For years, conversations about patient safety in chiropractic care have been dominated by questions about harm—how often adverse events occur, how serious they are, and what risks are associated with spinal manipulation. Yet patient safety, as defined by the World Health Organization (WHO), is far more than the absence of harm. Patient safety is a culture, a set of shared beliefs and behaviours, embedded within every aspect of care delivery.

When the World Federation of Chiropractic (WFC) launched its Global Patient Safety Initiative (GPSI) in 2023—aligned with the WHO Global Patient Safety Action Plan —it became clear that the chiropractic profession needed an evidence-based starting point. Before developing new policies, tools, or education strategies, we needed to answer a fundamental question:

What do we actually know about patient safety culture in chiropractic, and where are the gaps?

This question became the driving force behind our recent publication, Patient Safety Culture Research Within the Chiropractic Profession: A Scoping Review. The work was later recognized with the 2025 NCMIC–JMPT Research Award at the WFC Biennial Congress—an affirmation of the global relevance of this topic and the profession’s growing commitment to safety.

A Puzzle with Missing Pieces

Going into this project, we expected to find scattered evidence on adverse events or clinical decision-making. What surprised us was how unbalanced the research landscape truly was.

Across 65 studies published over three decades, we found:

•    95% focused on safety performance—primarily adverse event reporting
•    81% examined safety processes, such as clinical decision-making or documentation
•    Only 23% addressed the beliefs, values, and attitudes that form the foundation of safety culture

The closest thing to “culture”—the underlying norms that influence how practitioners think about risk, communicate with patients, or learn from mistakes—was nearly absent.

This pattern reflects where the global patient safety movement stood in the early 2000s: focused on errors and events, rather than systems and culture. But while other health professions moved toward a deeper examination of safety climate, leadership, communication, and patient engagement, chiropractic research largely stayed anchored in incident reporting.

Our findings confirmed what many clinicians and leaders have felt intuitively, that we cannot improve what we do not measure, and we have not been appropriately measuring the cultural aspects of safety that matter most.

Why This Review Matters Now

This review comes at a pivotal moment. The WHO has made eliminating preventable harm a global priority. Health systems worldwide are investing in safety leadership, interprofessional communication, patient engagement, and reliable reporting systems. And increasingly, patients expect transparency and accountability from all health professions.

Our findings highlight several opportunities for the chiropractic profession:

•    Developing standardized adverse event definitions and reporting systems
•    Embedding safety culture training into chiropractic education
•    Building collaborative research across disciplines
•    Engaging patients in defining what safe chiropractic care looks like and feels like
•    Strengthening leadership and policy structures that support a safety-first mindset

These are not small tasks. But they are achievable—and essential.

Looking Forward

This scoping review is not the final word on patient safety in chiropractic. —Our authorship team welcomes chiropractors and chiropractic patients to join us at the beginning of a long-term agenda.

Our hope is that this work will serve as a foundation for the WFC Global Patient Safety Initiative and inspire researchers, educators, regulators, clinicians, and patients to create and sustain a stronger, clearer, and more unified approach to safety.

Patient safety culture is not built overnight. But with deliberate effort, open dialogue, and evidence-based strategies, the chiropractic profession can take meaningful steps toward ensuring safer care for every patient, in every setting, around the world.