BMJ Qual Saf 21:369-380 doi:10.1136/bmjqs-2011-000443
  • Original research

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

Open Access
  1. John Wright2
  1. 1Institute of Psychological Sciences, University of Leeds, Leeds, UK
  2. 2Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
  3. 3Health Sciences, University of York, York, UK
  1. Correspondence to Dr Rebecca Lawton, Senior Lecturer in Health Psychology, Institute of Psychological Sciences, University of Leeds, Leeds LS2 9JT, UK; r.j.lawton{at}
  1. Contributors RL and RM devised the review protocol. RM and RS performed searches according to protocol, coded studies and extracted data. RM, RL, SG, JW and IW developed the framework. RL, RM and SG contributed to the first draft of the manuscript. All authors commented on and revised subsequent drafts. All authors read and approved the final manuscript. RL is the guarantor.

  • Accepted 24 January 2012
  • Published Online First 15 March 2012


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.


  • Funding This article presents independent research commissioned by the National Institute for Health Research (NIHR) under the Programme Grants for Applied Research (Improving safety through the involvement of patients). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. This work was undertaken as part of the NIHR funded ‘Patient involvement in patient safety’ programme grant for applied research (Grant number: RP-PG-0108-10049).

  • Competing interests All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We would be happy to share the database of contributory factors extracted for each of the papers in this review.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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