Adverse event reporting priorities: an integrative review.

Maureen L Falcone; Stephanie K Van Stee; Umit Tokac; Anne F Fish

Review

Adverse event reporting priorities: an integrative review.

June 29, 2022

Falcone ML, Van Stee SK, Tokac U, et al. J Patient Saf. 2022;18(4):e727-e740.

View more articles from the same authors.

Adverse event reporting is foundational to improving patient safety, but many events go unreported. This review identified four key priorities in increasing adverse event reporting: understanding and reducing barriers; improving perceptions of adverse event reporting within healthcare hierarchies; improving organizational culture; and improving outcomes measurement.

PubMed citation

Available at

Related Resources From the Same Author(s)

Factor structure and construct validity of a hospital survey on patient safety culture using exploratory factor analysis.

August 2, 2023

Disparities in adverse event reporting for hospitalized children.

August 3, 2022

The impact of the built environment on patient falls in hospital rooms: an integrative review.

June 16, 2021

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review.

June 8, 2022

Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

June 29, 2022

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

March 30, 2022

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

June 15, 2022

Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture.

August 31, 2022

Preventing medication errors in pediatric anesthesia: a systematic scoping review.

November 9, 2022

High-risk medication in home care nursing: a Delphi study.

September 7, 2022

Central venous catheter guidewire retention: lessons from England's never event database.

May 4, 2022

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review.

January 26, 2022

Characteristics of critical incident reporting systems in primary care: an international survey.

January 19, 2022

In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments.

June 22, 2022

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.

June 8, 2022

Evaluation of the culture of safety and quality in pediatric primary care practices.

July 6, 2022

Implementing high-reliability organization principles into practice: a rapid evidence review.

November 11, 2020

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

September 7, 2022

Why an open disclosure procedure is and is not followed after an avoidable adverse event.

September 8, 2021

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.

December 14, 2022

Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.

June 22, 2022

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

April 6, 2022

Ambulatory virtual care during a pandemic: patient safety considerations.

March 9, 2022

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.

August 17, 2022

Patient safety issues from information overload in electronic medical records.

September 14, 2022

The morbidity and mortality conference: opportunities for enhancing patient safety.

February 9, 2022

Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient medication safety.

September 21, 2022

Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review.

August 18, 2021

Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support.

May 18, 2022

Patient perceptions of hospital experiences: implications for innovations in patient safety.

March 16, 2022

Prescribing errors with low-molecular-weight heparins.

October 13, 2021

Pediatric trainee perspectives on the decision to disclose medical errors.

March 30, 2022

Association between physician burnout and self-reported errors: meta-analysis.

January 26, 2022

What do patients and their carers do to support the safety of cancer treatment and care? A scoping review.

December 14, 2022

National and institutional trends in adverse events over time: a systematic review and meta-analysis of longitudinal retrospective patient record review studies.

March 3, 2021

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

January 1, 2022

Frequency and nature of communication and handoff failures in medical malpractice claims.

April 6, 2022

A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital.

April 27, 2022

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.

May 4, 2022

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis.

April 13, 2022

Addressing patient safety hazards using critical incident reporting in hospitals: a systematic review.

January 18, 2023

Bedside clinicians' perceptions on the contributing role of diagnostic errors in acutely ill patient presentation: a survey of academic and community practice.

March 16, 2022

Why is patient safety a challenge? Insights from the Professionalism Opinions of Medical Students' research.

November 2, 2022

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Technology-based closed-loop tracking for improving communication and follow-up of pathology results.

February 2, 2022

Exploring care left undone in pediatric nursing.

September 28, 2022

Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care.

October 5, 2022

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

October 5, 2022

Test-retest reliability of an experienced Global Trigger Tool review team.

October 27, 2021

Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.

October 26, 2022

The use of anatomical side markers in general radiology: a systematic review of the current literature.

August 26, 2020

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

Morbidity and mortality caused by noncompliance with California hospital licensure: immediate jeopardies in California hospitals, 2007-2017.

March 9, 2022

Data collection for adverse events reporting by US dental schools.

September 30, 2020

Cost of health care-associated infections in the United States.

March 23, 2022

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

August 10, 2022

Lessons learned in implementing a chronic opioid therapy management system.

December 21, 2022

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study.

September 7, 2022

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

May 11, 2022

The Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey: a brief, diagnostic, and actionable metric for the ability to speak up in healthcare settings.

September 14, 2022

Detach yourself: the positive effect of psychological detachment on patient safety in long-term care.

September 29, 2021

Accuracy of spinal anesthesia drug concentrations in mixtures prepared by anesthetists.

January 11, 2023

Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients.

April 27, 2022

Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse.

April 20, 2022

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review.

November 3, 2021

Intravenous smart pumps at the point of care: a descriptive, observational study.

October 12, 2022

An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review.

December 8, 2021

To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.

February 16, 2022

Patient safety and legal regulations: a total-scale analysis of the scientific literature.

October 19, 2022

A machine learning approach to reclassifying miscellaneous patient safety event reports.

July 29, 2020

A safe practice standard for barcode technology.

June 3, 2015

Scientific view of the global literature on medical error reporting and reporting systems from 1977 to 2021: a bibliometric analysis.

November 16, 2022

Feelings of trust and of safety are related facets of the patient's experience in surgery: a descriptive qualitative study in 80 patients.

August 24, 2022

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review.

November 10, 2021

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

September 29, 2021

A systematic review of methods for medical record analysis to detect adverse events in hospitalized patients.

March 2, 2022

The analysis of hospital readmission rates after the implementation of hospital readmissions reduction program.

April 13, 2022

The trigger tool as a method to measure harmful medication errors in children.

May 13, 2015

Physician reporting of clinically significant events through a computerized patient sign-out system.

September 14, 2011

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population.

August 3, 2022

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

November 17, 2021

What do we really know about crew resource management in healthcare?: An umbrella review on crew resource management and its effectiveness.

March 2, 2022

Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States.

October 12, 2022

Predictors of serious opioid-related adverse drug events in hospitalized patients.

July 8, 2020

Are the World Health Organization's patient safety learning objectives still up-to-date: a group concept mapping study.

December 21, 2022

Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient care.

April 28, 2021

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.

June 16, 2021

Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study.

January 19, 2022

Ethical issues in patient safety research: a systematic review of the literature.

September 9, 2015

Nurse workarounds in the electronic health record: an integrative review.

August 12, 2020

Institution of just culture physician peer review in an academic medical center.

October 13, 2021

Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.

July 22, 2020

A quality improvement initiative to improve patient safety event reporting by residents.

February 9, 2022

Related Resources

Patient safety: listen to whistleblowers.

September 27, 2023

Defining speaking up in the healthcare system: a systematic review.

September 20, 2023

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.

September 13, 2023

In search of an international multidimensional action plan for second victim support: a narrative review.

September 13, 2023

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review.

August 16, 2023

Physician burnout and medical errors: exploring the relationship, cost, and solutions received.

August 9, 2023

Nurses and nursing students as second victims: a scoping review.

July 19, 2023

Psychological safety, communication openness, nurse job outcomes, and patient safety in hospital nurses.

July 12, 2023

An integrative systematic review of employee silence and voice in healthcare: what are we really measuring.

June 28, 2023

Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events.

June 28, 2023

'Speaking Up' for patient safety and staff well-being: a qualitative study.

June 7, 2023

Managing near-miss reporting in hospitals: the dynamics between staff members’ willingness to report and management’s handling of near-miss events.

June 7, 2023

Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: a systematic review.

May 10, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis.

April 19, 2023

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence.

April 12, 2023

What's changed 1 year after RaDonda Vaught's conviction?

April 12, 2023

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.

April 5, 2023

Psychosocial factors and safety in high-risk industries: a systematic literature review.

November 30, 2022

Predictors of response rates of safety culture questionnaires in healthcare: a systematic review and analysis.

October 26, 2022

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

October 12, 2022

Organizational factors that promote error reporting in healthcare: a scoping review.

September 14, 2022

Exploring the impact of employee engagement and patient safety.

September 14, 2022

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

Toward constructive change after making a medical error: recovery from situations of error theory as a psychosocial model for clinician recovery.

August 10, 2022

Monitoring preventable adverse events and near misses: number and type identified differ depending on method used.

June 29, 2022

Understanding the link between burnout and sub-optimal care: why should healthcare education be interested in employee silence?

May 4, 2022

Quality Special Issue.

April 13, 2022

A concept analysis of psychological safety: further understanding for application to health care.

February 23, 2022

See More About The Topic

Hospitals

Quality and Safety Professionals

Psychological and Social Complications

Epidemiology of Errors and Adverse Events

Institutional Reporting

Adverse event reporting priorities: an integrative review.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Adverse event reporting priorities: an integrative review.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site