This explored the links between psychological safety and objective patient safety outcomes: · “No clear conclusions can be extracted regarding the relationship between psychological safety and patient safety” · “The evidence linking psychological and patient safety is equivocal” · “Overall, there is relatively little hard data to link PS and patient safety outcomes” · “Only nine studies fit the… Continue reading Psychological safety and patient safety: A systematic and narrative review
Tag: patient safety
Safe As podcast ep15: Root Cause Analyses (RCA) and incident prevention – do they ‘work’?
Many organisations rely on their root cause analyses (RCA) to help learn about incidents, and, ideally, prevent incident reoccurrences. So the logic goes. But does the published evidence support RCA approaches as effective means for preventing incident reoccurrences? Today’s paper is Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J.… Continue reading Safe As podcast ep15: Root Cause Analyses (RCA) and incident prevention – do they ‘work’?
Using the hierarchy of intervention effectiveness to improve the quality of recommendations developed during critical patient safety incident reviews
This study evaluated the Hierarch of Intervention Effective (HIE) for improving patient safety incident recommendations. They were namely interested in increasing the proportion of system-focused recommendations. Data came from over 16 months. Extracts: Ref: Lan, M. F., Weatherby, H., Chimonides, E., Chartier, L. B., & Pozzobon, L. D. (2025, June). Using the hierarchy of intervention… Continue reading Using the hierarchy of intervention effectiveness to improve the quality of recommendations developed during critical patient safety incident reviews
A new perspective on blame culture: an experimental study
This study explored how fear of blame and punishment affects different healthcare professions, experience levels and gender. 249 healthcare practitioners were involved, and were asked how fear of blame or punishment resulting from an error which caused no, mild, severe or death of a patient. Extracts: · “blame culture can be defined as a set of… Continue reading A new perspective on blame culture: an experimental study
Avoiding ‘second victims’ in healthcare: what support do staff want for coping with patient safety incidents, what do they get and is it effective? A systematic review
This systematic review evaluated evidence for what support staff want vs what they receive, and whether the support is effective. 99 studies were included. Some extracts: · PSI (patient safety incident) lead to emotional shame, guilt, anger, shock, depression, fear, flashbacks, helplessness, fatigue, withdrawal and more · The three most desired support types staff want before and… Continue reading Avoiding ‘second victims’ in healthcare: what support do staff want for coping with patient safety incidents, what do they get and is it effective? A systematic review
The systems approach to medicine: controversy and misconceptions — Dekker & Leveson
This was a really brief discussion paper from Dekker and Leveson, covering systems thinking in medicine. Three parts – see comments. Nothing new for most, but they cover: · “The ‘systems approach’ to patient safety has recently led to questions about its ethics and practical utility” · E.g. A recent paper from a retired neurosurgeon questioned systems… Continue reading The systems approach to medicine: controversy and misconceptions — Dekker & Leveson
Investigators are human too: outcome bias and perceptions of individual culpability in patient safety incident investigations
This study explored whether outcome bias might explain why healthcare investigations focus on individual culpability over addressing latent conditions in the system. 212 participants were allocated to one of three scenarios followed by the findings of an investigation (see scenario overviews below). For background: · Prior work has identified that the “overwhelming majority of recommendations… Continue reading Investigators are human too: outcome bias and perceptions of individual culpability in patient safety incident investigations
An ode to Drs Richard Cook, Jens Rasmussen & Bob Wears: A mini-compendium of their legacies
This is long overdue – but I wanted to cover some of the work from these giants who have played a significant part in modern safety thinking. Focus is on articles I’ve written about or used extracts from, or could find a full-text link for, and higher-cited articles. It’s not systematic – and unfortunately a… Continue reading An ode to Drs Richard Cook, Jens Rasmussen & Bob Wears: A mini-compendium of their legacies
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