldershot: Ashgate; 1997.

Gurses AP, Ozok AA, Pronovost PJ. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual Saf. 2012;21(4):347–51.PubMed

Russ AL, Fairbanks RJ, Karsh BT, Militello LG, Saleem JJ, Wears RL. The science of human factors: separating fact from fiction. BMJ Qual Saf. 2013;22(10):802–8.PubMedCentralPubMed

Lawton R, Ward NJ. A systems analysis of the Ladbroke Grove rail crash. Accid Anal Prev. 2005;37(2):235–44.PubMed

Helmreich RL, Foushee HC. Why crew resource management? Empirical and theoretical bases of human factors training in aviation. In: Cockpit resource management. San Diego: Academic; 1993. p. 3–45.

Helmreich RL. Anatomy of a system accident: the crash of Avianca Flight 052. Int J Aviat Psychol. 1994;4(3):265–84.PubMed

Helmreich RL, Merritt AC. Culture at work in aviation and medicine. Aldershot: Ashgate; 1998.

Hetherington C, Flin R, Mearns K. Safety in shipping: the human element. J Safety Res. 2006;37(4):401–11.PubMed

Carvalho PV, Dos S, Vidal MC. Safety implications of cultural and cognitive issues in nuclear power plant operation. Appl Ergon. 2006;37(2):211–23.PubMed

Burke CS, Salas E, Wilson-Donnelly K, Priest H. How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. Qual Saf Health Care. 2004;13 Suppl 1(1475–3898 (Print)):i96–104.

Klein G. Naturalistic decision making. Hum Factors. 2008;50(3):456–60.PubMed

Wahr JA, Prager RL, Abernathy JH, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation. 2013;128(10):1139–69.PubMed

Cook R. “Going solid”: a model of system dynamics and consequences for patient safety. Qual Saf Health Care. 2005;14(2):130–4.PubMedCentralPubMed

Stanhope N, Crowley-Murphy M, Vincent C, O’Connor AM, Taylor-Adams SE. An evaluation of adverse incident reporting. J Eval Clin Pract. 1999;5(1):5–12.PubMed

Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15(1):39–43.PubMedCentralPubMed

Kreckler S, Catchpole K, McCulloch P, Handa A. Factors influencing incident reporting in surgical care. Qual Saf Health Care. 2009;18(2):116–20.PubMed

Dekker SW. The field guide to human error investigations, vol. 1. Aldershot: Ashgate; 2002.

Dekker SW. Accidents are normal and human error does not exist: a new look at the creation of occupational safety. Int J Occup Saf Ergon. 2003;9(2):211–8.PubMed

Wood G. The I-knew-it-all-along effect. J Exp Psychol Hum Percept Perform. 1978;4:345–53.

Berlin L. Hindsight bias. Am J Roentgenol. 2000;175(3):597–601.

Sujan MA, Harrison MD, Steven A, Pearson PH, Vernon SJ. Demonstration of safety in healthcare organisations. In: Gorski J, editor. Computer safety, reliability, and security, proceedings, vol 4166. 2006. p. 219–32.

Sujan MA, Koornneef F, Chozos N, Pozzi S, Kelly T. Safety cases for medical devices and health information technology: involving health-care organisations in the assurance of safety. Health Informatics J. 2013;19(3):165–82.PubMed

Gordon M, Catchpole K, Baker P. Human factors perspective on the prescribing behavior of recent medical graduates: implications for educators. Adv Med Educ Pract. 2013;4:1–9.PubMedCentralPubMed

Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM. How can we improve guideline use? A conceptual framework of implementability. Implement Sci. 2011;6:26.PubMedCentralPubMed

Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf. 2012;21(10):876–84.PubMedCentralPubMed