Evidence map›Paper›PMID 41052815›Full record

SynthesisBMJ open quality2025

Systematic review of patient safety incident reporting practices in maternity care.

Emma Beecham, Gráinne Brady, Syka Iqbal, Qanita Fatima, Saeeda Arshad, Paulina Bondaronek, James O'Carroll, Stephanie Glaser, Dimitrios Siassakos, Katie Gilchrist and 3 more

Abstract readSystematic Review
PubMed Full text at PMC Publisher
In one paragraph

Synthesis in BMJ open quality, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.

0numbers the graph read from it
0cells of the map it votes in
2citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from 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.

2 · The registry

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.

3 · Its place in the literature

Who cites it

2 citing papers in PubMed.

  1. Article
  2. Review
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

13 authors.

Emma BeechamDepartment of Targeted Intervention, University College London, London, UK e.beecham@ucl.ac.uk.ORCID 0000-0002-1832-0286
Gráinne BradyDepartment of Targeted Intervention, University College London, London, UK.ORCID 0009-0002-2141-781X
Syka IqbalDepartment of Targeted Intervention, University College London, London, UK.
Qanita FatimaDepartment of Targeted Intervention, University College London, London, UK.
Saeeda ArshadDepartment of Targeted Intervention, University College London, London, UK.
Paulina BondaronekDepartment of Targeted Intervention, University College London, London, UK.ORCID 0000-0003-0096-1234
James O'CarrollUniversity College London Hospitals NHS Foundation Trust, London, UK.
Stephanie GlaserUniversity College London Hospitals NHS Foundation Trust, London, UK.
Dimitrios SiassakosUniversity College London Hospitals NHS Foundation Trust, London, UK.
Katie GilchristDepartment of Targeted Intervention, University College London, London, UK.ORCID 0000-0002-8529-4997
Jenny DoreyDepartment of Targeted Intervention, University College London, London, UK.
Rebecca KnaggDepartment of Targeted Intervention, University College London, London, UK.
Cecilia VindrolaDepartment of Targeted Intervention, University College London, London, UK.ORCID 0000-0001-7859-1646

Funding

National Institutes of Health Care Research NIHR204297
6 · The paper itself

Abstract

problemPatient safety incident reporting in maternity care is central for improving safety, yet inconsistencies in reporting practices and limited understanding of system functionalities may reduce its effectiveness.

backgroundReporting incidents allows healthcare providers to identify safety issues and implement improvements. However, variations in reporting practices, particularly in maternity care, have been found across different healthcare settings. Despite the growing use of electronic systems, challenges such as under-reporting, lack of feedback and insufficient organisational learning persist.

aimThis review explores how patient safety incidents are reported in maternity care, identifies the systems used globally, examines potential barriers and enablers to reporting, and highlights gaps in existing research and practice.

methodsA systematic review was conducted, analysing studies that focused on incident reporting practices in maternity care. An artificial intelligence text analysis tool (Caplena) was used to aid the synthesis of the study data. Methodologies included quantitative surveys, qualitative interviews and mixed methods approaches.

findingsA total of 15 studies from seven different countries were analysed. Reporting systems ranged from traditional paper-based methods to electronic platforms. Barriers included organisational culture, time pressures and inadequate reporting platforms. Enablers involved supportive leadership, training and user-friendly reporting systems. Substantial gaps included the under-reporting of near misses, lack of feedback mechanisms and insufficient attention to staff experiences. DISCUSSION: The findings highlight the need for consistent, user-friendly reporting systems and fostering a supportive, non-punitive culture. Strengthening and improving feedback mechanisms is also critical to enhance reporting practices. Recommendations are provided for designing future reporting systems.

conclusionImproving patient safety incident reporting in maternity care requires system improvements, cultural changes and further research to address identified gaps and optimise incident management systems.

Indexed as

Maternal Health ServicesPatient SafetyRisk ManagementFemaleHumansMedical ErrorsPregnancyIncident reportingObstetrics and gynecologyPatient safetySystematic Review

Identifiers

PMID41052815
PMCPMC12506158

What OpenQuestion holds

Textmetadata
LicenceCC BY
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Registered trials

None linked

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.