SynthesisBMJ quality & safety2012
Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.
Synthesis in BMJ quality & safety, 2012. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 118 papers, 7 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
118 citing papers in PubMed, 7 syntheses or guidelines pooled it.
- Nutritional Deficiencies Following Bariatric Surgery: A Rapid Systematic Review of Case Reports of Vitamin and Micronutrient Deficiencies Presenting More Than Two Years Post-Surgery.Clinical obesity · 2025Pooled it
- Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.Health expectations : an international journal of public participation in health care and health policy · 2023Pooled it
- How safe is prehospital care? A systematic review.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2021Pooled it
- Factors contributing to the patient safety culture in Saudi Arabia: a systematic review.BMJ open · 2020Pooled it
- The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review.BMC health services research · 2020Pooled it
- Factors that influence the recognition, reporting and resolution of incidents related to medical devices and other healthcare technologies: a systematic review.Systematic reviews · 2015Pooled it
- Patient complaints in healthcare systems: a systematic review and coding taxonomy.BMJ quality & safety · 2014Pooled it
- Trial
- User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.BMJ quality & safety · 2021Trial
- Patient safety incidents and medication errors during a clinical trial: experience from a pre-hospital randomized controlled trial of emergency medication administration.European journal of clinical pharmacology · 2020Trial
- What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study.BMJ quality & safety · 2018Trial
- Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention.BMJ quality & safety · 2017Trial
- Assessing the quality of patient safety incident investigation reports.International journal for quality in health care : journal of the International Society for Quality in Health Care · 2026Article
- Expanded nursing roles for person-centred care for people with cognitive impairment in hospitals: developing a complex intervention using a multi-method-approach.BMC health services research · 2026Article
- Article
- Article
- Improving the Understandability of Clinical Guidelines: Development and Evaluation of a GPT-4-Based Pipeline.Journal of medical Internet research · 2026Article
- Structuring medication safety narratives: development and evaluation of the medication-related incident reports annotation scheme.Frontiers in digital health · 2026Article
- Artificial intelligence approach to optimise safety for hospitalised patients with dementia.BMJ open quality · 2025Article
- Best practices in telesurgery: framework and recommendations from the society of robotic surgery (SRS) for safe and effective implementation.Journal of robotic surgery · 2025Review
58 more citing papers are in PubMed but not listed here.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
6 authors.
Funding
Abstract
objectiveThe 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.
designA 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.
results1502 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.
conclusionsThis 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.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.