Patient Safety Events Research Articles

The Health Services Safety Investigations Body (HSSIB) and safety management systems: An integrated approach to managing safety in healthcare

The Health Services Safety Investigations Body (HSSIB) was established by the Health and Care Act 2022 as a new non-departmental arm's length body, replacing the former Healthcare Safety Investigation Branch. HSSIB exists to help reduce patient harm by understanding the complex interactions that exist within healthcare that may lead to patient safety events occurring. In other safety critical industries, a safety management system (SMS) approach is used to help enable proactive assessments of risks, specification of how risks should be managed, and set clear lines of accountability and responsibility in addressing risks. HSSIB has begun to explore how an SMS may operate in healthcare to help better equip the system to identify, respond, and proactively identify emerging and recurring concerns that may impact on the safety of patients.

The Maternal Voice: Exploration of Mothers and Birthing Individuals' Voices in Patient Safety Event and Feedback Reports.

There is a growing body of research highlighting that Black women have more adverse maternal health events. Instead of only focusing on severe maternal morbidity and mortality events, patient safety events (PSEs) and feedback reports are data sources that can offer insights into a broader spectrum of maternal safety, including near misses, and unsafe conditions. In this work, we explore the racial differences in the representation of mothers and birthing individuals' (MBIs) voices in PSE and feedback reports. We analyze patient experience themes, dissatisfaction, and disrespect in PSE and patient feedback reports from two large birthing hospitals. We compare racial differences in how the voices of MBIs are represented in these reports. Reports were manually coded for the presence of MBIs' voices, patient experience themes, dissatisfaction, and disrespect by staff. In total, 866 reports were reviewed, of which 271 had explicit mentions of MBIs' voices. A statistically significant association (p < 0.001) was observed between patient experience themes and report type, driven by clinical safety event themes in PSE reports. A statistically significant association (p = 0.030) was observed between race and report type in 190 reports explicitly mentioning dissatisfaction. Delays with handoff and transfer, pain management, patient staff violence, and procedural harm were proportionally more commonly reported among Black MBIs, supporting prior research in pain management and procedural harm disparities. We also identified themes of positive feedback and good catches by patients, which are key components to patient-centered care and promoting resilience in the care process. PSE reports tended to capture predominantly clinical themes from Black MBIs, while feedback reports captured predominantly administrative themes from White MBIs. Important perspectives of the safety narrative can be missed when only PSE reports or feedback reports are considered.

Improving Resident Physician Participation in Reporting Patient Safety and Quality Concerns.

Background: Reporting medical errors, near misses, and adverse events is an important component of improving patient safety and resident learning. Studies have revealed that event reporting rates can be low for physicians, resident physicians, and fellows. The objective of this quality improvement project was to improve resident reporting of patient safety and quality events and engage residents in the analysis of events at a community-based teaching hospital in the United States. Methods: We developed a program to engage 122 residents from 6 Accreditation Council for Graduate Medical Education-accredited residency programs using a multifaceted approach that included instructing residents how to use the hospital's adverse event reporting system; requiring first-year residents to submit at least 1 report; reviewing all resident reports during a monthly multidisciplinary meeting; and ensuring that each resident who submitted a report received feedback on how the concern was being addressed. Results: The program resulted in a 41.8% (95% CI 31%-53%) absolute increase in the number of residents reporting a concern, and resident submissions led to several documented improvements in patient care. A survey was administered to the residents who submitted reports, and the majority (76.0% response rate) expressed satisfaction with both the reporting system and the feedback about how their submission was being addressed. The responding residents agreed that they were more likely to submit reports because of their experience with the program and that they felt the program would improve safety and the quality of care at the institution. Conclusion: This quality improvement project successfully increased resident event reporting and engaged residents in the review of submitted events. The program can serve as a model for other teaching hospitals.

Assessing Patient Safety Culture among Hospital Nurses in Mosul: A Comprehensive Survey

Background: Patient safety culture stems from the collective and individual values, attitudes, perceptions, skills, and behaviors that shape health providers' commitment, approach, and effectiveness in managing safety. Objective: This study aimed to evaluate the patient safety culture among nurses in various healthcare settings, examining demographic characteristics and perceptions across domains including teamwork, leadership, communication, reporting, and hospital management. Methods: A comprehensive cross-sectional survey was meticulously conducted with 130 nurses from different hospitals. The participants provided detailed demographic information, and their responses to a Patient Safety Culture Survey, which covered five domains: unit/Work Area, Supervisor/Manager/Clinical Leader, Communication, Reporting Patient Safety Events, and Hospital Management, were thoroughly analysed. Results: The study revealed several key findings that can improve patient safety culture. Notably, at the same time, people generally hold positive views about how healthy teams work together; they express concerns about not having enough staff and relying too much on temporary workers. There are also concerns about mistreatment. The Leaders' approach to managing and communicating indicates a need to carefully balance efficiency with patient safety. The culture of reporting problems is somewhat inclined, with people reporting issues at varying frequency levels. When it comes to how well the hospital is run, people have mixed feelings about the management's commitment, the resources provided, and the coordination among different parts of the hospital. Conclusion: The findings of this study, with their profound implications for the fields of patient safety and healthcare management, not only highlight the intricate dynamics within healthcare units but also identify specific areas where targeted interventions can significantly improve the patient safety culture. The critical steps to creating safer healthcare environments, including addressing staffing challenges, nurturing supportive leadership, enhancing communication, and promoting a strong reporting culture, present a roadmap for positive change. The potential for improvement in the patient safety culture is not only a possibility but a tangible goal that can be achieved with the right interventions and strategies. This potential for improvement should inspire healthcare professionals, researchers, and policymakers to take action and work towards a safer healthcare environment.

Anticipating Patient Safety Events in Psychiatric Care.

Although suicide prevention often dominates patient safety efforts in psychiatry and behavioral health, patients who seek such services are also prone to other kinds of adverse events. The purpose of this study was to more fully characterize the types of safety events that occur in the context of psychiatric care. This was a retrospective study of safety events that had been reported to a hospital-based psychiatry department during a 4-year period. The authors reviewed each incident, developed new and more precise event categories, and assigned each report to a category. Events that could not be categorized were assigned to an "Other" category. The percentages of categorizable events between the new and old frameworks were compared. A total of 366 reports were filed. In the updated framework, 324 events (89%) could be categorized compared to 225 (61%) in the original registry. Understanding the kinds of safety events that clinicians are likely to encounter in the context of psychiatric care may help to expand patient safety efforts beyond suicide risk prevention.

“CORRECT” Classification and Reporting of a Patient Safety Event

“CORRECT” Classification and Reporting of a Patient Safety Event

Patient Safety Events Related to the Placement of Drug-Eluting Stents

Patient Safety Events Related to the Placement of Drug-Eluting Stents

Characteristics and patient impact of boarding in the pediatric emergency department, 2018–2022

ObjectivesBoarding admitted patients in the emergency department is an important cause of throughput delays and safety risks in adults, though has been less studied in children. We assessed changes in boarding in a pediatric ED (PED) from 2018 to 2022 and modeled associations between boarding and select quality metrics. MethodsWe performed a retrospective analysis of PED patients admitted to non-psychiatric services, broken into four periods: pre-COVID-19 (Period I, 01/2018–02/2020), early pandemic (II, 03/2020–06/2021), COVID-19 variants (III, 07/2021–06/2022), and non-COVID respiratory viruses (IV, 07/2022–12/2022). Patients were classified as critical (intensive care units (ICU)) or acute care (non-ICU inpatient services) based on their initial bed request. We compared median boarding times with Kruskal-Wallis tests. We assessed the relationship between boarding time and hospital length-of-stay (LOS) through hazard regression models, and the association between boarding time and PED return visit, readmission, and patient safety events through adjusted logistic regressions. ResultsMedian PED boarding time significantly increased from Period I (acute: 2.4 h; critical: 3.0 h) to Period II (acute: 3.0 h, critical: 4.0 h) to Period III (acute: 4.4 h, critical: 6.6 h) to Period IV (acute: 6.2 h; critical: 9.5 h). On survival analysis, as boarding time increased, hospital LOS increased for acute admissions and decreased for critical admissions. Increased acute care boarding time was associated with higher odds of a filed safety report. ConclusionsSince July 2021, PED boarding time increased for admitted children across acute and critical admissions. The relationship between acute care boarding and longer hospital LOS suggests a resource-inefficient, self-perpetuating cycle that demands multi-disciplinary solutions.

Second Victim Symptoms and Desired Support Strategies Among Italian Health Care Workers in Friuli-Venezia Giulia: Cross-Sectional Survey and Latent Profile Analysis.

The second victim (SV) phenomenon concerns health care workers (HCWs) whose involvement in a medical error, as well as non-error patient safety events, has affected their well-being. Its prevalence ranges from 10% to 75% and can predispose HCWs to burnout, increasing the probability of committing errors. The primary aim of our study was to determine the prevalence of HCWs involved in an adverse patient safety event in Friuli Venezia Giulia Region (Italy). The secondary aims were to use latent profile analysis to identify profiles of SVs and factors influencing profile membership, and to evaluate the relationship between the severity of symptoms and desired support options. A cross-sectional survey through the Italian version of the Second Victim Experience and Support Tool tool was conducted in 5 local health authorities. Descriptive statistics were conducted for all variables. Associations and correlations were assessed with statistical tests, as appropriate. Latent profile analysis was based on the scores of dimensions measuring SVs' symptoms. Factors affecting profile membership were assessed through multinomial logistic regression. A total of 733 HCWs participated. Of them, 305 (41.6%) experienced at least 1 adverse event. Among dimensions measuring SVs' symptoms, psychological distress had the highest percentage of agreement (30.2%). Three latent profiles were identified: mild (58.7%), moderate (24.3%), and severe (17.0%) symptoms. Severe symptoms profile was positively associated with the agreement for extraoccupational support and negatively associated with the agreement for organizational support. A respected colleague with whom to discuss the details of the incident (78.7%) and free counseling outside of work (71.2%) were the support options most desired by HCWs. The severity of symptoms was directly associated with the desire for support strategies. The prevalence of HCWs involved in adverse events is consistent with the literature. Three latent profiles have been identified according to SV symptoms, and the higher the severity of symptoms, the greater the reliance on extraoccupational support.

Standardizing Patient Safety Event Reporting between Care Delivered or Purchased by the Veterans Health Administration (VHA)

Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation. In this retrospective study using patient safety event data from VHA's event reporting system (2020-2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant. A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively). Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.

Management of the Electronic Health Record Inbox: Results From a National Survey of Internal Medicine Program Directors.

Background Internal medicine (IM) resident physicians spend a considerable amount of time managing their inbox as part of their longitudinal continuity clinic experience. There are no standardized guidelines for how programs should train, monitor, or supervise residents in this type of patient care. Objective To understand how IM residency programs educate, monitor, and supervise resident electronic health record (EHR) inbox management as part of their longitudinal continuity clinic and determine whether patient safety events have occurred due to EHR inbox-related patient care decisions made by unsupervised resident physicians. Methods In August 2021, 439 program directors at accredited US IM residency programs who were members of the Association of Program Directors in Internal Medicine (APDIM) were asked 12 questions developed by the study authors and APDIM survey committee members regarding resident EHR inbox management as part of the annual APDIM survey. Results Two hundred and sixty-seven (61%) PDs responded. The majority (224 of 267, 84%) of programs provided guidelines for expected message response times; less than half (115, 43%) monitored timeliness metrics. Only half (135; 51%) of programs required faculty supervision of inbox messages for all residents; 28% (76) did not require supervision for any residents. Twenty-one percent of PDs (56) reported awareness of a patient safety event occurring due to an unsupervised resident inbox-related patient care decision. Conclusions Substantial variability exists in how IM residency programs train, monitor, supervise, and provide coverage for resident inbox work. Program directors are aware of patient safety events resulting from unsupervised resident inbox management.

A systematic review of how leadership affects the establishment of patient safety in the healthcare industry of low- and middle-income countries

Introduction: Patient safety is still a major challenge in all the countries. Finding a solution to the patient safety issue in healthcare has important global repercussions. Healthcare leadership is a critical factor which decides patient safety in positive, negative, or mixed relationships. A wide range of leadership styles are highlighted in the literature and leaders of all healthcare institutions should promptly attend patient safety events. Methods: A systematic review was carried out to find key attributes of leadership characteristics and dimensions which are more important in patient safety in LMICs. Eleven Journals were identified from quality sources based on the desired criteria and reviewed. The author critically evaluated the relationship between leadership and patient safety and proposed suitable leadership characteristics for optimal patient safety. Results. Main leadership attributes revealed that transformational leadership characteristics, the establishment of a patient safety culture and training and education of staff are important factors. Regarding patient safety aspects, improving the knowledge, skills and attitudes of staff, improving the work environment and teamwork are more important. Conclusion: The author suggests healthcare leaders should strengthen safe patient care by adhering to identified leadership attributes and allocating resources to ensure continuous improvement in identified safety dimensions and sustainability through monitoring and evaluation.

Factors influencing patient safety culture in hospitals: Literature review

Patient safety is a system that aims to enhance the safety of patient care and prevent injuries resulting from errors during the execution of action. According to the 2011 Minister of Health Regulation concerning Hospital Patient Safety, every hospital is required to undertake patient safety management because hospitals are the most likely locations for patient safety events to occur (Ministry of Health of the Republic of Indonesia, 2011). As a result, hospital culture and patient safety are intertwined. There are various factors that affect patient safety culture. Objectives: To determined the various factors that influence the culture of patient safety in a hospital. Methods: Article search is done through ScienceDirect database, Garuda Portal, and Google Scholar. The keywords entered use Indonesian and English, where for Indonesian keywords are "keselamatan pasien" DAN "rumah sakit", while for English are "patient safety" AND "factors" AND "hospital". From the articles found, the author took 5 articles whose articles were in accordance with inclusion criteria and considered relevant to the topic of discussion. Results: Factors that influence patient safety culture in hospitals include, 1) Economic Aspects; 2) Leadership; 3) Culture; 4) Risk Management System and Health Services; 5) Knowledge, Attitudes, and Actions; 6) Analysis of the Situation and Conditions of the Working Environment; 7) Stress Level and Workload of Nurses; 8) Mentoring Program; 9) Nursing Supervision and Evaluation of the Application of Patient Safety Goals; 10) Teamwork; and 11) Organizational Learning. Conclusions: There are various factors that influence the culture of patient safety in hospitals.

Evaluating the utility and challenges associated with "anonymous" patients in the electronic medical record

Abstract Electronic medical records (EMRs) allow for the creation of "test" patients that can be used for training new users, testing changes before they go "live", simulating the placement of orders, or for a range of similar applications. Test patients are commonly utilized in EMR validation, support, or “playground” environments that might use a copy of the production EMR database but do not connect to the official medical record to prevent billing errors or patient harm. However, there are a variety of cases where it is useful to have test or anonymous patients within the EMR production environment as well. One example of this is infectious disease testing for employee blood-borne pathogen exposure (e.g., needlestick injury) that may need to be stored in a de-identified or restricted manner to comply with workplace privacy regulations. There are also instances, generally in emergency situations, where a medical record is created for a patient about whom little identifying information is known. In this example, these so-called "anonymous" patients are assigned random or arbitrarily pre-determined birthdates (e.g., 1/1/1900) and on occasion have no sex assigned in their chart. This poses a variety of challenges from a laboratory standpoint as it can be difficult to provide accurate normal ranges for laboratory results that are age and/or gender specific. Additionally, this has on occasion resulted in an inability to identify appropriate blood products as these recommendations are similarly based on age and gender. Another layer of complexity comes as additional information regarding the patient is made available, and health care information services merges data from a previously anonymous account to a specific patient record. Such mergers can result in cancellation of pending orders, errors in reporting laboratory results, or other complications depending on the specific process utilized. Surprisingly, there is little to no literature regarding the use cases for these “test” and “anonymous” patients or the challenges associated with their existence in the EMR. To explore this topic, we identified three classes of patients in our institutional EMR: true virtual “test” patients, “anonymous” patients that were subsequently identified, and “anonymous” patients that were never identified. Basic characteristics of these patients (sex and date of birth) and available laboratory results were compiled. Along with this, we present a series of instructional cases adapted from actual patient safety events at our institution involving anonymous patient records. These illustrative cases highlight the utility of these “test” and “anonymous” patients, as well as the challenges these pose on an institutional and individual level. Lastly, we provide recommendations on how best to manage similar scenarios that may arise.

What do parents think about the quality and safety of care provided by hospitals to children and young people with an intellectual disability? A qualitative study using thematic analysis.

Children with intellectual disability experience patient safety issues resulting in poor care experiences and health outcomes. This study sought to identify patient safety issues that pertain to children aged 0-16 years with intellectual disability admitted to two tertiary state-wide children's hospitals and a children's palliative care centre; to describe and understand these factors to modify the Australian Patient Safety Education Framework to meet the particular needs for children and young people with intellectual disability. Parents of children with intellectual disability from two paediatric hospitals and a palliative care unit participated in semi-structured interviews to elicit their experiences of their child's care in the context of patient safety. Thirteen interviews were conducted with parents from various backgrounds with children with intellectual, developmental and medical diagnoses. Eight themes about safety in hospital care for children and young people with intellectual disability emerged from thematic analyses: Safety is not only being safe but feeling safe; Negative dismissive attitudes compromise safety, quality and care experience; Parental roles as safety advocates involve being heard, included and empowered; Need for purposeful and planned communication and care coordination to build trust and improve care; Systems, processes and environments require adjustments to prevent patient safety events; Inequity in care due to lack of resources and skills, Need for training in disability-specific safety and quality issues and Core staff attributes: Kindness, Patience, Flexibility and Responsiveness. Parents highlighted the dilemma of being dismissed when raising concerns with staff and being required to provide care with little support. Parents also reported a lack of comprehensive care coordination services. They noted limitations within the healthcare system in accommodating reasonable adjustments for a family and child-centred context. The development of an adapted Patient Safety Education Framework for children with intellectual disability should consider ways for staff to transform attitudes and reduce bias which leads to adaptations for safer and better care. In addition, issues that apply to quality and safety for these children can be generalised to all children in the hospital. Parent advocates in the project advisory team were shown the questions to determine their appropriateness for the interviews.

Transforming Team Performance Through Reimplementation of the Surgical Safety Checklist

Patient safety interventions, like the World Health Organization Surgical Safety Checklist, require effective implementation strategies to achieve meaningful results. Institutions with underperforming checklists require evidence-based guidance for reimplementing these practices to maximize their impact on patient safety. To assess the ability of a comprehensive system of safety checklist reimplementation to change behavior, enhance safety culture, and improve outcomes for surgical patients. This prospective type 2 hybrid implementation-effectiveness study took place at 2 large academic referral centers in Singapore. All operations performed at either hospital were eligible for observation. Surveys were distributed to all operating room staff. The study team developed a comprehensive surgical safety checklist reimplementation package based on the Exploration, Preparation, Implementation, Sustainment framework. Best practices from implementation science and human factors engineering were combined to redesign the checklist. The revised instrument was reimplemented in November 2021. Implementation outcomes included penetration and fidelity. The primary effectiveness outcome was team performance, assessed by trained observers using the Oxford Non-Technical Skills (NOTECH) system before and after reimplementation. The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to assess safety culture and observers tracked device-related interruptions (DRIs). Patient safety events, near-miss events, 30-day mortality, and serious complications were tracked for exploratory analyses. Observers captured 252 cases (161 baseline and 91 end point). Penetration of the checklist was excellent at both time points, but there were significant improvements in all measures of fidelity after reimplementation. Mean NOTECHS scores increased from 37.1 to 42.4 points (4.3 point adjusted increase; 95% CI, 2.9-5.7; P < .001). DRIs decreased by 86.5% (95% CI, -22.1% to -97.8%; P = .03). Significant improvements were noted in 9 of 12 composite areas on culture of safety surveys. Exploratory analyses suggested reductions in patient safety events, mortality, and serious complications. Comprehensive reimplementation of an established checklist intervention can meaningfully improve team behavior, safety culture, patient safety, and patient outcomes. Future efforts will expand the reach of this system by testing a structured guidebook coupled with light-touch implementation guidance in a variety of settings.

Factors influencing health worker compliance in implementing patient safety goals in Indonesia: Systematic review

The compliance rate of health workers in patient safety is not fully good at 68.7% and the implementation of patient safety in Indonesia is not optimal at 74.2% whereas in 2016 in Indonesia there were still 31 cases related to patient safety. To determine the factors that affect the compliance of health workers in the implementation of patient safety goals using a systematic review approach. This study uses a systematic review method from 9 studies using a quantitative approach commonly called a meta-analysis. The search for the source of this research data uses PRISMA flow charts from several databases such as Google Scholar, garuda portal, ProQuest, and Elsevier. Where published in the last 10 years (2013-2023). 25 variables were the same in the study between one researcher and another, namely age, gender, marital status, number of dependents, length of work, nurse knowledge, nurse motivation, supervision, nursing, organizational influence, educational status, compliance behavior, ability, supervisor support, fellow nurse support, workplace comfort, employment status, motivation, perception, nurse compliance, 6 patient safety goals, patient safety culture, patient identification, patient safety events, and patient fall prevention. The average P-Value value is 0.180, the minimum value of P-Value = 0.000, and the maximum value of P-Value = 0.995. 8 dominant factors influence health workers in implementing patient safety goals. 8 dominant factors influence health workers in implementing patient safety goals, namely knowledge, length of work, nurse work motivation, nurse perception, stress level and workload, nurse compliance, organizational influence, and supervisor support.

A Combined Assessment Tool of Teamwork, Communication, and Workload in Hospital Procedural Units

Teamwork, communication, and workload issues continue to contribute to patient safety events. The authors developed a diagnostic mixed methods toolkit combining a behavior observation tool, semistructured interview guide, and surveys to proactively identify relevant gaps. Applied across 14 units at three hospitals, this toolkit yielded 344 findings with 156 associated recommendations and took, on average, four days of observation. On a scale from 1 (not at all helpful) to 6 (substantially helpful), leaders indicated that the assessment and its recommendations were very helpful (median 5, interquartile range 5-6, 34 survey respondents, 47.9% individual-level response rate, 85.7% unit-level response rate). Integrating this tool into a broader safety strategy can help inform organizational improvement efforts.

A text mining approach to categorize patient safety event reports by medication error type

Patient safety reporting systems give healthcare provider staff the ability to report medication related safety events and errors; however, many of these reports go unanalyzed and safety hazards go undetected. The objective of this study is to examine whether natural language processing can be used to better categorize medication related patient safety event reports. 3,861 medication related patient safety event reports that were previously annotated using a consolidated medication error taxonomy were used to develop three models using the following algorithms: (1) logistic regression, (2) elastic net, and (3) XGBoost. After development, models were tested, and model performance was analyzed. We found the XGBoost model performed best across all medication error categories. ‘Wrong Drug’, ‘Wrong Dosage Form or Technique or Route’, and ‘Improper Dose/Dose Omission’ categories performed best across the three models. In addition, we identified five words most closely associated with each medication error category and which medication error categories were most likely to co-occur. Machine learning techniques offer a semi-automated method for identifying specific medication error types from the free text of patient safety event reports. These algorithms have the potential to improve the categorization of medication related patient safety event reports which may lead to better identification of important medication safety patterns and trends.

Factors influencing health worker compliance in implementing patient safety goals in Indonesia: Systematic review

The compliance rate of health workers in patient safety is not fully good at 68.7% and the implementation of patient safety in Indonesia is not optimal at 74.2% whereas in 2016 in Indonesia there were still 31 cases related to patient safety. To determine the factors that affect the compliance of health workers in the implementation of patient safety goals using a systematic review approach. This study uses a systematic review method from 9 studies using a quantitative approach commonly called a meta-analysis. The search for the source of this research data uses PRISMA flow charts from several databases such as Google Scholar, garuda portal, ProQuest, and Elsevier. Where published in the last 10 years (2013-2023). 25 variables were the same in the study between one researcher and another, namely age, gender, marital status, number of dependents, length of work, nurse knowledge, nurse motivation, supervision, nursing, organizational influence, educational status, compliance behavior, ability, supervisor support, fellow nurse support, workplace comfort, employment status, motivation, perception, nurse compliance, 6 patient safety goals, patient safety culture, patient identification, patient safety events, and patient fall prevention. The average P-Value value is 0.180, the minimum value of P-Value = 0.000, and the maximum value of P-Value = 0.995. 8 dominant factors influence health workers in implementing patient safety goals. 8 dominant factors influence health workers in implementing patient safety goals, namely knowledge, length of work, nurse work motivation, nurse perception, stress level and workload, nurse compliance, organizational influence, and supervisor support.