Applying a systems lens to understand patient safety effectiveness in low-and-middle-income countries.

Ensuring patient safety in low-and-middle-income countries (LMICs) requires tailored approaches that are appropriate to the unique challenges faced by health systems in LMICs. To date, the evidence on how to effectively improve patient safety in LMICs is limited and although we can infer lessons from high-income countries (HICs), there are meaningful differences between HICs and LMICs that require careful study. The study by Hall et al 1 in this issue of BMJ Quality & Safety, which used implementation science methods to study what helped or hindered the roll-out of a patient safety programme in Guatemala, is therefore a welcome addition to this evidence base.1 Based on the findings from Hall et al ,1 and the growing focus in the field of implementation science to analyse mechanisms by which implementation strategies work (or do not work), we argue that patient safety endeavours globally should consider systems-level barriers and explicitly include tailored strategies to overcome them.2 LMICs have unique contextual factors that require interventions to be adapted, rather than directly transported from HICs. Mixed-methods implementation science studies like those employed in Hall et al ’s paper1 are particularly helpful for increasing our understanding of how to translate systems thinking into real-world practice. Hall et al 1 used the Consolidated Framework for Implementation Research (CFIR)3 to identify facilitators and barriers for implementation and inform the optimisation of patient safety implementation strategies in Guatemala. They evaluated implementation determinants acting across multiple levels, including the individual, inner organisational context, and external environment which led to several insights related to the overall health system and context. The authors found that clinical staff were intrinsically motivated to provide high-quality and safe care for their patients, but often faced systems barriers of insufficient time, resources and staff to implement known evidence-based protocols. Some …