Enhancing Nursing Documentation Through Incident Reporting and Safety Training: A Systematic Review


crossmark

Authors

  • Irvan Maulana RSK Bedah BIMC Nusa Dua
  • I Made Benny Setiawan Head of Quality and Risk Department, RSK Bedah BIMC Nusa Dua, Kab. Badung, Bali

DOI:

https://doi.org/10.69606/jps.v3i01.217

Keywords:

Incident Reporting, Nursing Documentation, Patient Safety Training

Abstract

Background: Accurate nursing documentation is critical for patient safety and quality healthcare; however, many nurses face challenges in incident reporting and effective documentation practices. Objective: This study systematically reviews the relationship between incident reporting, patient safety training, and nursing documentation in hospital settings. Method: A systematic review was conducted following PRISMA guidelines. Relevant studies published from 2020 to 2025 were sourced from databases including PubMed and ScienceDirect. An initial search yielded 392 articles, which were screened for inclusion based on established criteria, resulting in the selection of 10 studies focusing on hospital-based nursing practices. Results: The findings indicate that patient safety training significantly enhances nurses’ understanding and skills in incident reporting, leading to improved quality in nursing documentation. Additionally, a supportive managerial framework and a non-punitive reporting culture are crucial elements that foster a culture of safety within healthcare organizations, encouraging proactive participation among nurses. This review emphasizes the need for structured training programs and strong institutional support to optimize nursing documentation and enhance patient safety. Conclusion: The insights gained from this systematic review provide a foundation for developing effective policies and training initiatives aimed at improving incident reporting and documentation practices within healthcare settings.

References

Baillie, L. (2025). Nurse education and patient safety: Critical perspectives and reports. LSBU Research Portal.

Bassah, N., Tendongfor, N., Ebob-Anya, B.-A., Eta, V. A. E., Esembeson, M., Ngah, N. E., & Abdul-Rahim, S. A. (2025). Impact of Psychosocial and Palliative Care Training on Nurses’ Competences and Care of Patients With Cancer in Cameroon: Protocol for Quasi-Experimental Study. JMIR Research Protocols, 14, e64871. https://doi.org/10.2196/64871

Benning, L., Teepe, G. W., Kleinekort, J., Thoma, J., Röttger, M. C., Prunotto, A., Gottlieb, D., Klöppel, S., Busch, H.-J., & Hans, F. P. (2024). Workplace violence against healthcare workers in the emergency department — a 10-year retrospective single-center cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 32(1), 88. https://doi.org/10.1186/s13049-024-01250-w

Brunero, S., Tetik, E., Donnelly, N., & Lamont, PhD, S. (2025). Understanding the Experience of Workplace Violence in Hospitals as Documented by Nursing Staff: Using the READ Approach. Workplace Health & Safety, 73(3), 139–149. https://doi.org/10.1177/21650799241282343

Dahmke, H. (2025). Development and Evaluation of a Clinical Decision Support System for the Reduction of Medication Errors. University of Basel. https://doi.org/https://doi.org/10.5451/unibas-ep96845

Godzik-Sagan, A. (2024). Adverse Events and Medical Errors in Nursing Care. UJ Repository. https://ruj.uj.edu.pl/handle/item/449341

Halinen, M., Tiirinki, H., Rauhala, A., Kiili, S., & Ikonen, T. (2024). Root causes behind patient safety incidents in the emergency department and suggestions for improving patient safety – an analysis in a Finnish teaching hospital. BMC Emergency Medicine, 24(1), 209. https://doi.org/10.1186/s12873-024-01120-9

Jerjes, W. (2025). Balancing specialist roles with generalist responsibilities in primary care: have we gone too far? Frontiers in Health Services, 5. https://doi.org/10.3389/frhs.2025.1438711

Kustini, T. Y. (2024). Pengaruh Pengetahuan Perawat tentang Budaya Keselamatan Pasien terhadap Pelaporan Insiden Keselamatan Pasien. Journal of Management Nursing, 3(3), 360–368. https://doi.org/10.53801/jmn.v3i3.186

Lloyd, S., Oshni Alvandi, A., Probst, Y., Roach, J., Olley, R., & Bain, C. (2024). Charting the course: Insights into EMR usability from Australian clinicians – A national survey. Finnish Journal of EHealth and EWelfare, 16(4). https://doi.org/10.23996/fjhw.147334

Nutbeam, T., Fenwick, R., Haldane, C., Leech, C., Foote, E., Todd, S., & Lockey, D. (2025). Extrication following a motor vehicle collision: a consensus statement on behalf of The Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 33(1), 3. https://doi.org/10.1186/s13049-024-01312-z

O’Connor, E., Coates, D., & Nicholas, J. (2025). Improving Incident Reporting in Healthcare: Strategies for Engagement and Compliance. Journal of Patient Safety. https://journals.lww.com/journalpatientsafety/fulltext/2025/03010/improving_incident_reporting_healthcare.pdf

Osaele, O. E. (2024). Pressure Ulcer Prevention among Elderly Bedridden Patient. Theseus.

Pramesona, B. A., Rengganis Wardani, D. W. S., Rahmawati, S., Nurmumpuni, D., & Rasyid, M. F. A. (2022). in House Training Pelaporan Insiden Keselamatan Pasien Sebagai Upaya Meningkatkan Mutu Pelayanan dan Keselamatan Pasien di Rumah Sakit. JCOMENT (Journal of Community Empowerment), 3(3), 194–204. https://doi.org/10.55314/jcoment.v3i3.327

Rosen, A. K., & Rivard, P. E. (2025). Moving the Needle on Measurement of Patient Safety: The Evolving Role of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators. Joint Commission Journal on Quality and Patient Safety, 51(3), 229–231. https://doi.org/10.1016/j.jcjq.2024.11.004

Schenzel, H. A., Palmer, A. K., Shah, N. B., Lawson, D. K., Fischer, K. M., Lapid, M. I., & DeFoster, R. E. (2025). Weighted Blankets for Agitation in Hospitalized Patients with Dementia: Protocol for a Randomized Controlled Trial. JMIR Research Protocols, 14, e57264. https://doi.org/10.2196/57264

Simpson, E., Rodger, R., & Qadri, H. (2025). P11 A quality improvement baseline evaluation of IV gentamicin management in the acute hospital setting following introduction of an electronic prescribing system (HEPMA). JAC-Antimicrobial Resistance, 7(Supplement_1). https://doi.org/10.1093/jacamr/dlae217.015

Zakiyyah, N., Handiyani, H., Hariyati, R. T. S., & Novieastari, E. (2024). Efikasi Diri dan Sikap Perawat dalam Melaporkan Insiden Keselamatan Pasien di Rumah Sakit. MAHESA : Malahayati Health Student Journal, 4(6), 2460–2471. https://doi.org/10.33024/mahesa.v4i6.14210

Downloads

Published

2025-03-31

How to Cite

Maulana, I., & Setiawan, I. M. B. (2025). Enhancing Nursing Documentation Through Incident Reporting and Safety Training: A Systematic Review. Journal of Pubnursing Sciences, 3(01), 42–50. https://doi.org/10.69606/jps.v3i01.217