1.
The importance of human resources management in health care: a global context, http://www.human-resources-health.com/content/4/1/20.
2.
Berwick, D.M., Godfrey, A.B., Roessner, J.: Curing health care: new strategies for quality improvement : a report on the National Demonstration Project on Quality Improvement in Health Care. Jossey-Bass, San Francisco, Calif (2002).
3.
Bicheno, J.: The service systems toolbox: integrating lean thinking, systems thinking, and design thinking. PICSIE Books, Buckingham (2012).
4.
Bicheno, J.: The new lean toolbox: towards fast, flexible flow. PICSIE Books, Buckingham (2004).
5.
Bicheno, J., Catherwood, P., James, R.: Six sigma: and the quality toolbox for service and manufacturing. Picsie Books, Buckingham (2005).
6.
Cusins, P.: Understanding Quality through Systems Thinking. TQM magazine. 6, 19–27 (1994).
7.
Deming, W.E.: Out of the crisis. MIT Press, Cambridge, Mass (2000).
8.
Edvardsson, B., Øvretveit, J., Thomasson, B.: Quality of service: making it really work. McGraw-Hill, Maidenhead (1994).
9.
Liker, J.K., Meier, D.: The Toyota way fieldbook: a practical guide for implementing Toyota’s 4Ps. McGraw-Hill, New York (2006).
10.
Liker, J.K., Meier, D.: The Toyota way fieldbook: a practical guide for implementing Toyota’s 4Ps. McGraw-Hill, New York (2006).
11.
McNulty, T., Ferlie, E.: Reengineering health care: the complexities of organizational transformation. Oxford University Press, Oxford (2004).
12.
Schonberger, R.: Best practices in lean six sigma process improvement: a deeper look. John Wiley & Sons, Hoboken, N.J. (2008).
13.
Schonberger, R.: Best practices in lean six sigma process improvement: a deeper look. John Wiley & Sons, Hoboken, N.J. (2008).
14.
Seddon, J.: Freedom from command & control: rethinking management for lean service. Productivity Press, New York (2005).
15.
Slack, N., Brandon-Jones, A., Johnston, R.: Operations management. Pearson Education UK, Boston, Mass (2013).
16.
Slack, N., Brandon-Jones, A., Johnston, R.: Operations management. Pearson, Harlow, England (2013).
17.
Spear, S., Kent Bowen, H.: Decoding the DNA of the Toyota Production System. Harvard business review. 77, 96–106 (1999).
18.
Womack, J.P., Jones, D.T.: Lean thinking: banish waste and create wealth in your corporation. Simon & Schuster, London (2003).
19.
Womack, J.P., Jones, D.T., Roos, D.: The machine that changed the world. Simon & Schuster, London (2007).
20.
Reason, J.T.: Human error. Cambridge University Press, Cambridge [England] (1990).
21.
Dekker, S., Dekker, S.: The field guide to understanding human error. Ashgate Publishing Ltd, Farnham (2006).
22.
Dekker, S., Dekker, S.: The field guide to understanding human error. Ashgate, Aldershot, England (2006).
23.
Norman, D.A.: The psychology of everyday things. Basic Books, New York (1988).
24.
Chassin, M.R.: The Wrong Patient. Annals of Internal Medicine. 136, 826–833 (2002). https://doi.org/10.7326/0003-4819-136-11-200206040-00012.
25.
Walshe, K., Offen, N.: A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Quality and Safety in Health Care. 10, 250–256 (2001). https://doi.org/10.1136/qhc.0100250.
26.
Walshe, K., Offen, N.: A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Quality in Health Care. 10, 250–256 (2001). https://doi.org/10.1136/qhc.0100250.
27.
Healthcare Commission: Investigation into outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust, http://webarchive.nationalarchives.gov.uk/20060502043818/http://healthcarecommission.org.uk/_db/_documents/Maidstone_and_Tunbridge_Wells_investigation_report_Oct_2007.pdf, (2007).
28.
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Executive summary, http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf, (2013).
29.
National Advisory Group on the Safety of Patients in England: Berwick Report into Improving the Safety of Patient, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf, (2013).
30.
McKee, M.: Improving the safety of patients in England. BMJ. 347, 5038–5038 (2013). https://doi.org/10.1136/bmj.f5038.
31.
McKee, M.: Improving the safety of patients in England. BMJ: British medical journal. 347, f5038–f5038 (2013). https://doi.org/10.1136/bmj.f5038.
32.
Vincent, C.: Patient safety. Wiley-Blackwell, Chichester, West Sussex, UK (2010).
33.
Kohn, L.T., Corrigan, J., Donaldson, M.S.: To err is human: building a safer health system. National Academy Press, Washington, D.C. (2000).
34.
Vincent, C., Neale, G., Woloshynowych, M.: Adverse events in British hospitals: preliminary retrospective record review. BMJ. 322, 517–519 (2001). https://doi.org/10.1136/bmj.322.7285.517.
35.
Vincent, C., Neale, G., Woloshynowych, M.: Adverse events in British hospitals: preliminary retrospective record review. BMJ: British medical journal. 322, 517–519 (2001). https://doi.org/10.1136/bmj.322.7285.517.
36.
de Vries, E.N., Ramrattan, M.A., Smorenburg, S.M., Gouma, D.J., Boermeester, M.A.: The incidence and nature of in-hospital adverse events: a systematic review. Quality and Safety in Health Care. 17, 216–223 (2008). https://doi.org/10.1136/qshc.2007.023622.
37.
de Vries, E.N., Ramrattan, M.A., Smorenburg, S.M., Gouma, D.J., Boermeester, M.A.: The incidence and nature of in-hospital adverse events: a systematic review. Quality & safety in health care. 17, 216–223 (2008). https://doi.org/10.1136/qshc.2007.023622.
38.
Taxis, K., Barber, N.: Causes of intravenous medication errors: an ethnographic study. Quality and Safety in Health Care. 12, 343–347 (2003). https://doi.org/10.1136/qhc.12.5.343.
39.
Taxis, K., Barber, N.: Causes of intravenous medication errors: an ethnographic study. Quality & safety in health care. 12, 343–347 (2003). https://doi.org/10.1136/qhc.12.5.343.
40.
Burke, J.P.: Infection Control — A Problem for Patient Safety. New England Journal of Medicine. 348, 651–656 (2003). https://doi.org/10.1056/NEJMhpr020557.
41.
Burke, J.P.: Infection control--a problem for patient safety. The New England Journal of Medicine. 348, 651–656 (2003).
42.
Donaldson, L.J., Great Britain: An organisation with a memory: report of an expert group on learning from adverse events in the NHS. Stationery Office, London (2000).
43.
Department of Health: Safety First: a report for patients, clinicians and healthcare managers, http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_064159.pdf, (2006).
44.
Reason, J.: Human error: models and management. BMJ. 320, 768–770 (2000). https://doi.org/10.1136/bmj.320.7237.768.
45.
Reason, J.: Human Error: Models and Management. BMJ: British medical journal. 320, 768–770 (2000). https://doi.org/10.1136/bmj.320.7237.768.
46.
Reason, J.T.: Managing the risks of organizational accidents. Ashgate, Aldershot, Hants, England (1997).
47.
Dekker, S.: Patient safety: a human factors approach. CRC Press, Taylor & Francis Group, Boca Raton (2011).
48.
Perrow, C.: Normal Accidents: Living with High Risk Technologies. Princeton University Press, Princeton (2011).
49.
Perrow, C.: Normal accidents: living with high-risk technologies. Princeton University Press, Princeton, NJ (1999).
50.
Leonard, M.S., Frankel, A., Simmonds, T., Vega, K.B.: Achieving safe and reliable healthcare: strategies and solutions. Health Administration Press, Chicago, IL (2004).
51.
Reason, J.T.: Managing the risks of organizational accidents. Ashgate, Aldershot, Hants, England (1997).
52.
Apkon, M., Leonard, J., Vitale, R., DeLizio, L., Probst, L.: Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Quality and Safety in Health Care. 13, 265–271 (2004). https://doi.org/10.1136/qshc.2003.007443.
53.
Apkon, M., Leonard, J., Probst, L., DeLizio, L., Vitale, R.: Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Quality & safety in health care. 13, 265–271 (2004). https://doi.org/10.1136/qshc.2003.007443.
54.
Armitage, G., Neary, M., Hollingsworth, G., Ashley, L.: A practical guide to Failure Mode and Effects Analysis in health care: Making the most of the team and its meetings. Joint Commission Journal on Quality and Patient Safety. 36, 358–351 (2010). https://doi.org/10.1016/S1553-7250(10)36053-3.
55.
Barber, N., Franklin, B., Burnett, S., Parand, A., Shebl, N.: Failure mode and effects analysis: Views of hospital staff in the UK. Journal of Health Services Research and Policy. 17, 37–43 (2012).
56.
Barach, P., Small, S.D.: Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 320, 759–763 (2000). https://doi.org/10.1136/bmj.320.7237.759.
57.
Barach, P., Small, S.D.: Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ: British Medical Journal. 320, 759–763 (2000). https://doi.org/10.1136/bmj.320.7237.759.
58.
Benn, J., Koutantji, M., Wallace, L., Spurgeon, P., Rejman, M., Healey, A., Vincent, C.: Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care. 18, 11–21 (2009). https://doi.org/10.1136/qshc.2007.024166.
59.
Benn, J., Koutantji, M., Wallace, L., Spurgeon, P., Rejman, M., Healey, A., Vincent, C.: Feedback from incident reporting: information and action to improve patient safety. Quality & safety in health care. 18, 11–21 (2009). https://doi.org/10.1136/qshc.2007.024166.
60.
Shojania, K.G.: The frustrating case of incident-reporting systems. Quality and Safety in Health Care. 17, 400–402 (2008). https://doi.org/10.1136/qshc.2008.029496.
61.
Shojania, K.G.: The frustrating case of incident-reporting systems. Quality and Safety in Health Care. 17, 400–402 (2008). https://doi.org/10.1136/qshc.2008.029496.
62.
Sujan, M.A.: A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. Reliability Engineering & System Safety. 101, 21–34 (2012). https://doi.org/10.1016/j.ress.2011.12.021.
63.
Flin, R.H., O’Connor, P., Crichton, M.: Safety at the sharp end: a guide to non-technical skills. Ashgate Publishing Ltd, Farnham (2008).
64.
Flin, R.H., O’Connor, P., Crichton, M.: Safety at the sharp end: a guide to non-technical skills. Ashgate, Aldershot, England (2008).
65.
Cohen, M.D., Hilligoss, P.B.: The published literature on handoffs in hospitals: deficiencies identified in an extensive review. BMJ Quality & Safety. 19, 493–497 (2010). https://doi.org/10.1136/qshc.2009.033480.
66.
Cohen, M.D., Hilligoss, P.B.: The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Quality & safety in health care. 19, 493–497 (2010). https://doi.org/10.1136/qshc.2009.033480.
67.
Raduma-Tomas, M.A., Flin, R., Yule, S., Williams, D.: Doctors’ handovers in hospitals: a literature review. BMJ Quality & Safety. 20, 128–133 (2011). https://doi.org/10.1136/bmjqs.2009.034389.
68.
Patterson, E.S., Wears, R.L.: Patient handoffs: standardized and reliable measurement tools remain elusive. Joint Commission Journal On Quality And Patient Safety. 36, 52–61 (2010).
69.
Sujan, M., Chessum, P.T., Rudd, M., Fitton, L., Inada Kim, M., Spurgeon, P., Cooke, M.W.: Emergency Care Handover (ECHO study) across care boundaries – the need for joint decision making and consideration of psychosocial history. Emergency Medicine Journal. 30, 873–873 (2013). https://doi.org/10.1136/emermed-2013-203113.17.
70.
Managing competing organizational priorities in clinical handover across organizational boundaries.
71.
Weick, K.E., Sutcliffe, K.M.: Managing the unexpected: resilient performance in an age of uncertainty. Jossey-Bass, San Francisco (2007).
72.
Weick, K.E., Sutcliffe, K.M.: Managing the unexpected: resilient performance in an age of uncertainty. Jossey-Bass, San Francisco (2007).
73.
Hollnagel, E., Woods, D.D., Leveson, N.: Resilience engineering: concepts and precepts. Ashgate, Aldershot, England (2006).
74.
Hollnagel, E., Braithwaite, J., Wears, R.L.: Resilient health care. Ashgate, Farnham (2013).
75.
Cook, R.I., Render, M., Woods, D.D.: Gaps in the continuity of care and progress on patient safety. BMJ. 320, 791–794 (2000). https://doi.org/10.1136/bmj.320.7237.791.
76.
Cook, R.I., Render, M., Woods, D.D.: Gaps in the Continuity of Care and Progress on Patient Safety. BMJ: British medical journal. 320, 791–794 (2000). https://doi.org/10.1136/bmj.320.7237.791.
77.
Hollnagel, E.: Resilient health care Volume 2,. The resilience of everyday clinical work. , Ashgate, 2015.