Books, papers, etc


“Health is more than the absence of disease”

“Safety is more than the absence of risk”

Books, papers, and other stuff to read ...

There is a considerable literature on patient safety or safety in health care. In fact, too much to list here. The following is a somewhat eclectic selection:


(If you think that important papers have been missed, please send me a note, and I will try to compensate for the oversight. Ditto for books.)


  • Amalberti, R., Auroy, Y., Berwick, D. & Barach, P. (2005) Five System Barriers to Achieving Ultrasafe Health Care. Ann Intern Med., 142, 756-764.
  • Brattheim, B., Faxvaag, A. & Seim, A. (2011). Process support for risk mitigation: a case study of variability and resilience in vascular surgery. BMJ Qual Saf, 20(8):672-79.
  • Brown,C., Hofer,T., Johal,A., Thomson, R., Nicholl, J., Franklin, B. D. & Lilford, R. J. (2008). An epistemology of patient safety research: a framework for study design and interpretation. Part 1. Conceptualising and developing interventions. Qual Saf Health Care, 17, 158–162.
  • Emanuel, L., Berwick, D., Conway, J., Combes, J., Hatlie, M., Leape, L., Reason, J., Schyve, P., Vincent, C. & Walton, M. (2008). What exactly is patient safety?Advances in Patient Safety: New Directions and Alternative Approaches. AHRQ Publication Nos. 08-0034 Volume 1, July
  • Furniss D, Back J. Blandford, A. (2011). Unwritten Rules for Safety and Performance in an Oncology Day Care Unit: Testing the Resilience Markers Framework. In Proceedings of the Fourth Resilience Engineering Symposium.
  • Furniss D, Back J, Blandford A., et al. (2011). A Resilience Markers Framework for Small Teams. Reliability Engineering and System Safety, 96(1):2-10.
  • Jeffcott SA, Ibrahim JE, Cameron PA. (2009). Resilience in healthcare and clinical handover. Qual Saf Health Care, 18:256–60.
  • Leape, L. L. (2009). Errors in medicine. Clinica Chimica Acta, 404, 2–5
  • Leape, L. L. & Berwick, D. M. (2005). Five Years After To Err Is Human: What Have We Learned? JAMA, May 18, Vol 293, No. 19, 2384-2390
  • NEW McNab, D. (2016). Understanding patient safety performance and educational needs using the ‘Safety-II’ approach for complex systems. Taylor & Francis Online. Find the publication here
  • Mesman, J. (2009). The geography of patient safety: A topical analysis of sterility. Social Science & Medicine. 69, 1705-1712
  • Reason, J. T., Paries, J. & Hollnagel, E. (2006). Revisiting the “Swiss cheese” model of accidents. Bretigny, France: Eurocontrol Experimental Center, EEC Note No. 13/06
  • Shojania, K. G. (2010). The elephant of patient safety: What you see depends on how you look. The Joint Commission Journal on Quality and Patient Safety, 36(9), 399-
  • Stelfox, H. T., Palmisani, S., Scurlock, C., Orav, E. J. & Bates, D. W. (2006). The ‘‘To Err is Human’’ report and the patient safety literature. Qual Saf Health Care, 15, 174–178.
  • Sujan, Mark A., Huayi Huang, and Jeffrey Braithwaite. "Learning from incidents in health care: critique from a Safety-II perspective." Safety Science (2016).
  • Sujan, Mark, Peter Spurgeon, and Matthew Cooke. "The role of dynamic trade-offs in creating safety—A qualitative study of handover across care boundaries in emergency care." Reliability Engineering & System Safety 141 (2015): 54-62.
  • Vincent, C., Aylin, P., Franklin, B. D., Holmes, A., Iskander, S., Jacklin, A. & Moorthy, K. (2008). Is health care getting safer? BMJ, Volume 337, 1205-1207
  • Westrum, R. (2004). A typology of organisational cultures. Qual Saf Health Care, 13 (Suppl II): ii22–ii27.
  • Woods, D. D. & Cook, R. I. (2002). Nine Steps to Move Forward from Error. Cognition, Technology & Work, 4, 137–144
  • Wears R, Perry S, McFauls A. (2006). "Free Fall" - A Case Study of Resilience, Its Degradation, and Recovery in an Emergency Department. In Proceedings of the Second Resilience Engineering Symposium.



  • Hollnagel (2017). Safety-II in Practice – Developing the resilience potentials. Routledge
  • Hollnagel, E., Braithwaite, J. & Wears, R. L. (Eds.) (2013). Resilient health care. Farnham, UK: Ashgate.
  • Iedema, R., Mesman, J. & Carroll, K. (Eds). (2013). Visualising Health Care Practice Improvement: innovation from within.
  • Rowley, E. & Waring, J. (Eds) (2011). A social-cultural perspective on patient safety. Farnham, UK: Ashgate.
  • Wears, R. L., Hollnagel, E. & Braithwaite, J. (2015). Resilient health care, Volume 2: The resilience of everyday clinical work. Farnham, UK: Ashgate.



  • Hollnagel, E. (2012). Proactive approaches to safety management. London: The Health Foundation.
  • Ideas to innovation: Stimulating collaboration in the application of resilience engineering to healthcare. Summary from a meeting June 13-14, 2013, Washington DC.
  • Hollnagel, E., Wears, R. L. & Braithwaite, J. (2015). From Safety-I to Safety-II: A White Paper

You find and download the White Paper here.


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