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First do no harm: practitioners’ ability to ‘diagnose’ system weaknesses and improve safety is a critical initial step in improving care quality
  1. Mike English1,2,
  2. Muthoni Ogola2,3,
  3. Jalemba Aluvaala2,3,
  4. Edith Gicheha2,4,
  5. Grace Irimu2,3,4,
  6. Jacob McKnight1,
  7. Charles A Vincent5
  1. 1Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
  2. 2Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
  3. 3Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
  4. 4Kenya Paediatric Research Consortium, Nairobi, Kenya
  5. 5Experimental Psychology, University of Oxford, Oxford, UK
  1. Correspondence to Professor Mike English, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK; menglish{at}


Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work.

  • health services research
  • neonatology
  • nursing care
  • data collection

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  • Contributors ME and CAV developed the ideas for this manuscript and created the first draft with all authors reviewing and developing subsequent drafts. All authors approved the final version of the manuscript.

  • Funding CV is supported by the Health Foundation (UK) and funds from The Wellcome Trust (#207522) awarded to ME as a Senior Fellowship support his work. The funders had no role in drafting or submitting this manuscript.

  • Disclaimer The authors have written this report in their personal capacities and any opinions expressed are their own and not indicative of the views of the institutions with whom they are affiliated.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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