• health policy
• healthcare quality improvement
• health professions education

The ability to spot services at risk of becoming unsafe, in order to address the underpinning causes and avoid the sorts of failures seen in Mid Staffordshire,1 Walter Reed2 or King Edward3 has become an increasing preoccupation of health systems in the developed world. In this issue, Nowotny and colleagues contribute to the emerging knowledge in this area with their retrospective study of which routinely available data may have given early warning of a service failure in a maternity service in Victoria, Australia.4

To date, most national approaches to using routine data to identify poor quality have concentrated on posthoc analyses of sentinel poor outcomes—typically clusters of deaths from similar diagnoses within hospitals and units.5 6 Done well, with appropriate statistical sophistication, this can allow relatively quick identification of emerging problems. Indeed, the Mid Staffordshire case was first spotted using precisely this approach.7

The approach adopted by Nowotny and colleagues moves one step beyond the monitoring of sentinel outcomes, triangulating a range of data pointing in the same direction and identifying which have predictive power in this case. They note that rapidly increasing clinical activity (or pressure on services) was associated with safety failure. This is worrying in the current environment. Even in many countries that appear to have gained control of the COVID-19 pandemic, a ‘backlog’ of patients who did not access services at the height of the pandemic has occurred. At the same time as this likely increase in demand, the need to keep a ‘corridor’ for patients with COVID-19 separated from others further reduces supply. Increased pressure on services is a likely fact of life in nearly all health systems over the …