Implementation of safety management systems (SMS) in healthcare: a systematic review and international comparison

Clinical Snapshot

Key Findings

• P Value: Not applicable - descriptive study

• Effect Size: Some improvement in hospital patient safety aspects noted

• Primary Outcome: Only Netherlands implemented explicit SMS-based patient safety programme

• Nnt Or Sensitivity: Not applicable - no quantitative effectiveness data

• Confidence Interval: Not reported

Clinical Application

Limited evidence for SMS implementation feasibility in healthcare settings Australia included as case study but limited specific evidence (5 publications). Findings suggest SMS concepts have influenced Australian patient safety approaches but formal SMS implementation not documented Australian healthcare system as one of five studied countries

Abstract

OBJECTIVES: Many industries where safety is a priority (eg, aviation) use safety management systems (SMSs), but evidence on their use in healthcare is needed to determine whether they could support patient safety improvement. We investigated the application of national-level SMSs to patient safety in terms of effectiveness, implementation and experience. DESIGN: Systematic review using a case study approach. DATA SOURCES: We identified patient safety organisations in each country and searched their websites. We also searched MEDLINE (in December 2023) and Embase (via Ovid), CINAHL (EBSCO) and Web of Science (in February 2024). ELIGIBILITY CRITERIA: Any evidence from five high-income countries that have publicly funded healthcare systems with universal coverage: Australia, Canada, Ireland, New Zealand and the Netherlands. We included publications on the effectiveness, implementation or experience of the patient safety approach in each country. DATA EXTRACTION AND SYNTHESIS: Included evidence was summarised and mapped onto an initial analytical framework based on analysis of SMSs in high-risk industries, enabling cross-country comparisons. Drafts were shared with experts from patient safety organisations in each country for comment. Formal quality appraisal was not possible as most evidence was non-evaluative. RESULTS: 53 publications were included, from Australia (5), Canada (7), Ireland (8), New Zealand (9) and the Netherlands (24). Only the Netherlands implemented a patient safety programme explicitly based on an SMS approach. Some aspects of patient safety in hospitals improved as a result, but there was significant variation in both the implementation of the programme and attributed outcomes.In the other four countries, the main components of an SMS were identified to some extent, along with evidence that their patient safety approaches had been influenced by concepts from high-risk industries and 'safety science' more widely. CONCLUSIONS: Emerging ideas from high-risk industries (beyond SMSs) and broader safety science have influenced all countries, reflecting increasing awareness of the need for initiatives to be context-specific to be successful. However, their implementation and impact need further evaluation. PROSPERO REGISTRATION NUMBER: CRD42023487512.

References

1. 1.de Bell, S., Zhelev, Z., Bethel, A., Clarke, M., Anderson, R., & Thompson Coon, J. (2026). Implementation of safety management systems (SMS) in healthcare: a systematic review and international comparison. BMJ Open. https://doi.org/10.1136/bmjopen-2025-107772