1. Newport, M., Smith, A. F. & Lewis, S. R. An arrow pointing somewhere: Qualitative study of the Helsinki declaration on patient safety and its role in European anaesthesiology. Eur J Anaesthesiol 37, 1–4 (2020).
2. Bainbridge, D., Martin, J., Arango, M., Cheng, D., & Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet 380, 1075–1081 (2012).
3. Staender, S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curr Opin Anaesthesiol 28, 735–739 (2015).
4. Higham, H. & Baxendale, B. To err is human: use of simulation to enhance training and patient safety in anaesthesia. Br J Anaesth 119, i106–i114 (2017).
5. Liu, T.-C. et al. Survey of 11-year anesthesia-related mortality and analysis of its associated factors in Taiwan. Acta Anaesthesiol Taiwan 48, 56–61 (2010).
6. Cook, T. M., Woodall, N., Frerk, C., & Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 106, 617–631 (2011).
7. Reason, J. Safety in the operating theatre - Part 2: human error and organisational failure. Qual Saf Health Care 14, 56–60 (2005).
8. Robertson, J. J. & Long, B. Suffering in Silence: Medical Error and its Impact on Health Care Providers. J Emerg Med 54, 402–409 (2018).
9. Hoffman, J. R. & Kanzaria, H. K. Intolerance of error and culture of blame drive medical excess. BMJ 349, g5702 (2014).
10. Helmreich, R. L. On error management: lessons from aviation. BMJ 320, 781–785 (2000).
11. Heard, G. Errors in medicine: A human factors perspective. Australasian Anaesthesia (2005).
12. Spaeth, J., Schweizer, T., Schmutz, A., Buerkle, H. & Schumann, S. Comparative usability of modern anaesthesia ventilators: a human factors study. Br J Anaesth 119, 1000–1008 (2017).
13. Preckel, B. et al. Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects. Eur J Anaesthesiol 37, 521–610 (2020).
14. Braithwaite, J., Wears, R. L. & Hollnagel, E. Resilient health care: turning patient safety on its head. Int J Qual Health Care 27, 418–420 (2015).
15. Smith, A. F. & Plunkett, E. People, systems and safety: resilience and excellence in healthcare practice. Anaesthesia 74, 508–517 (2019).
16. Carthey, J., Walker, S., Deelchand, V., Vincent, C. & Griffiths, W. H. Breaking the rules: understanding non-compliance with policies and guidelines. BMJ 343, d5283 (2011).
17. Vincent, C. & Amalberti, R. Progress and Challenges for Patient Safety. in Safer Healthcare: Strategies for the Real World (eds. Vincent, C. & Amalberti, R.) 1–12 (Springer International Publishing, 2016). doi:10.1007/978-3-319-25559-0_1.
18. Creswick, N., Westbrook, J. I. & Braithwaite, J. Understanding communication networks in the emergency department. BMC Health Serv Res 9, 247 (2009).
19. Schild, S. et al. A Digital Cognitive Aid for Anesthesia to Support Intraoperative Crisis Management: Results of the User-Centered Design Process. JMIR Mhealth Uhealth 7, e13226 (2019).
20. Staender, S., Davies, J., Helmreich, B., Sexton, B. & Kaufmann, M. The anaesthesia critical incident reporting system: an experience based database. Int J Med Inform 47, 87–90 (1997).
21. Pham, J. C., Girard, T. & Pronovost, P. J. What to do with healthcare incident reporting systems. J Public Health Res 2, e27 (2013).
22. Staender, S. Incident reporting in anaesthesiology. Best Pract Res Clin Anaesthesiol 25, 207–214 (2011).
23. Quandt, C. & Friedrich, L. [Competence-based Training in the ‘Protected Environment’: From Sheltered Space to Real Life]. Anasthesiol Intensivmed Notfallmed Schmerzther 53, 12–19 (2018).
24. Rothkrug, A. & Mahboobi, S. K. Simulation Training and Skill Assessment in Anesthesiology. in StatPearls (StatPearls Publishing, 2021).
25. Lei, C. & Palm, K. Crisis Resource Management Training in Medical Simulation. in StatPearls (StatPearls Publishing, 2021).
26. Howard, S. K., Gaba, D. M., Fish, K. J., Yang, G. & Sarnquist, F. H. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 63, 763–770 (1992).
27. Weaver, S. J., Dy, S. M. & Rosen, M. A. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf 23, 359–372 (2014).
28. John Doyle, D., Dahaba, A. A. & LeManach, Y. Advances in anesthesia technology are improving patient care, but many challenges remain. BMC Anesthesiol 18, 39 (2018).
29. Ruskin, K. J., Ruskin, A. C. & O’Connor, M. Automation failures and patient safety. Curr Opin Anaesthesiol 33, 788–792 (2020).
30. Zippel, C., Börgers, A., Weitzel, A. & Bohnet-Joschko, S. Many critical incidents could be avoided by preanaesthesia equipment checks: lessons for high reliability organisations. Eur J Anaesthesiol 31, 289–291 (2014).
31. Zippel, C. & Bohnet-Joschko, S. Innovation for Safe and Effective Medical Devices: Contributions From Postmarket Surveillance. Ther Innov Regul Sci 51, 237–245 (2017).
32. Perrow, C. Normal Accidents: Living with High Risk Technologies - Updated Edition. (Princeton University Press, 2011).