Beecham, Emma;
Brady, Gráinne;
Iqbal, Syka;
Fatima, Qanita;
Arshad, Saeeda;
Bondaronek, Paulina;
O'Carroll, James;
... Vindrola, Cecilia; + view all
(2025)
Systematic review of patient safety
incident reporting practices in
maternity care.
BMJ Open Quality
, 14
(4)
, Article e003432. 10.1136/bmjoq-2025-003432.
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Abstract
Problem: Patient 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. // Background: Reporting 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. // Aim: This 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. // Methods: A 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. // Findings: A 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. // Conclusion: Improving patient safety incident reporting in maternity care requires system improvements, cultural changes and further research to address identified gaps and optimise incident management systems.
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