Patient safety is a central determinant of healthcare quality. Preventable infections, medication injuries, diagnostic and communication errors, falls, and failures to recognize clinical deterioration arise from complex interactions among clinical processes, professional roles and hospital systems. Single interventions may therefore be insufficient unless accompanied by reliable teamwork, local ownership, continuous measurement and organizational support. Multidisciplinary quality-improvement teams typically include physicians, nurses, pharmacists, infection-prevention personnel, quality specialists and administrators. Their activities may include root-cause analysis, ward-based safety meetings, staff training, standardized checklists, audit and feedback, process redesign, and rapid-cycle testing. Team-based QI programmes differ from routine multidisciplinary clinical care because they explicitly aim to change the reliability and outcomes of the care-delivery system. Earlier reviews of QI collaboratives found encouraging but heterogeneous effects, with stronger claims commonly based on uncontrolled before–after evaluations. Wells and colleagues highlighted the importance of active implementation and valid outcome measurement, while Schouten and colleagues found that improvements were not universal across controlled studies [1,2]. This variability warrants an updated clinical synthesis that contrasts successful programmes with neutral evaluations rather than assuming that teamwork alone improves safety. The present review examines hospital QI interventions in which multidisciplinary teams, interdisciplinary communication or coordinated safety implementation were essential programme components. The primary emphasis is on clinically meaningful outcomes, while safety culture and workflow measures are considered intermediate indicators of programme functioning. 2. Objectives The primary objective was to assess whether multidisciplinary QI teams and team-based hospital safety programmes were associated with reductions in preventable adverse events, healthcare-associated infections, surgical complications and mortality. Secondary objectives were to compare effects across clinical domains, examine process and safety-culture outcomes, identify components associated with implementation success, and evaluate methodological limitations affecting causal interpretation.

.1 Review design and framework This evidence synthesis was structured around the PRISMA 2020 reporting domains [3]. The population comprised hospital inpatients and care units; the intervention was a multidisciplinary or team-based QI programme; comparators were baseline care, concurrent control facilities or usual-care units; and outcomes included patient harm, infection, mortality, complications, medication injuries, falls, clinical escalation, process adherence and safety culture. 3.2 Search strategy and information sources Search concepts combined terms for hospital, inpatient, quality improvement, multidisciplinary, interdisciplinary, patient safety, team training, safety culture, CUSP, infection prevention, surgical checklist, pharmacist rounds, handoff, sepsis bundles, fall prevention, rapid response, mortality and adverse events. PubMed/MEDLINE-indexed publications, original journal reports and linked reference records were reviewed through June 2026. Studies published from 1999 onward were eligible to capture foundational interventions and contemporary programme adaptations. 3.3 Eligibility criteria Original hospital-based intervention studies were eligible when a coordinated team, professional collaboration or structured implementation programme was central to the intervention and at least one quantifiable clinical, safety or process outcome was reported. Cluster-randomised trials, controlled comparisons, interrupted time-series evaluations and multicentre before–after studies were considered. Reviews, commentaries, outpatient-only programmes and purely descriptive studies without an intervention or outcome assessment were excluded from the primary evidence synthesis. 3.4 Data extraction and synthesis Data were extracted for publication year, setting, design, intervention components, denominators, primary outcomes and reported effect estimates. In the presence of several reports from the same programme, denominators were not pooled. Results were organized by safety domain. No pooled relative risk, odds ratio or standardized effect size was calculated because outcomes, units of analysis, intervention content and follow-up periods differed substantially. 3.5 Assessment of evidence limitations Studies were appraised descriptively for comparator validity, secular trends, outcome ascertainment, adjustment for case mix, intervention fidelity and possible selection bias. Particular attention was paid to the distinction between surrogate measures, such as perceived safety culture or checklist adherence, and patient-level outcomes such as injury, infection and mortality.

4.1 Study selection Sixteen original hospital intervention studies were included in the qualitative synthesis (Figure 1). Their designs, settings, team-based interventions, and clinical outcomes are summarized in Table 1. .2 Study characteristics The evidence synthesis comprised 16 original reports spanning the period 1999–2020. The studies covered intensive care and infection prevention, surgical safety, medication management, handover communication, fall prevention, sepsis care, emergency response and unit-level safety culture. They varied widely in scale, from single-unit evaluations to national programmes involving more than 1,000 intensive care units. For that reason, study populations and hospital denominators were not summed across publications. Table 1. Characteristics and principal findings of the 16 original intervention studies Study Setting and design Team-based intervention Main reported finding Pronovost et al., 2006 [4] 103 ICUs; prospective collaborative Central-line bundle plus CUSP Mean CRBSI 7.7 to 1.4/1,000 catheter-days Berenholtz et al., 2014 [5] 1,071 ICUs; national cohort CUSP, line-insertion bundle, feedback Mean CLABSI 1.96 to 1.15/1,000 catheter-days Bion et al., 2013 [6] 215 ICUs; stepped programme Technical and behavioural infection control Adult CVC-BSI 3.70 to 1.48; trend not accelerated Saint et al., 2016 [7] 926 units, 603 hospitals; cohort Technical plus socioadaptive CAUTI prevention Non-ICU CAUTI 2.28 to 1.54/1,000 days Haynes et al., 2009 [8] 8 hospitals; before–after WHO operating-room team checklist Complications 11.0% to 7.0%; death 1.5% to 0.8% de Vries et al., 2010 [9] 6 intervention, 5 control hospitals Whole-pathway SURPASS team checklist Complications/100 patients 27.3 to 16.7 Neily et al., 2010 [10] 108 VA hospitals; controlled cohort Team training, briefings, coaching Mortality -18% trained vs -7% comparators Urbach et al., 2014 [11] 101 hospitals; natural experiment Province-wide surgical checklist adoption Mortality 0.71% to 0.65%; not significant Leape et al., 1999 [12] ICU plus control unit; controlled before–after Pharmacist on physician rounds Preventable ADEs 10.4 to 3.5/1,000 patient-days Kucukarslan et al., 2003 [13] General-medicine units; controlled Pharmacist embedded in rounding team Preventable ADEs 26.5 to 5.7/1,000 days Starmer et al., 2014 [14] 9 hospitals; multicentre before–after I-PASS handover training and audits Errors 24.5 to 18.8/100 admissions Dykes et al., 2010 [15] 4 hospitals; randomised trial Tailored multidisciplinary fall toolkit Falls 4.18 control vs 3.15 intervention Dykes et al., 2020 [16] 3 hospitals, 14 units; nonrandomised Patient-centred fall toolkit and team engagement Injurious falls -34% (adjusted RR 0.66) Levy et al., 2010 [17] 165 sites; international QI cohort Multidisciplinary sepsis bundles and audits Mortality 37.0% to 30.8% Hillman et al., 2005 [18] 23 hospitals; cluster RCT Medical emergency response teams Composite 5.86 vs 5.31/1,000; not significant Timmel et al., 2010 [19] 18-bed surgical ward; before–after CUSP team rounds, goals sheet and feedback 5 of 6 safety-culture domains improved 4.3 Prevention of healthcare-associated infections In the Michigan Keystone initiative, Pronovost et al. [4] combined infection-prevention practices with multidisciplinary safety processes across 103 ICUs. The median catheter-related bloodstream infection (CRBSI) rate decreased from 2.7 to 0 per 1,000 catheter-days within three months, and the mean rate fell from 7.7 to 1.4 at 16–18 months. The national On the CUSP: Stop BSI programme subsequently included 1,071 ICUs with 4,454,324 catheter-days; mean central-line-associated bloodstream infection (CLABSI) rates decreased from 1.96 to 1.15 per 1,000 catheter-days after 16–18 months [5]. These programmes coupled technical practices with staff engagement, safety-culture work and feedback of infection data. The English Matching Michigan programme provided an important counterpoint. Among 215 ICUs, the adult central venous catheter-associated bloodstream infection rate declined from 3.70 to 1.48 per 1,000 catheter-patient days, but the downward trend did not accelerate after intervention training, indicating that secular improvement may have contributed materially [6]. In a separate US urinary-catheter programme across 926 units from 603 hospitals, adjusted catheter-associated urinary tract infection rates declined overall and markedly in non-ICUs (2.28 to 1.54 per 1,000 catheter-days; incidence-rate ratio 0.68, 95% CI 0.56–0.82), whereas ICU rates were largely unchanged [7]. These findings demonstrate both the potential effect and setting-specific variability of multidisciplinary infection-prevention programmes. 4.4 Surgical safety and mortality The WHO Safe Surgery Saves Lives implementation study reported reductions in complications from 11.0% to 7.0% and in-hospital mortality from 1.5% to 0.8% after introducing a surgical checklist across eight international hospitals [8]. A wider surgical-pathway intervention, SURPASS, evaluated 3,760 patients before and 3,820 after checklist implementation in six hospitals, with five control hospitals. Complications per 100 patients decreased from 27.3 to 16.7, and in-hospital mortality fell from 1.5% to 0.8%, while comparable improvements were not seen in controls [9]. The Veterans Health Administration team-training evaluation involved 182,409 sampled procedures in 108 facilities. Annual surgical mortality declined by 18% in 74 training hospitals compared with 7% in 34 hospitals not yet trained [10]. However, in a population-based evaluation of checklist adoption at 101 Ontario hospitals, adjusted mortality was 0.71% before and 0.65% after implementation (odds ratio 0.91; 95% CI 0.80–1.03; P=0.13), and adjusted complication rates also did not decline significantly [11]. Thus, checklist presence and checklist effectiveness should not be treated as equivalent; team briefing quality, local implementation and programme fidelity matter. 4.5 Medication safety and clinical handovers Two controlled medication-safety studies supported embedding pharmacists within clinical teams. In an ICU study, Leape et al. [12] found a 66% reduction in preventable adverse drug events due to ordering errors, from 10.4 to 3.5 per 1,000 patient-days, while rates were essentially unchanged in a contemporaneous control unit. In general medicine, Kucukarslan et al. [13] observed a reduction from 26.5 to 5.7 preventable adverse drug events per 1,000 hospital-days following pharmacist participation in ward rounds; 147 of 150 pharmacist recommendations were accepted. The multicentre I-PASS handover intervention included 10,740 admissions across nine hospitals. Medical errors decreased from 24.5 to 18.8 per 100 admissions (23% relative reduction), and preventable adverse events declined from 4.7 to 3.3 per 100 admissions (30% reduction) [14]. Standardized communication, training, observation and sustainability activities were integrated rather than relying on a handover template alone. 4.6 Falls, sepsis and recognition of deterioration In a randomised study of acute-care units, Dykes et al. [15] reported fall rates of 4.18 per 1,000 patient-days in controls and 3.15 in intervention units (P=0.04); falls with injury did not show a significant difference. A later multicentre evaluation involving 37,231 patients across 14 medical units found an adjusted 15% reduction in overall falls and a 34% reduction in injurious falls after introducing a patient-centred fall-prevention tool kit [16]. These studies illustrate the value of involving nursing staff and patients in repeated risk assessment, individualized prevention and shared safety plans. In an international performance-improvement programme, Levy et al. [17] analyzed 15,022 patients across 165 sites. Compliance with the complete sepsis resuscitation bundle increased from 10.9% to 31.3% over two years, while unadjusted hospital mortality declined from 37.0% to 30.8%. As an observational initiative, the results are consistent with benefit but do not establish that the programme alone caused the mortality change. In contrast, the cluster-randomised MERIT trial involving 23 Australian hospitals found no statistically significant difference in the composite incidence of cardiac arrest, unexpected death or unplanned ICU admission (5.86 vs 5.31 events per 1,000 admissions; P=0.640) following implementation of medical emergency teams [18]. 4.7 Safety culture and implementation On a surgical inpatient unit, Timmel et al. [19] evaluated a Comprehensive Unit-based Safety Program (CUSP) incorporating a daily-goals sheet, increased nurse participation on physician rounds and systematic identification of safety hazards. Five of six assessed safety-culture domains improved significantly; the study did not establish a corresponding reduction in patient-level complications. Alongside the infection-prevention and handover programmes, this finding supports the importance of culture, shared goals and structured communication as implementation mechanisms, while emphasizing that cultural outcomes should not substitute for clinical end points. Table 2. Quantitative clinical and patient-safety outcomes reported in the reviewed studies Domain and study Analytic scale Published measure Key interpretation CRBSI: Pronovost [4] 103 ICUs 7.7 → 1.4 / 1,000 catheter-days 16–18 months; mean rates CLABSI: Berenholtz [5] 1,071 ICUs 1.96 → 1.15 / 1,000 catheter-days 16–18 months; mean rates CVC-BSI: Bion [6] 215 ICUs 3.70 → 1.48 / 1,000 days Adult ICUs; prior trend present CAUTI: Saint [7] 926 units 2.28 → 1.54 / 1,000 catheter-days Non-ICUs; adjusted IRR 0.68 Surgical harm: Haynes [8] 7,688 patients Complications 11.0% → 7.0% Mortality 1.5% → 0.8% Surgical harm: de Vries [9] 7,580 intervention patients Complications/100 patients 27.3 → 16.7 Control hospitals also studied Team training: Neily [10] 108 hospitals Annual mortality -18% vs -7% Trained vs not-yet-trained hospitals Checklist adoption: Urbach [11] 215,711 procedures Mortality 0.71% → 0.65% OR 0.91 (95% CI 0.80–1.03); NS Medication safety: Leape [12] ICU with control unit ADEs 10.4 → 3.5 / 1,000 days 66% reduction Medication safety: Kucukarslan [13] General medicine units ADEs 26.5 → 5.7 / 1,000 days 78% reduction Handover: Starmer [14] 10,740 admissions Errors 24.5 → 18.8 / 100 Preventable AEs 4.7 → 3.3 / 100 Falls: Dykes 2010 [15] 4 hospitals 4.18 vs 3.15 / 1,000 days Control vs intervention; P=0.04 Falls: Dykes 2020 [16] 37,231 patients Falls 2.92 → 2.49 / 1,000 days Injurious falls 0.73 → 0.48 Sepsis: Levy [17] 15,022 patients Hospital mortality 37.0% → 30.8% Observational; P=0.001 Emergency teams: Hillman [18] 23 hospitals Composite 5.86 vs 5.31 / 1,000 Control vs intervention; P=0.640 4.8 Methodological appraisal The strength of causal inference varied widely. Cluster randomisation in the MERIT study [18] and unit randomisation in the fall-prevention trial [15] reduced some sources of selection bias, but both were context-dependent and may have been affected by treatment contamination or follow-up duration. Large multicentre controlled or interrupted time-series studies provided more robust comparison than simple before–after audits, while uncontrolled programme evaluations remained vulnerable to secular infection trends, local leadership differences and changes in case mix. Differences in outcome definitions—including catheter-days, patient-days, admissions, procedures and hospital-level rates—also prevented meaningful statistical pooling. Table 3. Design-related methodological considerations Design group Representative studies Principal consideration Cluster-randomised / randomised trials Hillman [18]; Dykes 2010 [15] Randomisation strengthens comparison; implementation uptake and contamination may limit effect estimation. Controlled multicentre or natural experiments de Vries [9]; Neily [10]; Urbach [11] Concurrent comparison valuable; nonrandom allocation, measured compliance and secular shifts remain important. Interrupted time-series / prospective multiunit Dykes 2020 [16]; Starmer [14]; Saint [7] Temporal measurement improves precision; no blinded allocation and concurrent improvement initiatives may confound results. Collaborative before–after / national cohorts Pronovost [4]; Berenholtz [5]; Bion [6]; Levy [17] Large real-world denominators; participation and pre-existing declines constrain causal attribution. Controlled unit evaluations Leape [12]; Kucukarslan [13] Medication outcomes directly measured; limited settings and potentially non-equivalent teams. Safety-culture programme Timmel [19] Directly relevant to teamwork mechanism; patient-level clinical endpoints not assessed. Checklist before–after Haynes [8] International scope; before–after design and potential concurrent changes cannot be excluded.

The present synthesis indicates that coordinated multidisciplinary QI programmes can reduce defined categories of hospital harm, particularly device-associated infections, medication-related injuries, clinical handover failures and inpatient falls. Their effectiveness appears strongest when technical interventions are combined with mechanisms that change how professionals communicate and act: daily goals, shared responsibility, explicit escalation pathways, checklists embedded in workflow, audit and feedback, and senior leadership support. The findings do not imply that simply assembling a team or requiring completion of a form is sufficient. Infection-prevention collaboratives are informative because they couple standardised care processes with repeated feedback. However, the English Matching Michigan evaluation found that infection rates were already declining before training, cautioning against attributing all observed improvement to the programme itself [6]. Likewise, the Ontario checklist study did not replicate the impressive surgical improvements reported in early implementation studies [11]. These discrepancies suggest that context, team engagement and fidelity are likely effect modifiers; they also demonstrate the limitations of before–after designs. Programmes integrating pharmacists into clinical rounds showed substantial reductions in preventable medication injuries [12,13]. This relatively direct mechanism—availability of drug expertise at the moment of prescribing—may explain greater reproducibility across ICU and general medicine settings. Similarly, the I-PASS programme combined scripted information exchange with observation, education and sustained reinforcement, thereby targeting the upstream failures responsible for many handover-related errors [14]. A second distinction concerns process indicators versus patient outcomes. Improved safety culture, higher bundle compliance and more frequent rapid-response activation may be necessary for reliable care, but none guarantees a measurable reduction in mortality. The MERIT trial found increased emergency-team calls without a statistically significant improvement in the primary composite outcome [18]. Conversely, reductions in preventable medication injury and device infection are outcomes more directly attributable to specific care processes, although they remain vulnerable to observational bias. For hospital leaders, the most practical implication is to invest in focused multidisciplinary teams with defined ownership of a small number of risk pathways, credible measurement, regular review of outcome data, and explicit plans to sustain successful interventions. Team composition should reflect the safety problem; pharmacists are particularly important for prescribing hazards, infection preventionists for device-associated infections, nurses for falls, and surgeons, anaesthetists and operating-room staff for perioperative hazards. Patients and families can also contribute to reliable risk prevention, as demonstrated by patient-centred fall initiatives [16]. 5.1 Strengths and limitations The review draws together 16 original interventions across several hospital service lines and explicitly includes well-conducted null studies, providing a more balanced picture than analyses confined to successful programmes. Nevertheless, outcome definitions were heterogeneous, intervention components were often bundled, and many studies lacked random allocation or independent controls. Differences in time periods, baseline risks, organizational support and evaluation methods precluded a valid pooled estimate. The synthesized studies therefore support domain-specific conclusions rather than one universal numerical effect of multidisciplinary QI teams. 5.2 Implications for implementation and research Future evaluations should prospectively specify patient-level outcomes, incorporate appropriate concurrent controls or interrupted time-series analyses, and report team composition, implementation fidelity, staff engagement, programme costs and unintended consequences. Where feasible, cluster-randomised or stepped-wedge trials should separate technical protocol effects from social and organizational implementation components. Longer follow-up is needed to assess sustainability, especially in hospitals with high staff turnover or resource constraints.

Multidisciplinary quality-improvement teams can contribute meaningfully to hospital safety and improved clinical outcomes when supported by evidence-based protocols, reliable communication, continuous performance feedback and local accountability. Published programmes demonstrate substantial reductions in specific infections, medication errors, handover-related harm and falls. Nevertheless, surgical checklist adoption and rapid-response systems have not consistently improved mortality in controlled evaluations. The greatest clinical value is likely to arise from carefully targeted, multidisciplinary improvement programmes that measure patient harm directly and adapt implementation to the hospital setting.

1. Wells S, Tamir O, Gray J, Naidoo D, Bekhit M, Goldmann D. Are quality improvement collaboratives effective? A systematic review. BMJ Qual Saf. 2018;27(3):226–240. doi:10.1136/bmjqs-2017-006926. 2. Schouten LMT, Hulscher MEJL, van Everdingen JJE, Huijsman R, Grol RPTM. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ. 2008;336(7659):1491–1494. doi:10.1136/bmj.39570.749884.BE. 3. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71. 4. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–2732. doi:10.1056/NEJMoa061115. 5. Berenholtz SM, Lubomski LH, Weeks K, Goeschel CA, Marsteller JA, Pham JC, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol. 2014;35(1):56–62. doi:10.1086/674384. 6. Bion J, Richardson A, Hibbert P, Beer J, Abrusci T, McCutcheon M, et al. “Matching Michigan”: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf. 2013;22(2):110–123. doi:10.1136/bmjqs-2012-001325. 7. Saint S, Greene MT, Krein SL, Rogers MAM, Ratz D, Fowler KE, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374(22):2111–2119. doi:10.1056/NEJMoa1504906. 8. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–499. doi:10.1056/NEJMsa0810119. 9. de Vries EN, Prins HA, Crolla RMPH, den Outer AJ, van Andel G, van Helden SH, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928–1937. doi:10.1056/NEJMsa0911535. 10. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693–1700. doi:10.1001/jama.2010.1506. 11. Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014;370(11):1029–1038. doi:10.1056/NEJMsa1308261. 12. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;282(3):267–270. doi:10.1001/jama.282.3.267. 13. Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003;163(17):2014–2018. doi:10.1001/archinte.163.17.2014. 14. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803–1812. doi:10.1056/NEJMsa1405556. 15. Dykes PC, Carroll DL, Hurley A, Lipsitz S, Benoit A, Chang F, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17):1912–1918. doi:10.1001/jama.2010.1567. 16. Dykes PC, Burns Z, Adelman J, Benneyan J, Bogaisky M, Carter E, et al. Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial. JAMA Netw Open. 2020;3(11):e2025889. doi:10.1001/jamanetworkopen.2020.25889. 17. Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010;38(2):367–374. doi:10.1097/CCM.0b013e3181cb0cdc. 18. Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet. 2005;365(9477):2091–2097. doi:10.1016/S0140-6736(05)66733-5. 19. Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the comprehensive unit-based safety program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf. 2010;36(6):252–260. doi:10.1016/S1553-7250(10)36040-5.