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BMJ Qual Saf doi:10.1136/bmjqs-2011-000582 Systematic review Strategies for improving patient safety culture in hospitals: a systematic review Renata Teresa Morello1, Judy A Lowthian1, Anna Lucia Barker1, Rosemary McGinnes1, David Dunt2, Caroline Brand1 1Centre of Research Excellence in Patient Safety, Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia 2Centre for Health Policy, Programs and Economics, Melbourne School of Population Health, University of Melbourne, Victoria, Australia Correspondence to Renata Teresa Morello, Centre of Research Excellence in Patient Safety (CRE-PS), School of Public Health and Preventive Medicine, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia; renata.morello{at}monash.edu Contributors RM: primary reviewer of included studies (data extraction and critical appraisal), drafting and finalisation of manuscript. JL: secondary reviewer of included studies (data extraction and critical appraisal) and revision of manuscript. AB: third reviewer and review of critical appraisal of studies, revision of the manuscript and finalisation of the discussion section of the manuscript. RMc: assisted with data extraction and critical appraisal of included studies and revision of the manuscript. DD: review and revision of the manuscript, in particular the introduction and methods sections. CB: overseeing the drafting and finalisation of the manuscript, with particular focus on the introduction and discussion sections. Accepted 4 July 2012 Published Online First 31 July 2012 Abstract Purpose To determine the effectiveness of patient safety culture strategies to improve hospital patient safety climate. Data sources Electronic search of the Cochrane Library, OVID Medline, Embase, CINAHL, proQuest and psychinfo databases, with manual searches of quality and safety websites, bibliographies of included articles and key journals. Study selection English language studies published between January 1996 and April 2011 that measured the effectiveness of patient safety culture strategies using a quantitative measure of patient safety climate in a hospital setting. Studies included were randomised controlled trials (RCTs), non-RCTs, controlled before and after studies, interrupted time series and historically controlled studies. Data extraction Data extraction and critical appraisal were conducted by two independent reviewers. Study design, intervention, level of application, setting, study participants, safety climate outcome measures and implementation lessons were extracted from each article. Results of data synthesis Over 2000 articles were screened, with 21 studies meeting the inclusion criteria, one cluster RCT, seven controlled before and after studies, and 13 historically controlled studies. There was marked methodological heterogeneity amongst studies. Impacts of 11 different strategies were reported. There was some evidence to support that leadership walk rounds (p=0.02) and multi-faceted unit-based programmes (p? Conclusions Despite strong face validity for a variety of patient safety culture strategies, there is limited evidence to support definitive impacts on patient safety climate outcomes. Organisations are advised to consider robust evaluation designs when implementing these potentially resource intensive strategies. Safety culture Patient safety Quality improvement Health services research Footnotes Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Data extraction and critical appraisal of included studies are available on request from the corresponding author. 
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OPEN ACCESS Mary Dixon-Woods, Sarah McNicol, Graham Martin Social Science Applied to Healthcare Improvement Research Group, Department of Health Sciences, School of Medicine, University of Leicester, Leicester, UK Correspondence to Professor Mary Dixon-Woods, Social Science Applied to Healthcare Improvement Research Group, Department of Health Sciences, School of Medicine, University of Leicester, 2nd Floor, Adrian Building, University Road, Leicester LE1 7RH, UK; md11{at}le.ac.uk Contributors MDW and GM designed the study, reviewed the evaluation reports, identified relevant literature and led on writing of the article. SM reviewed the evaluation reports, prepared summaries of the reports, coded the findings of the reports, contributed substantially to writing and redrafting and helped in managing the project. Accepted 20 February 2012 Published Online First 28 April 2012 Abstract Background Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature. Methods The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken. Results The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges. Discussion Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them. Adverse events epidemiology and detection qualitative research culture quality of care medical error Footnotes Funding The Health Foundation funded this review. Competing interests None. Patient consent Not applicable. Provenance and peer review Not commissioned; internally peer reviewed. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/3.0/ and http://creativecommons.org/licenses/by-nc/3.0/legalcode