Table 1

Current challenges to improving patient safety*

Health system	Fiscal constraints	‘Business case for safety’ not straightforward, and financial losses and care backlogs due to pandemic will make safety even harder to prioritise
	Competing priorities to improve equity and reduce health disparities	Hard to justify investing in marginal reductions in harms in face of massive disparities in life expectancy and other basic health outcomes across socioeconomic groups—disparities highlighted and exacerbated by pandemic
	Misguided metrics	Metrics often lack validity and fail to guide improvement
	Superficial approaches to thorny problems	Many problems reflect complex interplays of deeply rooted processes and pressures36 37
	Expecting local solutions to unsolved safety problems	Existing evidence often furnishes no clear solutions for common problems, yet we expect institutions to analyse reported incidents and develop prevention strategies
	Inaction on better staffing	Compelling evidence for improved nurse staffing ratios and pharmacists in clinical settings rarely acted on. Leaves onus on frontline staff and safety personnel to reduce harms while staffing shortfalls persist
	Equipment design issues	Minimal progress in applying human factors engineering to medical devices at either design or procurement stages
Settings of care	Persistence of fear and blame culture	Removing blame and fear is fundamental, yet still largely absent when staff are surveyed
	Improvement efforts consumed by measurement	Resources focused/exhausted by perpetual surveillance, effort to collect data, rather than cycles of measurement and improvement
	Overlooking qualitative inquiry	Disproportionate emphasis on numbers rather than richer understanding afforded by qualitative data and analysis
	Electronic health records	Disappointing benefits from computerised alerts and more complex decision support; resulting alert fatigue High institutional hurdles to improve existing systems, especially commercial ones Clinical documentation issues and related challenges in performing manual chart reviews38
	Loop-closing failures	Poor infrastructures, processes, and inattention to closing loops to reliably track tests results, referrals, symptoms
	Relative neglect of cross-cutting interventions (eg, teamwork, culture)	Effective interventions39 not disseminated because perceived as too intensive; effects on patient outcomes also harder to capture,40 so focus mostly on simpler, more marginal process improvements
	Problems in isolation	‘Whack-a-mole’ approach to numerous specific safety problems becomes exhausting and has borne little fruit25
Staff	Shortages of nurses, primary care and other essential workers	Pre-existing shortages substantially worsened by increased departures during pandemic
	Lack of time and support	For both doing clinical jobs and improvement work
	Burnout	Burnout, demoralisation, and change fatigue are already issues pre-pandemic and even more so during/after
	Little authentic interest in input from frontline staff or patients	Some organisational leaders may truly appreciate input from frontlines but feel constrained by resources to do anything other than manage dialogue and appearance of action
	Detachment from patients	Boundaries and barriers that keep patients and staff apart rather than more deeply and personally connecting and collaborating41 42

Table 1 lists some of the major challenges to progress in patient safety, organised into categories for the health system, the settings in which care occurs (hospitals, clinics, care homes, etc) and the staff who work in these settings. These challenges provide an agenda for where to direct quality and safety efforts in the future.
*Original table created by authors.