BACKGROUND: Perioperative patient safety aims to minimize risk and reduce adverse events throughout the surgical journey. Despite investments in national and international initiatives, sustaining these efforts remains a challenge. Contextual factors such as national policies and legal requirements play a key role in ensuring long-term success. This qualitative study examines the national patient safety policies and frameworks in five European countries and investigates contextual factors to understand how these policies may affect the implementation and sustainability of perioperative patient safety initiatives. METHODS: Semi-structured interviews were conducted with decision-makers from Ministries of Health, regulatory or accreditation bodies, professional medical or scientific societies, managerial hospital staff, and academic patient safety experts from Spain, the Netherlands, Portugal, Estonia, and the Czech Republic. A desktop search for relevant policy and regulatory frameworks around perioperative patient safety informed the development of the semi-structured interview guide. Generated data were coded using an a priori framework adapted from the updated Consolidated Framework for Implementation Research (CFIR) and a framework for assessing health systems' quality improvement and patient safety initiatives. Using content analysis, codes were thematically analysed to delineate and compare the perioperative patient safety landscapes of the five countries. RESULTS: In total, 28 high-level decision-makers were interviewed. Based on the insight from interviewees, a patient safety policy profile was generated for each of the five countries, capturing the key features of their frameworks and strategies. While all countries have developed policies to improve patient safety, the scope and structure of these frameworks vary widely. Some countries have established centralized systems with detailed national action plans and robust oversight mechanisms, whereas others rely on more fragmented approaches with responsibilities distributed across various organizations. Common challenges identified include the inconsistent integration of patient safety education into medical curricula and cultural barriers, such as a fear of blame that affects reporting practices. Interviewees provided several propositions how project-based patient safety initiatives could be embedded in national contexts. These propositions differed considerably between countries. CONCLUSION: This study highlights the diverse and evolving nature of patient safety policy landscapes across five European countries. The varying scope, structure, and implementation of patient safety frameworks emphasize the need for context-specific approaches to promote the sustainability of perioperative patient safety initiatives. As the field continues to advance, it is important to tailor approaches that aim to sustain patient safety initiatives.

Avedis Donabedian Research Institute Barcelona Spain

Departamento de Cirugía Universidad Rey Juan Carlos Alcorcon Spain

Department of Internal Medicine Institute of Clinical Medicine University of Tartu Tartu Estonia

Department of Public Health 3rd Faculty of Medicine Charles University Prague Czech Republic

Department Research and Innovation OptiMedis AG Hamburg Germany

Faculty of Management Economics and Society University of Witten Herdecke Witten Germany

Network for Research on Chronicity Primary Care and Health Promotion Madrid Spain

NOVA National School of Public Health Public Health Research Centre Comprehensive Health Research Centre CHRC Universidade Nova de Lisboa Lisbon Portugal

OECD ELS Health Division Organization for Economic Cooperation and Development Paris France

Sistema de Notificación en Seguridad en Anestesia y Reanimación Alcordon Spain

Spojená Akreditační Komise Praha 6 Czech Republic

Unidad de Anestesia y Reanimación Hospital Universitario Fundación Alcorcón Alcorcon Spain

Universitat Autònoma de Barcelona Barcelona Spain

University of Toronto Institute of Health Policy Management and Evaluation Canada

Zobrazit více v PubMed

Bates DW, Levine DM, Salmasian H  et al.  The safety of inpatient health care. N Engl J Med  2023;388:142–53. PubMed

Sousa P, Paiva SG, Lobão MJ  et al.  Contributions to the Portuguese national plan for patient safety 2021–2026: a robust methodology based on the mixed-method approach. Port J Public Health  2022;39:175–92. PubMed PMC

WHO Patient Safety, World Health Organization. Implementation manual WHO surgical safety checklist 2009 : safe surgery saves lives. https://www.who.int/publications/i/item/9789241598590, Geneva: 2009, ISBN 978 92 4 159859 0

Newport M, Smith AF, Lewis SR.  An arrow pointing somewhere: qualitative study of the Helsinki declaration on patient safety and its role in European anaesthesiology. Eur J Anaesthesiol  2020;37:1–4. PubMed

Arnal-Velasco D, Martinez-Nicolas I, Fabregas N  et al. ; SAFEST Advisory Group. Multidisciplinary, evidence-based, patient-centred perioperative patient safety recommendations: a European consensus study. Br J Anaesth  2025;135:723–36. 10.1016/j.bja.2025.04.047 PubMed DOI

Valli C, Schäfer WLA, Bañeres J  et al. ; SAFEST Consortium. Improving quality and patient safety in surgical care through standardisation and harmonisation of perioperative care (SAFEST project): A research protocol for a mixed methods study. PLoS One  2024;19:e0304159. PubMed PMC

Wiltsey Stirman S, Kimberly J, Cook N  et al.  The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement Sci  2012;7:17. PubMed PMC

Lennox L, Maher L, Reed J.  Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare. Implement Sci  2018;13:27. PubMed PMC

Damschroder LJ, Reardon CM, Widerquist MAO  et al.  The updated consolidated framework for implementation research based on user feedback. Implement Sci  2022;17:75. PubMed PMC

Ament SMC, Gillissen F, Moser A  et al.  Factors associated with sustainability of 2 quality improvement programs after achieving early implementation success. A qualitative case study. J Eval Clin Pract  2017;23:1135–43. PubMed

Parand A, Benn J, Burnett S  et al.  Strategies for sustaining a quality improvement collaborative and its patient safety gains. Int J Qual Health Care  2012;24:380–90. PubMed

WHO Regional Office for Europe. Taking the Pulse of Quality of Care and Patient Safety in the WHO European Region: Multidimensional Analysis and Future Prospects. Copenhagen: WHO Regional Office for Europe, 2024.

Allen P, Pilar M, Walsh-Bailey C  et al.  Quantitative measures of health policy implementation determinants and outcomes: a systematic review. Implement Sci  2020;15:47. PubMed PMC

El-Jardali F, Fadlallah R.  A review of national policies and strategies to improve quality of health care and patient safety: a case study from Lebanon and Jordan. BMC Health Serv Res  2017;17:568. PubMed PMC

Auraaen A, Saar K, Klazinga N.  System Governance towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. OECD, 2020.

Bryndová L, Šlegerová L, Votápková J  et al. eds. Czechia: Health System Review. Copenhagen Ø, Denmark: WHO Regional Office for Europe, 2023. PubMed

Kroneman M, Boerma W, van den Berg M, et al.  The Netherlands: Health System Review. Copenhagen: World Health Organization, 2016.

Kasekamp K, Habicht T, Võrk A, et al.  Estonia: Health System Review. Copenhagen Ø, Denmark: WHO Regional Office for Europe, 2023.

de Almeida Simões J, Figueiredo Augusto G, Fronteira I, et al.  Portugal: Health System Review. Copenhagen: World Health Organization, 2017. PubMed

Bernal-Delgado E, García-Armesto S, Oliva J, et al.  Spain: Health System Review. Copenhagen: World Health Organization, 2018.

Kuckartz U.  Qualitative Text Analysis: A Guide to Methods, Practice & Using Software. London, United Kingdom: SAGE Publications Ltd, 2014.

VERBI–Software. MAXQDA. 2020.

Spencer E, Walshe K.  National quality improvement policies and strategies in European healthcare systems. Qual Saf Health Care  2009;18: i22–7. PubMed PMC

Macrae C.  The problem with incident reporting. BMJ Qual Saf  2016;25:71–5. PubMed

de Bienassis K, Klazinga N.  Comparative Assessment of Patient Safety Culture Performance in OECD Countries. Paris: OECD Publishing, 2024.

Sánchez-García A, Saurín-Morán PJ, Carrillo I  et al.  Patient safety topics, especially the second victim phenomenon, are neglected in undergraduate medical and nursing curricula in Europe: an online observational study. BMC Nurs  2023;22:283. PubMed PMC

OECD/European Commission. Health at a Glance: Europe 2024: State of Health in the EU Cycle. 2024.

Dall’Ora C, Saville C, Rubbo B  et al.  Nurse staffing levels and patient outcomes: a systematic review of longitudinal studies. Int J Nurs Stud  2022;134:104311. PubMed

Keel G, Savage C, Rafiq M  et al.  Time-driven activity-based costing in health care: a systematic review of the literature. Health Policy  2017;121:755–63. PubMed