The investigation and analysis of critical incidents and adverse events in healthcare

Health Technology Assessment

Volumn 9, Issue 19, 2005, Pages

  Woloshynowych, M ^a   Rogers, S ^b   Taylor Adams, S ^c   Vincent, C ^a  

^a IMPERIAL COLLEGE LONDON   (United Kingdom)

^b UNIVERSITY COLLEGE LONDON   (United Kingdom)

^c NATIONAL PATIENT SAFETY AGENCY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ACCIDENT; CONCEPTUAL FRAMEWORK; CRITICAL INCIDENTS METHOD; DATA ANALYSIS; DATA BASE; EMERGENCY CARE; HEALTH CARE; HIGH RISK POPULATION; INCIDENT REPORT; INFORMATION PROCESSING; INTERVIEW; MEDICAL LITERATURE; MENTAL HEALTH CARE; METHODOLOGY; NATIONAL HEALTH SERVICE; PATIENT SAFETY; PRIMARY MEDICAL CARE; QUALITY CONTROL; REVIEW; RISK MANAGEMENT; ROOT CAUSE ANALYSIS; CLINICAL PRACTICE; HEALTH CARE QUALITY; HUMAN; RISK ASSESSMENT; STANDARD; TASK PERFORMANCE;

BENCHMARKING; HUMANS; PHYSICIAN'S PRACTICE PATTERNS; QUALITY ASSURANCE, HEALTH CARE; RISK ASSESSMENT; TASK PERFORMANCE AND ANALYSIS;

EID: 33646695679     PISSN: 13665278     EISSN: None     Source Type: Journal    
DOI: 10.3310/hta9190     Document Type: Review

References (179)

1. Department of Health. An organisation with a memory Report of an Expert Group on Learning from Adverse Events in the NHS. London: The Stationery Office; 2000.
2. Secker-Walker J, Donaldson L. Clinical governance: the context of risk management. In Vincent CA, editor Clinical risk management Enhancing patient safety. London: BMJ Publications; 2001. pp. 61-73.
3. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317-22.
4. Eddy DM. Clinical policies and the quality of clinical practice. N Engl J Med 1982;307:343-7.
5. Evidence based Medicine Working Group. Evidence based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268:2420-5.
6. Department of Health. A first class service: quality in the new NHS. Health Service Circular HSC[98]113. London: Department of Health, 1998.
7. Berwick D. A primer on leading the improvement of systems. BMJ 1996;312:619-22.
8. Walshe K. The development of clinical risk management. In: Vincent CA. Clinical risk management Enhancing patient safety. London: BMJ Publications; 2001. pp. 45-60.
9. Walshe K, Dineen M. Clinical risk management: making a difference? Birmingham: NHS Confederation; 1998.
10. NHS Executive. Clinical negligence costs. FDL(96)39. London: NHS Executive; 1996.
11. Vincent CA. Risk, safety, and the dark side of quality. BMJ 1997;314:1775-6.
12. Taylor D. Quality and professionalism in health care; a review of current initiatives in the NHS. BMJ 1996;312:626-9.
13. Smith R. All changed, changed utterly. BMJ 1998; 316:1917-18.
14. Corrigan J, Kohn L, Donaldson M, editors. To err is human: building a safer healthcare system. Committee on Quality of Healthcare in America, Institute of Medicine. Wellington DC: National Academy Press; 2000.
15. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995; 163:458-71.
16. Leape L, Berwick D. Safe healthcare: are we up to it? BMJ 2000;320:725-6.
17. Donaldson L. Championing patient safety: going global. Quality and Safety in Health Care 2002;11:113.
18. Leape LL. Error in medicine. JAMA 1994; 272:1851-7.
19. Leape LL, Brennan TA, Laird N, Lawthers A, Localio A, Barnes B, et al. The nature of adverse events in hospitalised patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
20. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 1999;38:261-71.
21. Vincent C, Neale C, Woloshynowych M. Adverse events in British hospitalised patients: a preliminary retrospective review. BMJ 2001; 322:517-19.
22. Rogers S. Risk management in general practice. In: Vincent CA, editor Clinical risk management Enhancing patient safety. London: BMJ Publications; 2001. pp. 241-59.
23. Vincent C, Taylor Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154-7.
24. Berlin A, Spencer JA, Bhopal RS, van Zwanenberg TD. Audit of deaths in general practice: pilot study of the critical incident technique. Qual Health Care 1992;1:231-5.
25. Bradley CP. Uncomfortable prescribing decisions: a critical incident study. BMJ 1992;304:294-6.
26. Hart JT, Humphreys C. Be your own coroner: an audit of 500 consecutive deaths in general practice. BMJ 1987;41:113-15.
27. Owen C. Formal complaints against general practitioners: a study of 1000 cases. Br J Gen Pract 1991;41:113-15.
28. Wright D, MacKenzie SJ, Buchan I, Cairns CS, Price LE. Critical incidents in the intensive therapy unit. Lancet 1991;338:676-8.
29. DeAnda A, Gaba DM. Role of experience in the response to simulated critical incidents. Anaesth Analgesia 1991;72:308-15.
30. Williamson J. Critical incident reporting in anaesthesia. Anaesth Intensive Care 1988;16:101-3.
31. Waterston T. A critical incident study in child health. Med Educ 1988;22:27-31.
32. Flanagan JC. The critical incident technique. Psychol Bull 1954;51:327-58.
33. Vincent C. The study of errors and accidents in medicine. In: Vincent C, Ennis M, Audley RJ, editors. Medical accidents. Oxford: Oxford Medical Publications; 1993. pp. 7-33.
34. Reason JT. The human factor in medical accidents. In: Vincent CA, Ennis M, Audley RJ, editors. Medical accidents. Oxford: Oxford Medical Publications; 1993. pp. 1-16.
35. Eagle CJ, Davies JM, Reason JT. Accident analysis of large scale technological disasters: applied to anaesthetic complications. Can J Anaesth 1992; 39:118-22.
36. Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: Bognor MS, editor. Human error in medicine. Hilldale, NJ: Lawrence Erlbaum; 1994. pp. 255-310.
37. Reason JT. Understanding adverse events: human factors. In: Vincent CA, editor. Clinical risk management. London: BMJ Publications; 1995. pp. 31-54.
38. Stanhope N, Vincent CA, Taylor Adams S, O'Connor A, Beard RW. Applying human factors methods to clinical risk management in obstetrics. Br J Obstet Gynaecol 1997;104:1225-32.
39. Taylor-Adams S, Vincent C, Stanhope N. Applying human factors methods to the investigation and analysis of clinical adverse events. Saf Sci 1999; 31:143-59.
40. Hale A, Glendon A. Individual behaviour in the control of danger. Amsterdam: Elsevier; 1987.
41. Ridley J. Safety at Work. 3rd ed. London: Butterworth; 1990.
42. Waring A. Safety management systems. London: Chapman and Hall; 1996.
43. Kirwan B, James NJ. The development of a human reliability assessment system for the management of human error in complex systems. Presented at Reliability '89, Brighton June 1989.
44. Taylor Adams S. A human error database. PhD thesis, University of Birmingham; 1996.
45. Reason J. Managing the risks of organisational accidents. Aldershot: Ashgate; 1997.
46. Gaba DM. Structural and organizational issues In Patient safety: a comparison of health care to other high-hazard industries. Calif Manage Rev 2000; 43:83-102.
47. Benner L. Rating accident models and investigation methodologies. J Saf Res 1985; 16:105-26.
48. Koorneek F, Hale A. Learning from incidents at work. In Redmill F, Rajan J, editors. Human factors in safety critical systems. Oxford: Butterworth-Heinemann; 1997. pp. 257-28.
49. Benner L. Accident investigation: multilinear events sequencing methods. J Saf Res 1975;7:67-73.
50. Ferry TS. Modern accident investigation and analysis An executive guide. New York: Wiley; 1981.
51. Ferry TS. Techniques to improve the effectiveness of the capable investigator. In Proceedings: Annual Seminar of the International Society of Air Safety Investigator Montreal. ISASI; 1979.
52. Center for Chemical Process Safety of the American Institute of Chemical Engineers. Guidelines for Investigating Chemical Process Incidents, New York; 1992.
53. Kirwan B, Ainsworth LK. Guide to task analysis. London: Taylor and Francis; 1992.
54. Rasmussen J, Pedersen OM, Mancini G, Carnino A, Griffon M, Gagnolet P. Classification system for reporting events involving human malfunction. Report No. RISC-M-2246. Roskude: RISC National Laboratories; 1981.
55. Whalley SP. Minimising the cause of human error. In Libberton GP, editor. 10th Advances in Reliability Technology Symposium. London: Elsevier; 1988. pp. 114-28.
56. Comer P, Fitt JS, Ostebo R. A driller's HAZOP method. Presented at Eurospec 86, Society of Petroleum Engineering, London, 1986. SPE 15867.
57. Kay BR. Key factors in effective foreman behaviour. Personnel 1959;36:25-31.
58. Meister D. Behavioural analysis and measurement methods. New York: Wiley; 1985.
59. Patrick J. Training research and practice. London: Academic Press; 1992.
60. Svenson O. The accident evolution and barrier function (AEB) model applied to incident analysis in the processing industries. Risk Analysis 1991; 11:499-507.
61. Suokas J, Rouhiainen V. Work safety analysis: method description and user's guide. Research Reports No. 314. Espoo: Technical Research Centre of Finland; 1984.
62. Kirwan BI. Human error identification in human reliability assessment. Part 1: overview of approaches. Appl Ergon 1992;23:299-318.
63. Kirwan BI. Human error identification in human reliability assessment. Part 2: detailed comparison of techniques. Appl Ergon 1992;23:371-81.
64. Hendrick K, Benner L. Investigating accidents with STEP. New York: Marcel Dekker; 1987.
65. Boeing Aerospace Company. Sneak circuit analysis handbook. Document No. D2-118341-1. Houston, TX: Boeing Aerospace Company; Space Systems Division, 1970.
66. Rankin JP. Sneak circuit analysis. Nucl Saf 1973;14:461-8.
67. Kletz, T. HAZOP and HAZAN - identifying and assessing process industry hazards. London: Institution of Chemical Engineers; 1992.
68. Doran JA, Van der Graaf GC. Tripod-BETA: incident investigation and analysis. In Proceedings of the International Conference on Health. Safety and Environment. New Orleans: Society of Petroleum Engineers; 1996. pp. 9-12.
69. Kirwan B, Embrey DE, Rea K. Human reliability assessors guide. Report RTS 88/95Q. Culcheth, Cheshire: NCSR, UKAEA; 1988.
70. Johnson WG. MORT safety assurance systems. New York: Marcel Dekker; 1980.
71. Johnson WG. MORT: the management oversight and risk tree. J Saf Res 1975;7:4-15.
72. Johnson W. Accident/incident investigation manual. 1-7-1-17. Washington, DC: Department of Energy, Government Printing Office; 1976.
73. Kepner H, Tregoe BB. The rational manager. 2nd ed. Princeton, NJ: Kepner-Tregoe; 1976.
74. Trost WA, Nertney RJ. Barrier analysts. Report No. US DOE - 76-45/29, SSDC-29. Idaho Falls, ID: DOE; 1985.
75. Buys JR, Clark JL. Events and causal factors charting. Report No. SSDC 14. Idaho Falls, ID: DOE/SSDC; 1978.
76. Warren I. Events and causal factor charting for healthcare. Presented at the St Paul Conference on Root Cause Analysis, London, 3 October 2001.
77. Lucas D. The causes of human error. In Redmill F, Rajan J, editors. Human factors in safety-critical systems. Oxford: Butterworth-Heinemann; 1997. pp. 37-62.
78. Joint Commission on Accreditation of Healthcare Organizations. Root cause analysis in healthcare: tools and techniques. Oakbrook Terrace, IL: JCAHO; 2000.
79. Botting RM, Johnson CW. A formal and structured approach to the use of task analysis in accident modelling. Int J Hum Comput Stud 1998;49:223-44.
80. Johnson C. Proving properties of accidents. In Holloway C, editor 4th NASA Langley Workshop on Formal Methods. Hampton, VA: NASA Langley Research Center; 1997. pp. 21-34.
81. Telford AJ, Johnson CW. Using formal methods to analyse human error and system failure during accident investigations. Software Eng J 1996; 11:355-6.
82. Hollnagel E. The phenotype of erroneous actions. Int J Man-Machine Stud 1993,39:1-32.
83. Mitchell CM. GT-MSOCC: a research domain for modelling human-computer interaction and aiding decision making in supervisory control systems. IEEE Trans Syst Man Cybernet 1987; SMC-17:553-72.
84. Rasmussen J. Human errors: a taxonomy for describing human malfunction in industrial installations. J Occup Acad 1982;4:311-33.
85. Reason J. Human error. Cambridge: Cambridge University Press; 1990.
86. O'Hare D. The wheel of misfortune: a taxonomic approach to human factors in accident investigation and analysis in aviation and other complex systems. Ergonomics 2000;43:2001-19.
87. O'Hare D, Batt R, Wiggins M, Morrison D. Cognitive failure analysis for aircraft accident investigation. Ergonomics 1994;37:1855-69.
88. Bruun O, Taylor JR, Rasmussen A. Cause-consequence reporting for accident reduction. RISO-M-2206. Roskilde: Risø National Laboratory; 1979.
89. Mulrow CD. The medical review article: state of the science. Ann Intern Med 1987;106:485-8.
90. NHS CRD. Undertaking systematic reviews of effectiveness CRD guidelines for those carrying out or commissioning reviews. York: University of York; 1996.
91. Fliess JL, Gross AJ. Meta analysis in epidemiology, with special reference to studies of the association between exposure to environmental tobacco smoke and lung cancer: a critique. J Clin Epidemiol 1991; 44:127-39.
92. Lemmer B, Grellier R, Steven J. Systematic review of non-random and qualitative research literature; exploring and uncovering an evidence base for health visiting and decision making. Qual Health Res 1999;9:315-28.
93. Popay J, Rogers A, Williams G. Rationale and standards for the systematic review of qualitative literature in health service research. Qual Health Res 1998;8:341-51.
94. Giacomini MK, Cook DJ. Users' guides to the medical literature: XXIII. Qualitative research in health care. What are the results and how do they help me care for my patients? JAMA 2000; 284:478-82.
95. Laurant M, Hulscher M, Wensing M, Grol R. Analysing and monitoring implementation strategies for changing professional practice. Nijmegen: Centre for Quality of Care Research (WOK). 1999.
96. Fahlbruch B, Wilpert B. Event analysis as problem solving process. In Hale A, Wilpert B, Freitag M, editors. After the event From accident to organisational learning. Oxford: Elsevier Science; 1997. pp. 113-29.
97. Drife J. Maternal mortality: lessons from the confidential enquiry. Hosp Med 1999;60:156-7.
98. Thompson C. The confidential inquiry comes of age. Br J Psychiatry 1999;175:301-2.
99. Pringle M, Bradley CR Carmichael CM, Wallis H, Moore A. Significant event auditing. A study of the feasibility and potential of case based auditing in primary medical care. Occas Pap R Coll Gen Pract 1995;70:1-71.
100. Green S, Lee R, Moss J. Problems in general practice Delay in diagnosis. Manchester: Medical Defence Union; 1998.
101. Green S. Goodwin H, Moss I. Problems in general practice Medication errors. Manchester: Medical Defence Union; 1996.
102. Mohammed MA, Cheng KK, Rouse A, Marshall T. Bristol, Shipman and clinical governance: Shewart's forgotten lessons. Lancet 2001; 357:463-7.
103. Graber ML. Physician participation in quality management. Expanding the goals of peer review to detect both practitioner and system error. Jt Comm J Qual Improv 1999;25:396-407.
104. Caplan RA, Posner KL, Caplan RA, Ward RJ. Adverse respiratory events in anaesthesia: a closed claims analysis. Anesthesiology 1990;72:828-33.
105. Ennis M, Vincent CA. obstetric accidents: a review of 64 cases. BMJ 1990;300:1365-7.
106. Vincent CA, Martin T, Ennis M. obstetric accidents: the patient's perspective. Br J Obstet Gynaecol 1991;98:390-5.
107. Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000;105:805-14.
108. Beydon L, Conreux F, Le Gall R, Safran D, Cazalaa JB. Analysis of the French health ministry's national register of incidents involving medical devices in anaesthesia and intensive care. Br J Anaesth 2001;86:382-7.
109. Linden JV. The release of unsuitable units through misinterpretation of laboratory results transmitted by facsimile. Transfusion 2000;40:435-8.
110. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-20.
111. Wanzel KR, Jamieson CG, Bohnen JM. Complications on a general surgery service: incidence and reporting. Can J Surg 2000; 43:113-17.
112. Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997;25:1289-97.
113. Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology 1984;60:34-42.
114. Ely JW, Levinson W, Elder NC, Mainous AG, Vinson DC. Perceived causes of family physicians' errors. J Fam Pract 1995;40:337-44.
115. Morris GP, Morris RW. Anaesthesia and fatigue: an analysis of the first 10 years of the Australian Incident Monitoring Study 1987-1997. Anaesth Intens Care 2000;28:300-4.
116. Steven D, Malpass A, Moller J, Runciman WB, Helps SC. Towards safer drug use in general practice. J Qual Clin Pract 1999;19:47-50.
117. Sinclair M, Simmons S, Cyna A. Incidents in obstetric anaesthesia and analgesia: an analysis of 5000 AIMS reports. Anaesth Intens Care 1999; 27:276-81.
118. Chen PP, Ma M, Chan S, Oh TE. Incident reporting in acute pain management. Anaesthesia 1998;53:730-5.
119. Vinen J. Incident monitoring in emergency departments: an Australian model. Acad Emerg Med 2000;7:1290-7.
120. Cooper JB, Newbower RA, Long CD, McPeek B. Preventable anaesthetic mishaps: a study of human factors. Anesthesiology 1978;49:399-406.
121. Anon. Critical questions, critical incidents, critical answers. Lancet 1988;1:1373-4.
122. Robinson LA, Stacy R, Spencer JA, Bhopal RS. Use of facilitated case discussions for significant event auditing. BMJ 1995;311:315-18.
123. Westcott R, Sweeney G, Stead J. Significant event audit in practice: a preliminary study. Fam Pract 2000;17:173-9.
124. Pringle M. Preventing ischaemic heart disease in one general practice: from one patient, through clinical audit, needs assessment, and commissioning into quality improvement. BMJ 1998;317:1120-3.
125. Handley CC. Quality improvement through root cause analysis. Hosp Mater Manage Q 2000; 21:74-8.
126. Hirsch KA, Wallace DT. Conduct a cost effective RCA by brainstorming. Hosp Peer Rev 1999; July:105-12.
127. Berry K, Krizek B. Root cause analysis in response to a near miss. J Healthcare Qual 2000;22:16-18.
128. Beyea SC, Nicoll LH. When an adverse sentinel event is the cause for action. AORN J 1999; 70:703-4.
129. Vincent CA, Taylor Adams S, Chapman EJ, Hewett D, Prior S, Strange P, et al A protocol for the investigation and analysis of clinical incidents. London: University College London/Association of Litigation and Risk Management; 1999.
130. Norman DA. Categorisation of action slips. Psychol Rev 1981;88:1-15.
131. Cartlidge PH, Jones HP, Stewart JH, Drayton MR, Ferguson DS, Matthes JW, et al Confidential enquiry into deaths due to prematurity. Acta Paediatr 1999;88:220-3.
132. Walker GJ, Ashley DE, McCaw AM, Bernard GW. Maternal mortality in Jamaica. Lancet 1986; 1:486-8.
133. Burr ML, Davies BH, Hoare A, Jones A, Williamson IJ, Holgate SK, et al. A confidential enquiry into asthma deaths in Wales. Thorax 1999; 54:985-9.
134. Allnutt MF. Human factors in accidents. Br J Anaesth 1987;59:856-64.
135. Rasmussen J. Outlines of a hybrid model of the process operator. In Sheridan TB, Johannsen G, editors. Monitoring behaviour and supervisory control. New York: Plenum Press; 1976.
136. Van der Schaaf TW. Near miss reporting in the chemical process industry. PhD thesis, Eindhoven University of Technology; 1992.
137. Fitts PM, Jones RE. Analysis of factory contributing to 460 'pilot error' experiences in operating aircraft controls. Memorandum Report TSEAA-694-12. Dayton, OH: Aero Medical Laboratory, Air Material Command, Wright Patterson Air Force Base; 1 July 1947.
138. Reprinted in Sinaiko HW, editor. Selected papers on human factors in the design and use of control systems. New York: Dover; 1961. pp. 332-58.
139. Reason JT. A systems approach to organisational error. Ergonomics 1995;38:1708-21.
140. New Zealand Standards Ministry of Health. Sentinel events workbook: process for standard investigation and reporting. Draft Pre-publishing Report SNZ HB 8152. New Zealand Standards, Ministry of Health, 2001.
141. Vincent CA, Bark P. Accident analysis. In Vincent CA, editor. Clinical risk management. London: BMJ Publications; 1995.
142. Runciman WB, Sellen A, Webb RK, Williamson JA, Currie M, Morgan C, et al. Errors, incidents and accidents in anaesthetic practice. Anaesth Intens Care 1993;21:506-19.
143. Runciman WB, Webb RK, Lee R, Holland R. System failure: an analysis of 2000 incident reports. Anaesth Intent Care 1993;21:684-95.
144. Cooper JB, Long CD, Newbower RS, Philip JH. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology 1982;56:456-61.
145. Short TG, O'Regan A, Lew J, Oh TE. Critical incident reporting in an anaesthetic department quality assurance programme. Anaesthesia 1993; 48:3-7.
146. Vincent C, Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, et al. How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol. BMJ 2000;320:777-81.
147. Amo MF. Root cause analysis: a tool for understanding why accidents occur. Balance 1998;2(5):12-5.
148. Shinn JA. Root cause analysis: a method of addressing errors and patient risk. Prog Cardiovasc Nurs 2000;15:24-5.
149. Davies JM. Application of the Winnipeg model to obstetric and neonatal audit. Top Health Inf Manage 2000;20:12-22.
150. Vincent C, Stanhope N, Taylor Adams S. Developing a systematic method of analysing serious incidents in mental health. J Mental Health 2000;9:89-103.
151. Durrheim DN, Frieremans S, Kruger P, Mabuza A, de Bruyn JC. Confidential inquiry into malaria deaths. Bull World Health Organ 1999;77:263-6.
152. Payne JN, Milner PC, Saul C, Bowns IR, Hannay DR, Ramsay LE. Local confidential inquiry into avoidable factors in deaths from stroke and hypertensive disease. BMJ 1993;307:1027-30.
153. Bucknall CE, Slack R, Godley CC, Mackay TW, Wright SC. Scottish Confidential Inquiry into Asthma Deaths (SCIAD), 1994-6. Thorax 1999; 54:978-84.
154. Tan KH, Wyldes MP, Settatree R, Mitchell T. Confidential regional enquiry into mature stillbirths and neonatal deaths - a multi disciplinary peer panel perspective of the perinatal care of 238 deaths. Singapore Med J 1999;40:251-5.
155. Wood B, Catford JC, Cogswell JJ. Confidential paediatric inquiry into neonatal deaths in Wessex, 1981 and 1982. BMJ (Clin Res Ed) 1984; 288:1206-8.
156. Callum KG, Whimster F, Dyet JF, Gaines PA, Gillespie I, Johnston LC, et al. The report of the National Confidential Enquiry into Perioperative Deaths for Interventional Vascular Radiology. Cardiovasc Intervent Radiol 2001;24:2-24.
157. Beckmann U, Baldwin I, Durie M, Morrison A, Shaw L. Problems associated with nursing staff shortage: an analysis of the first 3600 incident reports submitted to the Australian Incident Monitoring Study (AIMS-ICU). Anaesth Intens Care 1998;26:396-100.
158. Wright M, Parker G. Incident monitoring in psychiatry. J Qual Clin Pract 1998;18:249-61.
159. Short TG, O'Regan A, Jayasuriya JP, Rowbottom M, Buckley TA, Oh TE. Improvements in anaesthetic care resulting from a critical incident reporting programme. Anaesthesia, 1996;51:615-21.
160. Holland R, Webb RK, Runciman WB. The Australian Incident Monitoring Study. Oesophageal intubation: an analysis of 2000 incident reports. Anaesth Intens Care 1993; 21:608-10.
161. Currie M. A prospective survey of anaesthetic critical events in a teaching hospital. Anaesth Intens Care 1989;17:403-11.
162. Williamson JA, Webb RK, Pryor GL. Anaesthesia safety and the "critical incident" technique. Aust Clin Rev 1985;17:57-61.
163. Boreham NC, Shea CE, Mackway-Jones K. Clinical risk and collective competence in the hospital emergency department in the UK. Soc Sci Med 2000;51:83-91.
164. Meurier CE, Vincent CA, Parmar DG. Learning from errors in nursing practice. J Adv Nurs 1997; 26:111-19.
165. Orser BA, Oxorn DC. An anaesthetic drug error: minimizing the risk. Can J Anaesth 1994;41:120-4.
166. Newbower RS, Cooper JB, Long CD. Learning from anesthesia mishaps: analysis of critical incidents in anesthesia helps reduce patient risk. Qual Rev Bull 1981;7:10-16.
167. Holden J, O'Donnell S, Brindley J, Miles L. Analysis of 1263 deaths in four general practices. Br J Gen Pract 1998;48:1409-12.
168. Redpath L, Stacey A, Pugh E, Holmes E. Use of the critical incident technique in primary care in the audit of deaths by suicide. Qual Health Care 1997;6:25-8.
169. Bennett IJ, Danczak AF. Terminal care: improving teamwork in primary care using significant event analysis. Eur J Cancer Care (Engl) 1994;3:54-7.
170. Tudor Hart J, Humphreys C. Be your own coroner: an audit of 500 consecutive deaths in a general practice. BMJ 1987;294:871-4.
171. Weinberg NS, Stason WB. Managing quality in hospital practice. Int J Qual Health Care 1998; 10:295-302.
172. Anon. Child's death leads to new medication error policies. Hosp Peer Rev 1998;23:141-3,146.
173. Haas D. Sentinel events. In memory of Ben - a case study. Jt Comm Perfect 1997;17:12-15.
174. Battles JB, Shea CE. A system of analyzing medical errors to improve GME curricula and programs. Acad Med 2001;76:125-33.
175. Rex JH, Turnbull JE, Allen SJ, Vande Voorde K, Luther K. Systematic root cause analysis of adverse drug events in a tertiary referral hospital. Jt Comm J Qual Improv 2000;26:563-75.
176. Brown PW, Fay MS. Sentinel event review. Part I: A new spirit of inquiry. Aspens Advis Nurse Exec 1997;12:8,7.
177. Meurier CE. Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in an adverse or potentially adverse event. J Adv Nurs 2000;32:202-7.
178. Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg 2001;72:300-5.
179. Mersey Region Working Party on Perinatal Mortality. Confidential inquiry into perinatal deaths in the Mersey region. Mersey Region Working Party on Perinatal Mortality. Lancet 1982;1:491-4.