ArticleFrontiers in health services2025
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.
Article in Frontiers in health services, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 5 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
5 citing papers in PubMed.
- The impact of the second victim phenomenon on nurse turnover intentions and absenteeism: a systematic review and meta-analysis.BMC nursing · 2026Article
- Fine-tuning and evaluating large language models for patient safety tasks: classification of contributing factors in incident reports.Journal of the American Medical Informatics Association : JAMIA · 2026Article
- Assessing the quality of patient safety incident investigation reports.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2026Article
- Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations.BMJ quality & safety · 2026Article
- What Do Consumers Need Before, During and After a Patient Safety Incident Review? A Qualitative Study.Health expectations : an international journal of public participation in health care and health policy · 2026Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
8 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
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 ( 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.
Indexed as
Identifiers
What Socratic holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the Socratic graph.