BMJ Qual Saf 20:611-617 doi:10.1136/bmjqs.2010.049379
  • Original research

What context features might be important determinants of the effectiveness of patient safety practice interventions?

Editor's Choice
  1. Paul G Shekelle1,2
  1. 1RAND Corporation, Santa Monica, California, USA
  2. 2Veterans Administration, Greater Los Angeles, Los Angeles, California, USA
  3. 3The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  4. 4Leeds Institute of Health Sciences University of Leeds, Leeds, UK
  5. 5Stanford University, Stanford, California, USA
  6. 6Medical Management Centre, The Karolinska Institutet, Stockholm, Sweden
  7. 7University of California, San Francisco, California, USA
  1. Correspondence to Stephanie L Taylor, VA Greater Los Angeles, 16111 Plummer St., Bldg. 25 (152), North Hills, CA 91343, USA; stephanie.taylor8{at}
  1. Contributors The technical expert panel included Alyce S. Adams, PhD, Peter Angood, MD, David W. Bates, MD, MSc, Len Bickman, PhD, Celia Brown, PhD, Pascale Carayon, PhD, Sir Liam Donaldson, MD, Naihua Duan, PhD, Donna O. Farley, PhD, MPH, Trisha Greenhalgh, MD, John Haughom, MD, Eileen T. Lake, PhD, RN, Richard Lilford, MB BCh, PhD, Kathleen N. Lohr, PhD, Gregg S. Meyer, MD, MSc, Marlene Miller, MD, MSc, Duncan Neuhauser, PhD, Gery Ryan, PhD, Sanjay Saint, MD, MPH, Kaveh Shojania, MD, Stephen M. Shortell, PhD, MPH, David P. Stevens, MD, and Kieran Walshe, PhD. The research reported here was supported under Contract No. HHSA-290-2009-10001C from the Agency for Healthcare Research and Quality, US Department of Health and Human Services. The authors of this paper are responsible for its content. Statements in this paper should not be construed as endorsement by the Agency for Healthcare Research and Quality or the US Department of Health and Human Services.

  • Accepted 1 April 2011
  • Published Online First 26 May 2011


Background Differences in contexts (eg, policies, healthcare organisation characteristics) may explain variations in the effects of patient safety practice (PSP) implementations. However, knowledge of which contextual features are important determinants of PSP effectiveness is limited and consensus is lacking on a taxonomy of which contexts matter.

Methods Iterative, formal discussions were held with a 22-member technical expert panel composed of experts or leaders in patient safety, healthcare systems, and methods. First, potentially important contextual features were identified, focusing on five PSPs. Then, two surveys were conducted to determine the context likely to influence PSP implementations.

Results The panel reached a consensus on a taxonomy of four broad domains of contextual features important for PSP implementations: safety culture, teamwork and leadership involvement; structural organisational characteristics (eg, size, organisational complexity or financial status); external factors (eg, financial or performance incentives or PSP regulations); and availability of implementation and management tools (eg, training organisational incentives). Panelists also tended to rate specific patient safety culture, teamwork and leadership contexts as high priority for assessing their effects on PSP implementations, but tended to rate specific organisational characteristic contexts as high priority only for use in PSP evaluations. Panelists appeared split on whether specific external factors and implementation/management tools were important for assessment or only description.

Conclusion This work can guide research commissioners and evaluators on the contextual features of PSP implementations that are important to report or evaluate. It represents a first step towards developing guidelines on contexts in PSP implementation evaluations. However, the science of context measurement needs maturing.


  • Linked articles 047993, 049296, 047035.

  • Funding Agency for Healthcare Research and Quality.

  • Competing interests None declared.

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