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Cited by 100Patient Safety and Medication ErrorsOccupational Health and Safety ResearchHealthcare Quality and Management

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature

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Archer, Stephanie, Hull, Louise, Soukup, Tayana, Mayer, Erik, Athanasiou, Thanos, Sevdalis, Nick, Darzi, Ara·2017·BMJ Open
DOI 10.1136/bmjopen-2017-017155PMC PMC5770969
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Abstract

Objectives: The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting. Design: To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers. Results: The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators). Conclusion: A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement.

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  • A systematic review of factors affecting patient safety incident reporting in healthcare by Archer and colleagues identified that the two main facilitating factors to engagement with incident reporting were processes and systems of reporting and organizational factors.

    “A systematic review of factors affecting patient safety incident reporting in healthcare by Archer and colleagues [43] identified that the two main facilitating factors to engagement with incident reporting were processes and systems of reporting (the features of the system that enable reporting, such as reducing the complexity of the process) and organizational factors (values, beliefs and”

    From Quality issue management and disclosure in forensic science: A survey of practice and perceptions (2025) · cites this paper as [43]

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Cited by

Sorted by citations

Authors
Archer, S., Hull, L., Soukup, T., Mayer, E., Athanasiou, T., Sevdalis, N., & Darzi, A.
Affiliations
  • National Institute for Health and Care Research (GB)
  • King's College London (GB)
Corresponding author
Archer, Stephanie
ORCID
Venue
BMJ Open
Publisher
BMJ
Published
2017-12
Volume
7
Issue
12
Pages
e017155
ISSN
2044-6055 (ISSN-L)
DOI
10.1136/bmjopen-2017-017155
PMC
PMC5770969
OpenAlex
W2777746310
Cited by
100
References
6
Citations by year
2026: 13 · 2025: 12 · 2024: 22 · 2023: 10 · 2022: 15 · 2021: 15 · 2020: 5 · 2019: 6 · 2018: 2
FWCI
6.11
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • BMJ Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Minerva Access (University of Melbourne) (submittedVersion, other-oa)
  • Research Portal (King's College London) (submittedVersion, cc-by)
  • Spiral (Imperial College London) (submittedVersion, other-oa)
Funders
National Institute for Health Research
Topics
  • Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
  • Health Sciences › Health Professions › Radiological and Ultrasound Technology › Occupational Health and Safety Research
  • Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
Keywords
patient safety, incident reporting, underreporting, barriers to reporting, reporting systems, organizational factors, preventable harm, theoretical framework
MeSH terms
Humans, Quality of Health Care, Risk Management, Medical Errors, Patient Safety

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