The Truax Group         Patient Safety Solutions

Bogner, MS (ed.). Human Error in Medicine. Hillsdale, New Jersey: Lawrence Erlbaum Associates, Inc., 1994

Multiple authors addressing the gamut of issues in the field of patient safety.

Casey S. Set Phasers on Stun and Other True Tales of Design, Technology, and Human Error. Santa Barbara California: Aegean Publishing Company, 1998

One of the earliest collections of descriptions and root cause analyses of disasters in several industries. Begins with the events leading to an unfortunate radiation therapy overdose.

Chalice R. Improving Healthcare Using Toyota Lean Production Methods: 46 Steps for Improvement. Milwaukee, Wisconsin: ASQ Quality Press, 2007

Excellent book applying the concepts of the Toyota Production System Methods and Lean Thinking to healthcare. Multiple practical examples of ways to use the concepts to improve quality and cut waste at the same time.

Cohen MR (ed.). Medication Errors. Causes, Prevention, and Risk Management. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2000

Outstanding work on medication errors, edited by the founder of the Institute for Safe Medication Practices.

Cohn RL. They Called It Pilot Error. True Stories Behind General Aviation Accidents. New York, New York: Tab Books, 1994

Book on aviation accidents. Though no direct references to healthcare, lessons learned in the accident investigations lend insight into the same issues that are seen in healthcare incident investigations.

Dekker S., The Field Guide to Human Error Investigations. Aldershot, England: Ashgate Publishing Limited, 2002

Dekker S., The Field Guide to Understanding Human Error. Aldershot, England: Ashgate Publishing Limited, 2006

Two “must-reads” for anyone involved in patient safety. Though much of his work has been in the aviation industry, Dekker’s work in human factors and cognitive systems engineering is directly applicable to medicine and patient safety. He masterfully walks the reader through the ways to avoid hindsight bias, remain objective and focus on how the participants perceived the unfolding events at the time. After all, the focus of an investigation is to determine why the events happened in order to prevent similar events and adverse outcomes in the future.

Gano, Dean L. Apollo Root Cause Analysis. Richland, WA: Apollonian Publications, LLC, 2007

Even though at times this book seems to exist to hype its software and training, it does have some very practical advice. It does a very good job at getting you to focus on looking for causal relationships and finding solutions that will truly prevent recurrence. The section on how to conduct intereviews and run effective investigations and meetings is also very useful.

Gibson R., Singh JP. Wall of Silence. The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. Washington, DC: LifeLine Press, 2003

Written from a patient/family perspective, this uses stories of the victims of medical mistakes to educate the general public on the many issues confronting our complex health system. Helps move us from the “wall of silence” to ethical disclosure and turning to constructive outcomes.

Gladwell M. Blink. New York: Back Bay Books/Little Brown and Company, 2007

The first premise of “Blink” is that decisions made quickly can often be as good or better than those requiring much more deliberation. This “rapid cognition” is really done at a subconscious level. You might refer to it as your “gut feeling” or “instincts” and you may not be able to explain well why you came to that decision but such decisions were probably processed very methodically by the subconscious brain.  However, there are experiential influences that may bias that rapid decision making and there are other influences that may interfere with rapid cognition. Knowing what circumstances are likely to cause those influences on rapid cognition may be very helpful in planning with patient safety in mind. For instance, knowing what scenarios are likely to lead to deleterious rapid decisions can help design effective training on avoidance of such decisions. Likewise, understanding when too much information interferes with rapid cognition can be important in design of clinical processes. Most of the best solutions to patient safety problems involve simplification rather than adding more steps to processes.

Groopman Jerome. How Doctors Think. Boston: Houghton Mifflin, 2007 (Mariner Books 2008)

Whether you are a patient or a physician or other healthcare worker, you need to read this book. It is a well-written compendium of the various types of cognitive errors that occur during physician encounters. Each example is provided in the context of real patients and real physicians. This book will help physicians avoid various error traps and help patients ask the questions that may alter a physician’s thinking.

See our review “Jerome Groopman’s “How Doctors Think”

Hollnagel E. The ETTO Principle: Efficiency-Thoroughness Trade-Off. Why Things That Go Right Sometimes Go Wrong. Burlington, VT: Ashgate Publishing Company, 2009

A somewhat different view of why we do the things we do and why some more traditional methods of accident investigation are missing the boat. A good human factors book and an easier read than some of the earlier work on this concept.

See our review “ETTO’s: Efficiency-Thoroughness Trade-Offs”

Institute of Medicine. Preventing Medication Errors. Washington, DC: National Academy Press, 2006

The most comprehensive book on medication errors available to date. Written by multiple authors, whose names everyone in the patient safety field will readily recognize.

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000

Though appearing late in the patient safety movement, this was the report that really brought the issue of medical error to the attention of the public and most of the medical profession.

Klein, Gary. Sources of Power. How People Make Decisions. Cambridge: MIT Press, 1999

Klein’s field research in the 1980’s unexpectedly led to challenging the traditional thinking about decision making. Interviews with people who had to make rapid, critical decisions (eg. fire captains, military officers, hospital nurses, etc.) led to surprises. Klein, as others before him, had thought most of these individuals probably considered multiple options and compared them before making critical decisions. Klein’s research actually showed that they often considered only a single option at the beginning. They drew upon their experience to rapidly recognize patterns, then apply actions that are likely solutions to those recognized patterns. They might modify those actions as new information and patterns emerged during evolving situations. The use of mental simualation models is very important.

See our review “If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work”

Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP, The Improvement Guide. A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers, 1996

Must-read for anyone involved in quality improvement. Poses the 3 fundamental questions for any change:

1. what are we trying to accomplish?
2. how will we know when we get there (and that the change is actually an improvement)?
3. how will we get there?

Maurino D, Reason J, Johnston N, Lee RB. Beyond Aviation Human Factors. Aldershot, England: Ashgate Publishing Limited, 1995

Excellent work using lessons learned from aviation accidents to apply human factors concepts to organizations of any kind.

Nance, John J. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman MT: Second River Healthcare Press. 2008

The missing link as to why we have not significantly impacted patient safety despite a wealth of best practices: we have failed to achieve a culture of safety. That is the theme of this insightful work by John Nance, the pilot and ABC expert on aviation safety.

See our review “Why Hospitals Should Fly…John Nance Nails It!”

Norman DA, The Design of Everyday Things. New York: Doubleday; 1989

(in paperback by Basic Books 2002)

Classic work on how design of things can lead people to do the correct action automatically (and, conversely, how poor design leads to doing the wrong action).

Norman DA, The Design of Future Things. New York: Basic Books; 2007

Sequel to his classic work. Great discussion on need for feedback and natural, deliberate signals.

See our review “Don Norman Does It Again!”

Perrow C. Normal Accidents: Living with high-risk technologies. Princeton, New Jersey: Princeton University Press, 1999

Great book describing how multiple events lead to bad outcomes in multiple hi-risk industries, including healthcare.

Petersen D. Human Error Reduction and Safety Management. New York, New York: Van Nostrand Reinhold, 1996

Text on changing the environment in industry to prevent errors and accidents. Many good lessons and concepts but not a healthcare book, per se.

Reason J, Hobbs A. Managing Maintenance Error. Aldershot, England: Ashgate Publishing Limited, 2003

More detail on human factors analysis and the practical approach to error management. Many analogies with implications to healthcare.

See “Role of Maintenance in Incidents”

Reason J. Human Error. Cambridge, United Kingdom: Cambridge University Press, 1990

The seminal work by the researcher often recognized as the father of the discipline of human factors analysis.

Reason J. Managing the Risks of Organizational Accidents. Aldershot, England: Ashgate Publishing Limited, 1997

A comprehensive human factors engineering work looking at risks in hazardous industries. Describes how errors in the interface between humans and technological systems can lead to accidents. Loaded with diagrams and pictorial descriptions of concepts, including Reason’s famous “Swiss cheese” defenses diagram.

Sagan SD. The Limits of Safety. Organizations, Accidents, and Nuclear Weapons. Princeton, New Jersey: Princeton University Press 1993

High reliability organizations and lessons learned from accidents in other industries.

Sharpe VA, Faden AI. Medical Harm. Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. Cambridge, UK: Cambridge University Press, 1998

A well-written treatise on the historical, philosophical and ethical aspects of the evolving patient safety movement.

Spath PL (ed.). Error Reduction in Health Care. San Francisco, California: Jossey-Bass, 2000

Multiple authors addressing the gamut of issues in the field of patient safety.

Strauch B., Investigating Human Error: Incidents, Accidents, and Complex Systems. Aldershot, England: Ashgate Publishing Limited, 2004

Though focusing mainly on industries other than medicine, this is an excellent review of human factors analysis, theories of human error, and identification of the various factors that can influence performance and lead to errors, incidents, and accidents.

Tenner E. Why Things Bite Back.Technology and the Revenge of Unintended Consequences. New York, New York: First Vintage Books, 1997

Good reminder that, no matter how well we design solutions to problems, we often create unintended consequences.

Thaler RH, Sunstein CR. Nudge. Improving Decisions About Health, Wealth, and Happiness. New Haven: Yale University Press, 2008.

“Nudge” is about how we think and how small, low-cost actions (“nudges”) can lead to big impacts. It is a contemporary psychosocial book of the type you’d expect from a Don Norman or Malcolm Gladwell that is both easy to read and full of practical advice that you can relate to. This book has lots of examples you can use in your personal and professional life.

Wachter RM, Shojania KG. Internal Bleeding. New York, New York: Rugged Land, LLC, 2004

Excellent overview of patient safety and medical error, written by leaders in the patient safety movement. Practical and insightful. A good read whether you are a physician, other healthcare worker, or a patient.

Youngberg BJ, Hatlie MJ (eds.). The Patient Safety Handbook. Sudbury, Massachusetts: Jones and Bartlett Publishers, 2004

Multiple authors addressing multiple issues in the field of patient safety.