Through a self-reflective narrative, this commentary offers insights into the authors' experience investigating, developing, and implementing a patient safety improvement project. The researchers suggest that this analysis helped improve understanding of key team member roles and areas to enhance collaboration.

This commentary explores why efforts to understand and establish safety culture have not incorporated systems concepts. The authors recommend integrating the two theories to help organizations promote safety and suggest shifting safety culture programs to use a more systemic approach in improvement work. One example is for an organization to establish a safety practice and implement processes to ensure the practice is maintained.

This piece examines the impact of bias on safety improvement efforts and safety culture.

This piece discusses patient safety culture and examines the organizational, social, and psychological patient dimensions surrounding it.

Analyzing research on accident investigation and incident feedback, this commentary recommends areas for future study.