Table 1

Literature on safety rounds

Reference	Objectives	Methods	Findings
Frankel et al 2003	To describe a patient safety advisory and leaders group programme developed in one large, integrated healthcare delivery system in the Boston, Massachusetts, area.	Descriptive; case study.	Implemented safety rounds as key milestone of the programme. This, and related efforts, have heightened awareness of patient safety, especially among hospital senior leaders, which has resulted in substantial support for patient safety initiatives.
Pronovost et al 2004	To describe a safety programme at the Johns Hopkins Hospital in which senior hospital executives each adopted an intensive care unit and worked with the unit staff to identify issues, and to empower staff to address safety issues.	Descriptive; case study.	The senior executive adopt-a-work unit programme was successful in identifying and eliminating hazards to patient safety and in creating a culture of safety.
Anonymous 2005	To describe the safety rounds programmes at Newton-Wellesley Hospital (Newton, MA) and Marian Hospital (Carbondale, PA), at which rounds were conducted by the Director of Legal Affairs.	Descriptive.	Safety rounds have identified the importance of problems thought to be small. They provide information based on which unit managers can act.
Budrevics and O'Neill 2005	To describe in detail the safety rounds programme at Sunnybrook & Women's College Health Science Centre in Canada.	Descriptive, case study.	Taking steps to prepare, set expectations, and build trust among all the participants enables meaningful dialogue that was open and honest. Environmental gaps and ageing facility infrastructure issues were most frequently identified.
Frankel et al 2005	To describe the experience of four hospitals (Brigham and Women's and three others) with safety rounds.	Descriptive; multiple case study; interviews.	In 28 months, 233 one-hour safety rounds yielded 1,433 comments; 30% related to equipment, 13% to communications, 7% to pharmacy, and 6% to workforce. Implementation feasibility featured more prominently than severity in determining actions.
Gandhi et al 2005	Based on experience with safety rounds and other reporting systems at Brigham and Women's Hospital (Boston), to discuss the importance of follow-up and feedback and describe an information-tracking database.	Descriptive.	Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item, yet feedback perpetuates the influx of information and closes the loop. Maintaining the information-tracking database requires significant effort, but has made providing feedback easier and more reliable.
Graham et al 2005	To describe Kaiser Permanente's experience with safety rounds in two pilot sites.	Descriptive; multiple case study.	Safety rounds created a remarkable change in the patient safety culture at the participating medical centers.
Thomas et al 2005	To measure the impact of safety rounds on non-clinician provider attitudes about the safety climate in 23 clinical units of one tertiary care teaching hospital.	Quantitative: survey, pre and post with randomized controlled design.	After safety rounds, the mean safety climate scores were not significantly different for all providers, nor for nurses in the control units and safety round units. However, nurses in the control group who did not participate in safety rounds had lower safety climate scores than nurses in the intervention group who did participate in a safety round session.
Beil-Hildebrand 2006	To describe the implications of safety rounds on healthcare employees in one German hospital.	Descriptive; in-depth case study in the hospital's nursing division.	Safety rounds were used as a means of managerial control and, as such, the positive vision for safety rounds was met with skepticism and cynicism.
Feitelberg 2006	To describe the safety rounds programme in the Kasier Permanente San Diego Service Area.	Descriptive, case study.	The safety rounds programme plays a major part in promoting responsible identification and reporting of patient safety issues.
Richardson et al 2007	To describe a safety rounds pilot project at Children's Hospital of Eastern Ontario that built on success factors identified in the literature.	Descriptive with online survey to solicit staff suggestions and support for safety rounds.	After 19 rounds, participants identified 181 issues, mostly related to organisational/management and work environment. Among 24% of staff responding, most supported rounds. Barriers included need for additional education and time and infrastructure for complex change.
Verschoor et al 2007	To describe the implementation and adaptation of safety rounds and other tools recommended by the Institute for Healthcare Improvement, at Children's' and Women's Health Centre of British Columbia.	Descriptive, case study.	Adaptations included longer discussions with more than one staff members. Discussions were Non-punitive in orientation.
Burnett et al 2008	To describe the complex social processes underpinning safety rounds in 20 organisations participating in Phase 2 of the UK NHS Safer Patients Initiative.	Qualitative analysis of 56 interviews, using an inductive approach and then a thematic analysis.	Safety rounds can help executives to learn about their organisation, leadership style and attitudes.
Donnelly et al 2008	To describe a safety rounds programme in a department of radiology, in which radiology leaders' visit imaging divisions at the site of imaging and discuss frontline employees' concerns.	Descriptive, case study.	Multiple patient safety and other issues have been identified and remedied. The authors believe that safety rounds have improved patient safety, quality of care, and efficiency of operations. The mean number of days between serious safety events involving radiology has doubled since programme inception.
Elder et al 2008	To explore perceptions of patient safety among nursing staff in ICUs following participation in a safety project that decreased hospital-acquired infections.	Mixed methods: including comparison of data from focus groups with 33 nurses, cross-sectional safety climate surveys with nurses and managers, and categories represented in safety checklists used on the safety rounds at three hospitals.	Less than half (47%) the patient safety dangers identified through focus groups were found on checklists from safety rounds.
Frankel 2008	To describe the experience of implementing safety rounds in four hospitals.	Descriptive.	Most of the safety concerns compiled were equipment and communication related. Frontline staff appreciated that their concerns are heard and acted on, and leaders gained insight into quality and safety concerns of which they were not previously aware.
Frankel et al 2008	To describe and evaluate the impact of rigorous safety rounds on frontline caregiver assessments of safety climate in seven hospitals.	Quantitative: survey with pre and postanalysis.	After 18 months, two of seven hospitals complied with the rigorous safety rounds approach. Safety climate scores improved among all caregivers. Main safety issues by category were equipment/facility and communication.
Matlow et al 2008	To describe the Blueprint for Patient Safety surveillance programme, which includes safety rounds as one part of a four-part approach to identify potential and existing vulnerabilities and failures and put measures in place to avoid and mitigate any harm, at the Hospital for Sick Children, and to discuss successes and challenges.	Descriptive, case study.	After two years, safety rounds identified 1433 comments from 233 sessions. Most comments related to equipment and environment. Issues identifed included ambiguous assignment for resolution, lack of mechanisms for prioritisation and follow-up.
Montgomery 2008	To describe a staff-led safety round approach at Kosair Children's Hospital in Louisville, KY.	Descriptive, case study.	Over 8 months, staff-led safety rounds reached 182 staff from 10 disciplines. They identified 79 safety concerns, most related to equipment and care delivery (eg, need for education regarding insulin administration).
Rinke et al 2008	Categorise three years of patient safety rounds in paediatric inpatient units and nine months of paediatric surgical safety rounds.	Descriptive, case study.	There were 159 completed patient safety issues; 48.4% were equipment- related, 35.8% were care coordination/records, 7.6% were errors.
Tucker et al 2008	To contrast the safety-related concerns raised by front-line staff in 20 US hospitals conducting safety rounds about hospital work systems (operational failures) with national patient safety initiatives.	Qualitative: classification of identified problems with comparison to objectives of national iniatives.	The two most frequent categories of operational failures, equipment/ supplies and facility issues, posed safety risks and diminished staff efficiency, but have not been priorities in national initiatives.
Zimmerman et al 2008	To describe experience with and evaluation of a safety rounds programme at Hamilton Health Sciences in Hamilton Ontario.	Descriptive with process evaluation.	After one year of monthly safety rounds, 1,351 patient safety issues were identified, of which 64–80% were resolved or had active improvement work in progress. The process evaluation demonstrated satisfaction with safety rounds. Five areas of opportunity for process improvement were identified: scheduling, scripts, feedback, reporting and resolving issues deferred for an organisation approach.
Linden 2009	To report a CEO's perspective on the experience and value of safety rounds at his hospital, Grinnell Regional Medical Center in Iowa, based on 15 years of conducting them.	Descriptive, narrative.	Safety rounds provide an opportunity to conduct problem solving through coaching, to make more informed decisions, and to recognise employees.
Shaw et al 2009	To describe characteristics thought to be related to patient safety within the Pediatric Emergency Care Applied Research Network, to measure staff perceptions of safety climate in EDs, and to measure associations between ED characteristics and safety climate.	Quantitative: cross-sectional safety climate survey in 21 EDs compared to survey assessing physical structure, staffing patterns, overcrowding, medication administration, teamwork, and methods for promoting patient safety.	A minority of EDs had organised safety activities, such as safety rounds (38%). Characteristics associated with an improved safety climate were a lack of ED overcrowding, a sick call back-up plan for physicians, and the presence of an ED safety committee. Conducting safety rounds more than quarterly was not associated with higher safety climate scores.
Yee et al 2009	To describe the weekly safety rounds programme implemented in 2005 at the North Carolina Children's Hospital.	Descriptive, case study.	Rounds occurred weekly and 191 issues were identified during the first year, of which 58% were resolved. Senior management participates and helps staff identify solutions. Just culture and Six-Sigma help establish a culture of safety.

Levtzion-Korach et al 2010	To examine and compare information gleaned from five different reporting systems within one institution: incident reporting, patient complaints, risk management, medical malpractice claims, and executive safety rounds.	Descriptive: data specific to each incident were abstracted from each system and then categorised using a common framework into one of 23 categories.	There was little overlap across safety systems, although each reporting system identified important safety issues. Safety rounds identified issues with equipment and supplies.
Menendez et al 2010	To describe improvements associated with using safety rounds and briefings in Monte Naranco Hospital, a 200 bed mostly geriatric hospital.	Quantitative: pre and post surveys, evaluations of leaders, interviews with frontline staff over 5 years.	Safety rounds and briefings allowed 20% higher number of adverse events to be detected, and are useful for Training health workers. Participants also experienced better feedback and less problems with equipment and outpatient units.
Rubin and Stone 2010	To describe and assess the use of safety rounds at Metropolitan Hospital Center for rolling out a new strategic plan over a 2-week period to all unit/departments and shifts.	Descriptive, with employee satisfaction survey.	Safety rounds involved 69% of MHC staff, and 88.9% of management level staff and 64.5% of unionised/labour stated that they understood the hospital's new strategic plan.
Benning et al 2011	To evaluate the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals.	Mixed methods: including five sub-studies using before and after comparisons of 4 intervention hospitals and 18 control hospitals in four countries in the UK National Health Service (NSH).	The introduction of SPI1 was associated with improvements in one of the types of clinical processes studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on multiple other targeted issues nor on other measures of generic organisational strengthening.
Benning et al 2011	To evaluate the second phase of the Health Foundation's Safer Patients Initiative (SPI2) on a range of patient safety measures.	Mixed methods. Using a controlled before and after design and five substudies: staff attitude survey, case notes from high-risk patients, case notes from surgical patients, use of handwashing materials, outcomes measurement (adverse events, mortality among high-risk medical patients, patients' satisfaction, mortality in intensive care, rates of hospital-acquired infection) in 9 intervention hospitals and 9 controls in UK NHS.	Organisational climate improved in control hospitals relative to those in the intervention. Several other measures showed temporal trends but no difference between intervention and control hospitals. Mortality rates of medical patients increased in control hospitals while falling in intervention hospitals (p=0.043), but this difference could not be explained by differences in preventable deaths. While there is evidence of good or improved quality and safety in NHS hospitals, authors did not detect a net effect attributable to SPI2.
Gravenstein et al 2012	To describe a Department of Anesthesiology's experience with safety rounds involving department leaders and multiple other disciplines.	Descriptive, case study with comparison of issues identified through safety rounds and other error-detection methods.	Over 23 months, rounds identified 14 significant opportunities to improve care. Conventional patient experience measures and chart audits did not identify these opportunities for improvement.
Parand et al 2012	To identify critical dimensions of hospital CEO involvement in quality improvement.	Qualitative: interviews with 17 CEOs overseeing 19 UK hospitals participating in the Safer Patient Initiative, and 36 interviews with middle managers from the same hospitals.	CEOs and staff identified five key roles for CEOs: (1) resource provision; (2) staff motivation and engagement; (3) commitment and support; (4) monitoring progress and (5) embedding programme elements. Findings stress the importance of safety rounds as a tool for two-way communication and demonstrating commitment.
Saladino et al 2013	To study the implementation of a nurse-led safety rounds programme in a critical care unit over a six-month period.	Mixed methods. Descriptive information and pre and post survey of unit nurses' safety climate perceptions.	Unit nurses' safety climate scores remained stable over the study period. Staff identified 77 safety issues and 57% were resolved during the study period.
Schwendimann 2013	To evaluate the association between safety rounds and caregiver assessments of patient safety climate and patient safety risk reduction across 49 hospitals (706 units) in a non-profit healthcare system.	Quantitative analysis using cross-sectional data to evaluate the association between participation in safety rounds and safety climate and patient safety risk reduction.	Units with ≥60% of caregivers reporting exposure to at least one safety round had higher safety climate, greater patient safety risk reduction, and a higher proportion of feedback on actions taken as a result of safety rounds compared with those units with <60% of caregivers reporting exposure.
Singer et al 2013	To assess the ability to refine, implement, and demonstrate the effectiveness of safety rounds in a Department of Veterans Affairs medical center by comparing 2 intervention units with 2 control units.	Interviews, observation, data-tracking forms, and pre and post surveys in intervention and control units to measure participant perceptions of the programme, operational benchmarks of effectiveness, and longitudinal change in safety climate.	Implementation showed fidelity to programme design, identification and resolution of issues. Senior managers' attitudes toward safety rounds were more positive than those of frontline staff, whose attitudes were mixed. Perceptions of safety climate deteriorated during the study period in the implementation units relative to controls.
Taylor et al 2013	To describe the safety rounds programme at The Children's Hospital of Philadelphia implemented in 6 pilot units.	Descriptive, case study.	The process of safety rounds was customised in each unit. In the first year, safety rounds engaged 149 individuals through 34 safety rounds. Safety rounds identified safety concerns that leaders considered previously unidentified, including predominantly nurse-medical team relationships, workflow flaws, equipment defects, staff education, and medication safety.
Chua and Luna 2014	To examine the impact of a brief safety rounds programme on safety climate in the operating rooms of two tertiary care hospitals under St Luke's Medical Center administration in Quezon City, Philippines.	Pre and postintervention surveys of OR staff nurses in both hospitals.	After a one-month interval, safety climate improved in the intervention hospital (albeit no more so for those exposed to the intervention than those who were not exposed) relative to the control hospital.
Lim et al 2014	To evaluate the effectiveness of a safety rounds programme in improving the patient safety culture in Tan Tock Seng Hospital, Singapore.	Mixed methods: including evaluation of documents, protocols, meeting minutes, Post-test surveys, action plans and verbal feedback over 7 years.	321 issues were identified during the study period, of which 308 (96.0%) issues had been resolved. Issues related to work environment were most common (45.2%); 72.9% of issues identified were not identified through other conventional methods of error detection. Most survey participants reported increased awareness of patient safety (94.8%) and comfort in openly and honestly discussing patient safety issues (90.2%).
Marck et al 2014	To explore perceptions of safety and quality in one haemodialysis unit using participatory photographic research methods.	Qualitative: Practitioners conducted a safety round to obtain photographs of patient care unit and nurses' stories (photo narration) about safety and quality issues identified through an initial focus group. Applied iterative coding, then used photos to elicit more input about themes in a second focus group with additional staff.	The major themes identified related to clutter, infection control, unit design, chemicals and air quality, lack of storage space, and health and safety hazards. The visual methods engaged researchers and unit nurses in rich dialogue about safety in this complex environment, and provides an ongoing basis for monitoring and enhancing safety.
Martin et al 2014	To explore how safety rounds are used in practice in multiple facilities participating in the English NHS, and to identify variations in implementation that might mediate their impact on safety and culture.	Qualitative: interviews (82 individuals); analysis using constant comparative method.	Modification and expansion of safety rounds to increase the scope of knowledge produced increased the value that executives drew from them, but replaced the objectives of identifying specific, actionable knowledge about safety issues and a more positive safety culture and relationship between senior managers and frontline staff with a form of surveillance that alienated frontline staff and produced fallible insights.
Profit et al 2014	To examine the relationship between safety rounds, caregiver assessments of patient safety culture, and healthcare worker burnout in 44 neonatal intensive care units.	Quantitative: cross-sectional survey evaluating the association between receiving feedback about actions taken as a result of safety rounds and healthcare worker assessments of patient safety culture at an individual level.	With 63% survey response, more safety round feedback was associated with better safety culture results, and lower burnout rates in the NICUs. Participation in safety rounds and receiving feedback about safety rounds were less common in NICUs than in a benchmarking comparison of adult clinical areas.
Rotteau et al 2014	To explore views and experiences of safety rounds in two major teaching hospitals with mature safety rounds programmes.	Qualitative: interviews with 11 senior leaders and 33 frontline staff, collected as part of a larger mixed-methods evaluation.	Senior leaders regarded executive visibility as an end in itself, and generally did not engage with staff concerns beyond the safety rounds encounter. Some senior leaders believed they understood patient safety issues better than frontline staff and even characterised staff concerns as 'stupid'. Senior leaders acknowledged that they often controlled the conversations, delimiting what counted as patient safety problems, and steered conversations to predetermined topics.
Tucker and Singer 2014	To rigorously examine the impact of safety rounds on organisational outcomes.	Mixed methods. Randomised controlled trial involving 20 intervention hospitals and 56 work areas; quantitative analysis examining problem resolution and problem-solving approach and qualitative analysis of interviews and observations to explore negative results.	After 18 months, on average, safety rounds had a negative impact on performance. Prioritising easy-to-solve problems was associated with improved performance, likely because it resulted in greater action-taking. Prioritising high-value problems was not successful. Assigning to senior managers responsibility for ensuring that identified problems get resolved also resulted in better performance.