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Tell me about the context, and more
  1. David P Stevens1,
  2. Kaveh G Shojania2,3
  1. 1Center for Leadership and Improvement, Dartmouth Institute for Health Policy and Clinical Care, Lebanon, New Hampshire, USA
  2. 2University of Toronto Centre for Patient Safety, Toronto, Ontario, Canada
  3. 3Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  1. Correspondence to Dr David P Stevens, Adjunct Professor, Dartmouth Institute for Health Policy and Clinical Care, 30 Lafayette Street, Lebanon, NH 03766, USA; david.p.stevens{at}

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The scholarly publication of patient safety initiatives must contribute more to accelerating reliable, safe patient care. Reports of safety initiatives generally describe specific safety practices and the resulting clinical outcomes. So why is progress so slow to make patients safer?1–3 Do the reported safety practices in such reports in fact lack convincing and plausible supporting evidence?4 Or, do the patient safety practices work, but require more explicit attention to implementation strategies?

We suggest “Yes”—to both questions. Moreover, context lies at the heart of the answers to both. The lack of useful focus on context has led to heterogeneity in both evaluation of effective patient safety practices and successful implementation strategies.5–7

In this issue of BMJ Quality & Safety, three papers report a project led by researchers from RAND with a national team of US researchers and international group of technical advisors that investigated the role of context in scholarly patient safety reports.8–10 Together with an earlier paper from the same group,7 they found that few reports actually define context in sufficient detail to offer strategies for replication. They report that most publications omit any empirical assessment of the impact of context on implementation of safety practices.10 They also provide an extensive list of specific contextual elements relevant to patient safety interventions and a typology for organising them.8 9

Towards a useful definition of context

The shortest definition of context is everything that is not the intervention itself.10 11 In conventional clinical research, this distinction is simple. For example, a medication under study constitutes the intervention. Clinic staff that educate patients about the medication and other infrastructure that enables patients to adhere to their treatment represent elements of context. Quality improvement scholars would agree these elements of context have the makings of a worthwhile intervention. In fact, case …

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