ArticleFuture healthcare journal2021
Systems-based investigation of patient safety incidents.
Article in Future healthcare journal, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 13 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
13 citing papers in PubMed.
- Assessing the quality of patient safety incident investigation reports.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2026Article
- Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations.BMJ quality & safety · 2026Article
- From Root Cause Analysis to Systems Thinking: A Comparative Content Analysis of Patient Safety Incident Investigation Reports in Mental Healthcare.Journal of evaluation in clinical practice · 2026Article
- Human Factors in Airway Management: Designing Systems for Safer, Team-Based Care.Journal of clinical medicine · 2025Review
- Understanding adverse incident responses in mental health care: a qualitative study of systems-based patient safety practices.BMJ open · 2025Article
- The impact of nurses' perceptions of systems thinking on patient safety competencies: a cross-sectional study.BMC health services research · 2025Article
- Using human centred design and human factors to support a rapid health information technology patient safety response.BMC health services research · 2025Article
- Human factors in anaesthetic practice part I: facts and fallacies.BJA education · 2023Review
- Advancing Staff Safety: Assessment of Quality Improvement Interventions in Reducing Needlestick Injuries Among Staff at Nyaho Medical Centre.Global journal on quality and safety in healthcare · 2023Article
- Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report.BMJ open quality · 2023Article
- Naming the "baby" or the "beast"? The importance of concepts and labels in healthcare safety investigation.Frontiers in public health · 2023Article
- Patient safety: time for a radical re-think.Future healthcare journal · 2021Article
- Safety and the pandemic: changing perspectives for patients, professionals and populations.Future healthcare journal · 2021Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Patient safety events are common in healthcare. We can learn from other safety-critical industries that further incidents are most likely to be prevented where lessons are learned at the system level rather than looking to attribute blame for errors to individuals. Progress has been made over the last 20 years and relies on a positive safety culture (or just culture) where staff trust organisations to investigate safety events for learning rather than blame. Systems-based investigation models, such as the Systems Engineering Initiative for Patient Safety (SEIPS), help investigators to consider the full range of contributory factors across a system and to identify important findings. Considering the hierarchy of controls, recommendations should be targeted at system changes which are more likely to produce sustained safety improvements, rather than at individual behaviours or training, which are less likely to influence future safety. Systems-based safety investigations can positively influence safety culture in organisations.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.