Psychological safety and patient safety: A systematic and narrative review (24 April 2025)

Summary

Various psychological concepts have been proposed over time as potential solutions to improving patient safety and quality of care. Psychological safety has been identified as a crucial mechanism of learning and development, and one that can facilitate optimal patient safety in healthcare. This study investigated the quantitative evidence on the relationship between psychological safety and objective patient safety outcomes.

Content

The authors searched 8 databases and conducted manual scoping to identify peer reviewed quantitative studies published up to February 2024. Nine papers were selected for inclusion which reported on heterogeneous patient safety outcomes. Five studies showed a significant relationship between psychological safety and patient safety outcomes (e.g., ventilator associated events, reported medical errors). The majority of studies reported on the experiences of nurses working in healthcare from the USA. Patient safety is consistently characterised as the absence of harm rather than a culture that creates a safe environment.

The findings of the review imply a contradiction in patient safety practices: enhancing team dynamics through patient safety culture may improve immediate problem-solving within the team, but it does not automatically translate into improved objective patient safety measures.

The simplest and initial point to accept is that we simply don’t have enough research yet to establish a link between patient safety and objective measures of patient safety. Absence of evidence is not evidence of absence. However, that caveat should not prevent us from discussing the potential factors influencing the relationship. For example, a line manager may espouse the importance of safety procedures while they fail to enact, enforce, and support the same safety procedures through their actions via monitoring and allocation of time and resources. As a result, employees may experience a double bind between these seemingly conflicting behaviours: “…when employees adhere to a norm that says, 'hide errors,' they know they are violating another norm that says, 'reveal errors'. ”The employees are thus in a double bind.

Ultimately, we are left with a paradox regarding patient safety in healthcare teams. Reporting patient safety problems in a team can be both an indication of high and low levels of patient safety. It’s difficult to know which without understanding the culture and history of the specific healthcare organisation, as patient safety primarily impacts emotions and attitudes rather than patient safety metrics.