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Patient Safety 101: Complete Reference List

The complete, searchable reference list for the Patient Safety 101 handbook: 58 sources across 9 chapters, first edition 2026.

Patient Safety 101 · A Practical Patient Safety Guidebook for Nurses · Aderonke Opawande

About Patient Safety 101

Introduction The Promise of Safety

5 references

  1. World Health Organization (WHO). (2023). Global patient safety report 2023. WHO.
  2. NHS England. (2022). Patient Safety Incident Response Framework (PSIRF). NHS England.
  3. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  4. Nightingale, F. (1863). Notes on hospitals (3rd ed.). Longman.
  5. Vincent, C., & Amalberti, R. (2016). Safer healthcare: Strategies for the real world. Springer Open.

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Chapter 1 The Foundation of Safety

8 references

  1. Reason, J. (2000). Human error: Models and management. British Medical Journal, 320(7237), 768–770.
  2. Edmondson, A. C. (2019). The fearless organisation: Creating psychological safety in the workplace for learning, innovation and growth. Wiley.
  3. NHS England. (2019). The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. NHS England.
  4. NHS England. (2022). Patient Safety Incident Response Framework (PSIRF). NHS England.
  5. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  6. Health and Safety at Work etc. Act 1974. HMSO.
  7. Care Quality Commission (CQC). (2023). Key questions and key lines of enquiry (KLOEs). CQC.
  8. World Health Organization (WHO). (2021). Global Patient Safety Action Plan 2021–2030. WHO.

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Chapter 2 Global Safety Cultures

7 references

  1. Hofstede, G., Hofstede, G. J., & Minkov, M. (2010). Cultures and organisations: Software of the mind (3rd ed.). McGraw-Hill.
  2. NHS England. (2021). NHS workforce race equality standard (WRES) report 2021. NHS England.
  3. Equality Act 2010. HMSO.
  4. World Health Organization (WHO). (2021). Global Patient Safety Action Plan 2021–2030. WHO.
  5. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  6. NHS England. (2022). NHS patient safety strategy update. NHS England.
  7. Public Interest Disclosure Act 1998. HMSO.

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Chapter 3 The Human Side of Error

7 references

  1. Reason, J. (1990). Human error. Cambridge University Press.
  2. Seys, D., et al. (2013). Healthcare professionals as second victims after adverse events: Evaluation of the evidence. Journal of Patient Safety, 9(1), 14–26.
  3. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20, Duty of Candour. HMSO.
  4. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  5. NHS England. (2022). Patient Safety Incident Response Framework (PSIRF). NHS England.
  6. Scott, S. D., et al. (2009). The natural history of recovery for the healthcare provider ‘second victim’ after adverse patient events. Quality & Safety in Health Care, 18(5), 325–330.
  7. Corporate Manslaughter and Corporate Homicide Act 2007. HMSO.

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Chapter 4 Communication Across Cultures

7 references

  1. NHS Institute for Innovation and Improvement. (2010). SBAR: Situation, Background, Assessment, Recommendation. NHS Institute.
  2. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  3. Edmondson, A. C. (2019). The fearless organisation: Creating psychological safety in the workplace for learning, innovation and growth. Wiley.
  4. NHS England. (2020). NHS communication and language support policy. NHS England.
  5. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20, Duty of Candour. HMSO.
  6. Equality Act 2010. HMSO.
  7. Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Health Care, 13(Suppl 1), i85–i90.

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Chapter 5 Medication Safety

8 references

  1. NHS England. (2019). The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. NHS England.
  2. World Health Organization (WHO). (2017). Medication without harm: WHO global patient safety challenge. WHO.
  3. Elliott, R. A., et al. (2018). Prevalence and economic burden of medication errors in England. Policy Research Unit in Economic Evaluation of Health and Care Interventions.
  4. National Institute for Health and Care Excellence (NICE). (2021). Medicines adherence: Involving patients in decisions about prescribed medicines. NICE guideline CG76. NICE.
  5. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  6. NHS England (formerly NHS Improvement). (2018). SBAR communication tool: Situation, background, assessment, recommendation. NHS Improvement.
  7. Aronson, J. K. (2009). Medication errors: Definitions and classification. British Journal of Clinical Pharmacology, 67(6), 599–604.
  8. Care Quality Commission (CQC). (2022). Medicines management: How CQC regulates medicines. CQC.

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Chapter 6 Deterioration & NEWS2

10 references

  1. NHS England. (2012). SBAR communication tool. NHS England.
  2. Royal College of Physicians. (2017). National Early Warning Score 2 (NEWS2). RCP.
  3. NHS England. (2018). The learning from deaths programme. NHS England.
  4. Resuscitation Council UK. (2021). Advanced Life Support (8th ed.). RCUK.
  5. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  6. National Institute for Health and Care Excellence (NICE). (2007). Acutely ill adults in hospital: Recognising and responding to deterioration. NICE guideline CG50. NICE.
  7. NHS Improvement. (2021). Reducing deterioration and preventable acute harm. NHS Improvement.
  8. Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses’ recognition of and response to patient deterioration? Nursing Open, 4(1), 6–23.
  9. NHS England. (2023). Inpatient falls. Patient Safety Incident Insights. NHS England.
  10. National Institute for Health and Care Excellence (NICE). (2025). Falls: Assessment and prevention in older people and in people 50 and over at higher risk. NICE guideline NG249. NICE.

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Chapter 7 Infection Prevention & Control

8 references

  1. NHS England. (2022). National Infection Prevention and Control Manual (NIPCM) for England. NHS England.
  2. World Health Organization (WHO). (2021). Hand hygiene in health care: First global patient safety challenge. WHO.
  3. UK Health Security Agency (UKHSA). (2022). Standard infection control precautions (SICPs). UKHSA.
  4. Pratt, R. J., et al. (2007). Epic2: National evidence-based guidelines for preventing healthcare-associated infections (HCAIs) in NHS hospitals. Journal of Hospital Infection, 65(Suppl 1), S1–S64.
  5. Care Quality Commission (CQC). (2022). Infection prevention and control: Key lines of enquiry. CQC.
  6. Public Health England. (2019). COVID-19: Infection prevention and control guidance. PHE.
  7. National Institute for Health and Care Excellence (NICE). (2012, updated 2021). Healthcare-associated infections: Prevention and control in primary and community care. NICE guideline PH36. NICE.
  8. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.

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Chapter 8 Technology and Patient Safety

8 references

  1. NHS England. (2021). What good looks like: Framework for digital health and care in England. NHS England.
  2. NHS England. (2023). Digital clinical safety: NHS DSPT, clinical risk management. NHS England.
  3. MHRA. (2022). The new framework for software and AI as a medical device. Medicines and Healthcare products Regulatory Agency.
  4. Royal College of Nursing (RCN). (2020). Nursing informatics and the nurse of the future: A framework for digital practice. RCN.
  5. NHS England. (2019). The NHS Long Term Plan: Technology and digital. NHS England.
  6. Topol Review. (2019). Preparing the healthcare workforce to deliver the digital future. Health Education England.
  7. Information Commissioner’s Office (ICO). (2018). Guide to the UK GDPR. ICO.
  8. British Computer Society (BCS). (2018). Code of conduct for ICT professionals. BCS.

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Chapter 9 Becoming a Patient Safety Champion

8 references

  1. NHS England. (2019). The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. NHS England.
  2. Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office.
  3. NHS England. (2022). Patient Safety Incident Response Framework (PSIRF). NHS England.
  4. National Guardian’s Office. (2023). Speaking up in the NHS. National Guardian’s Office.
  5. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  6. West, M. A., et al. (2020). Caring to change: How compassionate leadership can stimulate innovation in health care. The King’s Fund.
  7. Edmondson, A. C. (2019). The fearless organisation: Creating psychological safety in the workplace for learning, innovation and growth. Wiley.
  8. Health Education England (HEE). (2022). NHS leadership academy: Developing people, improving care. HEE.

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Full list All 58 References: Alphabetical Order

58 unique references

  1. Aronson, J. K. (2009). Medication errors: Definitions and classification. British Journal of Clinical Pharmacology, 67(6), 599–604.
  2. British Computer Society (BCS). (2018). Code of conduct for ICT professionals. BCS.
  3. Care Quality Commission (CQC). (2022). Infection prevention and control: Key lines of enquiry. CQC.
  4. Care Quality Commission (CQC). (2022). Medicines management: How CQC regulates medicines. CQC.
  5. Care Quality Commission (CQC). (2023). Key questions and key lines of enquiry (KLOEs). CQC.
  6. Corporate Manslaughter and Corporate Homicide Act 2007. HMSO.
  7. Edmondson, A. C. (2019). The fearless organisation: Creating psychological safety in the workplace for learning, innovation and growth. Wiley.
  8. Elliott, R. A., et al. (2018). Prevalence and economic burden of medication errors in England. Policy Research Unit in Economic Evaluation of Health and Care Interventions.
  9. Equality Act 2010. HMSO.
  10. Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office.
  11. Health and Safety at Work etc. Act 1974. HMSO.
  12. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20, Duty of Candour. HMSO.
  13. Health Education England (HEE). (2022). NHS leadership academy: Developing people, improving care. HEE.
  14. Hofstede, G., Hofstede, G. J., & Minkov, M. (2010). Cultures and organisations: Software of the mind (3rd ed.). McGraw-Hill.
  15. Information Commissioner’s Office (ICO). (2018). Guide to the UK GDPR. ICO.
  16. Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Health Care, 13(Suppl 1), i85–i90.
  17. Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses’ recognition of and response to patient deterioration? Nursing Open, 4(1), 6–23.
  18. MHRA. (2022). The new framework for software and AI as a medical device. Medicines and Healthcare products Regulatory Agency.
  19. National Guardian’s Office. (2023). Speaking up in the NHS. National Guardian’s Office.
  20. National Institute for Health and Care Excellence (NICE). (2007). Acutely ill adults in hospital: Recognising and responding to deterioration. NICE guideline CG50. NICE.
  21. National Institute for Health and Care Excellence (NICE). (2012, updated 2021). Healthcare-associated infections: Prevention and control in primary and community care. NICE guideline PH36. NICE.
  22. National Institute for Health and Care Excellence (NICE). (2021). Medicines adherence: Involving patients in decisions about prescribed medicines. NICE guideline CG76. NICE.
  23. National Institute for Health and Care Excellence (NICE). (2025). Falls: Assessment and prevention in older people and in people 50 and over at higher risk. NICE guideline NG249. NICE.
  24. NHS England (formerly NHS Improvement). (2018). SBAR communication tool: Situation, background, assessment, recommendation. NHS Improvement.
  25. NHS England. (2012). SBAR communication tool. NHS England.
  26. NHS England. (2018). The learning from deaths programme. NHS England.
  27. NHS England. (2019). The NHS Long Term Plan: Technology and digital. NHS England.
  28. NHS England. (2019). The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. NHS England.
  29. NHS England. (2020). NHS communication and language support policy. NHS England.
  30. NHS England. (2021). NHS workforce race equality standard (WRES) report 2021. NHS England.
  31. NHS England. (2021). What good looks like: Framework for digital health and care in England. NHS England.
  32. NHS England. (2022). National Infection Prevention and Control Manual (NIPCM) for England. NHS England.
  33. NHS England. (2022). NHS patient safety strategy update. NHS England.
  34. NHS England. (2022). Patient Safety Incident Response Framework (PSIRF). NHS England.
  35. NHS England. (2023). Digital clinical safety: NHS DSPT, clinical risk management. NHS England.
  36. NHS England. (2023). Inpatient falls. Patient Safety Incident Insights. NHS England.
  37. NHS Improvement. (2021). Reducing deterioration and preventable acute harm. NHS Improvement.
  38. NHS Institute for Innovation and Improvement. (2010). SBAR: Situation, Background, Assessment, Recommendation. NHS Institute.
  39. Nightingale, F. (1863). Notes on hospitals (3rd ed.). Longman.
  40. Nursing and Midwifery Council (NMC). (2018). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
  41. Pratt, R. J., et al. (2007). Epic2: National evidence-based guidelines for preventing healthcare-associated infections (HCAIs) in NHS hospitals. Journal of Hospital Infection, 65(Suppl 1), S1–S64.
  42. Public Health England. (2019). COVID-19: Infection prevention and control guidance. PHE.
  43. Public Interest Disclosure Act 1998. HMSO.
  44. Reason, J. (1990). Human error. Cambridge University Press.
  45. Reason, J. (2000). Human error: Models and management. British Medical Journal, 320(7237), 768–770.
  46. Resuscitation Council UK. (2021). Advanced Life Support (8th ed.). RCUK.
  47. Royal College of Nursing (RCN). (2020). Nursing informatics and the nurse of the future: A framework for digital practice. RCN.
  48. Royal College of Physicians. (2017). National Early Warning Score 2 (NEWS2). RCP.
  49. Scott, S. D., et al. (2009). The natural history of recovery for the healthcare provider ‘second victim’ after adverse patient events. Quality & Safety in Health Care, 18(5), 325–330.
  50. Seys, D., et al. (2013). Healthcare professionals as second victims after adverse events: Evaluation of the evidence. Journal of Patient Safety, 9(1), 14–26.
  51. Topol Review. (2019). Preparing the healthcare workforce to deliver the digital future. Health Education England.
  52. UK Health Security Agency (UKHSA). (2022). Standard infection control precautions (SICPs). UKHSA.
  53. Vincent, C., & Amalberti, R. (2016). Safer healthcare: Strategies for the real world. Springer Open.
  54. West, M. A., et al. (2020). Caring to change: How compassionate leadership can stimulate innovation in health care. The King’s Fund.
  55. World Health Organization (WHO). (2017). Medication without harm: WHO global patient safety challenge. WHO.
  56. World Health Organization (WHO). (2021). Global Patient Safety Action Plan 2021–2030. WHO.
  57. World Health Organization (WHO). (2021). Hand hygiene in health care: First global patient safety challenge. WHO.
  58. World Health Organization (WHO). (2023). Global patient safety report 2023. WHO.

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First Edition · © 2026 Aderonke Opawande · All rights reserved