1. 1 Secretary of State for Health .A First Class Service. Quality in the New NHS. London: Department of Health; 1998 .
2. 2 Chief Medical Officer .An Organisation with a Memory. Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. London: The Stationery Office; 2000 .
3. 3 C Argyris, and D Schon .Organizational Learning. London: Addison-Wesley; 1978 .
4. 4 M Pedlar, and K Aspinwall .A Concise Guide to the Learning Organisation. London: Lemos and Crane; 1998 .
5. 5 B Hedberg . How organizations learn and unlearn . In: P Nystrom, W Starbuck, eds.Handbook of Organizational Design, vol. 1. Oxford: Oxford University Press; 1981: 3-27.