1.
The importance of human resources management in health care: a global context [Internet]. Available from: http://www.human-resources-health.com/content/4/1/20
2.
Berwick DM, Godfrey AB, Roessner J. Curing health care: new strategies for quality improvement : a report on the National Demonstration Project on Quality Improvement in Health Care. San Francisco, Calif: Jossey-Bass; 2002.
3.
Bicheno J. The service systems toolbox: integrating lean thinking, systems thinking, and design thinking. Buckingham: PICSIE Books; 2012.
4.
Bicheno J. The new lean toolbox: towards fast, flexible flow. 3rd ed. Buckingham: PICSIE Books; 2004.
5.
Bicheno J, Catherwood P, James R. Six sigma: and the quality toolbox for service and manufacturing. Rev. ed. Buckingham: Picsie Books; 2005.
6.
Cusins P. Understanding Quality through Systems Thinking. TQM magazine [Internet]. 1994;6(5):19–27. Available from: http://0-www.emeraldinsight.com.pugwash.lib.warwick.ac.uk/doi/pdfplus/10.1108/09544789410067853
7.
Deming WE. Out of the crisis. 1st MIT Press ed. Cambridge, Mass: MIT Press; 2000.
8.
Edvardsson B, Øvretveit J, Thomasson B. Quality of service: making it really work. Vol. Quality in Action. Maidenhead: McGraw-Hill; 1994.
9.
Liker JK, Meier D. The Toyota way fieldbook: a practical guide for implementing Toyota’s 4Ps [Internet]. New York: McGraw-Hill; 2006. Available from: http://lib.myilibrary.com/browse/open.asp?id=86287&entityid=https://idp.warwick.ac.uk/idp/shibboleth
10.
Liker JK, Meier D. The Toyota way fieldbook: a practical guide for implementing Toyota’s 4Ps. New York: McGraw-Hill; 2006.
11.
McNulty T, Ferlie E. Reengineering health care: the complexities of organizational transformation. Oxford: Oxford University Press; 2004.
12.
Schonberger R. Best practices in lean six sigma process improvement: a deeper look [Internet]. Hoboken, N.J.: John Wiley & Sons; 2008. Available from: http://lib.myilibrary.com/browse/open.asp?id=109440&entityid=https://idp.warwick.ac.uk/idp/shibboleth
13.
Schonberger R. Best practices in lean six sigma process improvement: a deeper look. Hoboken, N.J.: John Wiley & Sons; 2008.
14.
Seddon J. Freedom from command & control: rethinking management for lean service. New York: Productivity Press; 2005.
15.
Slack N, Brandon-Jones A, Johnston R. Operations management [Internet]. 7th edition. Boston, Mass: Pearson Education UK; 2013. Available from: http://lib.myilibrary.com/browse/open.asp?id=502442&entityid=https://idp.warwick.ac.uk/idp/shibboleth
16.
Slack N, Brandon-Jones A, Johnston R. Operations management. Seventh edition. Harlow, England: Pearson; 2013.
17.
Spear S, Kent Bowen H. Decoding the DNA of the Toyota Production System. Harvard business review [Internet]. 1999;77(5):96–106. Available from: http://0-search.ebscohost.com.pugwash.lib.warwick.ac.uk/direct.asp?db=bth&jid=HBR&scope=site
18.
Womack JP, Jones DT. Lean thinking: banish waste and create wealth in your corporation. Rev. and updated. London: Simon & Schuster; 2003.
19.
Womack JP, Jones DT, Roos D. The machine that changed the world. New ed. London: Simon & Schuster; 2007.
20.
Reason JT. Human error. Cambridge [England]: Cambridge University Press; 1990.
21.
Dekker S, Dekker S. The field guide to understanding human error [Internet]. 2nd ed. Farnham: Ashgate Publishing Ltd; 2006. Available from: https://www.dawsonera.com/guard/protected/dawson.jsp?name=https://idp.warwick.ac.uk/idp/shibboleth&dest=http://www.dawsonera.com/abstract/9781472408402
22.
Dekker S, Dekker S. The field guide to understanding human error. Aldershot, England: Ashgate; 2006.
23.
Norman DA. The psychology of everyday things. New York: Basic Books; 1988.
24.
Chassin MR. The Wrong Patient. Annals of Internal Medicine [Internet]. 2002;136(11):826–33. Available from: http://0-doi.org.pugwash.lib.warwick.ac.uk/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. 2001;10(4):250–6.
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 [Internet]. 2001;10(4):250–6. Available from: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/10/4/250
27.
Healthcare Commission. Investigation into outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust [Internet]. 2007. Available from: http://webarchive.nationalarchives.gov.uk/20060502043818/http://healthcarecommission.org.uk/_db/_documents/Maidstone_and_Tunbridge_Wells_investigation_report_Oct_2007.pdf
28.
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Executive summary [Internet]. 2013. Available from: http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf
29.
National Advisory Group on the Safety of Patients in England. Berwick Report into Improving the Safety of Patient [Internet]. 2013. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
30.
McKee M. Improving the safety of patients in England. BMJ. 2013;347:5038–5038.
31.
McKee M. Improving the safety of patients in England. BMJ: British medical journal [Internet]. 2013;347(7921):f5038–f5038. Available from: http://0-www.bmj.com.pugwash.lib.warwick.ac.uk/content/347/bmj.f5038
32.
Vincent C. Patient safety. Chichester, West Sussex, UK: Wiley-Blackwell; 2010.
33.
Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Washington, D.C.: National Academy Press; 2000.
34.
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322(7285):517–9.
35.
Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ: British medical journal [Internet]. 2001;322:517–9. Available from: http://0-www.bmj.com.pugwash.lib.warwick.ac.uk/content/322/7285/517
36.
de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Quality and Safety in Health Care. 2008;17(3):216–23.
37.
de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Quality & safety in health care [Internet]. 2008;17:216–23. Available from: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/17/3/216.full
38.
Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Quality and Safety in Health Care. 2003;12(5):343–7.
39.
Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Quality & safety in health care [Internet]. 2003;12(5):343–7. Available from: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/12/5/343.full
40.
Burke JP. Infection Control — A Problem for Patient Safety. New England Journal of Medicine. 2003;348(7):651–6.
41.
Burke JP. Infection control--a problem for patient safety. The New England Journal of Medicine [Internet]. 2003;348(7):651–6. Available from: http://0-search.proquest.com.pugwash.lib.warwick.ac.uk/docview/223934778?accountid=14888
42.
Donaldson LJ, Great Britain. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: Stationery Office; 2000.
43.
Department of Health. Safety First: a report for patients, clinicians and healthcare managers [Internet]. 2006. Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_064159.pdf
44.
Reason J. Human error: models and management. BMJ. 2000;320(7237):768–70.
45.
Reason J. Human Error: Models and Management. BMJ: British medical journal [Internet]. 2000;320:768–70. Available from: http://0-www.jstor.org.pugwash.lib.warwick.ac.uk/stable/25187420
46.
Reason JT. Managing the risks of organizational accidents. Aldershot, Hants, England: Ashgate; 1997.
47.
Dekker S. Patient safety: a human factors approach [Internet]. Boca Raton: CRC Press, Taylor & Francis Group; 2011. Available from: http://0-marc.crcnetbase.com.pugwash.lib.warwick.ac.uk/isbn/9781439852262
48.
Perrow C. Normal Accidents: Living with High Risk Technologies [Internet]. Princeton: Princeton University Press; 2011. Available from: http://WARW.eblib.com/patron/FullRecord.aspx?p=827819
49.
Perrow C. Normal accidents: living with high-risk technologies. Princeton, NJ: Princeton University Press; 1999.
50.
Leonard MS, Frankel A, Simmonds T, Vega KB. Achieving safe and reliable healthcare: strategies and solutions. Vol. ACHE management series. Chicago, IL: Health Administration Press; 2004.
51.
Reason JT. Managing the risks of organizational accidents. Aldershot, Hants, England: Ashgate; 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. 2004;13(4):265–71.
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 [Internet]. 2004;13(4):265–71. Available from: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/13/4/265.full
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 [Internet]. 2010;36(8):358–351. Available from: http://www.jointcommissionjournal.com/article/S1553-7250(10)36053-3/pdf
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 [Internet]. 2012;17(1):37–43. Available from: https://arlir.iii.com/nonret~S0&atitle=Failure+mode+and+effects+analysis:+Views+of+hospital+staff+in+the+UK&title=Journal+of+Health+Services+Research+and+Policy&aufirst=N.&auinit=&aulast=Barber&issn=13558196&eissn=&coden=&volume=17&issue=1&spage=37&epage=43&quarter=&ssn=&date=2012&sid=&reqtype3
56.
Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320(7237):759–63.
57.
Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ: British Medical Journal [Internet]. 2000;320(7237):759–63. Available from: http://0-www.jstor.org.pugwash.lib.warwick.ac.uk/stable/25187418
58.
Benn J, Koutantji M, Wallace L, Spurgeon P, Rejman M, Healey A, et al. Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care. 2009;18(1):11–21.
59.
Benn J, Koutantji M, Wallace L, Spurgeon P, Rejman M, Healey A, et al. Feedback from incident reporting: information and action to improve patient safety. Quality & safety in health care [Internet]. 2009;18(1):11–21. Available from: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/18/1/11.full
60.
Shojania KG. The frustrating case of incident-reporting systems. Quality and Safety in Health Care. 2008;17(6):400–2.
61.
Shojania KG. The frustrating case of incident-reporting systems. Quality and Safety in Health Care [Internet]. 2008;17(6):400–2. Available from: http://0-dx.doi.org.pugwash.lib.warwick.ac.uk/10.1136/qshc.2008.029496
62.
Sujan MA. A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. Reliability Engineering & System Safety [Internet]. 2012;101:21–34. Available from: http://0-doi.org.pugwash.lib.warwick.ac.uk/10.1016/j.ress.2011.12.021
63.
Flin RH, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills [Internet]. Farnham: Ashgate Publishing Ltd; 2008. Available from: https://www.dawsonera.com/guard/protected/dawson.jsp?name=https://idp.warwick.ac.uk/idp/shibboleth&dest=http://www.dawsonera.com/abstract/9781472424006
64.
Flin RH, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills. Aldershot, England: Ashgate; 2008.
65.
Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. BMJ Quality & Safety. 2010;19(6):493–7.
66.
Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Quality & safety in health care [Internet]. 2010;19(6):493–7. Available from: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/19/6/493.full
67.
Raduma-Tomas MA, Flin R, Yule S, Williams D. Doctors’ handovers in hospitals: a literature review. BMJ Quality & Safety [Internet]. 2011;20(2):128–33. Available from: http://0-doi.org.pugwash.lib.warwick.ac.uk/10.1136/bmjqs.2009.034389
68.
Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Joint Commission Journal On Quality And Patient Safety [Internet]. 2010;36(2):52–61. Available from: https://arlir.iii.com/nonret~S0&atitle=Patient+handoffs:+standardized+and+reliable+measurement+tools+remain+elusive.&title=Joint+Commission+Journal+On+Quality+And+Patient+Safety&aufirst=E.S.&auinit=&aulast=Patterson&issn=15537250&eissn=&coden=&volume=36&issue=2&spage=52&epage=61&quarter=&ssn=&date=2010&sid=&reqtype3
69.
Sujan M, Chessum PT, Rudd M, Fitton L, Inada Kim M, Spurgeon P, et al. Emergency Care Handover (ECHO study) across care boundaries – the need for joint decision making and consideration of psychosocial history. Emergency Medicine Journal [Internet]. 2013;30(10):873–873. Available from: http://0-doi.org.pugwash.lib.warwick.ac.uk/10.1136/emermed-2013-203113.17
70.
Managing competing organizational priorities in clinical handover across organizational boundaries. Available from: http://hsr.sagepub.com/content/20/1_suppl/17.full
71.
Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty [Internet]. 2nd ed. San Francisco: Jossey-Bass; 2007. Available from: https://www.dawsonera.com/guard/protected/dawson.jsp?name=https://idp.warwick.ac.uk/idp/shibboleth&dest=http://www.dawsonera.com/abstract/9780470178591
72.
Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco: Jossey-Bass; 2007.
73.
Hollnagel E, Woods DD, Leveson N. Resilience engineering: concepts and precepts. Aldershot, England: Ashgate; 2006.
74.
Hollnagel E, Braithwaite J, Wears RL. Resilient health care. Vol. Ashgate studies in resilience engineering. Farnham: Ashgate; 2013.
75.
Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320(7237):791–4.
76.
Cook RI, Render M, Woods DD. Gaps in the Continuity of Care and Progress on Patient Safety. BMJ: British medical journal [Internet]. 2000;320(7237):791–4. Available from: http://0-www.bmj.com.pugwash.lib.warwick.ac.uk/content/320/7237/791
77.
Hollnagel E. Resilient health care Volume 2,. The resilience of everyday clinical work. 2nd edition. Ashgate, 2015;