case study of health and safety

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• 14 Jul 2022
• Research & Ideas

When the Rubber Meets the Road, Most Commuters Text and Email While Driving

Laws and grim warnings have done little to deter distracted driving. Commuters routinely use their time behind the wheel to catch up on emails, says research by Raffaella Sadun, Thomaz Teodorovicz, and colleagues. What will it take to make roads safer?

• 15 Mar 2022

This Workplace Certification Made Already Safe Companies Even Safer

New research by Michael Toffel and colleagues confirms what workplace safety advocates have long claimed: Adopting OHSAS 18001 reduces worker injuries and improves a brand's image. Open for comment; 0 Comments.

• 17 Aug 2021

Can Autonomous Vehicles Drive with Common Sense?

Driverless vehicles could improve global health as much as the introduction of penicillin. But consumers won't trust the cars until they behave more like humans, argues Julian De Freitas. Open for comment; 0 Comments.

• 17 Sep 2019
• Cold Call Podcast

How a New Leader Broke Through a Culture of Accuse, Blame, and Criticize

Children’s Hospital & Clinics COO Julie Morath sets out to change the culture by instituting a policy of blameless reporting, which encourages employees to report anything that goes wrong or seems substandard, without fear of reprisal. Professor Amy Edmondson discusses getting an organization into the “High Performance Zone.” Open for comment; 0 Comments.

• 11 Jun 2019
• Working Paper Summaries

Throwing the Baby Out with the Drinking Water: Unintended Consequences of Arsenic Mitigation Efforts in Bangladesh

In this study, households that were encouraged to switch water sources to avoid arsenic exposure experienced a significant rise in infant and child mortality, likely due to diarrheal disease from exposure to unsafe alternatives. Public health interventions should carefully consider access to alternatives when engaging in mass behavior change efforts.

• 31 Jan 2019

How Wegmans Became a Leader in Improving Food Safety

Ray Goldberg discusses how the CEO of the Wegmans grocery chain faced a food safety issue and then helped the industry become more proactive. Open for comment; 0 Comments.

• 09 May 2018

A Simple Way for Restaurant Inspectors to Improve Food Safety

Basic tweaks to the schedules of food safety inspectors could prevent millions of foodborne illnesses, according to new behavioral science research by Maria Ibáñez and Michael Toffel. Open for comment; 0 Comments.

• 12 Sep 2016

What Brands Can Do to Monitor Factory Conditions of Suppliers

For better or for worse, it’s fallen to multinational corporations to police the overseas factories of suppliers in their supply chains—and perhaps make them better. Michael W. Toffel examines how. Open for comment; 0 Comments.

• 17 Jun 2016

Companies Need to Start Marketing Security to Customers

The recent tragedies in Orlando underscore that businesses and their customers seem increasingly vulnerable to harm, so why don't companies do and say more about security? The ugly truth is safety doesn't sell, says John Quelch. Open for comment; 0 Comments.

• 05 Jan 2016

The Integrity of Private Third-party Compliance Monitoring

Michael Toffel and Jodi Short examine how conflict of interest and other risks lead to inaccurate monitoring of health, labor, and environmental standards.

• 21 May 2012

OSHA Inspections: Protecting Employees or Killing Jobs?

As the federal agency responsible for enforcing workplace safety, the Occupational Safety and Health Administration is often at the center of controversy. Associate Professor Michael W. Toffel and colleague David I. Levine report surprising findings about randomized government inspections. Key concepts include: In a natural field experiment, researchers found that companies subject to random OSHA inspections showed a 9.4 percent decrease in injury rates compared with uninspected firms. The researchers found no evidence of any cost to inspected companies complying with regulations. Rather, the decrease in injuries led to a 26 percent reduction in costs from medical expenses and lost wages—translating to an average of $350,000 per company. The findings strongly indicate that OSHA regulations actually save businesses money. Closed for comment; 0 Comments.

• 24 Jan 2011

Terror at the Taj

Under terrorist attack, employees of the Taj Mahal Palace and Tower bravely stayed at their posts to help guests. A look at the hotel's customer-centered culture and value system. Open for comment; 0 Comments.

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The ROI of Safety: Making the Business Case for Safety and Health

The road to workplace safety and health regulations is long and twisty. Over the years, millions of workers have died as a result of injuries and illnesses caused by their work or workplace—caused, in fact, by employers that perceived safety as a cost center and workers as an easily replaced commodity.

In the 1968 article, “ The Economics of Safety ,”  Joseph J. Spengler  asked: “How [can] an optimal balance … be achieved between the value of varying degrees of safety and the cost of providing these degrees?” and “How [can] combinations of rewards and penalties … give rise to a degree of safety that is neither excessive nor deficient but optimal in the sense that its value and cost are in balance?” 

The prevailing attitude of the time (and earlier) was that safety—both in the workplace and consumer safety—was a resource-absorbing “product” with associated costs that didn’t necessarily outweigh the benefit of not injuring or killing employees. Injuries and fatalities were (and are) perceived by many organizations as part of the cost of doing business.

This perception stemmed, in part, from consumer safety. Companies felt it was cheaper to pay a large legal settlement than change a manufacturing process or product design.

Probably one of the most well-known safety advocacy efforts was the fight to install seat belts and other safety-related equipment in automobiles, a move fought by automotive manufacturers because of the additional manufacturing costs associated with installing seatbelts and airbags as well as redesigning popular car models to remove structural hazards.

Safety advocates took on these issues in the 1960s, 1970s and beyond, believing that the ultimate ROI of these measures was protecting lives. Meanwhile, a similar battle was being waged in the workplace.

When Safety Fails: Making Headlines 

It’s difficult to calculate the cost of events—chiefly workplace fatalities and injuries—that don’t happen. Unlike consumer safety issues, workplace injuries and deaths are often handled outside of the courtroom, by employer attorneys negotiating citations and fines with regulatory agencies and the filing of workers’ compensation claims.

Only high-profile cases with large numbers of casualties or those that have an impact on the surrounding community or environment make the news, such as the Deepwater Horizon drilling platform fire and explosion, the Bhopal methyl isocyanate gas leak and the Upper Big Branch Mine disaster.

Investigations of these tragedies often highlight issues similar to those found in consumer safety cases:

• Employers that knew about—and ignored—hazards, believing the likelihood of a major incident to be negligible or the cost of a solution to be too high in terms of resources and cost;
• Copies of reports about safety concerns ended up in someone’s bottom desk drawer;
• Deferred maintenance; and
• Pressure to meet production deadlines that superseded safety.

The Financial Cost of Injuries

Not all workplace injury and illness cases or fatalities make headlines—in fact, most do not—but that doesn’t mean that they don’t carry an economic cost as well as an emotional and physical toll on the workers and their families.

Workplace fatalities, injuries and illnesses cost employers billions of dollars every year . In its 2021 Workplace Safety Index, Liberty Mutual estimated that U.S. employers paid more than $1 billion per week for direct workers’ compensation costs—a total of $58 billion per year—for disabling, nonfatal workplace injuries.

That total doesn't factor in indirect costs, including training replacement employees, accident investigation and implementation of corrective measures, lost productivity, repairs of damaged equipment and property, and costs associated with lower employee morale and absenteeism.

The National Safety Council (NSC) estimated that U.S. work-related deaths and injuries cost the nation, employers and individuals $171 billion in 2019. These cost estimates are a measure of the economic impact of preventable injuries and may be compared to other economic measures, such as gross domestic product, per capita income and personal consumption expenditures. The costs reflect the impact to society, not specifically to employers.

According to NSC, the total cost of fatal and nonfatal injuries per worker—all workers, not just injured workers—in 2019 was $1,100. This includes the value of goods or services each worker must produce to offset the cost of work injuries; it is not the average cost of a work-related injury. Cost per medically consulted injury in 2019 was $42,000, while the cost per death was $1.22 million. These figures include estimates of wage losses, medical expenses, administrative expenses and employer costs but exclude property damage costs, except to motor vehicles.

CSR and ESG: Protecting Valuable Assets

Fifty years later, after groundbreaking changes to consumer safety laws and with the costs of injuries steadily rising, society is embracing the belief that corporate leaders and their boards of directors have more than a moral and ethical reason to protect workers; they have a fiduciary duty to do so. The rollout of corporate social responsibility (CSR) and environment, social and corporate governance (ESG) guidelines and reporting have made employee safety and health high on the list of corporate values required by companies wishing to remain sustainable, viable and profitable entities.

That said, international injury and fatality statistics are staggering. Each year, more than 2 million men and women die from workplace injuries and illnesses, according to the International Labour Organization. Businesses need to understand two things:

• That workplace safety is an issue they can manage and control, and
• That safety professionals need better tools and technology for measuring the economic impact of occupational injuries and illnesses.

Both CSR and ESG place great emphasis on creating a safe work environment for employees, and the value a safe and healthy work environment brings to a company’s reputation and bottom line. A 1996 study by Turban and Greening 1996 found that a higher level of corporate social performance “may provide a competitive advantage by attracting more applicants.” They also showed that “job applicants have a higher self-image when they work in a socially responsive firm.”

CSR should be seen as an investment policy in human resources—employees are, after all, a company’s greatest and most valuable asset—and can help to reduce turnover rate, retain the most productive employees, retain high levels of employee engagement and reduce the risk of conflict long-term.

Paul O’Neill and the Story of Alcoa

There is one legendary story that does a better job than any other of linking safety performance with operational excellence. Through the years, many corporate leaders have embraced safety as a measurement of operational excellence, but none so famously as Paul O’Neill .

O’Neill, who was CEO of the Alcoa Corporation from 1987-2000, made waves when he addressed a group of 250 Wall Street analysts and investors in October 1987. “I want to talk to you about worker safety,” he told them. “Our safety record is better than the general American workforce, especially considering that our employees work with metals that are 1500 degrees and machines that can rip a man’s arm off. But it’s not good enough. I intend to make Alcoa the safest company in America. I intend to go for zero injuries.”

Then O’Neill dropped the biggest bombshell of all: “We’re going to put safety over profits,” he added, causing one shareholder to declare that he was a “crazy hippie” who was going to “kill the company.”

“Focusing on worker safety can transform an entire organization and dramatically improve culture, quality, productivity, communication and ultimately profits,” O’Neill theorized. In the case of Alcoa, he was right. Under O’Neill’s watch, Alcoa dropped from 1.86 lost workdays per 100 workers to 0.2. A year after O’Neill’s speech, the company’s profits hit a record high. With O’Neill as CEO, Alcoa’s market value climbed from $3 billion to $27 billion, and its annual net income was five times higher than when he started.

Author Charles Duhigg  refers to Alcoa’s focus on safety as a “keystone habit,” something that created a change that rippled through the corporate culture at the company in  his 2012 book, The Power of Habit: Why We Do What We Do in Life and in Business . According to Duhigg, the focus on worker safety revealed an inefficient manufacturing process, one that created substandard products and was dangerous for workers.

“All that growth occurred while Alcoa became one of the safest companies in the world,” Duhigg wrote. “Before O’Neill’s arrival, almost every Alcoa plant had at least one accident per week. Once his safety plan was implemented, some facilities would go years without a single employee losing a workday due to an accident. The company’s worker injury rate fell to one-twentieth the U.S. average.”

The Rise of Safety Technology

O’Neill noted that technology advancements—specifically the ability to track injuries in real time—gave Alcoa the ability to transform its safety culture. O’Neill credited the development of a safety-data system at Alcoa for being a catalyst for dramatic improvements in the company’s safety record during his 13-year tenure as CEO.

Shortly after joining Pittsburgh-based Alcoa in 1987, O’Neill tasked several Carnegie Mellon University graduates to develop the IT infrastructure for a real-time safety reporting system. O’Neill’s vision was to have Alcoa facilities post all injuries and incidents within 24 hours after they occurred, along with the corresponding root-cause analyses and corrective actions. O’Neill wanted the reports to include the names of the employees involved.

In a keynote address to attendees at the 2013 National Safety Congress, O’Neill said, “One of the things I’ve learned is if you’re managing numbers, it feels a lot different than if you’re dealing with individuals, human lives and injuries to people.” The point of sharing the names was not to penalize the injured employees, he said, but to make those injuries feel “real” to other employees. “I wanted their co-workers to know, ‘My friend got hurt.’ This is another human being. This is not about OSHA recordable rates or something—this is about individual human beings who are part of our family.”

Alcoa’s safety and financial success under O’Neill undermined the long-standing assumption that injuries and accidents were inevitable byproducts in the quest for profits. “People confused the idea that customers and production were the most important thing with the idea that workers had to put themselves at risk for the greater good of the company,” O’Neill told the NSC audience. “It was always a stupid idea. But it took a while to get people to believe that it was neither right nor necessary.”

Sandy Smith is director of global content with Intelex Technologies , a provider of EHSQ management software. She is an award-winning newspaper reporter and business-to-business journalist who has spent 20+ years researching and writing about EHS and networking with EHS professionals, including her previous tenure as content director of EHS Today. This article was condensed from the Intelex ebook The ROI of Safety: Making the Business Case for Safety and Health .

Sandy Smith

Sandy Smith is the former content director of EHS Today , and is currently the EHSQ content & community lead at Intelex Technologies Inc. She has written about occupational safety and health and environmental issues since 1990.

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• v.84(1); 2006 Mar

Stories from the Sharp End: Case Studies in Safety Improvement

Motivated by pressure and a wish to improve, health care organizations are implementing programs to improve patient safety. This article describes six natural experiments in health care safety that show where the safety field is heading and opportunities for and barriers to improvement. All these programs identified organizational culture change as critical to making patients safer, differing chiefly in their methods of creating a patient safety culture. Their goal is a safety culture that promotes continuing innovation and improvement, transcending whatever particular safety methodology is used. Policymakers could help stimulate a culture of safety by linking regulatory goals to safety culture expectations, sponsoring voluntary learning collaborations, rewarding safety improvements, better using publicly reported data, encouraging consumer involvement, and supporting research and education.

In any successful effort to create social change, innovations proliferate, outpacing the ability of the scientific process or the published literature to assess and report their results. This is certainly true of the safety improvement effort in the U.S. health care system at the current time. Motivated by governmental and nongovernmental regulators, pressure from their staffs and patients, and their own wish to do the right thing, leaders of health care organizations around the country are introducing programs to improve patient safety. Many of these are not being evaluated and probably never will be studied with the rigor that academicians would like. Yet when properly interpreted, the histories of these programs may offer valuable insights into where the safety field is heading and opportunities for and barriers to improvement. With this in mind, we conducted case studies of ten potentially promising examples of safety improvement programs in health care institutions around the country. This article briefly reports the characteristics and lessons of six of these ongoing natural experiments in health care safety (see Table 1 for an overview of the cases).

Case Study Sites, Context, and Sources

Note: Additional background information on the topics and cases is available from the Commonwealth Fund website ( http://www.cmwf.org ).

To choose our cases, we contacted recognized leaders in the patient safety field and asked them which institutions were, in their view, doing the most exciting work in the patient safety field. Among our informants were individuals from the Institute for Healthcare Improvement, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), research funders, and academicians who study patient safety. These informants identified more than twenty potential cases, of which we selected ten for closer study that we considered the most interesting and promising for broad application. We present here six unique cases for analysis; the other four cases describe similar interventions. A fuller description of all ten cases and a list of those persons whom we consulted can be found at the Commonwealth Fund website ( http://www.cmwf.org ). We collected the information presented in these cases through telephone interviews and written communications with leaders in each organization and from a review of relevant publications (sources are listed in Table 1 ). We conducted our fieldwork in the fall of 2004. A brief version of our findings was presented on November 4, 2004, at a conference sponsored by the Commonwealth Fund of New York City to mark the fifth anniversary of the publication of To Err Is Human , the Institute of Medicine's seminal report on the patient safety issue.

We should mention at the outset some of the limitations of our work. Our methods were intended to capture a snapshot of the key accomplishments of leading organizations and to synthesize the self-perceived learning of their internal change leaders. Our findings are not meant to be representative of all health care organizations. The cases pertain to the hospital setting, because to date that has been the focus of most patient safety improvement efforts. We did not examine expensive high-technology innovations, such as computerized physician order entry systems, because we wished to concentrate on approaches that would be broadly applicable, regardless of an institution's ability to make large capital investments. Reliance on a small number of key informants means that the cases present a necessarily circumscribed perspective from which it is not possible to critically examine organizational dynamics or test theoretical models. Hence, our work should be considered only a starting point for more detailed organizational analyses.

One overriding lesson of our work has emerged. All the programs we examined cited cultural change—the creation of a “patient safety culture”—within their organizations as critical to making patients safer. Thus the organizations seemed to differ chiefly in the methods they were using to create this safety culture. Some were trying to change culture directly. Others were using less direct methods by relying on particular reforms in the structure or process of care, such as promoting teamwork to improve safety vigilance or introducing methods to reduce variability in the processes of care, and hoping that attitudes would change as behavior changed. Some were using both direct and indirect approaches. But regardless of means they chose, our study organizations shared the goal of cultural reform.

The fact that real organizations undertaking real change are focusing on culture in this way is both reassuring and sobering. As we shall see, the published literature on safety improvement in health care and other fields emphasizes the centrality of organizational culture in developing high-reliability organizations, institutions that are resistant to catastrophic failures that injure clients or patients ( Roberts 1993 ; Weick 1987 ). Thus it is encouraging that in the health care field, which has come late to the safety movement, this important insight is taking root so quickly, at least in the pioneering organizations. At the same time, the fact that changing the culture lies at the foundation of safety improvement is sobering because there is as yet no proven formula or well-trod path for creating cultural change in health care organizations. Cultural change efforts are also extremely hard to study because culture is difficult to measure reliably and changes seem to occur incrementally and unpredictably in organizations. The lack of a clear road map for cultural change and the very elusiveness of safety culture as a destination make this a particularly daunting goal for leadership to set. Yet leadership commitment, our cases suggest, is essential to success. One function of our cases may be to assure leaders who are taking personal and organizational risks to create a safety culture that they are in good company and to offer ideas and examples that they can take back to their own institutions.

Our article has four parts. First, because the concept of safety culture is central to understanding what currently is happening at the forefront of safety improvement, we briefly review the topic of patient safety culture. Second, we provide abbreviated versions of six of the cases we examined. Third, we analyze the attributes of the safety culture acquired by these organizations. Finally, we provide concluding lessons, observations, and policy implications. Table 1 provides an overview of the case study organizations, and Table 2 defines the key terms we use.

Definition of Key Terms

Safety Culture: Its Importance, Definition, and Attributes

In To Err Is Human , the Institute of Medicine noted that “a strong culture of safety … is viewed by many in the safety field as being the most critical underlying feature of their accomplishments” ( IOM 1999 , 160). Likewise, a review of several high-profile patient safety failures occurring internationally in health care organizations found that “preventing future failures depends on cultural as much as structural change in health care systems and organizations” ( Walshe and Shortell 2004 , 103). Certain prevailing aspects of health care's organizational and professional culture, such as steep authority hierarchies and a lack of teamwork, an unwillingness to acknowledge human fallibility, and the tendency to punish rather than learn from error, can act as barriers to patient safety and its improvement ( Akins and Cole 2005 ; Sexton, Thomas, and Helmreich 2000 ; VanGeest and Cummins 2003 ).

The IOM recommended that health care organizations “develop a culture of safety such that an organization's design processes and workforce are focused on a clear goal—dramatic improvement in the reliability and safety of the care process.” To achieve this goal, “safety must be an explicit organizational goal that is demonstrated by clear organizational leadership and professional support” ( IOM 1999 , 166).

Although organizational safety culture has no one agreed-upon definition, one used in the nuclear power industry is helpful:

Safety culture is the product of individual and group values, attitudes, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of an organization's health and safety programmes. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by confidence in the efficacy of preventive measures. ( ACSNI 1993 , quoted in IAEA 2002 , 14)

Based on research on human error and the ways that organizations have achieved or failed to achieve safety, James Reason (1997) and other experts ( Helmreich and Merritt 1998 ; IAEA 2002 ) contend that organizations can create a safety culture by identifying and consistently applying practical measures associated with enhanced safety. Changes often begin at the level of the unit or work group, both to test approaches before using them more widely and, given limited resources, to narrow the scope of work. Surveys of safety cultures reveal that an organization's culture varies within units of the same hospital ( Sexton 2005 ). Hence, changing the local culture might require tailoring improvements to the specific local working environment.

As far as we know, no health care organization as yet can offer a model of what other health care institutions should strive to achieve in their safety culture. Accordingly, health care leaders must determine their own objectives. In our view, this makes it all the more important that institutions share their aspirations, efforts, progress, and disappointments in as close to real time as possible. To help analyze what case study organizations have learned, we examined the cases using a framework developed by James Reason (1997) , which defines five interrelated attributes for a safety culture: an informed culture, a reporting culture, a just culture, a flexible culture, and a learning culture (see Table 3 for definitions). These attributes have been used to describe the development of a safety culture in other industries and sectors such as nuclear power generation, oil and gas extraction and refining, and commercial and military aviation ( Hudson 2003 ; Reason 1997 ). The IOM's reliance on Reason's work has made it a touchstone for the patient safety movement, and several of our informants cited these attributes when describing their own work.

Five Attributes of a Safety Culture

Source: Reason 1997 , 195–96, 213.

Before presenting the cases, we call attention to an important distinction: several of the cases describe their results as observed or reported numbers of events, which may differ from the number that actually occurred. The fact that errors and their consequences may not be immediately obvious to patients and caregivers is one reason that the health care field lags in pursuing safety. Although medicine has a strong tradition of professional concern for patients' welfare, the complexity of modern systems in which health care professionals perform their work means that they are often unable to see the safety implications of their human and technological interactions. The goal of patient safety is to rectify this system “blindness” by providing the means to detect and eliminate or mitigate system vulnerabilities that could harm patients.

Case Studies

Sentara norfolk general hospital.

Beginning in 2002, Sentara Norfolk General Hospital (SNGH), in Norfolk, Virginia, tried to improve patients' safety by strengthening its organizational culture of safety. Despite a record of successful technology and process improvements, the hospital's leaders were frustrated that the overall pace and scope of organizational change was not greater. Although changes in culture were deemed the best strategy for improving safety, the lesson of other industries was not to focus on the organization's culture itself but to make safe behaviors a regular practice ( Krause, Seymour, and Sloat 1999 ). To help in this effort, SNGH retained industrial consultants with a reputation for safety improvement in the nuclear power and manufacturing industries.

The consultants conducted a baseline organizational assessment and suggested four strategies to promote safety-related behaviors:

• Develop for all hospital staff, physicians, and hospital leaders three sets of behavior-based expectations (BBEs) linked to techniques for preventing errors (e.g., communicate clearly by using repeat-backs and clarifying questions).
• Establish “red rules” (high priority rules) to focus employees' attention on the potential for harm if certain critical safety procedures are not followed exactly (e.g., positive identification before taking any action with a patient, verifying the site before surgery).
• Improve the staff's ability to conduct timely and rigorous “root cause analysis” (see Table 2 for definition) of major safety events, such as by identifying the common contributing causes of a series of events, so that these analyses identify long-lasting, systems-oriented change.
• Adopt a human factors approach to simplifying policies and procedures (e.g., using a checklist to identify and standardize the principal steps in a process).

A “grassroots” group of employees developed the hospital staff and leadership BBEs, and another group of physicians and nurses created the physician BBEs. The groups also reviewed and adapted proven error management behaviors, tools, and techniques from other high-risk industries to fit the health care environment.

To help make expected behaviors become habits, supervisors regularly offer feedback on BBEs, which serve as core competencies for staff performance reviews. Managers informally observe progress when they make walk rounds in hospital units. Trained observers from the hospital's clinical effectiveness department use validated tools adapted from other high-risk industries to determine whether opportunities for applying behaviors are handled appropriately at critical safety junctures, such as during shift-change reports. These observations form the basis for measuring overall organizational progress on BBEs through a system called Real-Time Behavior-Based Monitoring, which is one of the several safety-related measurements in the hospital's integrated performance indicator system.

The preliminary results of these efforts include a 42 percent increase in the use of expected communications behaviors by hospital staff from 2003 to 2004, an 84 percent reduction in ventilator-associated pneumonias from 2001 to June 2004, and a 63 percent decrease in the rate of device-associated bloodstream infections from 2002 to June 2004. Based on SNGH's experience, Dr. Gary Yates, vice president and medical director of clinical effectiveness, said that health care leaders need to exhibit “measured impatience” if they want to see breakthroughs in patient safety and move to the next level of organizational performance.

U.S. Department of Veterans Affairs

The Veterans Health Administration, a component of the U.S. Department of Veterans Affairs (VA), established its National Center for Patient Safety in 1999 to lead the change in the organizational culture by empowering local facilities and frontline staff with proven tools, methods, and initiatives to improve patients' safety. This culture change program used human factors principles and the experience and lessons from high-reliability industries such as aviation and nuclear power. It was initiated as part of a broader organizational transformation undertaken by the VA in response to public and congressional concerns about the quality of care in VA facilities. The safety program's main components were:

• Establishing a nonpunitive approach to patient safety that protects the confidentiality of those who report unintended errors, which are clearly distinguished from blameworthy acts. With the cooperation of Congress, its unions, and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the VA defined a blameworthy act as a criminal act, an act related to alcohol or substance abuse or patient abuse, or an intentionally unsafe act that an individual knew to be unsafe. Such acts are reported to the local facility administration for investigation and possible disciplinary action.
• Encouraging the reporting of both adverse events and close calls (see Table 2 for definitions). VA employees are asked to report safety events to their facility's patient safety manager. The employee who makes these internal reports remains “identified” until the root cause analysis is completed so that the employee can be notified of and comment on the findings. If an employee is not comfortable reporting internally, he or she may report a safety event to an external reporting system operated by the NASA Ames Research Center on the VA's behalf. This external patient safety reporting system is modeled on the Aviation Safety Reporting System, which NASA operates for the Federal Aviation Administration. Employees making external reports are asked to identify themselves so that they can be contacted if additional information is needed, but the reports are subsequently “de-identified.” In this way, the external system protects the employees' anonymity.
• Designing and providing training on easy-to-use, computer-aided root cause analysis tools and cognitive aids for multidisciplinary teams of frontline staff to analyze reported safety events in each facility. The goal is to determine what happened, why it happened, and what can be done to prevent it from happening again. The National Center analyzes similar events to decide how to address common issues throughout the system.
• Adapting a systems engineering tool, known as “failure modes and effects analysis” (see Table 2 for definition), to discover critical system vulnerabilities and to design and assess improvements that will prevent and reduce harm to patients.
• Disseminating throughout the VA warnings about potential safety threats and lessons learned about effective system improvements.

Within ten months of enhancing its internal patient safety reporting system in 1999, the VA experienced a thirtyfold increase in the reporting of events, indicating that the promise of confidential, nonpunitive reporting was important to the workforce. The relatively small number of reports received by the external reporting system (fewer than four hundred since its inception in 2002, compared with hundreds of thousands of safety events reported internally) suggests that the VA has achieved a high level of trust in its internal reporting system. Since the creation of enhanced tools and training, nearly all root cause analyses have been able to recommend a solution, whereas previously about half the reviews of patient safety events failed to identify a solution—a 100 percent increase in the perceived preventability of events. In addition, the types of root causes identified have shifted from patients' behavior and professional training to human factors and systems issues, leading to what managers regard as more effective and sustainable solutions. These trends suggest that teams no longer consider the circumstances giving rise to errors as impossible to change. One measure of the change in the VA's culture is that its personnel seem to be applying what they have learned about systems thinking to other areas, and they want to set and achieve safety goals that exceed the JCAHO's accreditation requirements, said Dr. James Bagian, director of the VA National Center for Patient Safety.

Kaiser Permanente

Kaiser Permanente (KP) instituted a program of organizational learning in 2002 to promote teamwork and communication in high-risk areas such as surgery and labor and delivery. Clinical leaders were taught safety-oriented principles and techniques adapted from the U.S. Navy and from airline crew resource management training ( Helmreich 2000 ) (see Table 2 for definition).

At the KP Anaheim, California, Medical Center, a multidisciplinary team designed a preoperative safety briefing to enhance basic patient safety practices required by the JCAHO, such as the “time out” to verify surgical sites. A one-page checklist was created to prepare team members for cases, including practices to assess and mitigate safety risks. Analogous to the preflight checklist used in the airline industry, this checklist is adapted to the needs of each case and is posted throughout the operating theater as a reminder. Operating room personnel are periodically trained in human factors principles, followed by a short self-assessment for reinforcement.

Four northern California KP medical centers piloted a perinatal patient safety project (PPSP) in which they received training on safety sciences and instituted improvements to close local gaps in the characteristics of a high-reliability perinatal unit ( Knox, Simpson, and Garite 1999 ). The principal interventions were:

• Multidisciplinary patient rounds to ensure that the care plan was understood.
• Assertive and structured communication techniques to promote accurate situational briefings (such as when interpreting and responding to fetal distress).
• A communication escalation policy defining how safety concerns can be forwarded through the chain of command to avoid delays in responding to critical events.
• Team briefings before a procedure and debriefings following an adverse outcome.

A multidisciplinary team developed a critical-event team-training program to practice teamwork and communication skills in simulated crisis situations using computerized mannequins. Complex training scenarios are based on actual cases that force the team to recover from errors. Drills are videotaped for debriefing, during which the team sees where improvement is needed.

After a six-month trial of preoperative briefings at the Anaheim Medical Center, no wrong-site surgeries were reported (three were reported in the previous year, but the small number of events means that no firm conclusions can be drawn). At the same time, other reported error management behaviors increased, such as a willingness to speak up about safety concerns and to report and discuss mistakes, suggesting that team members had better “situational awareness” (see Table 2 for definition). Comparing responses to the University of Texas Safety Attitudes Questionnaire ( Sexton et al. 2004 ) made before and after the intervention indicates that operating room staff perceived an improvement in the safety culture and teamwork. The turnover rate among nurses fell by two-thirds (from 23 percent to 7 percent) and has been sustained at a lower level than that in comparison contract hospitals. One year following the implementation of the PPSP, the labor and delivery staff in all four perinatal sites rated the safety culture more highly than before the intervention. (Several years of data will be required to measure the effect of the PPSP on perinatal adverse events.)

Briefings are a powerful way to change the way that people think about and practice teamwork, said Dr. James DeFontes, physician director of surgical services for KP Orange County. Explicit communication helps people attend to the task at hand, bridges cognitive gaps in training and experience levels, and avoids unjustified assumptions about others' knowledge, he added. Improving team communication is, ultimately, about organizational cultural change. Effective change requires a “bottom-up approach” supported by leadership and physician involvement, combined with ways of inculcating expected behaviors in everyday practice, Dr. Michael Leonard, physician leader for patient safety at Kaiser Permanente, said.

Missouri Baptist Medical Center

Missouri Baptist Medical Center, in St. Louis, tried to improve patient outcomes by enhancing its existing emergency response capability to intervene early with patients showing signs of medical deterioration before they suffered crises such as cardiac or respiratory arrest. The hospital's leaders were impressed by the benefits of rapid response teams (also known as medical emergency teams) in reducing adverse events in Australian hospitals ( Bellomo et al. 2003 , 2004 ) and a few institutions in the United States ( IHI 2004a ). In 2004, they made a similar effort in their hospital. Ideas for their plan were obtained from collaboration with the Institute for Healthcare Improvement and from the experience of other adopters. The intervention was carried out during an organization-wide culture change initiative aimed at aligning the hospital's mission, structure, reward system, and leadership with patient safety goals and building a partnership with affiliated physicians to institute safety improvements.

Missouri Baptist's rapid response team consists of a physician assistant acting as the team leader, a critical care nurse, and a respiratory therapist. The team is empowered to take whatever action is needed to stabilize the patient, within the scope of their practices, while reporting to and consulting with the hospital's ICU physician intensivist as needed. The patient's attending physician is notified and informed of the team's assessment and may order additional tests at his or her discretion. Patients are transferred to the ICU or to an intermediate care unit when appropriate.

The hospital staff were taught the purpose and use of the rapid response team before it was put in place, a step that the hospital's leaders considered necessary to its success. Specific clinical criteria were compiled to guide the nursing staff in deciding when a patient's condition warranted calling for help. In addition, anyone could call for help when he or she was simply worried or concerned about a patient. The benefit of the rapid response team was reinforced by sharing stories of successful interventions.

After two months of full implementation, calls for the rapid response team steadily increased to about seventy to eighty per month, indicating that the floor nurses recognized the value of this safety resource. During this time, there was a 60 percent decrease in emergency calls for respiratory arrest and similar crises and a 15 percent decrease in cardiac arrests, suggesting that these acute crises were being averted through early intervention. Anecdotal feedback from family members indicated they were impressed and gratified by efforts made on behalf of the patients, according to Nancy Sanders, the hospital's performance improvement coordinator.

A rapid response team should be considered a support resource for frontline staff, observed Dr. John Krettek, vice president of medical affairs. Incidents can be used as a teaching opportunity for the ICU nurse to share insights into the case so that the floor nurse can sharpen his or her assessment skills and learn how to respond to a similar event in the future. In this way, rapid response teams may promote a culture of safety by building teamwork and spreading knowledge and skills throughout the hospital.

Johns Hopkins Hospital

In 2001, intensive care unit (ICU) physicians and staff at the Johns Hopkins Hospital in Baltimore developed its Comprehensive Unit-Based Safety Program (CUSP) as a framework for quality improvement that can be tested, adapted, and introduced sequentially in the hospital units. This program is part of a broader institutional commitment to improve patient safety that was partly based on a partnership with the family of a pediatric patient, Josie King, who was a victim of medical error at the hospital. The King family donated funds and worked with Hopkins physicians to create a patient safety program in the hospital's Children's Center, which has served as a model for improvement.

CUSP has eight steps: to (1) assess the unit's culture of safety, (2) educate staff about safety sciences such as systems thinking, (3) identify safety concerns, (4) meet regularly with a senior hospital executive who supports the removal of system barriers, (5) prioritize and implement improvements, (6) document and analyze results, (7) share success stories, and (8) reassess the unit's safety culture.

Improvement teams (consisting of a physician, nurse, and administrator, plus other staff who wished to join) spent time each week (four to eight hours) identifying and promoting safety improvement efforts. For example, a short-term patient goals form was drawn up based on a survey finding that nursing staff and residents frequently did not know the goals of patients' therapy. The form is used as a checklist during physician-led rounds to identify tasks that need to be completed by the care team and to identify and mitigate safety risks. A related project aimed to reduce bloodstream infections associated with the use of central venous catheters, which are often inserted in ICU patients to provide medication, nutrition, and fluids. A multidisciplinary team decided on the following interventions:

• Require providers to receive education about evidence-based infection control practices and successfully complete a posttest as a precondition to inserting catheters.
• Supply a catheter insertion cart with standardized supplies needed to meet infection control guidelines for the sterile insertion of catheters.
• Follow a checklist to ensure adherence to evidence-based guidelines for safe catheter insertion.
• Empower nurses to intervene if guidelines are violated.
• Add an item to the daily goals sheet that prompts the ICU team to ask physicians daily during patient rounds whether catheters can be removed.

After the daily goals sheet was introduced, self-reported understanding of goals of care increased from 10 percent to 95 percent of residents and nurses during an eight-week period. One year following the implementation of the CUSP initiative, the average ICU length-of-stay fell by one day in one ICU and by two days in a second ICU. Medication errors were eliminated in orders to transfer patients out of the ICU. The proportion of the ICU staff who gave positive ratings of the safety culture rose by nearly half in one ICU and nearly doubled in the other, as measured on the Safety Climate Scale ( Sexton and Thomas 2003 ). Senior executives' involvement with the ICU led to structural changes, including the creation of specialized patient transport teams and the presence of pharmacists in ICUs. Documented catheter-related bloodstream infections were eliminated, preventing an estimated forty-three infections and eight deaths and saving an estimated $2 million annually.

CUSP is now being used as a framework for patient safety improvement throughout Johns Hopkins Hospital. Initiating change efforts within a single work unit and then replicating successful approaches in other units appears to be a promising approach to building an organizational culture of safety in the Hopkins system. “When you create a system that reliably delivers the processes or interventions that work, spectacular performance improvement follows,” Dr. Peter Pronovost, medical director of the Johns Hopkins Center for Innovations in Quality Patient Care, said in a recent interview for the Joint Commission Journal on Quality and Safety ( Berman 2004 , 663).

OSF St. Joseph Medical Center

OSF St. Joseph Medical Center, in Bloomington, Illinois, used several strategies to promote an organizational safety culture: the widespread reporting of errors, systems thinking about preventing errors, and collaborating for improvement. Many ideas were derived from participation in the Institute for Healthcare Improvement's Quantum Leaps in Patient Safety collaboration, which the hospital joined in 2001. For example, safety concerns and ideas for improvement are elicited from nursing staff during safety briefings at shift changes and through executive walk rounds ( Frankel et al. 2003 ), during which hospital executives periodically meet with frontline staff in each of the hospital's work units.

For its first patient safety effort, the hospital instituted several ways of reducing medication errors. An enhanced medication reconciliation process was established as the foundation for preventing adverse drug events ( Rozich and Resar 2001 ). This process had the following steps:

• A nurse interviews the patient or the patient's advocate at hospital admission to obtain the best possible information about home medication use.
• When patients are transferred between hospital units or discharged from the hospital, their existing medications are compared with those ordered by the physician to be continued.
• Any discrepancy between medications ordered and currently being taken at hospital admission, transfer, or discharge must be reconciled by the patient's physician within four to twenty-four hours, depending on the type of medication.
• A pharmacist reviews the patient's home medication use and the physician's orders to detect and avoid any medication errors in dosing or other problems such as potential drug interactions.

An automated standard medication reconciliation sheet doubles as the medication order sheet for review and approval by the physician at admission, transfer, and discharge, which saves time and prevents transcription errors. A duplicate copy is given to the patient to take home, and another copy is sent to the patient's referring physician.

Other improvements in the medication process used human factors principles, such as standardized order sets and dosing services for certain high-risk medications, to reduce complexity and unnecessary variation that could lead to errors and harm to the patient. Pharmacists on nursing units perform independent double checks while entering medication orders, which permits them to detect dosing errors or potential drug interactions and to immediately contact physicians for resolution. A systematic risk assessment (known as “failure modes and effects analysis,” see Table 2 for definition) is used to identify vulnerabilities in the medication-dispensing process and to design countermeasures. For example, to prevent the reuse of leftover medication, the floor nurse places it in a plastic bag, which is picked up by pharmacy technicians during hourly rounds on the floor. The telephonic Adverse Drug Event Hotline was instituted to simplify reports of adverse drug events and permit pharmacists to analyze potential problems each day.

Following these interventions, the rate of adverse drug events dropped by 91 percent (from 5.8 to 0.5 per 1000 doses) from June 2001 to May 2003, as detected using a “trigger tool” for sampling medical records developed by the Institute for Healthcare Improvement ( IHI 2004b ). The hospital's perceived safety culture also improved, as measured using the University of Texas Safety Climate Survey ( Sexton and Thomas 2003 ).

Discussion: Acquiring a Safety Culture

The cases illustrate how health care organizations are working to instill the five characteristics of high-reliability safety culture identified by James Reason (1997) and defined in Table 3 . They are seeking, first of all, to become informed about system vulnerabilities that threaten patients' safety so that they can plan and prioritize system improvements. Sentara Norfolk General Hospital and OSF St. Joseph Medical Center, for example, have integrated performance indicator systems that track progress in meeting safety goals by measuring safety-related attitudes, behaviors, events, risks, and outcomes using multiple data sources such as surveys, assessments, incident reports, direct observation, medical records, and malpractice claims. At the apex of this system, executives at these hospitals make walk rounds on hospital wards to cultivate an awareness of safety issues and demonstrate to the staff that safety is important. The kind of top-to-bottom organizational safety audit conducted by Sentara Norfolk General Hospital appears to be a valuable but underused resource for detecting weaknesses and opportunities for improvement.

To support an informed culture, case study organizations encourage the reporting of safety incidents and concerns (including near misses or close calls) through internal and external reporting systems, safety briefings, and executive walk rounds. They appear to have moved beyond a superficial preoccupation with the volume of reports as a barometer of safety culture to a more mature outlook that values reports for the learning that they enable when accompanied by effective analytic tools. For example, insights obtained by analyzing close calls, which occur more frequently than adverse events, can be used to discover weaknesses in the system before they harm patients. To encourage participation and build trust in the efficacy of reporting, case study organizations have established feedback loops to discuss with both management and frontline staff what they are learning and doing as a result. Although several organizations use anonymous reporting systems, the experience of the Veterans Health Administration suggests the feasibility of a confidential reporting system in which incident reporters identify themselves so that they can be included directly in the feedback loop.

These organizations recognize the necessity of providing a psychologically safe environment for reporting medical errors so that mistakes can be identified, learned from, and prevented rather than hidden out of fear of punishment. Some have characterized this as a “blame-free” environment for patient safety. Others have more carefully defined their aspiration as a nonpunitive, or just culture , that protects the reporting of honest errors while recognizing that misconduct—in which an individual intentionally endangers patients—is not an error ( Leape 2005 ). The Veterans Health Administration, for example, found that its employees were willing to greatly increase the reporting of safety incidents under a credible promise of confidentiality that clearly defined misconduct and excluded it from protection.

A flexible culture encourages greater teamwork and collaboration across disciplines to help maintain and improve patients' safety under the often complex and demanding delivery of health care ( Leonard, Graham, and Bonacum 2004 ). Kaiser Permanente and Johns Hopkins Hospital, for example, are attempting to flatten the hierarchy by training and encouraging surgical and critical care team members to “speak up for safety” when they observe an unsafe situation and to cross-check one another's work to prevent errors. Kaiser Permanente has learned that training obstetrical teams using simulated emergencies gave them a new awareness of how their behavior affected others and built appreciation for teamwork in critical situations. Cross-cutting interventions such as the rapid response team at Missouri Baptist Medical Center promote a flexible culture by facilitating learning and information sharing across traditional organizational boundaries where breakdowns in communication and safety can often occur. These kinds of role changes may lead to what Karl Weick (2002, 193) called a “mindful interdependence” in which people “subordinate their idiosyncratic intentions to the effective functioning of the system.”

Finally, study organizations seem to be promoting a learning culture by undertaking system reforms based on data and knowledge gleaned from both inside and outside their local environment. Providing easy-to-learn analytic tools and training for frontline staff to draw useful conclusions and take action based on incident reports promoted a sense of local ownership for improvement and was “the single most noteworthy means of changing culture” within the Veterans Health Administration, said Dr. James Bagian, director of its National Center for Patient Safety. The VA encourages an action orientation by requiring local executives to reach an agreement with incident investigation teams on remedies that will be taken to address identified vulnerabilities. Kaiser Permanente and the OSF St. Joseph Medical Center use safety briefings and debriefings as a means of ongoing, self-guided team learning and error management. The use of risk assessment tools supports learning at OSF St. Joseph Medical Center by helping teams find weaknesses in the system and objectively weigh options for improving their reliability, thereby avoiding “quick fixes” that might actually increase harm. Sentara Norfolk General Hospital is combining direct observation of behaviors with coaching and feedback to promote the practical learning of new safety-enhancing behaviors that, over time, can become an internalized safety culture.

The organizations we studied differed in approaching culture change as an organization-wide project or through a team- or unit-based undertaking. The experience of Sentara Norfolk General Hospital suggests that a comprehensive change strategy can help accelerate the pace and scope of organizational change. Such an approach is likely to require much more upfront investment of staff time and resources. But the hospital also found that corporate principles had to be adapted and embedded in each unit's specific work. Those taking a unit-based approach, such as Johns Hopkins Hospital, find that discrete achievements build interest and momentum for introducing change in other units. Dr. Peter Pronovost, a patient safety change leader at Johns Hopkins, explained that the dissemination of change requires a commitment to apply scientifically valid safety principles within a flexible structure that relies on local wisdom to determine improvement priorities. The intersection between unit-based and organization-wide culture change should be better understood as unit-based efforts are replicated throughout hospitals. It is likely that change will be uneven across units. Hospital managers might be able to use culture surveys and techniques like executive walk rounds to identify and focus attention on units in need of greater improvement so as to produce a more consistent safety culture across the organization.

A fair question is how discrete efforts at improvement add up to organization-wide change. Patient safety practitioners such as Kathy Haig at OSF St. Joseph Medical Center describe a gradual process in which specific improvements produce cascading effects that build higher levels of awareness and engagement in management and the workforce. With sustained effort over several years, there is a sense of gaining traction, that management is really “walking the talk,” and that frontline staff and physicians are getting on board. Several case study organizations found that introducing improvements through small-scale tests of change helped pave the way for institutionalizing new safety practices while minimizing the risk of failure by involving staff in giving feedback at incremental stages of the implementation.

Lessons Learned

Change agents in the case study organizations learned much from their experience implementing patient safety improvements. These lessons include:

• Apparently dramatic improvements in safety, such as the elimination of documented catheter-related bloodstream infections in the ICU and a tenfold reduction in detected adverse drug events, seem to challenge the assumption that adverse events must be tolerated as an inevitable side effect of health care.
• Safety principles and techniques developed in other industries, such as airline crew resource management training, may be applicable to health care for similar human factors issues. Simple human factors engineering approaches, such as the standardization and simplification of processes and independent checks to catch errors, often seemed to be effective. Nevertheless, knowledge and tools must be adapted to fit the culture of medicine and the particular organizational context and safety threat ( Musson and Helmreich 2004 ).
• Safety awareness and vigilance can be taught by training and coaching staff to use practical skills, tools, and behaviors so that they gain the ability and confidence to identify safety threats and mitigate their causes, in both real-time work and later analysis. A safety culture is inculcated as these ways of systems thinking and behaving become the norm for individuals and teams. One practical result is to greatly increase the number of events that staff regard as preventable.
• An organization's leadership can motivate and support a “bottom-up” approach to safety improvement among physician leaders and other frontline clinical staff. Some improvements require direct financial investment, and all require dedicated staff time to plan and implement. Several organizations noted the importance of repeatedly telling stories about successful improvements to introduce and reinforce desired cultural values and behaviors and to build momentum for change.
• Focusing on patients' needs can be a powerful motivator for change. Some of the organizational changes described in the cases required renegotiating traditional roles. Resistance to change was typically overcome through education on the evidence for a practice and by focusing on an intrinsic motivator—doing what is best for the patient.
• Seeking and measuring improvement in both systems (e.g., reduction of errors and vulnerabilities) and outcomes (e.g., reduction of adverse events) seems to enhance sustainability by validating clinical success factors while helping make a valid and meaningful case for patients' safety. Because many errors do not harm patients, it is important to concentrate on activities that will have the largest impact on improving safety.

Policy Implications

What has induced the organizational leaders we studied to undertake these efforts, and are these motivations applicable to other organizations? Interviews suggest that these institutions are internally motivated to perform well. Reputational rewards appear paramount, typically to fulfill high public expectations but, in some cases, as part of a wider effort to shore up reputation. Several organizations cited the financial and operational benefits of safety improvement, such as reductions in hospital length of stay and nursing staff turnover. Accreditation requirements are viewed by these leaders as a floor on which to build. In contrast, accreditation requirements appear to be the primary driver of safety efforts in most hospitals ( Devers, Pham, and Liu 2004 ).

Can a culture of safety in health care be encouraged so that these examples become the norm? The success of the internal mechanisms for building a safety culture in health care organizations, as described in these cases, seems more likely if it accords with the external policy forces influencing these organizations and the professionals who work in them. We offer the following observations for how policymakers in both the public and private sectors might build on intrinsic motivations to encourage a culture of safety through responsive regulation, voluntary collaboration, purchaser incentives, public reporting, consumer involvement, education, and research. Given that so little is known about safety culture, we offer our policy recommendations cautiously. Ideally, they should stimulate creative learning and continuing innovation to address evolving challenges over time.

Link Safety Goals to Safety Culture

The JCAHO appears to be acting as a proxy for government regulation in the safety sphere, with a stated goal of encouraging a culture of safety through continuous improvement ( O'Leary 2003 ). In 2001 the JCAHO required that accredited institutions meet general patient safety standards such as creating a culture of safety and implementing a patient safety program. Since 2003, an evolving set of specific patient safety goals, such as establishing a medication reconciliation process, has been incorporated into accreditation requirements.

The JCAHO might capitalize on its position of influence to help health care organizations decide how they can apply specific patient safety goals to meet safety culture expectations. For example, the JCAHO might convene stakeholders to develop (and periodically update) guidance on how to create a safety culture in health care organizations based on lessons learned from leaders in the field and on practical improvement and culture change strategies that have been shown to work under particular circumstances and that can be instituted over time. Such guidance would need to be designed and used as a road map offering different routes to a common goal.

Hospitals could use safety culture guidance to structure organizational assessments for learning and improvement. Creating a repository linking assessment findings to standardized performance data and safety attitude surveys could help to identify potentially promising safety practices associated with good outcomes. Initially this could be done on a voluntary, collaborative basis. If this approach were successful, the JCAHO and its stakeholders might consider whether accreditation would be enhanced by incorporating a safety culture assessment into the accreditation survey process, as either a standard or an optional component. Alternatively, the JCAHO might certify third-party experts or methods to perform assessments. In any case, the goal should be to improve patients' safety in ways that are responsive to local needs and priorities.

Encourage Collaboration

Voluntary efforts to spread evidence-based practices, such as the Institute for Healthcare Improvement's 100,000 Lives Campaign ( IHI 2005b ), illustrate the potential for setting bold improvement goals when stakeholders band together to sponsor and participate in an initiative. Indeed, Gosfield and Reinertsen (2005) argue that the scientific basis and wide acceptance of the campaign's goals makes them de facto national standards of care that are likely to be enforced through tort liability against hospitals that fail to undertake them. Other public-private partnership opportunities to disseminate practical knowledge and speed interorganizational learning have involved Medicare Quality Improvement Organizations ( Dellinger et al. 2005 ), regional and statewide coalitions of stakeholders ( Comden and Rosenthal 2002 ; Sirio et al. 2003 ), and recognition programs such as the Malcolm Baldrige National Quality Award and its state-level counterparts ( McCarthy 2005b ).

Offer Incentives

The financial returns from improvement often do not fully compensate health care providers for the cost of their efforts ( Leatherman et al. 2003 ; O'Leary 2003 ). In response, health care purchasers—including federal and state governments, large self-insured employers, and health plans and insurers—are experimenting with pay-for-performance programs to reward health care providers for improvements in quality or attainment of quality goals ( Rosenthal et al. 2004 ). Given the newness of incentive approaches, there is as yet little evidence of their effectiveness ( Dudley et al. 2004 ; Galvin et al. 2005 ). Payment incentives might help stimulate a safety culture if enough public and private purchasers participate, the reward recognizes efforts to achieve accepted safety goals, and providers can share substantially in the savings achieved by their efforts—in other words, if rewards are perceived as real, important, and attainable. Other, simpler incentives are defraying the cost for institutions to participate in collaborative improvement initiatives ( McCarthy 2005a ) and offering providers a discount on malpractice liability insurance for participating in safety-enhancing activities, such as crisis management teamwork training in labor and delivery units ( McCarthy and Staton 2005 ).

Leverage Public Data

Almost half the states require hospitals to report certain adverse events and incidents to a state agency, typically for the purpose of accountability ( Wood and Nash 2005 ). Although in the past these data often were not systematically collected or analyzed, recently a few states have created patient safety centers to analyze data, educate health care providers and the public, foster collaboration, and stimulate a culture of safety ( Rosenthal and Booth 2004 ). If experience shows that such centers are able to use state reporting data to disseminate new information about critical safety threats and promote worthwhile improvements, then their creation should be encouraged. The aviation industry's experience suggests that a centralized safety reporting system can improve safety awareness if it is nonpunitive, confidential, independent, and easy to use and it produces timely, expert, and systems-oriented feedback ( Leape 2002 ). The newly enacted federal Patient Safety and Quality Improvement Act may contribute to the achievement of these goals by protecting the voluntary, confidential reporting of safety data to independent, federally certified patient safety organizations.

A few states now publicly report hospital-specific data on certain adverse events or hospital-acquired infections ( IDSA 2005 ; Marchev, Rosenthal, and Booth 2003 ), which supporters advocate as both a matter of the public's right to know and a means to empower consumer choice and induce improvement. The public reporting of hospital-specific clinical quality data has been associated with better quality of care ( Hibbard, Stockard, and Tusler 2005 ). Adverse event rates, however, might not be comparable if a higher rate reflects better reporting rather than worse quality. Moreover, some hospital leaders fear that nonconfidential public reporting might discourage internal error reporting ( Weissman et al. 2005 ). The publication of process measures, such as the Leapfrog Group's voluntary survey of hospital compliance with recognized safety practices, appears to be more widely accepted.

Involve Consumers

Consumers have a potentially compelling stake in promoting a culture of safety in health care ( NPSF 2003 ), but efforts in this regard are still nascent. The federal government, the JCAHO, advocacy groups, and hospitals are encouraging patients to be vigilant about their care and assertive in protecting themselves from errors. Patients may need education and coaching to gain the understanding and confidence needed to take recommended actions, such as questioning their health care professional ( Hibbard et al. 2005 ). Some hospitals are including patients in interdisciplinary rounds held at the bedside to increase the detection of errors ( Uhlig et al. 2002 ). Other hospitals, such as the Dana-Farber Cancer Institute, recruit patients to serve on Patient and Family Advisory Councils that help design and evaluate organizational policies, systems, and quality improvement initiatives ( Ponte et al. 2003 ). Respect for patients and a desire to maintain their trust demand that hospitals and health professionals disclose the occurrence of adverse events to affected patients and their families. Current disclosure practices may not be adequately meeting patients' desire for an honest accounting and emotional support ( Gallagher et al. 2003 ).

Advance Education and Research

Medical and nursing education are essential to shaping health care professionals' safety-related attitudes and behaviors by instilling an understanding of systems thinking about error and an appreciation for human factors such as teamwork and communication that can help keep patients safe. Federal funding for the Agency for Healthcare Research and Quality is vital to support research on safety culture and for the development of valid metrics and tools with which to measure and promote it ( Clancy 2005 ). To help guide policy, new research is needed on how specific policy actions influence organizational behaviors and safety outcomes.

Conclusions

Organizational leaders in patient safety are undertaking various interventions to instill a safety culture, and the organizations we studied view culture change as a key element and accomplishment of their safety improvement efforts. These organizations appear to view safety culture as an aspirational system property that is more than the sum of their individual safety improvement efforts. The reason for this outlook appears to be a belief that a sustained safety culture allows continuing innovation and improvement that will transcend whatever particular safety methodology is used at any particular time.

The cases describe many impressive results, but they do not permit us to draw firm conclusions about the effects of culture vis-à-vis other potential causal explanations for the observed outcomes. All the case study organizations were part of integrated health care systems or multihospital systems that might offer advantages, such as greater in-house expertise, physician commitment, and financial resources for carrying out organizational change strategies. Nevertheless, the changes described are not beyond the reach of independent institutions. We examined other cases in which community hospitals made similar safety improvements when they were part of a supportive learning collaboration ( McCarthy 2004 ).

Creating an organizational culture of safety may be both foundational to safety improvement and elusive as a goal. The process of instilling a safety culture requires the integration of both systems engineering and social engineering skills. A paradoxical insight is that the adoption of specific improvements both furthers—and is furthered by—organization-wide culture change. All the tools and techniques described in these case studies display promise in promoting a culture of safety when used as part of an intentional strategy to move the organization toward that goal. Yet as James Reason (1997) warned, safety improvement tools and techniques are not pieces of machinery that can simply be plugged in, turned on, and then forgotten. Rather, they are part of an organic organizational growth process that must be nurtured over a prolonged period of time.

Perhaps the most sobering discovery from our cases is that those who are furthest along the patient safety pathway report that their learning has made them realize how much more they need to accomplish to achieve a truly safe environment for patients. A question for practitioners, policymakers, and researchers is whether the kinds of approaches described here will provide the impetus to change the culture of health care in positive and enduring ways. Because of the dynamic and emergent nature of the safety field in health care, ongoing assessment will be valuable to take stock of progress and new learning as experience accumulates over time.

Acknowledgments

This research was supported by a grant to Massachusetts General Hospital/Partners Health System by the Commonwealth Fund. The authors acknowledge the Commonwealth Fund for grant support for this research, the interviewees who shared their organizational experiences (see Table 1 ), the experts who recommended cases for consideration (names can be found at http://www.cmwf.org ), and three anonymous reviewers who provided valuable suggestions for improvement. The views expressed in this article are the authors' and do not necessarily reflect the opinions of the Commonwealth Fund or its directors, officers, or staff.

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Supporting Occupational Health and Safety Risk Assessment Skills: A Case Study of Five Companies

Affiliation.

• 1 Center for Safety Management and Engineering, CSME, Faculty of Management and Business, Tampere University, 33014 Tampere, Finland.
• PMID: 35162743
• PMCID: PMC8835380
• DOI: 10.3390/ijerph19031720

Financial burden due to poor occupational safety practices remains high although occupational health and safety (OHS) have improved in recent years. Conducting risk assessment is one way to improve OHS. Workplaces may not have sufficient expertise in risk assessment. The aim of this study was to identify the needed OHS risk assessment skills, current support in the workplaces and the ways to improve risk assessment skills. This study was conducted with the Delphi survey for OHS experts ( n = 13) and with interviews ( n = 41) in the case companies. OHS experts agreed that the most significant skills were for employees to identify hazards and minimize risks in one's work; for supervisors to influence others with a good example; and for OHS experts to understand and manage the wholeness of safety practices and understand and manage the meaning, concepts, and criteria of risk assessment. The current main support methods were learning at work, training and written instructions. However, many of the interviewees felt that they had not received risk assessment training and that the support depended on their activity. Finally, the OHS experts determined that the most feasible ways to improve risk assessment skills were training, coaching and giving clear instructions. Likewise, the interviewees suggested various training methods. Based on these results, concrete development plans to improve risk assessment skills can be made.

Keywords: development; expertise; occupational health and safety; risk assessment; skill; support; training.

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Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Opinions of occupational health specialists…

Opinions of occupational health specialists and managers on the most important risk assessment…

Opinions of the occupational health…

Opinions of the occupational health specialists and managers on the most important risk…

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Injuries and Illness

Case studies in safety: a great training tool.

Updated: Nov 6, 2011

Case studies are a great safety training tool. It’s like CSI. Employees can really get involved examining the evidence and seeing why an accident occurred.

Safety case studies are fun, challenging, interactive, and a highly effective training method.

Armed with the knowledge they gain from examining the facts of real workplace accidents, workers can learn how to avoid similar incidents and injuries.

Here’s an example of such a case from BLR’s OSHA Accident Case Studies . This case is about a confined space incident.

The Incident

Two employees arrived at concrete pit at demolition site where they’d been working to salvage the bottom part of a cardboard baler imbedded in the pit. When the employees uncovered the pit, they both felt a burning sensation in their eyes.

Employee #1 climbed down into the pit to determine what might be causing their eyes to burn. He immediately climbed back out of the pit because it was hot. He decided to put a water hose into the pit to help cool it down.

The employees climbed down into the pit with the water hose. Both employees experienced chest tightness, difficulty breathing, and burning eyes. They decided to exit the pit because of the intolerable conditions.

Employee #2 climbed out first. As Employee #1 was climbing the ladder to get out, he was overcome by the fumes and fell back into the pit. He landed on his back, unconscious.

Employee #2 climbed down into the pit in an attempt to rescue employee #1, but was unable to lift him. Employee #2 exited the pit in order to get help. Unfortunately, by the time help arrived, Employee #1 had died of asphyxiation.

The accident investigation determined that employee #1 had attempted to extinguish a small cutting torch fire the day before by covering it with sand and dirt. Apparently the fire was not extinguished and smoldered overnight, which resulted in a build up of carbon monoxide inside the pit.

Try OSHA Accident Case Studies and give a boost to your safety training program with real-life case studies of actual industrial accidents from OSHA files. We have a great one on lifting. Get the details.

Discussion Questions

Once the case has been presented, some discussion questions can help kick off the analysis of the incident. For example:

• What are the potential hazards of confined spaces?
• What was the specific hazard in this case that cause a fatality?
• Were these workers properly trained and equipped to enter a confined space?
• What type of air monitoring should be done before entering a confined space?
• Was this a permit-required confined space? If so, were the workers familiar with the safety requirements of the permit?
• Was confined space rescue equipment readily accessible?
• Training? There is no indication on the accident report that the employees were trained as authorized entrants of confined spaces. If they did receive any confined space entry training, they clearly didn’t apply what they learned. Authorized entrants are trained on the hazards of confined spaces, atmosphere testing procedures, symptoms of lack of oxygen or exposure to toxic chemicals, personal protective equipment (PPE), communication equipment, rescue retrieval equipment, etc.
• Hazard warning? These employees entered the space despite experiencing "red flags," such burning eyes and unusual heat. An important part of training for confined space workers includes learning about hazards such as the symptoms of a lack of oxygen or exposure to toxic chemicals. Workers should never enter a space, and should immediately leave a space, in which they experience signs of hazardous conditions.

Even your most skeptical workers will see what can go wrong and become safety-minded employees with OSHA Accident Case Studies . They’ll learn valuable safety training lessons from real mistakes—but in classroom training meetings instead of on your shop floor. Get more info.

• Permit-required? Most confined spaces require a permit before workers can enter the space. Permit-required confined spaces have the potential for hazards such as hazardous atmospheres, engulfment, entrapment, falls, heat, combustibility, etc. By reviewing a permit, entrants know they have obtained all the necessary equipment and the atmosphere has been monitored so they know the space is safe to enter.
• Testing? This worker died of asphyxiation, or lack of oxygen. If the atmosphere in the pit had been tested prior to entry, this accident would not have occurred. Common monitoring practices require a check of the oxygen concentration, a check for flammable gases or vapors (especially important if welding is going to be done in the space), and finally, a check for any other toxic chemicals known to potentially be in the space. Monitoring is conducted before entering the space and periodically while workers are in the space.
• Rescue procedures and equipment? The worker who collapsed back into the pit while climbing out could not be rescued because he was not wearing required rescue equipment. He should have been wearing a full-body harness attached to a retrieval line that was connected to a winch-type system that could have been used to pull the unconscious worker out of the pit. Of course, the other employee would have had to have been trained in confined space rescue procedures.

Tomorrow, we’ll introduce you to another case from OSHA Accident Case Studies, this one about a materials handling accident that resulted in a serious back injury.

More Articles on Injuries and Illness

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HHS Publishes First Round of Inflation Reduction Act Case Studies on Health Sector Climate Investments

The HHS Office of Climate Change and Health Equity highlights safety net health care providers using Inflation Reduction Act funds and tax credits to decarbonize their communities and protect patients

The HHS Office of Climate Change and Health Equity (OCCHE) published two case studies today highlighting how Boston Medical Center and OhioHealth, a pair of nonprofit safety net health care providers, are using the Inflation Reduction Act (IRA) to reduce carbon emissions. The case studies are meant to offer health organizations in similar situations a roadmap to use the IRA to serve their core mission, reduce climate-related health impacts and advance health equity.

One case study explains Boston Medical Center’s creation of a pilot program providing solar energy credits to patients. The other highlights OhioHealth’s decision to use IRA tax incentives to fund electric vehicle charging stations that offer free charging to residents in a rural area.

The case studies are part of OCCHE’s Catalytic Program on Utilizing the IRA, an ongoing effort to connect safety net health care providers to the billions of dollars the IRA makes available for energy efficiency, sustainability, and environmental justice. IRA funding opportunities help providers make investments that allow them to stay open before, during, and after emergencies and reduce their own pollution levels.

The case studies explore Boston Medical Center’s Clean Power Prescription and OhioHealth’s charging station infrastructure to help providers consider how they might successfully plan a project leveraging IRA funding to support their community. Both providers also share key lessons learned from their processes and advice for pitching a similar project to organizational leadership.

In addition to the new case studies, the Catalytic Program features more than two dozen hours of rewatchable, free-to-access webinars with experts from across the federal government and health sector, as well as a Quickfinder tool summarizing key IRA programs and policies.

“Boston Medical Center and OhioHealth are showing their peers the power of the Inflation Reduction Act to save hospitals money and reduce environmental health burdens at the same time,” said ADM Rachel L. Levine, MD, Assistant Secretary for Health. “The law offers unprecedented opportunities for health care providers and other nonprofits to make long-term investments that reduce their climate impact and protect public health. OCCHE’s work to educate safety net health care providers is vital to meeting our overall climate goals, and I look forward to seeing many more success stories in the months and years ahead.”

“The IRA is the most significant climate legislation in our country’s history, but it didn’t come with a roadmap telling the health sector where to plug in,” said John M. Balbus, MD, MPH, Deputy Assistant Secretary for Climate Change and Health Equity. “The health sector offers crucial support for frontline communities and also contributes about 8.5 percent of US carbon emissions, which is why it needs to reduce its own impacts as much as possible. The Catalytic Program is crucial to promoting health equity and a green energy economy, and I hope more health care providers take advantage of these opportunities.”

Many providers, including Boston Medical Center and OhioHealth, presented on their plans to use the IRA as part of the Catalytic Program’s webinar series over the summer. All previous sessions are recorded and available online. OCCHE will roll out new case studies over the course of this year.

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OSHA's most interesting cases

What happened – and lessons learned.

Every OSHA investigation offers an opportunity for using what comes to light to help prevent similar incidents.

At the 2022 NSC Safety Congress & Expo in September, OSHA staffers highlighted three investigations – and the lessons learned – during the agency’s “Most Interesting Cases” Technical Session.

• Brian Elmore , an OSHA inspector based in Omaha, NE
• Marie Lord , assistant area director of the OSHA office in Marlton, NJ
• Peter Vo , safety engineer in OSHA’s Houston South area office

Here are the cases they presented.

• Shelving collapse in a cold storage warehouse
• Lockout/tagout-related amputation
• Crane collapse  

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Call for Case Studies: Strategic Action for Urban Health

The WHO Urban Health team is seeking examples that illustrate a strategic approach to urban health. Collectively, these case studies are intended to show that such an approach can originate and flourish from a wide range of entry points across a diversity of sectors and scales, while leveraging many different combinations of partners. The case studies will inform a major global WHO report on strategic action for urban health, expected in fall 2024. Selected cases will be developed for inclusion in the report; the urban health team will work with submitters of these cases to produce concise summaries. All submitted cases that meet eligibility criteria will be promoted and made available on the WHO website and, as appropriate, in subsequent publications.

Background to this call

The health of urban populations emerges from the interactions of urban environments with the behaviour of individual actors and human institutions. Urban health is both a measure of the levels and patterns of health and wellbeing in cities and the art and science of safeguarding and continually improving them.

Because every aspect of urban life can affect human wellbeing, urban health relies on action across all sectors—not only within health, but across planning, housing, transportation, water, sanitation, energy, and many others. This breadth of influences is widely recognized, yet urban health action has often focused on improving health impacts within a single sector or system, or alternatively, on addressing a narrowly defined set of health outcomes, modifying certain key behaviours, or improving health for a particular population group.

Such efforts have widely succeeded in improving urban health outcomes, and cities are healthier, on average, than rural areas. Yet, much remains to be done. Urban areas feature large—and often growing—health inequities, especially in slums and informal settlements. In virtually all cities, there remain unrealized opportunities to improve health and health equity.

Moreover, the actions needed to improve health in cities often positively impact other goals of sustainable development. There is thus tremendous potential for achieving co-benefits through an approach that accounts for dynamic interactions across sectors.

Achieving the highest levels of urban health—and realizing its wide-ranging potential co-benefits—requires coordinating action across all urban sectors and systems while anticipating future challenges. That is, it depends on a strategy to sustainably mainstream health across urban policy and practice. This ‘strategic’ approach to urban health depends, among other things, on sophisticated arrangements for governance and finance, generating and working with evidence, fostering innovation, and generating and sustaining effective partnerships while promoting broad participation.

WHO’s urban health team has been working to develop guidance on strategic action for urban health, including through a recent series of policy briefs focusing on these issues. This case study call will add to this effort, helping to make visible the relevance, potential, and possibilities of strategic action.

Eligibility criteria and call information

Case studies may represent action at national or subnational (e.g., province, state, municipality, or city) scales and should describe specific interventions, policies, institutions, partnerships, or other pertinent efforts. They need not involve the health sector (though many will) but should be relevant to the health and wellbeing of urban residents. Cases need not represent unqualified successes—indeed, cases that illustrate barriers to success or failed attempts at strategic action will be considered. We are seeking illustrative cases representing all regions, cultures, and levels of development, and a diverse range of urban contexts (including different city sizes, demographic profiles, informal communities, governance structures, and other factors).

This call is for cases that illustrate strategic action, as described in the WHO Strategic Guide to Urban Health Policy briefs. Cases that highlight potential or intended actions that have yet to be formalized or initiated will not be accepted. Likewise, cases that describe narrowly focused interventions or research related to health determinants, risk factors, or outcomes will not be considered unless linked to broader strategic action. We are particularly interested in cases that can demonstrate evidence of health impacts.

Cases should:

• involve a diversity of stakeholders (both government and non-government)
• encompass multiple sectors and health outcomes
• illustrate one or more of the eight principles underlying a strategic approach to urban health referenced in the WHO Strategic Guide to Urban Health Policy briefs.  
• ideally, be relevant to one or more of the cross-cutting recommendations from the WHO Strategic Guide for Urban Health policy briefs.
• represent action currently underway or implemented during the past decade.

Please review the principles and recommendations in the policy briefs to ensure that your case meets the established criteria.

Any stakeholder involved in managing the actions described is invited to submit a case study by completing the survey form here .

In responding, you will be asked to provide basic contact and descriptive information, describe how your case is relevant to the principles and recommendations, answer several questions intended to capture key elements (e.g., context, enablers and barriers, what was done and by who, outcomes) with short textual summaries, and supply additional materials to enrich and substantiate your description (potentially including figures, photos or video, internal or external reports, links to media coverage, or other). Your complete, clear answers will help us ensure that cases are relevant and useful.

The deadline for case submission is July 30, 2024. Please be prepared to work with the WHO team to produce a concise summary if your submission is selected for inclusion in the WHO global report. Any questions can be directed to [email protected] .

Case studies: Successful leadership

There are many benefits to be gained from successful leadership in health and safety, as these case studies show.

Case study - North Staffordshire Combined Healthcare NHS Trust

The board found itself facing service improvement targets. Using new corporate and clinical guidance, it set about taking a 'whole systems' approach to managing corporate risk, giving one of its directors responsibility for the leadership of health and safety for the first time. Health and safety was also made a key item on the board agenda.

This has resulted in a much better integrated health and safety management system that increases the opportunity to identify and manage all corporate risks, and a much more open culture, improving reporting and monitoring. The board actively promotes a culture that gives staff the confidence to report incidents. This has resulted in:

• incidence rates reduced by 16% over two years;
• insurance premiums reduced by 10%.

Case study - British Sugar

The company had an excellent safety record and had no indication of the devastating events that were to happen – in one year three deaths occurred. Although health and safety had always been a business priority, a change in focus was needed to achieve behavioural change. This included:

• the CEO assigning health and safety responsibilities to all directors, and monthly reports go to the board;
• creating effective working partnerships with employees, trade unions and others;
• overseeing a behavioural change programme and audits;
• publishing annual health and safety targets, and devising initiatives to meet them.

Results include:

• time lost to injuries reduced by 43% over a two year period;
• 63% reduction in major issues over the course of a year;
• much greater understanding by directors of health and safety risks.

Case study – Mid and West Wales Fire and Rescue Service

To give health and safety a high priority, Mid and West Wales Fire and Rescue Service recognised that it was critical for its leadership to demonstrate to its staff that accountability for health and safety was a fundamental element in the success of its overall service delivery. The director of service policy and planning was nominated as the health and safety director for the service in order to clearly define the importance this subject held within the organisation. The director implemented a revised health and safety framework, which included a programme of fire station visits to engage the workforce, and placed a renewed emphasis on improving incident reporting, investigation and monitoring procedures. The service has reported:

• £100,000 reduction in insurance liability premiums in one year through improved corporate strategic risk management;
• 50% reduction in sickness absence through work related injury over a two year period;
• 50% reduction in injury incidence rate over a three year period.

Case study – Sainsbury's

An external health and safety audit identified a need to develop a unified approach, and also recommended more direction from the board, to develop an effective strategy.

The result was a radical revision of the company's approach, including:

• the group human resources director creating a health and safety vision, supported by a plan with targets over three years;
• training on health and safety responsibilities was introduced for all board directors.

This has resulted in:

• the board providing a role model for health and safety behaviour;
• 17% reduction in sickness absence;
• 28% reduction in reportable incidents;
• improved morale and pride in working for the company;
• raising the profile of health and safety so it is becoming embedded in the culture of the organisation.

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• Safety Management

Health and safety prosecutions: recent cases provide some important lessons

Health and safety practitioners will already appreciate how extensive the duties on their companies to protect safety can be, how easy it is to fall foul of them and the importance of learning from any incidents to prevent any further serious events.

Two recent reported cases have emphasised the duty is to ensure that each and every employee is to be kept safe and that the company’s clean record, good safety culture, low accident rates and avoiding repeat incidents are now more critical than ever.

In Evergreen Construction the Health and Safety Executive (HSE) called evidence at trial of previous accidents involving the defendant company, and reported contraventions of safety laws where the company had admitted to having breached its duty. HSE argued that this was relevant background evidence to prove that the defendant company had breached the Health and Safety at Work Act 1974 on this occasion as well and so was guilty of the current alleged offence it was charged with.

The seriousness of any injury involved and whether or not the company was actually prosecuted is irrelevant. Particular care needs to be taken with any Improvement Notices or Notices of Contravention (NOC). Even RIDDOR reports of incidents which are similar to the current offence could demonstrate this propensity.

Often for economic or practical reasons, it is common for a company to choose not to challenge a notice – even when they might usually have good grounds to appeal and contest an allegation of breach by HSE. If the Fee for Intervention (FFI) costs invoiced are not significant, sometimes if no improvement or prohibition notice is served and no prosecution brought, then a business may decide not to appeal the HSE’s NOC, the contents of any Notice or the process it followed.

Usually when challenged the HSE will have to review the amounts claimed under FFI (which are often incorrect) and at the very least will often come back with a reduced claim for costs. They would need to ensure that the process they followed in serving the notice would survive the scrutiny of a challenge and that the wording of the notice has met the formal legal requirements when demanding works are undertaken to remedy the alleged offences that HSE say have been committed.

In the unlikely event that, following a challenge an HSE notice is upheld without any modification at all, the company is in no worse a position than if it had simply accepted a breach anyway and – most critically – the enforcement could not be used against it at a later date in the event of a repeat incident. By definition, the fact that HSE did not deem the offence serious enough to serve a formal notice or prosecute reflects the lack of public interest in taking any more serious enforcement action and an incident cannot be upgraded to a prosecution simply because a company might choose to appeal against the conduct of the HSE – which it is perfectly entitled to do in any case.

Just as a tribunal can consider evidence relevant to an alleged breach of safety after a notice is served, the same is true in response to a NOC, and HSE would have to keep the balancing exercise in mind between upholding its enforcement decision and the time, trouble, cost, and inconvenience of pursuing its response to any appeal brought.

In short, what looks to be a minor matter with little short-term effects can come back to haunt practitioners and any such notice should be considered in the same detail as more formal cases involving proceedings being taken.

Morrisons case highlights need to take full account of employees’ individual safety needs

The wide-ranging extent of a company’s duty to protect each and every employee even when they may have particular individual needs or subjective requirements has been highlighted by another recent case.

Supermarket chain Morrisons was convicted of charges brought by Tewkesbury Council following the death of an employee in one of its stores. The employee in question was epileptic and had experienced episodes both personally and while at work. Morrison’s had correctly identified the possible risk which in fact eventuated; namely that of him suffering an epileptic episode and falling on the stairs leading from the upstairs canteen to the shop floor during a shift.

The employee fell on the stairs one day while he was alone, and an episode occurred. Tragically, he later died of his injuries. Sometime previously Morrisons had gone to great lengths to make reasonable adjustments to his duties. The company changed his job role to a position based downstairs so as to reduce the number of times he had to climb the stairs. During most shifts however he still used the stairs to access his locker and was still required to go upstairs to undertake additional activities.

Morrisons was fined £3.5 million because despite taking various specific protective measures to protect that individual’s safety, there were additional ‘reasonable adjustments’ it could have made to further reduce the likelihood of falling and the consequences which could and turned out to be fatal.

Practitioners may wish to contact their HR departments to check how many existing staff members where reasonable adjustments have been made have been assessed for risks of injury and their own personal safety (rather than solely for their comfort and convenience), and whether the safety department has been notified.

HR should ask the employee to consent, and the business may wish to alert others to come forward if a particular physical or mental characteristic or requirement could increase the level of risk to that employee above the level involved in the normal day-to-day activities of the role when performed by persons who do not require reasonable adjustments to be made.

The solution needs to comply with safety laws as well as HR requirements, although the former must prevail over the latter in the common scenario where there may be a tension between the two. Practitioners may wish to review any existing epilepsy policies they have in place and/or of any other characteristics that may vary the level of risk posed to any single employee. Once accidents or near misses occur, the business is then on notice of a risk and the onus is on them to eliminate the risk entirely if reasonably practicable will become even higher still as previous incidents will act as warnings and aggravate any future offences if and when a further event takes place.

Chris Green is a partner at Keoghs law firm and leads its crime and regulatory team across the Midlands. He specialises in providing expert advice in relation to adverse incidents and compliance with regulatory requirements. Contact him at: keoghs.co.uk/our-people/chris

• prosecutions

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Menopause at work: government failing to grasp benefits of providing more support to women workers

Many employers are waking up to the realities of menopause, and the benefits of providing a supportive environment for women at work. CIPD (Chartered Institute of Personnel and Development) research shows that 30 per cent of UK employers now have menopause policies, up from 10 per cent in 2019. But I am increasingly worried that the government has not appreciated the need to seize momentum.

Time for a double celebration!

May is one of my favourite months. Not only is the weather (finally, surely!) starting to feel more Spring-like here in the UK, it’s also when we hold our prestigious event, the International Safety Awards (ISAs).And this year, we get to celebrate not just once, but twice.

Let me tell you a story…

I recently addressed a room full of people waiting to hear if they had won an International Safety Award (ISA), at our gala dinner in London. This is something I do every year, so nothing unusual there. This year, I decided I’d do something I’ve never really done before. I told a personal story, about my own experiences, from my own career.

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• Volume 14, Issue 6
• Facilitating interprofessional learning: experiences of using a digital activity for training handover of critically ill patients between a primary health care centre and ambulance services – a qualitative study
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• Conte Helen 1 ,
• Marina Taloyan 2 , 3 ,
• Åkesson Ninni 4 ,
• Sofie Guldbrand 5 ,
• http://orcid.org/0000-0003-1386-3203 Veronica Lindström 6 , 7
• 1 Department of Neurobiology, Care Sciences and Society, Division of Nursing , Karolinska Institutet , Stockholm , Sweden
• 2 Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care , Karolinska Institute , Stockholm , Sweden
• 3 Academic Primary Health Care Center , Region Stockholm , Stockholm , Sweden
• 4 Rehab North West , Region Stockholm , Stockholm , Sweden
• 5 Child Health Care Centre , Region Stockholm , Stockholm , Sweden
• 6 Department of Nursing and the Ambulance Service, Västerbotten , Umeå University , Umea , Sweden
• 7 Department of Health Promotion Science , Sophiahemmet Hogskola , Stockholm , Sweden
• Correspondence to Professor Veronica Lindström; veronica.lindstrom{at}umu.se

Objective To explore students’ and facilitators’ experiences of using a developed digital activity for interprofessional learning (IPL) focusing on critically ill patient handovers from a primary healthcare (PHC) centre to the ambulance service.

Design A qualitative study design was employed, and the reporting of this study adheres to the Consolidated criteria for Reporting Qualitative research guidelines for qualitative studies.

Setting A PHC centre and the ambulance service in Stockholm, Sweden.

Participants A total of 31 participants were included in the study: 22 students from five different healthcare professions, seven facilitators and two observers.

Intervention A digital IPL activity was developed to overcome geographical distances, and the scenario included the handover of a critically ill patient from personnel within the PHC centre to the ambulance service personnel for transport to an emergency department. Four digital IPL activities were conducted in 2021.

Results The digital IPL activity eliminated the issue of geographical distance for students and facilitators, and it enabled the students to find an interprofessional model for collaboration through reasoning, by communicating and sharing knowledge with the support of a common structure. Participants perceived the digital IPL activity and scenario as authentic, feasible and facilitated IPL. Using a case with an acute and life-threatening condition was a success factor for students to experience high realism in their IPL on patient safety, handover, care and treatment.

Conclusion The developed digital IPL activity facilitated the students’ IPL and demonstrated potential sustainability as the digital approach supported overcoming geographical distances for both students and facilitators. By using a scenario involving an authentic case focusing on handovers of a critically ill patient, IPL, feasibility and acceptability were supported. However, it is crucial to emphasise that a comprehensive evaluation, both quantitative and qualitative, over an extended period of clinical rotations and involving a larger group of students is still warranted to ensure continuous improvement and development.

• MEDICAL EDUCATION & TRAINING
• ACCIDENT & EMERGENCY MEDICINE
• Primary Health Care
• Feasibility Studies
• QUALITATIVE RESEARCH

Data availability statement

Data are available upon reasonable request. The data analysed during the current study are not publicly available due to the participants’ privacy could be compromised but are available in Swedish from the corresponding author upon reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2023-083585

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STRENGTHS AND LIMITATIONS OF THIS STUDY

To our knowledge, this study is the first to collect data from digital interprofessional learning (IPL) learning activities with students in clinical rotations in both the primary healthcare centre and the ambulance service.

Multiple data sources (interviews, notes, observations) and 31 participants creating new knowledge based on qualitative analysis.

The number of participants and completed IPL activities could be considered low, and we do not know if all eligible students were reached.

Not all professions were representative among the students during all IPL activities.

The authors’ preconceptions and personal experiences may have influenced the interpretation and understanding of the study.

Introduction

Establishing interprofessional learning (IPL) activities that ensure high-quality education is essential. This is particularly critical in clinical settings where IPL is still in the early stages of development. In the ambulance service, IPL is not yet firmly established. Historically, the ambulance service has been perceived as suboptimal for undergraduate students’ clinical rotations, primarily due to the services’ previous function of responding to emergency calls and conveying sick or injured individuals to hospitals. However, as the ambulance service has developed into a recognised discipline of pre-hospital emergency care, delivering advanced medical interventions and care, 1 it has been shown that within the ambulance service, students can gain proficiency in nursing, medical and collaborative skills. 2 As the number of undergraduate nursing students completing clinical rotations in the ambulance service has increased, so have the expectations for activities to be conducted to support the students’ IPL. However, different student professions undertaking clinical rotations in the ambulance service are limited. Therefore, in collaboration with other healthcare organisations such as primary healthcare (PHC) centre, there is a need to develop and systematically evaluate easily accessible IPL activities that are not dependent on the co-location of students. IPL activities have been developed and evaluated over the years, but the setting and context matter, 3 and contextual factors influence IPL. 3 Therefore, this study aimed to explore students’ and facilitators’ experiences using a developed digital activity for IPL focusing on critically ill patient handovers from the PHC centre to the ambulance service.

IPL includes various activities depending on goals and desired outcomes, for example, short digital seminars or shadowing where the students’ learning originates from interactive group processes, including collaborative analysis and joint critical reflection. 4 The students are active participants and learn with and from each other in authentic and patient-centred activities. 5 They negotiate their different experiences to fully understand their role and the roles of other professions. 6 However, finding places, spaces and time for students from various educational programmes to learn together in healthcare can be challenging since education is not always situated in contexts that support IPL. 7 Environments and care activities that naturally could support IPL are situated during clinical rotations where students from different educational programmes collaborate in patient care. 8 9 Students acknowledged that experiencing diverse IPL activities during clinical rotations is vital for learning how to work together. 10 Co-location is important but not enough for different professions to learn together. 10 Facilitated learning is part of building interprofessional rapport in groups, and balancing the participation of the different professions in their interactions is vital for learning together. 2 6 10 Students suggest that bringing a sense of their profession into the interactions and being inclusive of other professions are two key qualities for IPL 10 and that gaps in role conceptions are a crucial barrier 11 and could cause patient risks.

The WHO states that healthcare services should be safe and person-centred. 12 Research has shown that IPL activities can introduce patient safety concepts and experiential practice through interprofessional communication and analysis among students. 13 14 To improve patient safety in the healthcare setting, training must start with students. 15 16 Working as a professional in the ambulance service involves collaborating with various healthcare professionals when providing care for patients transported to emergency departments or when responding to incidents in home healthcare settings. 17 There is limited knowledge about how undergraduate students perceive digital IPL activities focusing on handovers of critically ill patients within and between the PHC centre and the ambulance service. The handover between different healthcare settings is a complex process that includes communicating information between professionals responsible for the patient’s care at different units or sites, 18 and communication failures are one of the leading causes of adverse events, particularly in handover situations. 19 When the handover is compromised, essential information can be altered or lost, transfer of cognitive bias may occur, patients may be exposed to adverse events, and patient safety issues may occur. 20 Expanding IPL activities beyond organisational boundaries to include the handover of patients between different healthcare organisations could allow students to practice and learn handover and patient safety in a new context. The ambulance service collaborates with PHC and community-based care and receives and hands over patients within these organisations. 21 22 To our knowledge, the handover of critically ill patients from the PHC centre to the ambulance service has not previously been used for IPL.

A qualitative study design was used to collect and analyse the students’ and facilitators’ experiences through their reflections on the newly developed digital IPL activity based on an authentic scenario. By examining the experiences of supervisors and students, conclusions can be reached regarding IPL in a sparsely explored IPL context, as well as the acceptability and feasibility of the developed digital IPL activity. Acceptability captures how the intended recipients react to the activity, that is, is it appropriate, relevant or sustainable, 23 and feasibility captures if the developed digital IPL activity is sustainable for continual use in the setting. The consolidated criteria for reporting qualitative research Consolidated criteria for Reporting Qualitative research guidelines guided the study. 24 The study was approved by the ethics review authority in Sweden (No.: 2021–00586).

Patient and public involvement

No patient and public involvement.

The PHC centre provides clinical rotations for medical, nursing, physiotherapy (PT), occupational therapy students (OT), and nurses studying at an advanced level to become primary healthcare nurses (PHCNs). In the PHC centre, the learning environment is characterised by care activities of acute and non-acute visits, short and long patient encounters, and the students care for patients with all varieties of complaints. The learning environment varies between care for patients at home and the clinic; some patients are followed up on over time, and some only visit the clinic once. The PHC centre has established IPL activities but has never collaborated with the ambulance service concerning IPL activities for undergraduates. The ambulance service provides regular clinical rotations for nursing students and medical students more irregularly. The ambulance service responds to emergency calls, and the students care for patients with various complaints and acuity. Short patient care encounters characterise the learning environment in the ambulance service, care at patients’ homes, at the scene of an injury and during transports between different healthcare facilities. The team in the ambulance consists of an emergency medical technician with basic life support competence and a registered nurse (RN) with 1 year of additional training in emergency care. 25 The clinical supervisor for both medical and nursing students in the ambulance service is the RN. Collaboration between PHC centres and the ambulance service primarily revolves around the handover of patients suffering from acute illness and needing to be transported from the PHC centre to an emergency department. With two different healthcare organisations collaborating and a lack of co-location, a prerequisite for conducting the IPL activity was that they were conducted digitally. In addition, using a digital format for the IPL activity increased the possibilities for students to participate and increased environmental sustainability by reducing unnecessary travel.

Developing the Interprofessional learning activity and the scenario used

The scenario was developed by facilitators and researchers who were clinicians working in the ambulance service, PHC centre or intensive care unit. To ensure that students from ambulance services and PHC centre could collaborate and contribute with their various professional knowledge, the content of the scenario included (1) situations where different healthcare professionals cared for the patient, (2) handovers of patients in acute situations, and (3) patient safety in the context of PHC and the ambulance service. The scenario was built on several sources: (1) evidence-based guidelines 26–28 , (2) perspectives of person-centred care 29 , (3) the situation-background-assessment-recommendation (SBAR) communication tool 30 and finally, (4) crew resource management (CRM). 31 After developing the scenario, short sequences were recorded with a smartphone to illustrate different aspects of the care and handover situations. To reduce costs, the patient was acted by one of the facilitators and the recording was made by a clinical colleague from the ambulance service. In total, approximately six working hours were required for the development, filming and editing of the scenario and for embedding the material into a PowerPoint presentation. The scenario included critical events in the patient’s symptom development when suffering from an acute myocardial infarction leading to a cardiac arrest and, after advanced cardio-pulmonary resuscitation (CPR), return to spontaneous circulation. The scenario also included handover situations and supplementary information (eg, vital signs and ECG). There was a balance between information and questions related to each healthcare profession to enable the students to learn from each profession during the scenario. Questions about CRM and SBAR were added in connection to each care transition in the scenario. The scenario included three episodes of handovers: (1) physiotherapist—primary healthcare nurse, (2) primary healthcare nurse or physician or physiotherapist—dispatcher at the emergency medical communication centre, and (3) physiotherapist or primary care nurse or physician—ambulance personnel. The IPL activity was completed within 150 min, including a 15-min break.

Data collection and participants

The study and data collection were done in Stockholm, Sweden, where students did their clinical rotations in the ambulance service or at a PHC centre. The students invited to participate and evaluate the developed IPL activity were from three higher education institutions. The digital IPL activities were scheduled when there were eligible students from different educational programmes at their clinical rotations in the PHC centre or the ambulance service at the same time. The students were invited to participate in the IPL activity through e-mail and/or electronic bulletin boards and had no previous relationship with the researchers (VL, MT, HC). Some facilitators had prior knowledge about the students at the PHC centre as they also worked as clinical teachers (NÅ, SG), but they were not responsible for the students’ grading. Data collection took place on four different occasions, once during the spring of 2021 and three times during the fall of 2021.

A combination of data sources was used to capture the participant’s experiences in and on the activity. The students’ and facilitators’ reflective interplay during the IPL activity and group discussions after the activity were collected (a total of 12 hours of recording) using the digital platform recording function (image and sound). After each IPL activity, separate group discussions were held with the facilitation team. Data collection from the student and facilitator group discussions was initiated with an open-ended question (‘What was your experience of this IPL activity?’ vs ‘What did you think about this activity?’). The facilitator’s reflective notes were collected after each IPL activity.

In total, 22 students were consecutively included in the study, and seven facilitators and two observers participated in the IPL activity. The scenario was first piloted in the spring of 2021 with eight students, three interprofessional facilitators and two observers. The observers in this first scenario took notes on body language, group dynamics and reflections. The results of the analysis of the pilot led to minor adjustments with the addition of a normal ECG and reminders in the PowerPoint to discuss CRM and SBAR. The pilot was included in the analysis. After piloting, three additional activities with 14 students from five educational programmes (medical, nursing, PT, OT and PHCN) were performed during the fall of 2021. In each activity, three facilitators participated. The interprofessional team of facilitators consisted of clinical teachers with previous experiences in IPL activities: two physical therapists, one specialist nurse with extensive expertise in the ambulance service, one specialising in paediatrics, one in primary healthcare and one physician. Participating facilitators in the activities were determined by the opportunity to participate. The recordings were transcribed verbatim, and the reflective notes were electronically transcribed.

The qualitative materials were analysed thematically, and the analysis was conducted according to the steps described by Kiger and Varpio. 32 Initially, the transcribed text and field notes from the four IPL activities were read multiple times to gain familiarity with the collected material. After this, codes were identified from the texts, and this step was followed by a search and construction of preliminary themes by sorting the identified codes. The preliminary themes were then refined and labelled. In the final step, the analysis was concluded by writing the results. No distinction was made in the analysis regarding either where the students did their clinical rotations or from which programme. Both medical and nursing students can do their clinical rotations in the ambulance service or the PHC centre. Neither were the quotes from the participants, distinguishing as this study aimed to explore on group levels both students’ and facilitators’ experiences of using a developed digital activity for IPL, focusing on critically ill patient handovers from a PHC centre to the ambulance service. The analysis process was iterative; a continuous movement between the codes, preliminary themes, and themes was made to preserve the essence of the collected data. Each step in the process was initiated by the last author and then reviewed by the co-authors. Any differences in interpretation were resolved through discussion until a consensus was reached.

Three themes describing participants’ experiences of IPL, the acceptability and the feasibility of the developed and used IPL activity, from both the students’ and facilitators’ perspectives, were constructed through the analysis: (1) interprofessional learning through collaborative reasoning in an authentic scenario, (2) sharing a common model by communicating information in a structured way and (3) reaching an understanding through collaborative reasoning.

Interprofessional learning through collaborative reasoning in an authentic scenario

All participants discussed and evaluated the scenario as authentic and based on the patients’ needs during handover in an acute situation. The students perceived the activity as a feasible and beneficial way of learning through analysing the patient’s changing problems and needs between and with different professions throughout the whole chain of care. The students experienced that the IPL activity expanded their understanding since they usually did not get a chance to find out what happened with the patient before or after a care encounter. In addition, the students discussed that the developed scenario supported them in their discussions about the patient’s follow-up care at PHC after an acute illness and the support needed for the patient’s family.

…a strength of today’s seminar was that many different aspects of care, including discussions on the follow-up of the patient, became clear…(nurse student, activity #3)

The students agreed that all healthcare professionals need to know how to handle acute situations, for example, the CPR scenario. To enhance IPL during clinical rotations, students and facilitators also discussed the feasibility and possibilities of developing scenarios for future digital IPL activities by incorporating new film sequences into the scenario, for example, by changing symptom presentation and/or changing the outcome for the patient and thereby having the possibility to include other students in the IPL activity.

Think about it, adding another outcome for the patient in the scenario can make it relevant for other students, eg, dietician or maybe homecare personnel (nurse facilitator 1, activity #3).

The facilitators, students and observers emphasised that sometimes, the medical focus took over the discussions between the students and risked reducing the possibilities for IPL. Facilitators explained several reasons for this. The first reason could be that not all healthcare professionals and care aspects were explicitly presented in the scenario and, therefore, were not discussed or analysed. The second reason was associated with the facilitators themselves.

….XXXX [name of facilitator] needs to take a step back, keep quiet and wait for the students to talk, discuss and analyse all different aspects of the care… (nurse facilitator 3, activity #2).

An additional reason contributing to the medical focus was the composition of the group of participants. When the group consisted of more medical students than nursing students, the discussions had more of a medical perspective. In contrast, when there were more OT or PT students in the group, their care perspective was discussed to a greater extent, and the medical issues in the scenario needed to be clarified more. In these situations, the facilitators needed to ensure that all aspects were discussed to ensure IPL and the acceptability of the developed scenario. During the scenario, the facilitators created a space for the students to take control, verbalise and analyse together by listening, confirming and adding critical questions when needed. The facilitators encouraged the students to explain and describe their professional aspects when caring for the patient. Facilitators experienced initial uncertainty among the students and guided them to communicate by open and de-dramatising questions such as: ‘Do you have any experience with something similar?…What good reflection do you have, anyone else? Don’t think about right or wrong answers; start reasoning, and together we will find the solution’ (PT facilitator 2 & nurse facilitator 3, activity #2,3,4)

Sharing a common model by communicating information in a structured way

The students discussed how the scenario highlighted the importance of interprofessional communication in an acute situation and that all participants shared patient information in a structured way using SBAR. They described that using the same structure contributed to understanding how to communicate and reach a shared and patient-centred mental model.

I know what to say, and the other person knows what to expect (PT student, activity #2).

The shared information is depending, on the other hand, on who they were communicating with and that participants were willing to listen to each other’s point of view:

You need to be an active listener…it doesn’t matter what I say if they don’t listen (PHCN student, activity #4).

Facilitators, observers and students commonly experienced using CRM to discuss leadership and professional responsibilities in care and in handover situations supported the students’ learning of who is leading and who is responsible for which part of the care action. A conclusion was that situated leadership and responsibility should be taken by the person with the best knowledge of handling an acute situation regardless of professionally situated leadership.

The one with the most experience and knowledge needs to take the lead in a cardiac arrest situation… I may not have the best knowledge… (medical student, activity #2) and a PT student continued in the same opinion: How to use everybody in a team when caring for a patient with a time-critical illness is essential (PT student, activity #1).

Reaching an understanding through collaborative reasoning

According to students, the developed IPL activity and scenario facilitated both wider understanding and new knowledge through interprofessional collaborative reasoning. They learnt from each other about both the chain of care and the roles and responsibilities of other professions while switching between thinking and speaking from their perspective and listening to others in planning care and medical treatment in both the ambulance service and at the PHC centre. One medical student expressed it as follows:

The patient had been somewhere else before entering the PHC…, It [the scenario] had a holistic perspective …even though I know the physiotherapist profession, I did not understand their roles and responsibilities in the chain of care (medical student activity #2).

The students experienced the benefits of solving problems in an interprofessional team instead of doing it by themselves or with peers, as nurse students (activity #2) describe:

…reasoning with different professions gave me more knowledge about what everyone can do and did in the care of the patient (nurse student, activity #2).

As students described, IPL in digital form added a new dimension and facilitated learning about each other’s professions, knowledge, roles and responsibilities in different contexts without needing to go between different healthcare facilities. By verbalising their perspectives, listening to others, sharing knowledge and experiences, the students reached interprofessional conclusions regarding patient care. It can be illustrated by the following quotation:

To do it [Scenario] interprofessional adds another dimension… that is very good… instead of just solving the case with my study colleagues … “… everyone has shared their knowledge… I have listened…and reflected on how to act in a similar situation in my context (OT student, activity #3).

The nurse students discussed that both CRM and SBAR also supported interprofessional reasoning when discussing the care for the patient during the different transitions in and between PHC centre and ambulance service:

I have little experience of the emergency care… the discussions have been good to prepare myself… knowledge about whom I should turn to, who has the knowledge, what information I should pass on, what will they want to know (nurse student, activity #4).

The facilitators addressed the gap in the discussion when not all healthcare professionals were represented in the group of students who participated in the current study. In such cases, the facilitators took an active part in the discussion using their own clinical experiences to secure the authenticity and acceptability of the newly developed IPL activity. They contributed with their perspectives and knowledge to facilitate IPL and collaborative learning, including their learning from both the students and the other participating facilitators. However, the facilitators’ participation was an act of balancing as the activity was developed for the students, and they needed the space to discuss and solve the case in collaboration with the other students.

The study explored IPL through the lens of collaborative reasoning using an authentic scenario presented in a digital IPL activity for students doing their clinical rotations in the ambulance service or at the PHC centre. A rationale for developing a digital IPL activity was the need for IPL activities in the ambulance service. By examining students, facilitators and observers’ experiences of the activity, the study has shed light on the acceptability, feasibility and practical implications of incorporating a digital IPL activity for undergraduate students from different healthcare facilities, particularly in the context of critically ill patient handovers between PHC centre and the ambulance services. The findings show that digital IPL activity also positively impacts students’ knowledge of and understanding of how to communicate by sharing information in a structured way, how to handle an acute care situation, and the value of collaborative reasoning. The scenario used in the IPL activity broadened all the students’ perspectives on the chain of care and enhanced discussions and knowledge of various professions’ roles and responsibilities. The use of a digital format of an IPL activity enabled learning across multiple geographical areas, which was necessary for the ambulance service, and in addition, underscored the importance of interprofessional problem-solving in handovers of patients within an acute care situation between different healthcare organisations. The findings also showed that when the activity was considered authentic, the students were able to communicate and share information, which enabled an interprofessional analysis. Therefore, it is reasonable to assume that the developed IPL activity supported students’ learning through an interactive group process consisting of collaborative analysis and joint critical reflections, factors that are also described by Reeves et al 4 to support IPL. However, there is a need to balance the different professions in their interactions and for the students to maintain communication while facilitating learning and supporting interprofessional discussions. 2 6 10 With all the different healthcare professionals represented in the current IPL activity, the scenario covered different perspectives to achieve an interprofessional perspective on patient care through the entire care process. However, the different group compositions that could not be predicted before each IPL activity clarified the need for a scenario that could be used regardless of which professions participated in the IPL activity. Overall, it seemed that the digital IPL activity with a scenario including a patient with an acute illness was feasible and relevant for all healthcare professionals as they should be able to initiate care in an acute situation. However, out of this study, we do not know the effects of the uneven distribution among different health professions in the IPL activity; facilitators became more active and participated in the discussions by using their clinical profession when necessary. According to both facilitators and students, the facilitators directly impacted how the IPL activity was carried out. Students expressed a desire for more guidance and support from the facilitators, while facilitators recognised the importance of incorporating various professions’ knowledge and perspectives into the clinical reasoning process for discussing optimal patient care. During the IPL activity, the facilitators employed different strategies to enhance the IPL. These strategies included encouraging active student participation, contributing additional knowledge to the scenario and discussions, asking questions to promote reflection and guiding students to summarise the discussions and patient findings using, for example, SBAR. The supervisors used facilitation strategies aligned with strategies identified in the Evans et al review. 33 The facilitators in the study did not represent all professionals of the students participating in all IPL activities, as suggested in previous literature. 34 In our study, when the facilitators did not represent all students’ disciplines in the activity, they met before, after and during breaks and sent text messages during each activity to ensure that perspectives from all healthcare professionals were considered and discussed during the scenario. In addition, the meetings aimed to adjust the facilitators’ different roles and strategies, as suggested in a previous study. 35 It may be considered important that the facilitator’s healthcare professions represent all the various disciplines of students participating in an IPL activity, but it may also be of more importance that the students themselves represent the different disciplines in the discussions as described by Oosterom et al . 9 However, further research is needed to clarify whether facilitators must represent all the various disciplines of students participating in an IPL activity. Regardless, the ambulance service needs to collaborate with other healthcare organisations to be able to conduct IPL activities because the number of different professions within the organisation is limited. Finally, to our knowledge, this study is the first to describe a collaboration between a PHC centre and the ambulance service in developing a digital IPL activity for students. This collaboration can facilitate cooperation between two healthcare organisations to enhance safe patient care.

The main findings of this study showed that the digital IPL activity and scenario developed were feasible for enhancing IPL related to acute situations, handover and patient safety in the context of PHC and the ambulance service. The positive impact of IPL concerning understanding and knowledge of different professions’ perspectives on care and treatment in acute situations, particularly in the ambulance service and PHC context, was evident. The findings also underscored the central role of facilitators in promoting collaborative reasoning, emphasising the need for a balanced and inclusive approach for optimal IPL outcomes. The developed digital IPL activity demonstrated potential sustainability and a necessity for the ambulance service as the digital approach supported overcoming geographical distances for both students and facilitators. By using a scenario involving an authentic case focusing on handovers of a critically ill patient, the feasibility and acceptability of using the developed digital activity for IPL were supported. By using digital solutions for the IPL activity, the ambulance service can offer IPL activities in collaboration with other healthcare settings for students doing their clinical rotations in the ambulance service. Finally, to our knowledge, this study is the first to describe a collaboration between a PHC centre and the ambulance service in developing a digital IPL activity for students. This collaboration can facilitate cooperation between two healthcare organisations to enhance safe patient care.

Limitations

The study has several limitations. First, the number of participants and completed IPL activities could be considered low. All students doing their clinical rotation in the PHC centre or the ambulance service when the activities were conducted were invited by e-mail and/or electronic bulletin board, but we do not know if all eligible students were reached. Second, not all professions among the students were representative during IPL activities. This was adjusted for by the facilitators taking an active professional role in the IPL activity, which may have caused a decrease in students’ participation in the discussions. However, this was not obvious during the analysis, but we do not know how the facilitators affected the IPL when the students did not represent all healthcare professionals. The third limitation of this study may have been the authors’ preconceptions and personal experiences, which may have influenced the interpretation and understanding of the study. The fact that the authors are female and have extensive clinical experience in the ambulance service or the PHC, and the fifth author is an intensive care nurse and IPL promotor may introduce biases during the study design, data collection and analysis. Despite the potential for bias, the authors’ preconceptions can also be a strength as they contribute to interpreting and understanding the study findings. Despite these limitations, this is the first study using data from IPL learning activities with students in clinical rotations in both the PHC centre and the ambulance service. Another strength of this study is that it was reasonable to assume that the IPL activity gave the students a possibility for IPL from the perspective of patient safety and patient needs in an acute situation. The third strength of the current study are multiple data sources (interviews, notes, observations) and 31 participants creating new knowledge based on qualitative analysis. Concerning the transferability of the study’s findings, as the study is based on IPL, CRM, SBAR, guidelines and patient safety, considered as generic elements within healthcare services, it is reasonable to assume that the findings from this study are transferable to different contexts where interprofessional education and learning on acute situations and patient handovers take place. Using a digital activity for IPL was considered to facilitate sustainability, which can enhance transferability and collaboration among different healthcare providers with students doing their clinical rotations in different geographical areas. However, quantitative and qualitative evaluation is warranted for IPL learning activities with authentic scenarios in acute transition situations over a longer period of clinical rotations and with a higher number of students.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by Etikprövnings myndigheten (The ethics review authority), Sweden (No.: 2021-00586). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

Thank you to all the students who participated in this study, Kristina Björk sharing knowledge on care in the ambulance service, and academic clinical adjuncts Helena Solman, Hege Jahr, and Abdullah Almaasarani.

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Contributors The first, second and last authors contributed during the study planning. HC and MT have a co-first authorship. VL, AN and SG collected data. VL initiated data analysis. HC and MT supported the data analysis. MT organised and coordinated learning activities at the Academic Primary Healthcare Centre. VL drafted the manuscript and all authors contributed, read and approved the final manuscript. VL is the guarantor and responsible for the overall content of this study.

Funding Karolinska Institutet, Stockholm, Sweden (educational funds for employees no.: 20200792), and Region Stockholm (ALF project no.: 20200223). No person from the founding committee participated in the study's design, data collection, analysis or writing of the manuscript.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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Towards reliable healthcare llm agents: a case study for pilgrims during hajj.

1. Introduction

• Knowledge retrieval: When the model encounters uncertain or ambiguous input, the RAG module retrieves relevant knowledge from specific external resources. This retrieval process enables the model to augment its understanding of the topic at hand and generate more informed responses.
• Validation of uncertain text: After retrieving relevant knowledge, the RAG module validates the uncertain text generated by the GPT-3.5 Turbo model against the retrieved information. By cross-referencing the model’s output with external knowledge sources, the RAG module assesses the accuracy and credibility of the generated text, identifying and correcting any inaccuracies or inconsistencies before finalizing the response.
• Domain-specific fine-tuning of LLM: We fine-tune a large language model (LLM) specifically for the domain of healthcare and cultural sensitivities relevant to Hajj pilgrims. This fine-tuning process ensures that the model is capable of understanding and generating relevant responses within the context of healthcare conversations during the pilgrimage.
• Introducing the HajjHealthQA dataset: To facilitate the development and evaluation of our healthcare chatbot, we introduce the HajjHealthQA dataset. This dataset contains a diverse collection of questions, answers, and conversations relevant to healthcare issues faced by Hajj pilgrims. We also employ synthetic data augmentation techniques ( https://github.com/AbeerMostafa/HajjHealthQA-Dataset (accessed on 1 March 2024)).
• RAG module for uncertainty validation: We add a retrieval-augmented generation (RAG) module to validate uncertain information provided by the chatbot. This mechanism enhances the reliability and accuracy of the chatbot’s responses by cross-referencing generated text with external knowledge sources.
• Training a secondary AI agent on the HealthVer dataset: We train two separate models as part of our framework, one on the HajjHealthQA dataset for Hajj-specific healthcare inquiries and another on the HealthVer dataset for medical information verification. The latter is used to verify that the medical information generated by our chatbot is supported by medical evidence.
• Prompt engineering for case study specifics: We employ prompt engineering techniques tailored to the specific case study of building a healthcare chatbot for Hajj pilgrims. This ensures that the chatbot’s responses are optimized for relevance, accuracy, and cultural appropriateness within the context of Hajj-related healthcare scenarios.
• Multilingual support: To accommodate the linguistic diversity of Hajj pilgrims, our chatbot offers multilingual support, allowing users to interact in their preferred language.

2. Related Work

2.1. health challenges faced by hajj pilgrims, 2.2. medical q&a, 2.3. use of synthetic data, 2.4. hajj q&a, 3. hajjhealthqa dataset, 4. methodology, 4.1. model fine-tuning, 4.2. retrieval-augmented generation, 4.3. evidence-based verification, 4.4. prompt engineering.

• Task-specific prompts
• Multilingual support
• Customization for cultural sensitivity
• Contextual awareness and follow-up prompts
• Iterative improvement through user feedback

5. Experimental Setup

5.1. hyperparameter tuning, 5.1.1. number of epochs, 5.1.2. batch size, 5.1.3. learning rate multiplier, 5.2. evaluation metrics, 6. results and discussion, 6.1. accuracy analysis, 6.2. quality metrics, 6.3. comparison with benchmark results, 7. data privacy and ethical considerations, 8. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Alghamdi, H.M.; Mostafa, A. Towards Reliable Healthcare LLM Agents: A Case Study for Pilgrims during Hajj. Information 2024 , 15 , 371. https://doi.org/10.3390/info15070371

Alghamdi HM, Mostafa A. Towards Reliable Healthcare LLM Agents: A Case Study for Pilgrims during Hajj. Information . 2024; 15(7):371. https://doi.org/10.3390/info15070371

Alghamdi, Hanan M., and Abeer Mostafa. 2024. "Towards Reliable Healthcare LLM Agents: A Case Study for Pilgrims during Hajj" Information 15, no. 7: 371. https://doi.org/10.3390/info15070371

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• Open access
• Published: 22 June 2024

Phytotherapeutic potential against MRSA: mechanisms, synergy, and therapeutic prospects

• Qiqi He 1 ,
• Julie Meneely 1 ,
• Irene R. Grant 1 ,
• Jason Chin 1 ,
• Séamus Fanning 2 &
• Chen Situ 1  

Chinese Medicine volume  19 , Article number:  89 ( 2024 ) Cite this article

136 Accesses

Metrics details

Rising resistance to antimicrobials, particularly in the case of methicillin-resistant Staphylococcus aureus (MRSA), represents a formidable global health challenge. Consequently, it is imperative to develop new antimicrobial solutions. This study evaluated 68 Chinese medicinal plants renowned for their historical applications in treating infectious diseases.

The antimicrobial efficacy of medicinal plants were evaluated by determining their minimum inhibitory concentration (MIC) against MRSA. Safety profiles were assessed on human colorectal adenocarcinoma (Caco-2) and hepatocellular carcinoma (HepG2) cells. Mechanistic insights were obtained through fluorescence and transmission electron microscopy (FM and TEM). Synergistic effects with vancomycin were investigated using the Fractional Inhibitory Concentration Index (FICI).

Rheum palmatum L., Arctium lappa L. and Paeonia suffructicosaas Andr. have emerged as potential candidates with potent anti-MRSA properties, with an impressive low MIC of 7.8 µg/mL, comparable to the 2 µg/mL MIC of vancomycin served as the antibiotic control. Crucially, these candidates demonstrated significant safety profiles when evaluated on Caco-2 and HepG2 cells. Even at 16 times the MIC, the cell viability ranged from 83.3% to 95.7%, highlighting their potential safety. FM and TEM revealed a diverse array of actions against MRSA, such as disrupting the cell wall and membrane, interference with nucleoids, and inducing morphological alterations resembling pseudo-multicellular structures in MRSA. Additionally, the synergy between vancomycin and these three plant extracts was evident against MRSA (FICI < 0.5). Notably, aqueous extract of R. palmatum at 1/4 MIC significantly reduced the vancomycin MIC from 2 µg/mL to 0.03 µg/mL, making a remarkable 67-fold decrease.

Conclusions

This study unveil new insights into the mechanistic actions and pleiotropic antibacterial effectiveness of these medicinal plants against resistant bacteria, providing robust evidence for their potential use as standalone or in conjunction with antibiotics, to effectively combat antimicrobial resistance, particularly against MRSA.

With a global median resistance level of 35%, Methicillin-resistant Staphylococcus aureus (MRSA) is acknowledged as one of the priority pathogens worldwide [ 1 ]. The World Health Organization has declared an urgent need for the development of novel antimicrobial compounds and antibiotic alternatives to safeguard the efficacy of existing antibiotics in a race to combat the emergence and spread of antimicrobial resistance (AMR), one of the world’s most pressing health and environmental issues. This has sparked a renewed interest in exploring medicinal plants as potential antimicrobial agents, or as supplementary phytotherapy in the management of infectious disease [ 2 , 3 ]. The use of whole plants or plant mixtures to cure diverse ailments has a long history that predates the Palaeolithic era, and this practice persists in many parts of the world today. Undoubtedly, mounting evidence from both in vitro and in vivo studies has demonstrated the pharmacological and therapeutic superiority of crude plant preparations over single constituents [ 4 ]. The multifactorial effects of plant-based therapies are believed to arise from the presence of a vast array of phytochemicals within the plant, which can target multiple bacterial sites simultaneously [ 5 ]. Cutting-edge research has uncovered the remarkable ability of phytochemicals to sensitize and potentiate the effectiveness of antibiotics, as well as possessing high susceptibility to resistant bacteria with low toxicity towards host cells [ 6 ].

Plants possessing medicinal properties represent an important component of the pharmaceutical industry due to their attributes and effectiveness in disease prevention and treatment. The medicinal plants selected for this study have a long history of traditional use in management of a diverse array of infectious diseases [ 7 ]. In the present study, we evaluate the antibacterial activity of aqueous preparations of these plants against MRSA (NCTC 12493), individually and/or in combination with vancomycin, the last resort of antibiotic for this deadly resistant pathogen. The safety profile of the candidate plants was assessed for their potential cytotoxicity on mammalian cells. Consequently, we employed both fluorescence microscopy (FM) and transmission electron microscopy (TEM) to determine the mechanistic principles underlying the efficacy of these medicinal plants, with respect to morphological and ultrastructural changes in MRSA. This is the first report that illustrates the subcellular structural alterations that occur in MRSA following exposure to medicinal plant extracts.

Bacterial strains and growth conditions

The MRSA (NCTC 12493) used in this study was supplied by the National Collection of Type Cultures (Public Health England, Colindale, London, UK). Mueller–Hinton (MH) agar or Mueller–Hinton (MH) broth was employed for preculturing and preparing the bacterial suspension for MRSA.

Preparation of medicinal plant extracts

The 68 dried commercial medicinal plants with specific parts of plant used for this study are listed in Table  1 . The processing of plant materials involved grinding the dried medicinal plants into fine powder using a planetary ball mill (PM100, Retsch, UK). The fine plant material was suspended in distilled water at 1:1000 (w/v) and subjected to ultrasonic treatment (VWR Ltd, UK) at 45 kHz for 15 min, followed by immersion in a boiling water bath for an additional 30 min. The resulting extract was centrifuged at 12,000 rpm for 10 min at room temperature (RT) and the supernatant was filtered through a 0.45 μm syringe filter (Merck Millipore Ltd, Ireland) before testing.

Anti-MRSA activity screening

Following the guidelines set by the British Society for Antimicrobial Chemotherapy (BSAC), the microdilution method was employed to determine both MBC and MIC [ 8 ]. Extracts of plants and antibiotic vancomycin (CAS 1404-93-9; Sigma-Aldrich Ltd, Poole, UK) were serially diluted in MH broth at concentrations ranging from 0.9 to 1000 mg/L and 0.25 to 128 mg/L, respectively, and added to microtiter plates (M2311-100EA, Greiner, UK). The extracts exhibited a subtle green or yellow tint, which did not obstruct or interfere with the observation of bacterial growth manifested as turbidity within the well.

MRSA suspensions, initially adjusted to McFarland standards (0.5), were diluted at a ratio of 1:100 in MH broth. A sterile (negative) control containing MH broth only, a growth control with a bacterial suspension, and a positive control with vancomycin were included in each 96-well plate. The plates were incubated for 18–20 h at 37 °C. The MIC value was established as the lowest concentration of the test sample that completely inhibited bacterial growth, confirmed by the absence of visible growth under the specified experimental conditions. The determination of MBC involved sub-culturing 10 μL of each dilution from and above MIC wells and spotting onto Mueller–Hinton (MH) agar (Oxoid, CM0337; Hampshire, UK) plate and incubated for a further 24 h at 37 °C. The MBC was defined as the lowest micro-dilution of antimicrobial compound that prevents organism growth on the agar plate, with a 99.9% killing (3 log reduction) in CFU/mL compared to untreated organism (growth control) [ 9 ].

The kinetics of bacterial growth were studied to evaluate the efficacy of medicinal plant extracts in inhibiting bacteria. This assessment was carried out at three concentrations (MIC, 2MIC, and 4MIC) at 37 °C, using a microplate reader (SynergyTM HT, BioTek, Winooski, Vermont, USA) for accurate measurements. The OD at 600 nm of each well was automatically measured and recorded every 30 min over 24 h. Data were acquired using Gen5 1.10 software, exported to Microsoft Excel for processing, and expressed as the mean value of three replicates. Analysis was conducted using Microsoft Excel and GraphPad Prism 7.0 (GraphPad Software Inc., San Diego, CA, USA). Normalization for comparison involved aligning the same starting point of all datasets, with different values shown on the y-axis for each sample.

The time-kill assay was carried out to determine the rate and extent of microbial killing over time by the plant-derived substances. A bacterial suspension (1 × 10 6  CFU/mL) was treated with a medicinal plant extract (500 μL) at concentrations of 1, 2, 3 and 4 × MIC (7.8 μg/mL, 15.6 μg/mL, 23.4 μg/mL, 31.2 μg/mL) of R. palmatum, Arctium lappa L. and P. suffructicosa , respectively. The mixture was incubated at 37 °C with gentle agitation in a Labwit shaker (ZWY-100H, Australia). Samples (10 μL) were taken at 0, 1, 3, 6, 20 and 24 h, serially diluted, and plated on MH agar. After incubation for 24 h at 37 °C, a bactericidal effect was defined as a 3-log reduction in viable cell count. The time-kill assays were performed in triplicate, and GraphPad Prism 7.0 was used for graphical representation.

Evaluation of the synergistic effect

A broth checkerboard microdilution assay was employed to investigate combined treatments of vancomycin and plant extracts [ 10 ]. The assay featured a two-dimensional checkerboard with two-fold dilutions of the antibiotic vancomycin (0.25–128 mg/L) horizontally and plant extract (0.9–1000 mg/L) vertically. The bacterial suspension (1 × 10 6  CFU/mL) was added and incubated for 18–20 h at 37 °C in 96-well plates. Controls included bacterial suspension, antibiotics and plant dilution controls. The MIC was determined to be the lowest concentration of plant extracts and antibiotic without visible bacterial growth. Effective combinations were identified, and the fractional inhibitory concentration (FIC) was calculated for the first clear well containing both antimicrobial agents:

FIC of A (plant extract) = MIC A+B in combination/ MIC A alone.

FIC of B (antibiotic) = MIC B+A in combination/ MIC B alone.

The FIC index (FICI), the sum of both calculated FIC values, was interpreted as follows: synergistic (≤ 0.5), additive (> 0.5 and ≤ 1); indifferent (> 1 and ≤ 4); antagonistic (> 4) [ 10 ].

Cytotoxicity evaluation of potential plant candidates

The cytotoxicity of plant extracts against hepatocellular carcinoma (HepG2) and colorectal adenocarcinoma (Caco-2) cell lines was assessed using the MTT (3-(4, 5-dimethylthiazolyl-2)-2, 5-diphenyltetrazolium bromide) colorimetric assay [ 11 ]. Cell lines were subcultured at 37 °C in a CO 2 incubator with 5% CO 2 gas and 95% humidity, using minimal essential medium (MEM) supplemented with 10% fetal bovine serum, 1% penicillin–streptomycin, 1 mM sodium pyruvate, and 2 mM L-glutamine. All reagents used were purchased from Life Technologies (Paisley, Scotland, UK). Cell suspension (100 μL) was seeded into BD Falcon 96-well microtiter plates (BD Biosciences, US) at a density of 1 × 10 4 cells/well and 5 × 10 3 cells/well for HepG2 and Caco-2 cells, respectively. After a 24 h cell attachment period, plant extracts (100 μL) at dilutions ranging from 0.0002 to 10 mg/mL were applied and incubated for 48 h. Following cell washing with phosphate buffered saline (PBS), 50 μL of 2 mg/mL MTT solution was added. After a 4 h incubation, the supernatant was discarded, and 200 μL of preheated dimethyl sulfoxide (DMSO) was introduced to dissolve formazan crystals. The plate was incubated at 37 °C with agitation for a further 10 min. Absorbance was measured at 570 nm with a reference filter at 630 nm using a TECAN microtiter plate reader (Safire II, BASIC). Viability was determined by calculating the percentage of sample absorbance relative to the untreated control. According to ISO 10993-5, the standard for test in vitro cytotoxicity, cell viability percentages less than 40% indicate significant cytotoxicity, values between 40 and 60% suggest moderate cytotoxic effects. Viability within the range of 60% to 80% is considered weak, and percentages above 80% are classified as non-cytotoxic [ 11 ].

FM analysis

Cultures of MRSA in the exponential phase were used to prepare a cell suspension at a concentration of 1 × 10 6  CFU/mL. Subsequently, 500 μL of each medicinal plant extracts of R. palmatum , A. lappa and P. suffructicosa at their MIC (7.8 μg/mL) diluted in MH broth was introduced into the prepared bacterial cell suspension (500 μL). The mixture was then incubated at 37 °C for 20 h before applying fluorescent dyes. As a growth control, a 500 μL cell suspension in 500 μL of MH broth was used. Following incubation, cells were rinsed, pelleted, and treated with 20 μl solution of 4% (v/v) formaldehyde for 10 min at room temperature in the absence of light. For nucleus staining, 20 μl Hoechst 33342 (Life Technologies, Scotland, UK) at 2 μM was added and incubated with the cells for 10 min at room temperature (RT) followed by three washes with PBS. Subsequently, the cells were counterstained with the red membrane dye FM 4–64 64 (Thermo Fisher Scientific, UK) at a concentration of 5 μg/mL for 5 min at RT, followed by additional 2 min on ice. The staining process was protected from light. FM images were captured immediately using the Olympus BX63 fluorescent microscope equipped with an Olympus DP74 camera with an excitation wavelength of 515 nm and an emission wavelength of 640 nm for the membrane, Excitation/Emission: 361/497 for the nuclear images, and co-staining using CellSens Dimension imaging acquisition software (Olympus, Center Valley, USA).

TEM analysis

Following a 24 h exposure to the medicinal extracts of R. palmatum , A. lappa and P. suffructicosa , bacterial cells were fixed for 2 h at RT in 2.5% (v/v) glutaraldehyde and 1.5% (v/v) paraformaldehyde buffered in PHEM (pH 7). The PHEM buffer comprised of 60 mM PIPES (piperazine- N, N' -bis), 25 mM HEPES (4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid), 10 mM EGTA (ethylene glycol-bis(β-aminoethyl ether)- N,N,N',N' -tetraacetic acid) and 2 mM MgCl 2 . Afterward, the cells underwent three times washes with PHEM buffer and resuspended in a 2% agarose solution. The agarose embedding technique, typically employed for tissue sample preparation, was repurposed with slight modifications for the current study to preserve bacterial cell integrity and ensure optimal image quality. The embedded cell pellets were processed using an automated tissue processor Leica EM-TP. Samples were first rinsed in PHEM buffer, then fixed, and stained with 1% (v/v) osmium tetroxide for 45 min, followed by dehydrated with a sequential ethanol series (30%, 50%, 75%, 95%, 3 × 100%), and finally three times washes in 100% acetone before embedding in Spurr resin (Electron Microscopy Sciences, Hatfield, USA). Semi-thin Sects (1 μm) were cut with a glass knife, followed by further cutting into ultrathin Sects. (90 nm) using a diamond knife via Ultracut-UCT ultramicrotome (Leica Microsystems, Vienna, Austria). Ultrathin sections were placed on formvar-coated, 300-mesh copper grids, and post-stained in the 2% (w/v) uranyl acetate and 1% (v/v) osmium tetroxide. The micrographs were captured using TEM (Jeol JEM-1400, USA), operated at 80 kV and magnification between × 1000 and × 50,000.

Anti-MRSA activity of aqueous plant extracts

The MICs of 68 crude aqueous plant preparations against MRSA (NCTC 12493) are shown in Table  1 . Eight plants exhibited significant anti-MRSA efficacy, displaying MIC values ranging from 7.8 μg/mL to 31.2 μg/mL. The minimum bactericidal concentrations (MBCs) for all eight plants extract a four-fold increase compared to their respective MICs, except for Reynoutria japonica Houtt (8 × MIC) (Table  2 ). The positive control, vancomycin, displayed MIC and MBC values of 2 µg/mL and 8 µg/mL (4 × MIC), respectively.

The growth inhibition effectiveness of these eight medicinal plant extracts were monitored over a 24 h period (Fig.  1 ). Treatment with Paeonia suffructicosa Andr. and Arctium lappa L. at their respective MICs resulted in pronounced growth inhibition, characterized by relatively flat curves compared to vancomycin, the antibiotic control (Fig.  1 B). Whereas at 4 × MICs (i.e. MBCs), R. palmatum, P. suffructicosa , A.lappa and Cyrtomium fortunei J. Smith exhibited the strongest anti-MRSA effect, similar to the antibiotic control of vancomycin.

Kinetic growth curves of MRSA (NCTC 12493) treated with eight aqueous medicinal plant extracts against MRSA (NCTC 12493). A MIC, B 2MIC, and C 4MIC. Antibiotic control: vancomycin at MIC. Growth control: MRSA suspension in MH broth

Time-kill assay revealed the bactericidal activity of three plants possessed against MRSA (NCTC 12493): R. palmatum, Arctium lappa L. and P. suffructicosa . The bactericidal properties of the medicinal plant extracts at 1, 2, 3 and 4 times the MIC are outlined in Table  3 , presenting the log reduction in viable bacterial cell count following a 24 h treatment period. As shown in Fig.  2 , treatment with R. palmatum (Fig.  2 a) or A. lappa (Fig.  2 b) at doses ≥ 2 × MICs resulted in similar growth patterns, manifesting an initial decline of 1-log within the first hour and a 3-log reduction (at 4 × MICs) after 24 h compared to the growth control. Whereas exposure to P. suffructicosa (Fig.  2 c) at ≥ 3 × MIC induced a significant reduction of viable MRSA after 1 h incubation followed with a fast downward trend of the growth curve, achieving > 3-log reduction by 6 h.

Log10 total viable bacterial colonies after treatment with R. palmatum ( a ) , A. lappa ( b ) and P. suffructicosa ( c ) extract at 1, 2, 3 and 4 × MIC for 0, 1, 3, 6, 20 and 24 h against MRSA (NCTC 12493)

Synergistic interactions between medicinal plants and the antibiotic vancomycin

Eight medicinal plants exhibiting promising anti-MRSA activity were chosen for a combination study with antibiotic vancomycin, and a summary of the results is provided in Table  4 . A synergistic effect was noted between vancomycin and three plant extracts, R. palmatum , Lithospermum erythrorhizon Sieb. et Zucc. and A. pilosa , with FIC indices of 0.25, 0.28 and 0.5, respectively.

Safety profile of antibacterial plant candidates towards mammalian cells

Table 5 illustrates the cell viability resulting from the application of plant extracts at four different concentrations (i.e. 1/4 × MIC, MIC, 4 × MIC, 16 × MIC). HepG2 cells remained remarkable viability even at elevated concentrations up to 16 × MIC (equivalent to 4 × MBC) from different plants, ranging from 88.3% to 101.5%. Exceptions were observed for C. fortune  (Fig. 3 e), with viability recorded at 84.3% at 4 × MIC and 72.1% at 16 × MIC, and P. suffructicosa with 83.3% at 16 × MIC (Fig. 3 c). When testing on Caco-2 cells, A. pilosa exhibited 74.7% viability at MIC which was further reduced to 67.1% (4 × MIC) and 65.7% (16 × MIC), respectively (Fig. 3 f). Whereas application of R. japonica (Fig. 3 d) and S. china (Fig  3 g) at 4 × MBC resulted in a cell viability of 81.5% and 82.2%, respectively. Based on the ISO 10993–5 standard for test in vitro cytotoxicity [ 12 ], there was no observed cytotoxicity activity in any of the tested plant extracts at their concentrations ranging from MIC to 8 × MIC, except for A. pilosa, which displayed weak cytotoxicity on Caco-2 cells without a distinct dose-dependent pattern.

Viability of HepG2 and Caco-2 cells was assessed using MTT after treatment with medicinal plants. Plant extractions included a R. palmatum , b A. lappa , c P. suffructicosa , d R. japonica , e C. fortune , f A. pilosa , g S. china , h L.erythrorhizon . Four times the MBC equals 16 × MIC for all plant extracts except R. japonica, where it is 32 × MIC. Error bars represent one standard deviation (SD) from the mean. Statistical analyses were conducted using ordinary one-way ANOVA, Dunnett’s multiple comparisons test in Graph Pad Prism 7 software. Statistical significance was defined as p values below 0.05, denoted as * for p < 0.0332 (*) and ** for p < 0.0021 (**)

Morphological and ultrastructural alterations of MRSA

MRSA grown in the absence of plant extract exhibited the characteristic spherical and regular shape surrounding by a smooth membrane stained in red with the blue-stained nucleoid DNA evenly distributed in the cytoplasm (Fig.  4 a). In contrast, cells exposed to plant extracts displayed marked changes in MRSA including bulging or invagination of membrane (Fig.  4 -ii), disassociated or loss of membrane, or irregular blue DNA staining (Fig.  4 -iii). Notably, treatment of R. palmatum resulted in the greatest cell membrane damage in MRSA compared to A. lappa and P. suffructicosa .

Fluorescence images of MRSA cells after treatment with plant extracts of R. palmatum (RP) , A. lappa (AL) and P. suffructicosa (PS) . FM 4–64 (red) for cell membrane and Hoechst 33342 (blue) for the DNA, in the absence ( a ) or presence of plant extracts at MIC (7.8 μg/ml) for 20 h ( b – d ). The images were captured under the magnification of 100 × to illustrate various types of damage to the bacterial cells. (i) The zoomed typical cells of irregular shape. (ii) The zoomed representative cells of losing membrane integrity including the changes of disassociated membrane, bulging and invaginations in the membrane. (iii) The zoomed distinctive cells with changes in DNA

The TEM micrographs (Fig.  5 ) unveil several distinct markers denoting the impairment of bacterial cells treated with the plant extracts at their MICs, including significantly thickened cell wall and septal (pink arrows); protruded blebs/blisters outside the cell wall (blue arrows); bugles and invaginations of membrane (yellow arrows); central condensation of nucleoid DNA (green arrows); and the bursting and/or lysing of cells (red arrows). The control cells, on the other hand, retained a unified cell wall and dense cytoplasm structure with non-distinguishable DNA (Fig.  5 A1–A2). The TEM images also reveal a crumpled cytoplasmic membrane after treatment of R. palmatum (Fig.  5 B) and A. lappa , with the latter also accompanied with the central condensed electron-lucent nucleoid DNA appearance (Fig.  5 C). Additionally, exposure to P. suffructicosa led to the formation of pseudo-multicellular Staphylococci with conspicuous thickened and disrupted cell walls and enlarged cell phenotype compared to the untreated cells (Fig.  5 -D2). Fig  6 illustrates a characteristic increase in the prevalence of pseudo-multicellular morphology (orange arrows) in MRSA following treatment with P. suffructicosa , displaying various degrees of thickened cell wall (pink arrows) and disruption in the cell membrane (yellow arrows). Table 6 provides a summary of the main morphological changes observed in both FM and TEM images.

TEM images of MRSA exposed to plant extracts of R. palmatum (RP) (B1–2) , A. lappa (AL) (C1–2) and P. suffructicosa (PS) (D1–2) at their MIC for 20 h. Control: MRSA cells without treatment (A1–2). The images were captured under the magnification of 30,000 × (scale bar = 200 nm) (A1–D1), and 20,000 × (scale bar = 500 nm) (A2–D2). The coloured arrows mark various types of damage in treated bacterial cells, including: thickened septal and peripheral portions of the cell wall (pink arrows), formation of blebs or invagination of cell membrane (yellow arrows), bubbles protruded from cell surface (blue arrows), central condensation (green arrows) and fragmentation (purple arrows) of bacterial DNA, lysed cells (red arrows), and bleb-like gaps between the cell wall and the cytoplasmic membrane (black arrow)

TME micrographs of MRSA exposed to plant extracts of P. suffructicosa (PS) at its MIC (7.8 μg/ml) for 20 h. The images were captured under the magnification of 15,000 × (scale bar = 500 nm). MRSA displayed a pseudo-multicellular form as a result of treatment (orange arrow), accompanied with thickened septal and cell wall (pink arrows), bubbles observed outside the cell wall (blue arrows), invagination of the cell membrane (yellow arrows), and the bleb-like gaps between the cell wall and membrane (black arrow)

Owing to Staphylococcus’s intrinsic resistance and the widespread use of antibiotics over the past decades, MRSA has evolved to resist virtually all beta-lactams [ 13 ]. As vancomycin is reserved as a last resort treatment for MRSA infections, it is imperative to investigate new and potent antimicrobial agents. The utilisation of traditional herbal medicine for the treatment of infectious diseases has gained global prominence as a leading alternative medicine [ 14 ]. Traditional plant species have been extensively examined for their antimicrobial properties using a variety of extraction methods, although many studies have focused on individual compounds derived from medicinal plants. A notable level of antibacterial potency is indicated when the MIC of natural products falls below 1 mg/mL [ 15 ].

Antimicrobial agents kill or inhibit bacteria primarily by disrupting their membranes or by interacting with intracellular components, thereby chemically with synthesis or functioning. Consequently, this affects bacterial cell-wall biosynthesis, membrane permeability, and DNA replication and repair [ 16 ]. Studies have shown that R. palmatum possesses antibacterial properties against a wide range of Gram-positive and Gram-negative bacteria, including Escherichia coli , S. aureus and MRSA [ 17 ]. Aloe-emodin, a prominent phytoconstituents found in R. palmatum extracts, inhibited the growth of S. aureus by affecting the permeability of the cell membrane, which was evidenced by the reduction of intracellular contents in treated bacterial cells and the disruption of membrane integrity, impacting on components such as phosphatidylethanolamine and phosphatidylglycerol [ 18 ]. Isopanduratin A, one of the main flavonoids present in A. lappa , induced damage to the cell wall of Gram-positive bacteria, such as Streptococcus mutans [ 19 ]. Qian and colleagues demonstrated that the phenolic compound paeonol, an active constituent of P. suffructicosa , effectively combated Klebsiella pneumoniae and Enterobacter cloacae, displaying a MIC of 64 μg/mL. It disrupted the integrity of bacterial cell membranes, resulting in cytoplasm leakage, as confirmed by the field emission scanning electron microscopy [ 20 ]. The present study is the first to report morphological and ultrastructural changes of MRSA induced by the crude aqueous extracts of R. palmatum, A. lappa and P. suffructicosa which were produced in a way resembling the traditional preparation of medicinal plants.

In this study, diverse crude plant extracts demonstrated low remarkably low MIC values ranging from 7.8 µg/mL to 31.2 µg/mL, comparable to the antibiotic control of vancomycin (MIC 2 µg/mL). Specifically, R. palmatum, A. lappa and P. suffructicosa extracts exhibited the strongest antibacterial activity with the lowest MIC (7.8 μg/mL) and MBC (31.2 μg/mL). The time-kill curves illustrated the dosage and time-dependent efficacy of these three plants. Notably, P. suffructicosa at 3 × MIC (i.e. 23.4 µg/mL) exerted a rapid and persistent bactericidal impact, eradicating over 99.9% (> 3-log) of MRSA within 6 h (Fig.  2 c). A prior study showed that aqueous extracts of R. palmatum inhibited the growth of both Gram-positive bacteria (e.g. S. aureus ) and Gram-negative bacteria (e.g. E. coli ) [ 21 ]. These results underscore the antibacterial potential of these plants, emphasizing their promising role as antimicrobials.

In addition to evaluating the antibacterial activity of individual medicinal extracts, we explored the interaction between plant substances and therapeutic antibiotics. R. palmatum , A. pilosa , and R. arnebiae exhibited a synergistic effect when combined with vancomycin. Significantly, at their respective MICs, these plant extracts demonstrated the capability to reduce the MIC of vancomycin against MRSA by a factor of four. A comparable effect has been noted with catechin, a flavonoids compound present in plants such as R. palmatum , Cyrtomium fortunei J. Smith and Agrimonia pilosa Ledeb [ 22 , 23 ]. Catechin has demonstrated diverse effects on the tested examined S. aureus strains. A decrease in MIC values of up to two-fold was observed for vancomycin in the presence of catechin [ 24 ]. Taylor et al. reported its mechanism of action, involving the disruption of the cell wall and depolarisation of the bacterial cytoplasmic membrane [ 25 ]. To our knowledge, this is the first report of synergism between vancomycin and medicinal plants R. palmatum , A. pilosa and R. arnebiae , respectively. Antibiotics have been found to be more effective when combined with plant-derived compounds capable of inhibiting efflux pump proteins and/or inactivating enzymes involved in multidrug resistance [ 26 ]. Synergistic mechanism of plant-derived substances and antibiotics may arise from the disruption of the bacterial cell membrane and cell wall facilitated by the phytochemicals, consequently increasing the influx of antibiotics into bacterial cells [ 27 ]. The results in this study reinforce the notion that this phenomenon could lead to effective treatments for infections caused by antibiotic-resistant bacteria. In contrast to single-component antibiotics, medicinal plants encompass a diverse array of bioactive phytochemicals, making it more challenging for microbes to adapt and develop resistance [ 28 ]. Further research on medicinal plants is required to comprehensively understand the synergistic mechanism, laying the foundation for developing pharmaceutical drugs derived from medicinal plants to control bacterial infections effectively.

Adverse effects stemming from cytotoxicity represent a significant concern in therapeutic drug especially when plant-based therapies are under consideration. In the present study, crude aqueous extracts from eight promising plants demonstrated significant safety profiles for both HpeG2 and Caco-2 cells at concentrations as high as 16 × MIC, with exceptions of C. fortune showing weak cytotoxicity towards HepG2 at 16 × MIC (72%), and A. Pilosa on Caco-2 with cell viability of 67% at 4 × MIC (Table  5 ). According to ISO 10993-5 standards, these eight tested plants would not be classified as potential cytotoxic substances, as their viability at MIC is greater than 80%, with the exception of A. pilosa (75%) [ 29 ]. Traditional medicine integrates plant species with inherent toxic properties, which are counteracted or detoxified by other herbal components. While toxicity may lead to different levels of adverse or undesirable effects, these may not necessarily be lethal [ 30 ]. Nonetheless, the challenge arises from insufficient comprehension of the in vivo biokinetic behavior of compounds, preventing the direct utilization of in vitro toxicity data to assess and extrapolate compound toxicity across entire organisms [ 31 ]. Consequently, future research endeavors will need to include in vivo toxicity investigations specifically focused on the examined medicinal plant extracts.

Cell membranes serve as a selective barrier, controlling the passage of molecules and ions from the extracellular environment to maintain cellular homeostasis [ 32 ]. Upon exposure to the plant extracts at their MICs, both FM and TEM images disclosed the formation of extensive and distinct bulges and invagination. Among them, R. palmatum induced the most substantial damage to the membrane (yellow arrows in B1 and B2 of Fig.  5 ), manifested by the presence of rough, wrinkled membrane, as well as retracted and ruptured cells and cell lysis (red arrow).

With its intricate multicomponent structure, the bacterial cell wall plays a crucial role in maintaining the physical architecture necessary to preserve the shape, size, and overall integrity of bacterial cells. Staphylococcal peptidoglycan (PG), the major component of the cell wall, features pentaglycine cross-bridges of nascent peptides that provide mechanical strength and flexibility for bacterial growth in the presence of countering osmotic pressure [ 33 ]. Impeding peptidoglycan biosynthesis or destabilizing its integrity can arrest cell growth, as bacterial biological pathways are intricately interlinked, and disruption in one system inevitably affects numerous other functional mechanisms with the cell [ 34 ]. In this study, the exposure of MRSA to crude plant extracts resulted in a significantly thickening of the bacterial cell wall. Notable, P. suffructicosa induced the most pronounced thickening in both cell wall and the septal, which are characteristics of RNA and/or protein synthesis inhibitors [ 35 ]. β-lactam antibiotics, such as imipenem and oxacillin, can induce cell wall thickening by inhibiting peptidoglycan cross-linking, resulting in the accumulation of loose and non-structural cell wall material. This association has also been observed between cell wall thickening and decreased peptidoglycan hydrolase activity [ 36 ]. Importantly, recent studies have confirmed that S. aureus cells cannot survive without a pentaglycine cross-bridge [ 37 ]. Moreover, an intriguing morphological transformation observed in MRSA in our study was the emergence of blebs/vesicles outside the cell wall upon treatment with R. palmatum and A. lappa (Fig.  6 , blue arrows). Formation of blebs, seen as protrusions found in the outer membrane of gram-negative species, has been reported following treatment with membrane-active agents such as peptides. The abundance of bleb-like structures witnessed in MRSA in this study might be attributed to the bacterial defence mechanism against membrane damage and cell lysis caused by plant extracts [ 38 , 39 ].

Besides impairing cell membranes and walls, the antibacterial impact of plant extract was observed internally within bacterial cells, evidenced by nucleoid condensation in the cytoplasm. It is worth noting that the capability of plant substances to induce alteration in nucleoid DNA has not been documented in previous literature. As illustrated in Fig.  4 A, the DNA in MRSA is typically evenly dispersed and indistinguishable in the cytoplasm. However, following treatment with plant extract, the nucleoid DNA exhibited condensation (indicated by green arrows) or fragmentation (purple arrow) in Fig.  5 . Nucleoid fragmentation has been reported to coincide with impaired chromosome segregation in S. aureus after treatment with nalidixic acid—a quinolone-based antimicrobial compound that damages DNA by targeting the DNA gyrase enzyme [ 40 ]. Our discovery of alterations in the nucleoid DNA in addition to cell walls and membranes serves as compelling proof of the multifaceted effects of plant-derived phytochemicals, akin to the impacts of antibiotics and antibacterial peptides.

Remarkably, the application of P. suffructicosa treatment led to the formation of pseudo-multicellular MRSA, featuring an unusually thickened cell wall and septum, along with conspicuous bleb-like gaps that separated the cell envelope from the cytoplasm. This finding emphasizes the profound structural changes induced by P. suffructicosa on MRSA. Pseudo-multicellular staphylococci has been found in S. aureus treated with low concentrations of chloramphenicol and some beta-lactam antibiotics, probably a result of inhibitions of autolytic wall enzymes that typically facilitate cell separation [ 41 ]. Similarly, exposure to subinhibitory concentration of vancomycin was observed to swiftly and completely suppress the autolytic system of S. aureus , resulting in a transit pseudo-multicellular form [ 42 ]. In this study, we discovered that P. suffructicosa extract was effective in induced the pseudo-multicellular phenotype after 20 h of treatment at MIC against MRSA. Recognizing the potential of this plant for monotherapy or in combination with vancomycin in managing vancomycin-resistant and other serios infections is a significant factor. The finding may offer insights into the observed rapid and sustained bactericidal activity of P. suffructicosa , as reflected in the time-kill curves.

Moreover, it has been shown that inactivation of methicillin resistance genes ( fem ) encoded for FemA and FemB proteins that are essential for pentaglycine bridge synthesis, can give rise to varying forms of pseudo-multicellular morphology. Specifically, the femA mutant MRSA exhibited irregularly shaped multiple cells, whereas the femB mutant displayed a more regularly arranged pseudo-multicellular phenotype, similar to our observations, suggesting a potential role of P. suffructicosa on the femB gene. More recently, Monteiro et al . confirmed that the emergence of pseudo-multicellular forms in femAB depleted S. aureus is associated with substantial membrane rupture, ultimately leading to bacterial lysis [ 37 ]. Together, it is conceivable to speculate that the anti-MRSA activity of P. suffructicosa may be attributed to its distinctive mechanistic action, which involves modulating gene expression, inhibiting DNA replication, and disrupting cell separation.

Our study’s findings unequivocally demonstrated the multifaceted impact of crude medicinal plant extracts prepared in a way that resembles their traditional usage. The coexistence of diverse active phytocomponents in plant-based therapeutics may lead to multifactorial effects, especially when these bioactive compounds act on various bacterial targets or synergize to improve the bioavailability of each constituent [ 43 ]. Surmounting AMR requires novel antibacterial agents that can prevail the resistant mechanisms of bacteria and/or resensitize the efficacy of existing antibiotics. The capability of plants to multitarget is crucial in treating multidrug-resistant (MDR) bacterial infections. More importantly, the superiority of phytotherapy is further emphasized by its lower tendence to elicit resistance, a fact that is attested by its longstanding effectiveness in the annals of traditional medicine. Moreover, there is a growing realisation that the conventional approach may not be the most appropriate for advancing phytobiotic developments, which involves bioassay-guided separation, purification, and isolation of individual specific bioactive compound to elucidate their precise mechanisms against resistant bacteria.

In conclusion, the findings presented in this paper offer robust evidence supporting the potential of medicinal plants as effective phytobiotics against resistant bacteria, either independently or in combination with existing antibiotics. This represents a pivotal advancement in phytotherapeutic research, providing a foundation for further exploration and development of botanical alternatives to address the escalating challenge of antimicrobial resistance in the healthcare landscape. Future research endeavours should focus on evaluating the antimicrobial potential of the promising medicinal plants against various MRSA strains, including clinical isolates, to enhance our understanding of their effectiveness. Additionally, conducting further in vivo cytotoxicity and antibacterial assessments towards different strains and clinical isolates will be crucial for developing therapeutic agents that can combat antibacterial resistance and enhance treatment outcomes.

Availability of data and materials

Data and materials presented in this study are available on request from the corresponding author. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

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This study was conducted as part of Qiqi He’s PhD program at Queen’s University Belfast, UK.

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Qiqi He, Julie Meneely, Irene R. Grant, Jason Chin & Chen Situ

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QH: Conceptualization, methodology, formal analysis, investigation, writing—original draft. JM: Methodology, writing – review. IG: Methodology, writing – review. JC: Methodology, writing—review. SF: Writing – review. CS: Supervision, resources, investigation, conceptualization, methodology, writing—review & editing.

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He, Q., Meneely, J., Grant, I.R. et al. Phytotherapeutic potential against MRSA: mechanisms, synergy, and therapeutic prospects. Chin Med 19 , 89 (2024). https://doi.org/10.1186/s13020-024-00960-8

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• Antimicrobial resistance
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• Medicinal plants
• Rheum palmatum L.
• Pseudo-multicellular cells
• Morphological changes

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