The missing evidence: a systematic review of patients' experiences of adverse events in health care
Open accessAbstract
PURPOSE: Preventable patient harm due to adverse events (AEs) is a significant health problem today facing contemporary health care. Knowledge of patients' experiences of AEs is critical to improving health care safety and quality. A systematic review of studies of patients' experiences of AEs was conducted to report their experiences, knowledge gaps and any challenges encountered when capturing patient experience data. DATA SOURCES: Key words, synonyms and subject headings were used to search eight electronic databases from January 2000 to February 2015, in addition to hand-searching of reference lists and relevant journals. STUDY SELECTION: Titles and abstracts of publications were screened by two reviewers and checked by a third. Full-text articles were screened against the eligibility criteria. DATA EXTRACTION: Data on design, methods and key findings were extracted and collated. RESULTS: Thirty-three publications demonstrated patients identifying a range of problems in their care; most commonly identified were medication errors, communication and coordination of care problems. Patients' income, education, health burden and marital status influence likelihood of reporting. Patients report distress after an AE, often exacerbated by receiving inadequate information about the cause. Investigating patients' experiences is hampered by the lack of large representative patient samples, data over sufficient time periods and varying definitions of an AE. CONCLUSION: Despite the emergence of policy initiatives to enhance patient engagement, few studies report patients' experiences of AEs. This information must be routinely captured and utilized to develop effective, patient-centred and system-wide policies to minimize and manage AEs.
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Patient-provider miscommunication is often identified as a quality and safety concern by patients even without an adverse event.
“Similar to our findings, patient-provider miscommunication is often identified as a quality and safety concern by patients even without an adverse event [37].”
From The hospital-to-home care transition experience of home care clients: an exploratory study using patient journey mapping (2023) · cites this paper as [37]
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Self-citation
- Authors
- Harrison, R., Walton, M., Manias, E., Smith–Merry, J., Kelly, P., Iedema, R., & Robinson, L.
- Affiliations
- The University of Sydney (AU)
- The Royal Melbourne Hospital (AU)
- University of Tasmania (AU)
- University College London (GB)
- Corresponding author
- Harrison, Reema
- Venue
- International Journal for Quality in Health Care
- Publisher
- Oxford University Press (OUP)
- Published
- 2015-09-29
- Volume
- 27
- Issue
- 6
- Pages
- 424-442
- ISSN
- 1353-4505 (ISSN-L)
- 1464-3677
- OpenAlex
- W1938826846
- Cited by
- 134
- References
- 73
- Citations by year
- 2026: 7 · 2025: 6 · 2024: 13 · 2023: 14 · 2022: 9 · 2021: 16 · 2020: 22 · 2019: 11 · 2018: 9 · 2017: 15 · 2016: 11
- FWCI
- 2.77
- Type
- journal article
- Language
- en
- Open access
- green
- figshare.com
- Licence
- cc-by
- Locations
- International Journal for Quality in Health Care (publishedVersion)
- PubMed (publishedVersion)
- eCite Digital Repository (University of Tasmania) (submittedVersion)
- Deakin Research Online (Deakin University) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- Research Portal (King's College London) (submittedVersion, other-oa)
- Funders
- National Health and Medical Research Council (NHMRC)
- Project Grant (1049703)
- NHMRC
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Life Sciences › Pharmacology, Toxicology and Pharmaceutics › Toxicology › Pharmacovigilance and Adverse Drug Reactions
- Health Sciences › Health Professions › General Health Professions › Patient Satisfaction in Healthcare
- Keywords
- adverse events, patient experience, patient harm, patient safety, medication errors, healthcare communication, care coordination, patient distress, patient engagement, quality of care
- MeSH terms
- Female, Humans, Health Knowledge, Attitudes, Practice, Male, Patients, Medical Errors
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