Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

Lawton, Rebecca; McEachan, Rosemary R C; Giles, Sally J; Sirriyeh, Reema; Watt, Ian S; Wright, John

doi:10.1136/bmjqs-2011-000443

Cited by 311Patient Safety and Medication ErrorsHospital Admissions and OutcomesHealthcare Quality and Management

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

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Lawton, Rebecca, McEachan, Rosemary R C, Giles, Sally J, Sirriyeh, Reema, Watt, Ian S, Wright, John·2012·BMJ Quality & Safety

DOI 10.1136/bmjqs-2011-000443PMC PMC3332004

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Abstract

OBJECTIVE: The aim of this systematic review was to develop a 'contributory factors framework' from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings. DESIGN: A mixed-methods systematic review of the literature was conducted. DATA SOURCES: Electronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts. ELIGIBILITY CRITERIA: Studies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety. RESULTS: 1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. CONCLUSIONS: This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.

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The social influences and environmental context and resource domains of the Theoretical Domains Framework point to organisational and systems context for change.
“For example, the social influences and environmental context and resource domains point to organisational and systems context for change and can be further elaborated, e.g. by Normalisation Process Theory [66], the Consolidated Framework For Implementation Research [67] and the Yorkshire Contributory Factors Framework [68].”
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Authors: Lawton, R., McEachan, R. R. C., Giles, S. J., Sirriyeh, R., Watt, I. S., & Wright, J.
Affiliations: University of Leeds (GB)
Bradford Royal Infirmary (GB)
University of York (GB)
Corresponding author: Lawton, Rebecca
ORCID: Lawton, Rebecca
McEachan, Rosemary R C
Giles, Sally J
Watt, Ian S
Wright, John
Venue: BMJ Quality & Safety
Publisher: BMJ
Published: 2012-03-15
Volume: 21
Issue: 5
Pages: 369-380
ISSN: 1475-3898 (ISSN-L)
2044-5415
2044-5423
DOI: 10.1136/bmjqs-2011-000443
PMC: PMC3332004
OpenAlex: W2164086521
Cited by: 311
References: 129
Citations by year: 2026: 13 · 2025: 14 · 2024: 16 · 2023: 21 · 2022: 21 · 2021: 34 · 2020: 24 · 2019: 31 · 2018: 28 · 2017: 19 · 2016: 24 · 2015: 27 · 2014: 23 · 2013: 15
FWCI: 5.26
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: cc-by-nc
Locations: BMJ Quality & Safety (publishedVersion, cc-by-nc)
Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
PubMed Central (publishedVersion, cc-by-nc)
PubMed (publishedVersion)
White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
Research Explorer (The University of Manchester) (submittedVersion, cc-by-nc)
Funders: National Institute for Health and Care Research (RP-PG-0108-10049)
Programme Grants for Applied Research (RP-PG-0108-10049)
Topics: Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
Keywords: patient safety incidents, hospital errors, active failures, team factors, communication, patient harm prevention, secondary care
MeSH terms: Data Interpretation, Statistical, Hospitals, Humans, Quality Assurance, Health Care, Databases, Bibliographic, Adverse Drug Reaction Reporting Systems, Medical Errors, Empirical Research, Evidence-Based Practice, Root Cause Analysis, Patient Safety

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Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

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