Burnout and patient safety: navigating between exaggerated evidence and warranted assertability

Job burnout is widely assumed to be a key driver of patient safety failures in healthcare, underpinning numerous research programmes and policy interventions. However, the strength and quality of the empirical evidence supporting this assumption remain unclear. Using a critical interpretive synthesis, we reviewed quantitative systematic reviews and interrogated the primary studies they included, allowing direct comparison between review-level conclusions and the underlying empirical evidence. Across eight reviews, only a minority of primary studies examined objective safety outcomes, and findings were inconsistent. Despite this, review conclusions often implied stronger and more generalisable effects than the evidence warranted. We identify four recurring problems in the literature: a narrow occupational focus, limited theoretical positioning of burnout within patient safety systems, extrapolation beyond objective evidence, and conflation of reported with observed safety events. Drawing on the concept of warranted assertability, we argue that burnout cannot currently be justified as a direct predictor of patient safety outcomes. Instead, burnout is better understood as a system-level condition that shapes care processes, reporting practices, and organisational adaptation. We conclude by proposing an open-systems framework for theorising burnout and patient safety that aligns psychological constructs with the realities of complex socio-technical healthcare systems.