Examining patient safety events using the behaviour change wheel: a cross-sectional analysis.
Somerville M, Cassidy C, MacPhee S, et al. Examining patient safety events using the behaviour change wheel: a cross-sectional analysis. Jt Comm J Qual Patient Saf. 2025;51(2):135-143. doi:10.1016/j.jcjq.2024.11.001.
Patient safety event reports offer unique opportunities for learning and preventing future events. In this study, researchers analyzed 58 precursor safety events and associated follow-up actions in a maternal/pediatric hospital. Using a behavioral change framework, the research team found poor alignment between the underlying causes of the events and the type of intervention/follow-up action in one-third of the cases. These findings highlight the importance of systematic, behavior-informed approaches to improve event reporting and intervention design.