BMJ Qual Saf 20:604-610 doi:10.1136/bmjqs.2010.047035
  • Original research

How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research

  1. Robert M Wachter11
  1. 1Medical Management Centre, The Karolinska Institutet, Stockholm, Sweden
  2. 2Southern California Evidence-Based Practice Center, USA
  3. 3RAND Corporation, UCLA and VA Greater Los Angeles, Los Angeles, California, USA
  4. 4The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  5. 5Stanford University, California, USA
  6. 6RAND Corporation, Santa Monica, California, USA
  7. 7Departments of Anesthesiology and Critical Care, Surgery, and Health Policy and Management, The Johns Hopkins University School of Medicine Baltimore, Maryland, USA
  8. 8Center for Innovations in Quality Patient Care, The John Hopkins University School of Medicine, Baltimore, Maryland, USA
  9. 9VA HSRD Center of Excellence for the Study of Healthcare Provider Behavior, North Hills, California, USA
  10. 10Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
  11. 11Department of Medicine, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to John Øvretveit, Medical Management Centre, Karolinska Institute, MMC, Karolinksa Institute, Berzelius Vag 3, Stockholm 17177, Sweden; jovret{at}
  1. Contributors JCØ was the main author.

  • Accepted 24 February 2011
  • Published Online First 13 April 2011


Background Logic and experience suggest that it is easier in some situations than in others to change behaviour and organisation to improve patient safety. Knowing which ‘context factors’ help and hinder implementation of different changes would help implementers, as well as managers, policy makers, regulators and purchasers of healthcare. It could help to judge the likely success of possible improvements, given the conditions that they have, and to decide which of these conditions could be modified to make implementation more effective.

Methods The study presented in this paper examined research to discover any evidence reported about whether or how context factors influence the effectiveness of five patient safety interventions.

Results The review found that, for these five diverse interventions, there was little strong evidence of the influence of different context factors. However, the research was not designed to investigate context influence.

Conclusions The paper suggests that significant gaps in research exist and makes proposals for future research better to inform decision-making.


  • Linked article 049296, 049379, 047993.

  • Funding This study was financed by the US Agency for Healthcare Research and Quality Contract No HHSA-290-2009-10001C.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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