title: A quest for patient-safe culture: contextual influences on patient safety performance.
abstract: OBJECTIVE
  To use organizational change theory to explore the interplay of contextual influences on patient safety.
  
  
  METHODS
  A multi-level comparative case study of eight National Health Service (NHS) acute hospital trusts in England, including 144 depth interviews with senior managers, staff involved with risk analysis and reporting, middle managers, and senior and junior clinicians, supplemented with documentary data and observation of nine meetings. Organizational change theory was used to identify content, contextual and process influences on patient safety.
  
  
  RESULTS
  Organizational stability and staff engagement appeared to influence patient safety and specific contextual factors appeared to influence both organizational stability and staff engagement, both of which were important for patient safety. These contextual factors comprised: environmental shocks; cultural characteristics; processes and structures supportive of patient safety; and trust leadership style. A model is suggested that analyses the trusts in terms of these factors and then groups them into four trust types.
  
  
  CONCLUSIONS
  The study highlights the massive and unpredictable impact of both internal and external environmental shocks and how they destabilize trusts distracting attention from patient safety. It also underlines the importance of regular self-assessment of internal and external risks and awareness of context.
authors: Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, UK. k.charles@abdn.ac.uk
authors: Kathryn
authors: K
authors: Charles
authors: Lorna
authors: L
authors: McKee
authors: Sharon
authors: S
authors: McCann
mesh_terms: D004739:England; D006779:Hospitals, Public / Q000458:organization & administration*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D055361:Multilevel Analysis; D019982:Organizational Case Studies; D015279:Organizational Culture; D009936:Organizational Innovation; D036301:Qualitative Research; D011785:Quality Assurance, Health Care; D017751:Safety Management / Q000458:organization & administration*; D013222:State Medicine