Proficient safety professionals are the cornerstone of effective patient safety programs. In this study, safety professionals provided insights about theoretical factors influencing the role of safety professionals in healthcare (e.g., legal regulation, organizational context, safety culture).

This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on Systems Theory), an alternative approach to root cause analysis. The CAST approach is based on the principle that accidents are not only the result of individual system component failures or errors but more generally result due to inadequate enforcement of constraints on the behavior of the system components (i.e., safety constraints enforced by controls, such as checklists).  Many adverse events (AEs) appear to be related to the design of the system involved and not attributable to unsafe individual behavior. This technique can be useful in identifying causal factors to help health care systems learn from mistakes and design systems-level changes to prevent future AEs.

… of safety professionals at an energy company, a high reliability industry often used as a model for patient safety . The results reveal that safety …

Interruptions can contribute to medication errors, but efforts to reduce interruptions may result in unintended consequences. The authors suggest that designing interventions around high reliability and resilience principles can address risks and increase the likelihood of lasting improvements.

… Safety Science … Saf Sci … A just culture balances organizational context with …

Interruptions are a common occurrence in health care. This commentary suggests that research about interruptions clearly determine definitions, data collection methods, and processes that are affected to enhance understanding regarding the impact of disruptions on patient safety.

Highlighting how the systems approach is often misunderstood to ascribe responsibility for failure to the system when things go wrong, this commentary explains that the approach is instead meant to reduce variation and enhance individual responsibility and competence with standard procedures.

In the context of public reactions to the Francis report, this commentary discusses why the poor conditions were missed and how to prevent failures from recurring once they are identified. The authors advocate for a just culture that balances blame and accountability to address complexities in the health care setting.

This commentary explores the just culture concept and how the assignment of accountability for acceptable and unacceptable actions can best promote justice and safety.

This review of the literature on bile duct injury during cholecystectomy focuses on cognitive errors made by surgeons, including inappropriate use of heuristics.

… The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics … …

The author discusses the complexities of defining and responding to health care provider negligence by examining the various methods of assigning error accountability.

… author proposes that safety should be considered a dynamic and interactive process, and outlines a new framework for understanding safety in complex systems. …