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Understanding adverse events: human factors. London: BMJ Publications, (1995)Human error: models and management. BMJ, 320 (7237): 768--770 (March 2000)Human Factor Analysis of JCO Criticality Accident: A Comment on the Analytical Models.. Cogn. Technol. Work., 2 (4): 230-231 (2000)Beyond the organisational accident: the need for error wisdom on the frontline. Quality and Safety in Health Care, 13 (suppl 2): ii28--ii33 (December 2004)Cognitive Aids in Process Environments: Prostheses or Tools?. Int. J. Man Mach. Stud., 27 (5-6): 463-470 (1987)Human Error. Cambridge University Press, (1990)Human error. Cambridge University Press, Cambridge u.a., 19. edition, (2008)Diagnosing vulnerable system syndrome: an essential prerequisite to effective risk management, , and . Quality in Health Care, 10 (suppl 2): ii21--ii25 (December 2001)