Decades of failure to prevent harm to patients—where are we going wrong? A mixed methods study of the perspectives of health services staff across Australia and internationally

Mia Bierbaum; Yinghua Yu; Charlotte J. Molloy; Lorelle Bowditch; Paul M. Salmon; Sandy Middleton; Jeffrey Braithwaite; Peter Hibbert

doi:10.3389/frhs.2025.1645575

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Decades of failure to prevent harm to patients—where are we going wrong? A mixed methods study of the perspectives of health services staff across Australia and internationally

Journal article

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Peer reviewed

Decades of failure to prevent harm to patients—where are we going wrong? A mixed methods study of the perspectives of health services staff across Australia and internationally

Mia Bierbaum, Yinghua Yu, Charlotte J. Molloy, Lorelle Bowditch, Paul M. Salmon, Sandy Middleton, Jeffrey Braithwaite and Peter Hibbert

Frontiers in Health Services, Vol.5, pp.1-26

2025

DOI: https://doi.org/10.3389/frhs.2025.1645575

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Abstract

patient safety

hospital incident reporting

risk management

hospitals

medical errors

incident review

human factors

adverse events

Context: Patient Safety Incident (PSI) reviews are undertaken frequently across health services in response to serious adverse events. This study investigated experiences and perceptions of healthcare professionals involved in incident review processes across four jurisdictions in Australia, alongside insights from international patient safety experts. These findings will inform the co-design of improvements to PSI reviews. Methods: Semi-structured interviews and focus groups were conducted, and participants completed an attitudinal and demographic survey. Inductive thematic analysis was conducted, and findings were deductively mapped against the Consolidated Framework for Implementation Research. Findings: Australian (n = 99) and international (n = 11) participants took part in one of 25 focus groups (n = 78) or 32 interviews. Most participants (n = 99) completed the survey. Nearly all survey participants agreed/strongly agreed that PSI reviews are valuable for improving patient safety (95%), particularly when human factors and contextual influences on performance (76%) are considered. Two-thirds of participants agreed that investigations help prevent PSI recurrence (68%), avoid unfair blame (67%), and support continuous improvement (61%). However, fewer participants felt recommendations are consistently accepted by organisations (58%) or are appropriately targeted within the healthcare system (57%). Key strengths and challenges of the PSI review process were identified across three themes: Selection of PSI Reviews; Reviews, Recommendations and Implementation; and Health Organisations and Wider System Influences. Key PSI review challenges included: limited capacity and engagement, high staff workloads, turnover, and burnout, as well as variable skills, and limited human factors and systems thinking experience across review teams. Despite strong efforts to reduce a punitive culture, resistance to reporting and blame persists across some hospitals. Participants highlighted a learned powerlessness when developing systems thinking-based recommendations, resulting in the development of weaker, less resource intensive recommendations. Limited sharing of learnings and feedback on review findings, and variable monitoring, evaluation and accountability of recommendation implementation were also common challenges. Conclusions: These findings have identified a need for system re-engineering of PSI reviews to address identified challenges and will inform the development of Best Practice Principles and a codesign of patient safety tactics for trial in-situ.

Details

Title: Decades of failure to prevent harm to patients—where are we going wrong? A mixed methods study of the perspectives of health services staff across Australia and internationally
Authors: Mia Bierbaum - Macquarie University
Yinghua Yu - Macquarie University
Charlotte J. Molloy - Macquarie University
Lorelle Bowditch - Macquarie University
Paul M. Salmon - University of the Sunshine Coast, Queensland, Centre for Human Factors and Systems Science
Sandy Middleton - Australian Catholic University
Jeffrey Braithwaite - Macquarie University
Peter Hibbert (Corresponding Author) - Macquarie University
Publication details: Frontiers in Health Services, Vol.5, pp.1-26
Publisher: Frontiers Research Foundation
Date published: 2025
DOI: 10.3389/frhs.2025.1645575
ISSN: 2813-0146
Copyright note: © 2025 Bierbaum, Yu, Molloy, Bowditch, Salmon, Middleton, Braithwaite and Hibbert. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Data Availability: The datasets presented in this article are not readily available because the data supporting the conclusions made in this paper may be available on request from the corresponding author subject to ethics and confidentiality requirements. Requests to access the datasets should be directed to Peter Hibbertpeter.hibbert@mq.edu.au.
Grant note: This includes funding from the following partners: NSW Clinical Excellence Commission, Clinical Excellence QLD, Safer Care Victoria and ACT Health.
Organisation Unit: Centre for Human Factors and Systems Science
Language: English
Record Identifier: 991156025402621
Output Type: Journal article

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