Modifications and adaptations to evidence-based interventions are common, and of special relevance to complex interventions in healthcare. Although they play an important role in scale-up and sustainment, the potential exists for negatively affecting the core functions of an intervention. This study explores modifications to rapid response systems (RRSs), using the established Framework for Reporting Adaptations and Modifications – Expanded (FRAME). RRSs are patient safety interventions developed to identify and respond to hospital patients in clinical deterioration. Despite widespread use, little evidence-based guidance exists for necessary adaptations to local context. Applying adaptation frameworks is a novel perspective to improve RRS intervention design and implementation guidance. We aimed to explore which modifications and adaptations to RRSs that have taken place in Norwegian hospital units, how they occurred, and what the underlying reasons were by using FRAME. Nine hospital units across six hospitals, which had initiated the implementation of RRSs 4 to 12 years previously, were included. Data was collected through focus group and individual interviews with clinicians and leaders. Analysis involved two steps: a conventional, inductive content analysis to identify and categorize modifications, followed by further characterization of these modifications through deductive analysis employing FRAME. Inductive analysis identified 5 categories and 24 subcategories of modifications to the RRS intervention. Application of FRAME revealed modifications to be mainly reactive and occurring in the maintenance/sustainment phase, decided at the unit level and with varying fidelity consistency. Both structured and informal processes were identified. The goals of modifications were improvement of feasibility, effectiveness and fit, and reasons were related to available resources, service structure, clinical judgment and patient factors. Minor adaptations to FRAME were necessary to fit the RRS intervention and the methods of data collection. Studying real-life implementations of RRSs provides insight in modification processes, highlights which intervention elements are modified for better fit and feasibility, and which modifications are prone to fidelity inconsistency. Our findings underline the ubiquity of modifications to RRSs, and the need to systematically anticipate them throughout all implementation stages. Further exploration of RRS core functions and application of FRAME within collectively implemented patient safety interventions could advance the field.

BACKGROUND:Engaging patients in surgical safety is challenging and has not been thoroughly investigated. Although surgical checklists and other safety protocols have been introduced across various surgical fields, preventable adverse events still occur, highlighting the need for additional research. A Patient's Safety Checklist (PASC) has been developed and validated for use by surgical patients. Its effect on patient safety and patient outcomes is currently being investigated in a Stepped Wedge Cluster Randomised Controlled Trial (NCT03105713). In connection with this trial, we have examined elective patients' experiences with using the PASC. METHODS:An exploratory qualitative study was conducted based on individual in-depth telephone interviews with 31 elective surgical patients. The interviews were carried out across three Norwegian hospitals including seven surgical specialties. The patients interviewed were part of the trial's intervention arm and had used PASC. The interviews were transcribed verbatim, and reflective thematic analysis was applied. RESULT:Three themes were identified in the data: patient awareness, patient actions and utility value. Patients perceived PASC to increase awareness around surgical information, preparations, what to speak up about and which information to seek and repeat. This awareness led to a series of actions, such as ensuring medication control, optimising their own health, contacting healthcare professionals, asking questions, and for some no actions were needed. Patients perceived PASC to have high utility value for their surgical preparation. CONCLUSIONS:The PASC enhanced patients' involvement in surgical care and safety by ensuring they received systematic, accurate, clear, and understandable information and instructions throughout the surgical pathway. It is one of the few existing interventions that specifically focuses on assisting patients in preparing for surgery and managing their recovery. Further research is needed on the implementation of PASC and its adaptation to other clinical settings. TRIAL REGISTRATION NUMBER:NCT03105713.

Introduction Overuse of high-cost imaging like MRI and CT scans is a growing concern, with 4-100% of examinations deemed of low value. This contributes to unnecessary healthcare costs and patient risks such as overdiagnosis. Norwegian general practitioners (GPs) demonstrate variable referral practices, with many referrals being inconsistent with guidelines. The study aimed to evaluate the feasibility and usability of 'VeRaVest,' a multicomponent intervention targeting improved radiology referral practices among GPs in Western Norway.Methods The intervention combined three elements: (1) referral guidelines integrated into electronic systems, (2) group-based courses on guideline compliance using quality improvement principles and (3) a web-based feedback system. The study was conducted with 139 GPs recruited in two cohorts in 2023, evaluated using a step-wedge design. Data sources included qualitative feedback from GPs and quantitative measures like referral completion rates. Participants' referral data were anonymised and analysed using a PACS/RIS (Pictures Archive and Communications System/Radiology Information System) system.Results Preliminary results indicate high GP satisfaction with the intervention. About 76% of participants reported changes in referral practices, including improved indication assessments, better referral descriptions and enhanced patient communication. GPs emphasised the importance of accessible guidelines, peer-based learning and actionable feedback. Integration of decision support tools and guideline-based training was pivotal in aligning practices with national standards.Discussion The multicomponent VeRaVest intervention demonstrated feasibility and potential to reduce low-value imaging practices. Success hinged on embedding guidelines into workflows, fostering peer engagement and ensuring practical relevance. Future evaluations will focus on quantitative outcomes, including referral rates and quality. Findings suggest scalability to other healthcare settings and regions.

Introduction Despite malnutrition being established as a well-known risk for postoperative complications, the lack of screening for nutritional risk remains a challenge. The aim of this study was to investigate whether self-screening for nutritional risk prior to surgery is feasible in a home setting and if it will increase number of patients screened for nutritional risk, and secondly, to compare their screening results with the “in-hospital assessments” conducted by healthcare professionals. Materials and methods This was a prospective study involving patients from six randomly selected surgical wards at two Norwegian hospitals as a part of the “Feasibility study of implementing the surgical Patient Safety Checklist the (PASC)”. This checklist included a self-reported screening tool based on the Nutritional Risk Screening tool (NRS 2002) to identify “at risk of malnutrition” in patients that will undergo surgery the next 3 months or less. The original screening tool (NRS 2002) was used as a standard routine to identify “at risk of malnutrition” by healthcare professionals at hospital. The interrater reliability between these results was investigated using Fleiss multi rater Kappa with overall agreement and reported with Landis and Koch’s grading system (poor, slight, fair, moderate, substantial, and almost perfect). Results Out of 215 surgical patients in the home setting, 164 (76.7%) patients completed the self-reported screening tool. A total of 123 (57.2%) patients were screened in-hospital, of whom 96 (44.7%) prior to surgery and 96 (44.7%) were screened both at hospital (pre- and post-surgery) and at home. Self-screening at home improved malnutrition screening participation by 71.9% compared to hospital screening prior to surgery (165 (76.7%) and 96 (44.7%), respectively) and by 34.1% compared to pre- and postoperative in-hospital screening, 165 (76.7%) and 123 (57.2%), respectively). The degree of agreement between patients identified to be “at risk of malnutrition” by the self-reported screening tool and healthcare professionals was poor (κ = - 0.04 (95% CI: -0.24, 0.16), however, the degrees of agreement between the patients and healthcare professionals answers to the initial NRS 2002 questions “low BMI”, “weight loss”, and “reduced food intake” were almost perfect (κ = 1.00 (95% CI: 0,82, 1.18)), moderate (κ = 0.55 (95% CI: 0.34, 0.75)), and slight (κ = 0.08 (95% CI: - 0.10, 0.25) respectively. Conclusions Three out of four patients completed the self-screening form and the preoperative screening rate improved with 70%. Preoperatively self-screening in a home setting may be a feasible method to increase the number of elective surgical patients screened for risk of malnutrition. Trial registration The trial is registered in ClinicalTrials.gov ID NCT03105713. https://classic.clinicaltrials.gov/ct2/show/NCT03105713.

Introduction Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted.Objective The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research.Methods We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed.Results From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement. Most studies reported activities from multiple categories. Implementation factors included: clinical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation. Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread. Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities.Conclusions The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice.

Background The World Health Organization’s Global Patient Safety Action Plan 2021–2030 call for attention to patient and family involvement to reduce preventable patient harm. Existing evidence indicates that patients’ involvement in their own safety has positive effects on reducing hospitalisation time and readmissions. One intervention reported in the literature is the use of checklists designed for patients’ completion. Studies on such checklists are small scale, but they are linked to reduction in length of hospital stay and readmissions. We have previously developed and validated a two-part surgical patient safety checklist (PASC). This study aims to investigate the feasibility of the PASC usage and implementation prior to its use in a large-scale clinical trial. Methods This is a prospective cross-sectional feasibility study, set up as part of the design of a larger stepped-wedge cluster randomised controlled trial (SW-CRCT). Descriptive statistics were used to investigate patient demographics, reasons for not completing the PASC and percentage of PASC item usage. Qualitative patient interviews were used to identify barriers and drivers for implementation. Interview was analysed through content analysis. Results Out of 428 recruited patients, 50.2% (215/428) used both parts of PASC. A total of 24.1% (103/428) of the patients did not use it at all due to surgical or COVID-19-related cancellations. A total of 19.9% (85/428) did not consent to participate, 5.1% (22/428) lost the checklist and 0.7% (3/428) of the patients died during the study. A total of 86.5% (186/215) patients used ≥ 80% of the checklist items. Barriers and drivers for PASC implementation were grouped into the following categories: Time frame for completing the checklist, patient safety checklist design, impetus to communicate with healthcare professionals and support throughout the surgical pathway. Conclusions Elective surgical patients were willing and able to use PASC. The study further revealed a set of barriers and drivers to the implementation. A large-scale definitive clinical-implementation hybrid trial is being launched to ascertain the clinical effectiveness and scalability of PASC in improving surgical patient safety. Trial registration Clinicaltrials.gov: NCT03105713. Registered 10.04.2017

Purpose To investigate ambulatory antibiotic use in children during 1 year before and 1 year after in-hospital antibiotic exposure compared to children from the general population that had not received antibiotics in-hospital. Methods Explorative data-linkage cohort study from Norway of children aged 3 months to 17 years. One group had received antibiotics in-Hospital (H+), and one group had not received antibiotics in-hospital (H-). The H+ group was recruited during admission in 2017. Using the Norwegian Population Registry, 10 children from the H- group were matched with one child from the H+ group according to county of residence, age and sex. We used the Norwegian Prescription Database to register antibiotic use 1 year before and 1 year after the month of hospitalisation. Results Of 187 children in the H+ group, 83 (44%) received antibiotics before hospitalisation compared to 288/1870 (15%) in the H- group, relative risk (RR) 2.88 (95% confidence interval 2.38-3.49). After hospitalisation, 86 (46%) received antibiotics in the H+ group compared to 311 (17%) in the H- group, RR 2.77 (2.30-3.33). Comorbidity-adjusted RR was 2.30 (1.84-2.86) before and 2.25 (1.81-2.79) after hospitalisation. RR after hospitalisation was 2.55 (1.99-3.26) in children 3 months-2 years, 4.03 (2.84-5.71) in children 3-12 years and 2.07 (1.33-3.20) in children 13-17 years. Conclusions Children exposed to antibiotics in-hospital had two to three times higher risk of receiving antibiotics in ambulatory care both before and after hospitalisation. The link between in-hospital and ambulatory antibiotic exposure should be emphasised in future antibiotic stewardship programs.

Objectives To investigate whether infants exposed to antimicrobials in hospital during the first 3 months of life had an increased risk of ambulatory antimicrobial use during the following year compared with infants not exposed to antimicrobials during the first 3 months of life. Methods Norwegian cohort study of infants less than 3 months consisting of one group exposed to antimicrobials recruited during hospitalization and one group not exposed to antimicrobials. Ten unexposed infants were matched with one exposed infant according to county of residence, birth year and month, and sex. The Norwegian Prescription Database was applied to register antimicrobial use from the month after discharge and 1 year onward. We defined comorbidity based on antimicrobials prescribed as reimbursable prescriptions due to underlying diseases. Results Of 95 infants exposed to antimicrobials during the first 3 months of life, 23% had recurrent use compared with 14% use in 950 unexposed infants [relative risk (RR) = 1.7 (95% CI = 1.1-2.5) and comorbidity-adjusted RR = 1.4 (95% CI = 0.9-2.2)]. The recurrence use rate in exposed term infants (>= 37 weeks, n = 70) was 27% compared with 12% in their unexposed matches [RR 2.3 = (95% CI = 1.4-3.7) and comorbidity-adjusted RR = 1.9 (95% CI = 1.2-3.2). Of 25 exposed preterm infants, 3 (12%) had recurrent use. The total antimicrobial prescription rate was 674/1000 in the exposed group and 244/1000 in the unexposed group [incidence rate ratio = 2.8 (95% CI = 1.6-4.9)]. Conclusions Infants exposed to antimicrobials during the first 3 months of life had an increased risk of recurrent use during the following year. This increased risk also appeared in term infants without infection-related comorbidity.

DERR1-10.2196/37441.

Objectives: To evaluate cost-effectiveness of the WHO Surgical Safety Checklist. Background: The clinical effectiveness of surgical checklists is largely understood. Few studies to-date have evaluated the cost-effectiveness of checklist use. Methods: An economic evaluation was carried out using data from the only available randomized controlled trial of the checklist. Analyses were based on 3702 procedures. Costs considered included checklist implementation costs and length and cost of hospital stay, costs of warming blanket use, blood transfusions and antibiotics used in the operating room, and the cost of clinical time in the operating room – all calculated for each procedure and its associated admission. Nonparametric bootstrapping was used to simulate an empirical distribution of the mean effect of the checklist on total admission costs and the probability of observing a complication-free admission and to quantify sampling uncertainty around mean cost estimates. Results: The overall cost of checklist implementation was calculated to be $900 per 100 admissions. Implementation of the WHO checklist resulted in an additional 5.9 complication-free admissions per 100 admissions and an average of 110 bed-days saved per 100 admissions. Accounting for all costs included in the analysis, for every 100 admissions, use of the WHO checklist was estimated to save $55,899. Conclusions: Implementation of the WHO checklist was a cost-effective strategy for improving surgical safety.

Background Humans struggle to grasp the extent of exponential growth, which is essential to comprehend the spread of an infectious disease. Exponential growth bias is the tendency to linearize exponential functions when assessing them intuitively. Effective public health communication about the nonlinear nature of infectious diseases has strong implications for the public’s compliance with strict restrictions. However, there is a lack of synthesized knowledge on the communication of the exponential growth of infectious diseases and on the outcomes of exponential growth bias. Objective This systematic review identifies, evaluates, and synthesizes the findings of empirical studies on exponential growth bias of infectious diseases. Methods A systematic review will be conducted using the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) 2015 statement. Eligibility criteria include empirical studies of exponential growth bias of infectious diseases regardless of methodology. We include studies both with and without interventions/strategies. For information sources, we include the following five bibliographic databases: MEDLINE, Embase, Cochrane Library, PsychINFO, and Web of Science Core Collection. The risk of bias will be assessed using RoB 2 (Risk of Bias 2) and STROBE (Strengthening the Reporting of Observational Studies in Epidemiology). Data synthesis will be achieved through a narrative synthesis. Results By February 2022, we included 11 experimental studies and 1 cross-sectional survey study. Preliminary themes identified are the presence of exponential growth bias, the effect of exponential growth bias, and communication strategies to mitigate exponential growth bias. Data extraction, narrative synthesis, and the risk of bias assessment are to be completed by February 2023. Conclusions We anticipate that this systematic review will draw some lines related to how people comprehend and misperceive exponential growth and its consequences for infectious disease mitigation and communication. Furthermore, the study will conclude with the limitations of the research and suggestions for future research. International Registered Report Identifier (IRRID) DERR1-10.2196/37441

Objective: To describe epidemiology and antimicrobial susceptibility testing (AST) data of bacteria causing invasive infections in Norwegian children (0-18 years). Methods: Population-based observational study using prospectively collected AST data from the Norwegian Surveillance System of Antimicrobial Resistance from 2013 to 2017. We included all clinically relevant bacterial isolates (blood and cerebrospinal fluid), and compared incidence of invasive infections and AST data in isolates from children and adults. Results: We included 1173 isolates from children and 44,561 isolates from adults. Staphylococcus aureus accounted for 220/477 (46.2%, 95% CI: 41.6-50.7) of all isolates in schoolchildren (6-18 years). Compared with Streptococcus pneumonia isolates from adults (N = 2674), we observed higher nonsusceptibility rates to penicillin in isolates from children (N = 151), 11.9% versus 5.8%, P < 0.01; also higher resistance rates to erythromycin (11.3% vs. 4.9%, P < 0.01), clindamycin (9.3% vs. 3.6%, P < 0.001), and trimethoprim/sulfamethoxazole (17.9% vs. 6.4%, P < 0.001). Compared with Escherichia coli isolates in adults (N = 9073), we found lower rates of ESBL in isolates from children (N = 212), 2.4% versus 6.4%, P < 0.05. Conclusion: The study indicates the importance of microbiologic surveillance strategies in children and highlights the need for pediatric AST data. The high rates of nonsusceptibility to commonly used antibiotics among S. pneumoniae in children and the high burden of invasive S. aureus infections in schoolchildren calls for modifications of Norwegian guidelines.

Background: Implementation of antibiotic stewardship programmes (ASPs) in hospitals is challenging and there is a knowledge gap on how to pursue this process efficiently. Objectives: To evaluate whether audit and feedback (A&F) is a feasible and useful methodology to assess and support the implementation of ASPs in hospitals. Methods: A multidisciplinary team performed document reviews and on-site interviews with professionals involved in the implementation of ASPs. Oral feedback on preliminary findings and areas of improvement were provided on-site, followed by feedback reports summarizing major findings and recommendations. Descriptive statistics were used to present number of hospital trusts, interviewees, professions, disciplines, workload and costs. Results: All 22 hospital trusts in Norway participated in the A&F conducted October 2017 to April 2019. Altogether, 446 leaders and healthcare workers were interviewed: 110 leaders, 336 health professionals of whom 89 were antimicrobial stewardship team members. Median number of days from audits were performed till reporting were 36 (IQR 30-49). Median workload for auditors per visit was 7 days (6-8). Total costs were (sic)133 952. Main audit findings were that ASP structures were established in most hospital trusts, but leadership commitment and implementation of interventions were often lacking. The hospital trusts received feedback on establishing governance structures, setting local targets, implementing interventions and increased involvement of nurses. Conclusions: Nationwide A&F provides a unique and comprehensive insight into the implementation of ASPs in hospitals and is feasible with a reasonable amount of resources. This approach can identify targets for improved implementation of ASPs in hospitals.

Background & aims: Being "at risk of malnutrition", which includes both malnutrition and the risk to be so, is associated with increased morbidity and mortality in both surgical and non-surgical patients. Several strategies and guidelines have been introduced to prevent and treat this, but the effects are scarcely investigated. This study aims to evaluate the long-term effects of these efforts by examining trends concerning: 1) the prevalence of patients 'at risk of malnutrition >> and 2) the use of nutritional support and diagnostic coding related to malnutrition over an 11-year period in a large university hospital. Moreover, we wanted to investigate if there was a difference in trends between surgical and non-surgical patients. Methods: From 2008 to 2018, Haukeland University Hospital, Norway, conducted 34 point-prevalence surveys to investigate the prevalence of patients 'at risk of malnutrition >>, as defined by Nutritional Risk Screening 2002, and the use of nutritional support at the hospital. Diagnostic coding included ICD10 codes related to malnutrition (E43, E44 and E46) at hospital discharge, which were extracted from the electronic patient journal. Trend analysis by calendar year was investigated using logistic regression models with and without adjustment for age (continuous), gender (male/female) and Charlson Comorbidity Index (none, mild, moderate or severe). Results: The number of patients included in the study was 18 933, where 52.1% were male and the median (25th, 75th percentile) age was 65 (51, 76) years. Of these, 5121 (27%) patients were identified to be 'at risk of malnutrition >>. Fewer surgical patients (21.2%) were 'at risk of malnutrition >>, as compared to non-surgical patients (30.9%) (p < 0.001). Adjusted trend analysis did not identify any change in the prevalence of patients 'at risk of malnutrition >> from 2008 to 2018. The percentage of patients 'at risk of malnutrition >> who received nutritional support increased from 61.6% in 2008 to 71.9% in 2018 (p < 0.001), with a range from 55.6 to 74.8%. This trend was seen for both surgical and non-surgical patients (p < 0.001 for both). Similarly, dietitians were more involved in the patients' treatment (range: 3.8-16.7%), and there was increased use of ICD-10 codes related to malnutrition during the study period (range: 13.0-41.8%) (p < 0.001). These trends were seen for both surgical patients and nonsurgical patients (p < 0.001), despite use being less common for surgical patients, as compared to non-surgical patients (p < 0.001). Conclusions: This large hospital study shows no apparent change in the prevalence of patients 'at risk of malnutrition >> from 2008 to 2018. However, more patients 'at risk of malnutrition >>, both surgical and non-surgical, received nutritional support, treatment from a dietitian and a related ICD-10 code over the study period, indicating improved nutritional routines as a result of the implementation of nutritional guidelines and strategies. (c) 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Abstract Background The World Health Organization (WHO) Surgical Safety Checklist (SSC) has demonstrated beneficial impacts on a range of patient- and team outcomes, though variation in SSC implementation and staffʼs perception of it remain challenging. Precisely how frontline personnel integrate the SSC with pre-existing perioperative clinical risk management remains underexplored – yet likely an impactful factor on how SSC is being used and its potential to improve clinical safety. This study aimed to explore how members of the multidisciplinary perioperative team integrate the SSC within their risk management strategies. Methods An ethnographic case study including observations (40 h) in operating theatres and in-depth interviews of 17 perioperative team members was carried out at two hospitals in 2016. Data were analysed using content analysis. Results We identified three themes reflecting the integration of the SSC in daily surgical practice: 1) Perceived usefullness; implying an intuitive advantage assessment of the SSCʼs practical utility in relation to relevant work; 2) Modification of implementation; reflecting performance variability of SSC on confirmation of items due to precence of team members; barriers of performance; and definition of SSC as performance indicator, and 3) Communication outside of the checklist; including formal- and informal micro-team formations where detailed, specific risk communication unfolded. Conclusion When the SSC is not integrated within existing risk management strategies, but perceived as an “add on”, its fidelity is compromised, hence limiting its potential clinical effectiveness. Implementation strategies for the SSC should thus integrate it as a risk-management tool and include it as part of risk-management education and training. This can improve team learning around risk comunication, foster mutual understanding of safety perspectives and enhance SSC implementation.

ObjectivesOur primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel's safety culture perceptions.SettingA longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital.ParticipantsWe invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017.Primary and secondary outcome measuresPrimary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded.ResultsSurvey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being 'Hospital managers' support to patient safety' from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07-0.21).ConclusionThe National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.