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Leadership, safety culture and patient safety in hospitals: in search of evidence


At least since the publication of “To Err is Human” in the year 2000 we all know that hospitals could be safer than they are [1]. In the meantime the knowledge about patient safety and evidence based safety practices grew substantially but too often these practices do not reach the patients [2]. Evidence based medicine, nursing and therapy are advancing but the implementation gap seems also to be growing [3]. Are evidence based leadership and an appropriate safety culture the solution to this implementation gap since “more than enough evidence exists to prompt decisive action” [4]? Do we suffer blind spots on the roles of leadership and safety culture? The first objective of this study was to review theories, models and empirical evidence of the functions, roles and interdependences of leadership practices, safety cultures and patient safety outcomes in hospitals. Secondly, empirical studies will be conducted to test and validate the framework.

Materials and methods

Various databases and gray literature have been searched and the selected publications systematically reviewed. A framework for evidence based leadership has been developed as well as discussed with and validated by patient safety experts and organizational scientists.


The theoretical model derived from the literature and the workshops shows the respective influences and interdependences between leadership practices, safety cultures and patient safety outcomes. A framework for evidence based leadership has been developed.


The model seems to be functional as a framework for empirical studies to analyse the influences and interdependences between local leadership practices, safety cultures and patient safety outcomes.


  1. To Err is Human: Building a Safer Health System. Edited by: Kohn L et al. 2000, Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine: National Academy Press

  2. Shekelle PG, et al: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Comparative Effectiveness Review No. 211. 2013, Rockville, MD: Agency for Healthcare Research and Quality, (Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No, 290-2007-10062-I.) AHRQ Publication No. 13-E001-EF, []

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  3. IOM (Institute of Medicine): Redesigning the Clinical Effectiveness Research Paradigm: Innovation and Practice-Based Approaches: Workshop Summary. 2010, Washington, DC: The National Academies Press

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  4. Wachter RM, et al: Strategies to Improve Patient Safety: The Evidence Base Matures. Ann Intern Med. 2013, 158: 350-352. 10.7326/0003-4819-158-5-201303050-00010.

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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Kessler, O. Leadership, safety culture and patient safety in hospitals: in search of evidence. BMC Health Serv Res 14 (Suppl 2), P64 (2014).

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