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.

Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.

… a sense of normalcy for their children. … Soto C, Dixon-Woods M, Tarrant C. Families’ experiences of central-line …

… 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.

… can motivate and support speaking up behaviors. … Wu F, Dixon-Woods M, Aveling EL, et al. The role of the informal and …

In 2013, the UK National Health Service (NHS) implemented 7-day services to ensure that patients admitted on weekends receive quality care. To examine the impact of the policy, this analysis compared error rates among patients admitted to the hospital as emergencies on weekends versus weekdays before and after policy implementation. Error rates were not significantly different on weekends compared to weekdays, but errors rates overall improved significantly after implementation of 7-day services.

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.  

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.

… PSNet interview featured the study's senior author, Mary Dixon-Woods. …

Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.

… 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.

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

The NHS Safety Thermometer was developed by the National Health Service to facilitate harm measurement across different health care environments. In this qualitative study, researchers describe some of the challenges associated with the use of this tool in the community health setting.

Measuring patient safety is critical to improvement. This ethnographic study examined the implementation of a patient safety measurement program in the United Kingdom, the NHS Safety Thermometer, which measured incidence of pressure ulcers, harm from falls, catheter-associated urinary tract infection, and venous thromboembolism, with the goal of informing local improvement efforts. Investigators sought to examine how the measurement program was perceived by frontline staff. Despite the explicit emphasis on using the data for improvement, it was viewed as an external reporting requirement. The program was also viewed as a basis to compare organizations, especially because it included pay-for-performance incentives. The authors suggest that the intention of the program did not match the real-world considerations of participating health care systems and had the unintended consequence of creating potential for blame.

A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.