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

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

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

August 17, 2022

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

March 18, 2020

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

August 25, 2021

Disparities in adverse event reporting for hospitalized children.

August 3, 2022

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

June 29, 2022

Allergic adverse drug events after alert overrides in hospitalized patients.

September 21, 2022

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

June 16, 2021

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

April 6, 2022

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

November 24, 2021

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

September 7, 2022

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

November 11, 2020

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

July 6, 2022

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

March 30, 2022

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

November 17, 2021

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

January 26, 2022

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

September 7, 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

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

August 3, 2022

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

June 22, 2022

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

August 10, 2022

Prescribing errors with low-molecular-weight heparins.

October 13, 2021

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

March 2, 2022

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

April 27, 2022

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

August 31, 2022

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

August 18, 2021

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

November 9, 2022

Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.

May 25, 2022

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

January 26, 2022

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

January 19, 2022

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

December 8, 2021

Data collection for adverse events reporting by US dental schools.

September 30, 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

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

August 26, 2020

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

September 29, 2021

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs.

March 2, 2022

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

May 4, 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

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

July 8, 2020

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

December 14, 2022

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

June 16, 2021

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

October 26, 2022

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

September 29, 2021

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

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

July 29, 2020

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

February 9, 2022

The patients' perspective: hematological cancer patients' experiences of adverse events as part of care.

August 18, 2021

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

March 16, 2022

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

June 15, 2022

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

October 5, 2022

Ambulatory virtual care during a pandemic: patient safety considerations.

March 9, 2022

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

May 18, 2022

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

October 27, 2021

The impact of adverse events on clinicians: what's in a name?

November 22, 2017

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

September 21, 2022

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

December 14, 2022

Pediatric trainee perspectives on the decision to disclose medical errors.

March 30, 2022

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

January 18, 2023

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

Patient safety issues from information overload in electronic medical records.

September 14, 2022

Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.

August 10, 2022

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

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

April 6, 2022

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

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

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.

December 16, 2020

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

Adverse events in women giving birth in a labor ward: a retrospective record review study.

November 3, 2021

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

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

November 2, 2022

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care.

October 21, 2020

Lessons learned in implementing a chronic opioid therapy management system.

December 21, 2022

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

November 3, 2021

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

March 25, 2020

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

November 9, 2022

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

October 5, 2022

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

June 8, 2022

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

February 9, 2022

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

October 26, 2022

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

January 1, 2022

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

Maternal mortality: near-miss events in middle-income countries, a systematic review.

November 24, 2021

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

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

April 13, 2022

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

June 22, 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

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

March 2, 2022

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

September 7, 2022

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

November 10, 2021

Diagnostic error in pediatrics: a narrative review.

March 23, 2022

Defining and studying errors in surgical care: a systematic review.

August 17, 2022

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

July 22, 2020

Intersystem medical error discovery: a document analysis of ethical guidelines.

January 12, 2022

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

April 28, 2021

Analysis of risk factors for patient safety events occurring in the emergency department.

October 7, 2020

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

May 11, 2022

Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States.

June 22, 2022

Related Resources

The prevalence of incivility in hospitals and the effects of incivility on patient safety culture and outcomes: a systematic review and meta-analysis.

April 10, 2024

Key factors for effective implementation of healthcare workers support interventions after patient safety incidents in health organisations: a scoping review.

January 10, 2024

Interventions to promote safety culture in cancer care: a systematic review.

December 20, 2023

Disparities in patient safety voluntary event reporting: a scoping review.

December 20, 2023

A study of error reporting by nurses: the significant impact of nursing team dynamics.

November 15, 2023

Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review.

October 25, 2023

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

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

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

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