“Safety cases” are used in healthcare and other industries to communicate the safety of a product, system, or service. In this study, researchers use the “safety case” approach to evaluate the safety of the Safer Clinical Systems program, which is designed to improve the safety and reliability of clinical pathways.  

Children with complex medical needs are vulnerable to patient safety threats. This qualitative study explored the perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the persistent fear of central line-associated blood stream infections as well as the importance of maintaining a sense of normalcy for their children.

A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.

Reluctance of healthcare team members to speak up about concerns can hinder patient safety. The authors conducted semi-structured interviews with 165 participants (health system leadership, managers, healthcare providers, and staff) about policies, practice, and culture around voicing concerns related to quality and safety. Findings suggest that both formal and informal hierarchies can undermine the ability and desire of individuals to speak up, but that informal organization (such as personal relationships) can motivate and support speaking up behaviors.

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.

… and positive working relationships.   … Liberati EG, Tarrant C, Willars J, et al. Seven features of safety in …

Patients admitted to the hospital on the weekend have been shown to experience worse outcomes compared to those admitted on weekdays. This weekend effect has been observed numerous times across multiple health care settings. However, whether patient characteristics (patients admitted on the weekend may be more severely ill) or system factors (less staffing and certain services may not be available on the weekend) are primarily responsible remains debated. In this systematic review and meta-analysis including 68 studies, researchers found a pooled odds ratio for weekend mortality of 1.16. Moreover, the weekend effect in these studies was more pronounced for elective rather than unplanned admissions. They conclude that the evidence suggesting that the weekend effect reflects worse quality of care is of low quality. A past PSNet perspective discussed the significance of the weekend effect with regard to cardiology.

Interviews with frontline hospital staff and executive leaders revealed that they were generally supportive of engaging families and patients to promote infection prevention in the clinical setting when using a collaborative approach. Staff identified certain challenges including concerns related to the extent of responsibility patients and families should bear with regard to infection prevention as well as risks to infection control posed by patients themselves.

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.

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 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.

In-hospital mortality for many conditions is higher on the weekends than on weekdays—a phenomenon known as the weekend effect. Some hypothesize lower specialty physician staffing levels on weekends explains the mortality difference. This cross-sectional study compared specialist staffing levels and mortality rates at 115 hospitals in the English National Health Service on Sundays compared to Wednesdays. Researchers found a higher mortality rate and lower intensity of specialty services on weekends, but there was no correlation between the two ratios. Although this study is not definitive, it does imply that alternate mechanisms may explain the weekend effect, such as case mix differences, variation in nonphysician staffing, or lower availability of diagnostic services. A previous PSNet interview discussed the weekend effect in health care.

Achieving a positive safety culture requires that all team members feel comfortable voicing safety concerns. Hierarchy and poor communication are well-recognized barriers that prevent team members from speaking up about safety concerns. In this qualitative study across 19 intensive care units, researchers used data from hundreds of hours of ethnographic observation and interviews to understand how team members raised safety concerns and to characterize processes of social control exercised in response to mistakes, perceived safety risks, and deviations from normal practice. The authors argue that a better understanding of social control is necessary to facilitate voicing safety concerns in the clinical setting. A past WebM&M commentary discussed an incident involving a medical student who did not speak up when a urinary catheter was inserted without sterile technique.

Junior doctors at a British hospital reported a willingness to help improve safety by reporting concerns, but described several barriers to doing so. These included an overall lack of a culture of safety, a cumbersome reporting process, and insufficient role modeling by more senior physicians.

Evaluation of an intervention plays an important role in confirming the effectiveness of the work and the evidence it generates. This commentary reviews a process to guide evaluation teams in developing a collective understanding of purposes and scope to assure programs meet their goals. The authors illustrate how this process was used in a large-scale clinical system improvement initiative.

The Matching Michigan program attempted to replicate the success of the Keystone ICU study at preventing central line–associated bloodstream infections in intensive care units (ICUs) in England. However, Matching Michigan was unsuccessful in that infection rates declined at similar rates in both intervention and control units. A counterpart to the landmark study exploring why the Keystone ICU study succeeded, this ethnographic analysis identified external factors (Matching Michigan was perceived as a regulatory, top-down initiative) and internal factors (participating hospitals had widely varying prior experiences with quality improvement projects) that influenced uptake and success of the project at the individual hospital level. Overall, only 1 of the 19 intervention ICUs studied truly transformed their practices and culture toward preventing hospital-acquired infections.

This study of four medical wards in the United Kingdom highlights the importance of understanding how staff members identify, evaluate, and address risk in assessing their responses to efforts to promote change.