The Francis report served as a call to action for improvement, following its recording of elements contributing to systemic failure within the British National Health Service (NHS). This commentary considers the overarching problems that still exist at the NHS and that listening, learning, and leadership involvement are core elements for driving and realizing lasting change throughout the system.

… perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the … a sense of normalcy for their children. … Soto C, Dixon-Woods M, Tarrant C. Families’ experiences of central-line …

… J Health Serv Res Policy … A key aspect of patient safety culture is the perception that … whether an incident is considered a voiceable concern. … Dixon-Woods M, Aveling EL, Campbell A, et al. What counts as a …

Engaging patients and families in patient safety efforts and encouraging them to speak up about concerns is an ongoing healthcare priority. Based on narrative interviews with people raising and responding to concerns and complaints in six English National Health Service (NHS) organizations, this study explored how substandard responses to concerns and complaints can lead to organizational failures.

… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … competence for patient safety among global learners: a prospective cohort study. Nurse Educ …

… can motivate and support speaking up behaviors. … Wu F, Dixon-Woods M, Aveling EL, et al. The role of the informal and … formal organisation in voice about concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:114050. …

… , and improving patient outcomes . … van de Ruit C, Bosk CL. Surgical patient safety officers in the United …

Maternal harm is a sentinel event and improving maternal safety is receiving increased attention in both policy and clinical settings. The researchers used qualitative methods to generate a new plain language framework identifying safe behaviors and practices in inpatient maternity units. Several synergistic features were identified including a commitment to safety culture; technical competence; teamwork, cooperation, and positive working relationships.  

… errors to improve patient safety. … Singh H, Bradford A, Goeschel C. Operational measurement of diagnostic safety: …

This review synthesized research exploring how operational failures (e.g., distractions, situational constraints) in primary care affect the work of primary care physicians. The literature suggests that operational failures are common, and the gap between what physicians perceive that they should be doing and what they were doing (“work-as-imagined” vs, “work-as-done”) is largely attributed to operational failures over which the primary care physicians had limited control. The authors suggest that future research focus on which operational failures have the highest impact in primary care settings in order to prioritize areas for targeted improvement.

After findings of gross negligence, the National Health Service (NHS) introduced ‘Freedom to Speak Up Guardians’ to lead safety culture change with the ultimate goal that speaking up about safety issues becomes the norm. The authors used semi-structured interviews with 51 individuals (e.g., Guardians, clinicians, policymakers/regulators, etc.) to describe the rollout of the Guardians. These interviews revealed that the role of the Guardians is rich in potential but that the initial narrow role of addressing only quality and safety concerns was not consistent with the myriad of complex issues brought to them and may indicate the need to expand the role definition.

… of accurate and reliable measurements was identified as a major priority for the patient safety field in an … PSNet interview featured the study's senior author, Mary Dixon-Woods. …

… on the limitations of applying the principles of a science of safety to health care. These weaknesses involve …

… In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by …

… to improvement. A PSNet interview with senior author Mary Dixon-Woods expanded on the need to shape culture to foster …

Maternal harm is a sentinel event that has garnered increased attention in both policy and clinical environments. This qualitative study combined direct observation and interviews to understand the characteristics that enabled a high-performing maternity ward to achieve their excellent safety outcomes. Investigators identified a set of specific, evidence-based safety practices including standardization, monitoring, and emphasis on technical skill. They also identified a strong and consistent safety culture and noted that structural conditions, such as staffing levels and the physical environment, supported safe outcomes. The authors conclude that all of these factors influence each other and jointly produce safety. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.

The United Kingdom National Health Service (NHS) is known for both patient safety achievements and failures. This commentary discusses the unique opportunity the NHS embodies to improve practice. Highlighting system-level challenges due to lack of resources and funding, the author describes the role of health care professions in fostering continued achievements through the application of improvement science.

This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.

… Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event , a multidisciplinary quality improvement team worked to … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …

… or assessing feasibility and effectiveness . … Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve …