Why safety recommendations don’t (always) work: understanding the problems and exploring some solutions (June 2025)

Summary

The paper from Carl Macrae explores why safety recommendations in healthcare often fail to produce meaningful or sustained safety improvements. It identifies common problems in how recommendations are created, used, and managed, and proposes principles to improve their effectiveness.

Content

Eight problems with safety recommendations

1. The Abundance Problem If safety recommendations are produced in large quantities and from many different sources, they can overwhelm recipients’ capacity to respond constructively and effectively.
2. The Rigour Problem If safety recommendations are based on weak evidence and superficial, unsystematic or flawed analysis, they can misdirect improvement effort and attention to inconsequential issues.
3. The Specificity Problem If safety recommendations make proposals that are under-specified and do not precisely articulate risks to be addressed, or are over-specified and target localised minutiae, they can cause scattered or myopic improvement efforts.
4. The Integration Problem If safety recommendations are developed in isolation and without regard to connections with other recommendations, safety issues or ongoing work, they can deter or distract from systemic improvement activity.
5. The Improvement Problem If safety recommendations present definitive solutions or corrective actions, they can preclude recipients from engaging in the collaborative, exploratory and locally adaptive work of learning.
6. The Management Problem If safety recommendations are used as a tool for directing and managing action, they can degrade or marginalise local management capabilities and impede development of robust safety infrastructure.
7. The Compliance Problem If safety recommendations issue mandatory or directive instructions, they can generate superficial compliance-oriented behaviour and box-ticking responses without addressing underlying risks.
8. The Accountability Problem If safety recommendations are not supported by robust processes for allocating and monitoring accountabilities for improvement, they can dilute responsibility for effecting material change. 

Eight guiding principles

1. Strategic Prioritisation: Recommendations are strategically selected and prioritised to target the most compelling and important risks. Careful consideration is given to any ongoing safety improvement activities, existing guidance or prior recommendations. Recommendations are prepared in a form that is actionable and accounts for recipients’ capacity and capabilities.
2. Analytical Rigour: Recommendations are based on robust evidence and grounded in systematic investigation and analysis. Recommendations target meaningful risks and propose credible routes to safety improvement. The evidentiary basis and logic underlying specific recommendations can be clearly explained.
3. Calibrated Specificity: Recommendations clearly articulate and describe the specific safety risks that are being targeted and which the recommendation seeks to address. The level of detail provided by recommendations is appropriate to the form and scale of action expected to be taken.
4. Systemic Integration: Recommendations account for existing safety improvement activities and any related or planned recommendations. System-level safety priorities are considered with reference to activities of other bodies and organisations. Recommendations are aligned to, or integrated with, those from other organisations to support systemic improvement.
5. Enabling Improvement: Recommendations encourage rigorous reflection and analysis and enable adaptive learning. Recipients are encouraged to rigorously explore, understand and address the risks targeted by recommendations. Safety innovation and collaborative learning are supported.
6. Capability Enhancement: Recommendations build and enhance local safety management and governance processes. Recommendations are designed to support and strengthen the safety governance capabilities and capacity of recipients, developing safety competencies.
7. Meaningful Engagement: Recommendations aim to generate genuine engagement with the challenge of addressing the safety risks being targeted. Thoughtful, reflective, rigorous and locally adaptive responses are supported and encouraged. Opportunities for narrow or superficial compliance are minimised.
8. Active Accountability: Recommendations assign clear responsibilities for monitoring implementation and achieving safety improvement. Recommendations are monitored and managed through robust and transparent processes for tracking progress and meaningful change and safety improvement.