Background Safety recommendations are one of the most widely used tools for translating analysis of safety issues into improvement actions, but can sometimes complicate and confuse rather than support systemic safety improvement efforts. Methods This paper explores the range of problems that can limit the effectiveness and impact of safety recommendations, and uses these problems as a basis for articulating a set of guiding principles which may support more systematic and robust approaches to making and monitoring safety recommendations. Results One of the most notable problems with safety recommendations in healthcare is the enormous quantity and abundance of recommendations that are produced, which can overwhelm those who are expected to act on them. Other problems include a lack of rigour in identifying and analysing the safety risks that recommendations aim to address, variability in specifying the risks to be addressed and the improvements to be achieved, and limited integration or connection between recommendations. Recommendations can also be inappropriately used as a management tool, can become confused with orders or requirements for compliance and can have little supporting infrastructure for ensuring system improvements actually result. Conclusions This paper explores these problems and argues that addressing these problems requires systematic and robust processes for defining the risks that need to be targeted by recommendations, as well as more sophisticated governance systems for supporting coordinated improvement activities. A set of eight principles is proposed, which can support a more systematic, integrated and robust approach to developing and using safety recommendations.
Carl Macrae (2026) studied this question.