Table 1

Current challenges to improving patient safety*

Health systemFiscal 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 disparitiesHard 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 metricsMetrics often lack validity and fail to guide improvement
Superficial approaches to thorny problemsMany problems reflect complex interplays of deeply rooted processes and pressures36 37
Expecting local solutions to unsolved safety problemsExisting evidence often furnishes no clear solutions for common problems, yet we expect institutions to analyse reported incidents and develop prevention strategies
Inaction on better staffingCompelling 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 issuesMinimal progress in applying human factors engineering to medical devices at either design or procurement stages
Settings of carePersistence of fear and blame cultureRemoving blame and fear is fundamental, yet still largely absent when staff are surveyed
Improvement efforts consumed by measurementResources focused/exhausted by perpetual surveillance, effort to collect data, rather than cycles of measurement and improvement
Overlooking qualitative inquiryDisproportionate emphasis on numbers rather than richer understanding afforded by qualitative data and analysis
Electronic health recordsDisappointing 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 failuresPoor 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
StaffShortages of nurses, primary care and other essential workersPre-existing shortages substantially worsened by increased departures during pandemic
Lack of time and supportFor both doing clinical jobs and improvement work
BurnoutBurnout, demoralisation, and change fatigue are already issues pre-pandemic and even more so during/after
Little authentic interest in input from frontline staff or patientsSome 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 patientsBoundaries 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.