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.

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.

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.

Prioritizing patient safety can be challenging for health system leadership. This qualitative study included interviews, extensive ethnographic observation, and review of documents to examine how three distinct hospitals conceived of and acted to improve patient safety. Researchers found that crises in the area of patient safety catalyzed activities in this area. They also highlight how differing perspectives on safety shaped organizational responses to crises. The authors conclude that shaping an understanding of patient safety issues as shared problems amenable to organization solutions is critical to improvement. A PSNet interview with senior author Mary Dixon-Woods expanded on the need to shape culture to foster improvement.

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.

Quality improvement activities are often conducted to enhance patient safety in the perioperative setting, but many of these initiatives are not reported in peer-reviewed literature. This systematic review found that published reports of perioperative quality improvement often lack necessary detail about the intervention and setting. The results suggest that standardized reporting guidelines may improve peer-reviewed articles about quality improvement.

This qualitative study sought to validate and understand the previously published results of the Safer Delivery of Surgical Services (S3) program, which showed that combining efforts aimed at improving the work system and safety culture was more efficacious than either approach alone. The investigators developed themes and lessons learned through semistructured interviews with hospital staff and the research team.

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.

Asking clinical and managerial staff across the National Health Service what concerns they would have if a friend or relative was treated at their organization provided vital insights into quality of care. Qualitative interviews using similar questions could be an effective method for uncovering detailed accounts of institutional safety problems.

An in-depth, qualitative analysis of a safety campaign at a hospital in the United Kingdom demonstrated variations in perceptions of its goals and utility between project leaders and frontline staff. The authors advocate for patient safety campaigns to be used with other interventions such as incentives and leadership development.

This editorial introduces a series of seven peer-reviewed commentaries that explore the ethical, sociolegal, academic, and clinical avenues to understanding system failures identified in the Francis inquiry, along with methods to identify gaps in knowledge such as measurement and feedback to drive improvement.

This study used the accident causation model to determine latent causes of medication errors requiring hospital admission in a sample of older patients in the United Kingdom. The authors identified concerns around decision-making, recording information, and acting on abnormal test results.

Although conceptually appealing, leadership walkrounds—visits by management to clinical units with the goal of engaging in frank discussion around safety concerns—have proven to be somewhat controversial in practice. Some studies have shown that walkrounds can improve safety culture, but both randomized trials and qualitative analyses have found that increased management visibility can paradoxically worsen safety perceptions, and executives often view walkrounds as an obligation to be endured. The United Kingdom's National Health Service uses walkrounds widely, and this qualitative study utilized interviews with management and frontline staff to identify key insights into why walkrounds succeed in some contexts and fail in others. According to this study, seemingly minor aspects of how walkrounds are conducted can result in staff perceiving that the rounds are being used for monitoring and evaluation rather than for their intended purpose of identifying and addressing safety concerns.

Achieving an organizational safety culture is a widely espoused goal. This study explores the tension between disciplinary approaches and more consensus-oriented methods for stimulating clinician behavior change to enhance safety in hospitals.

Achieving an organizational safety culture is a widely espoused goal. The authors of this study synthesized qualitative and quantitative data from interviews, surveys, ethnographic case studies, board minutes, and publicly available datasets to describe the extent of safety culture in the United Kingdom's National Health Service (NHS). Culture was inconsistent across the NHS and barriers to safety culture included competing priorities, redundant regulatory and compliance requirements, lack of timely and actionable data, suboptimal organizational and information systems, and variations in staff and leadership commitment. The accompanying editorial highlights the finding that safety culture is mostly local, with high and low performing units existing within the same institution. The authors propose three actions to foster a safety culture: engagement of health care providers, establishment of peer networks, and explicit commitment between clinicians and leadership to prioritize safety.

Ethnographic observations and semi-structured interview data showed that implementation of an electronic health record with prescribing and decision support led to greater oversight of and improvements in specific safety metrics.

Examining quality improvement program evaluations, this commentary identifies barriers to improvement and recommends tactics to address them.