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Bibliometric Analysis of Patient Safety in Nursing

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25 May 2024

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27 May 2024

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Abstract
Aim: The aim of the study is to analyze quantitatively the scientific literature covering nursing studies on patient safety. Method: The Web of Science database is queried in this retrospective bibliometric analysis to identify relevant publications. The study themes, contributing journals, countries, institutions, and authors were evaluated quantitatively. Thus, a total of 5470 publications concerning patient safety in nursing were included and analyzed. Findings: The number of studies conducted increased every year from 1992 to 2023. While the country whose articles receive the most citations (31072) is the United States of America (USA), Turkey is ranked as last with the lowest number of citations (581). Journal of Clinical Nursing, with 338 articles, appeared to have the highest number of publications, Chaboyer W. appeared to have the highest number of citations with a total of 1426 and 45 publications. The countries that have the strongest international cooperation for research in this field are the USA, England, Australia and China. Results: After examining the literature in the field of patient safety in nursing through bibliometric analysis, it is seen that themes such as patient safety, medication errors, nursing care, nursing, education, systematic review, quality care and leadership were emphasized as important considerations.
Keywords: 
Subject: Public Health and Healthcare  -   Nursing

1. Introduction

The World Health Organization defines patient safety as "the absence of preventable harm to the patient and reducing the risk of unnecessary harm associated with healthcare services to an acceptable minimum"[1]. Approximately one out of ten patients are harmed during healthcare service, and more than 3 million deaths occur annually due to unsafe care [1]. The role of nurses in preventing practice errors and achieving safe healthcare is to protect patient from being harmed during the healthcare, no matter long or short-term [2]. In addition, it is known that nurses' compliance with patient safety principles and institutional strategies is of critical importance in eliminating many causes of patient harm, such as medication errors, pressure ulcers, healthcare-associated infections, unsafe transfusion and injection practices [3,4].
Patient safety is a multidimensional and multifactorial interdisciplinary research topic. It became very hard to have a comprehensive overview because of the ever-increasing rate of publications on patient safety [5]. Obtaining a general perspective on patient safety in the literature becomes an extremely time-consuming process, when it comes to interdisciplinary research topics [2]. The frequently used method in performing these analyzes is bibliometric methodologies. Systematic reviews are prone to bias in sample selection. Bibliometric methodologies are good methods to eliminate this handicap [6,7]. It is also very successful in identifying journal performance, co-authorships, co-citation trends [8]. The study examined patient safety in nursing through a bibliometric analysis in order to guide future patient safety research in the field of nursing and to bring an alternative approach for searching, examining and evaluating huge amounts of bibliographic data in the literature.
The aim of the study is to identify and characterize the authors, journals, and research institutions, together with the related articles, in nursing research literature in terms of patient safety, and to define thematic structure of the objected topic.

2. Materials and Methods

The data collection framework and study design for the analysis of patient safety in nursing can be seen in Figure 1.
The articles in the Nursing category are filtered and 6514 articles have been found. Publication type is filtered as "Article or Review Article" and then ended up with 5749 articles. Language is filtered as "English", reduced to 5567. "SCI, SCI-E, ESCI, SSCI" is applied as another filter, the number of articles become 5541. Since the year has not ended yet, articles from 2024 is excluded, and the analyses is done with 5470 articles. In review, 5470 articles are examined in three parts. In the first part, basic information analysis of the articles in the field of patient safety in nursing is made, in the second part, collaboration, and in the third part, thematic analysis is made. No word combining is done during the analysis.

3. Results.

3.1. Basic Information Analysis

3.1.1. Authors, Sources, Documents, Country Analyzes

The result of the query is given in Table 1. The analysis on patient safety in nursing covers a wide period of time between 1992 and 2023. A total of 5470 articles were obtained from 187 different journals and 15855 different authors contributing to these articles. While 510 of these authors produced documents alone, there was an average of 4.05 co-authorships per document. The annual growth rate of the analysis was determined as 22.41%, The article average was calculated to be 7.07 years, The articles are broadly integrated with the literature, with a total of 115,901 references. A total of 4129 different keywords were used in 5470 articles and 8161 different keywords were used in the bibliographies of these articles. The international collaboration rate was determined as 14.48.
The annual number of scientific publications on patient safety in nursing produced between 1992 and 2023 was obtained using bibliometric analysis as presented in Figure 2.

3.1.2. Most Cited Countries

The top 20 countries according to the citations on patient safety in nursing, the scientific publication activities of the countries, and the collaboration rates of these publications among multiple countries are shown in Figure 3.
The United States is the country, having the most citations, with 31072 citations. This high number of citations shows that the USA is a pioneer in this field and that there is a wide academic interest in the research conducted. Additionally, it is seen that articles in America are cited 14.60 times as average. Second comes Australia with 8041 citations. This shows that Australia is an important country contributing to the literature on patient safety in nursing, being cited 14.60 times as average. These countries are followed by The United Kingdom with a total of 4915 citation and Canada with 4763 citations. The average citation rates of articles in these countries are 18.50 and 21.90, respectively. Bottommost countries are Turkey and Spain. While the average number of citations of articles in Turkey is 8.00, this rate is 5.90 in Spain.

3.1.3. Author Impact Factor

The relationship between the publication numbers and the total citation numbers of the top 20 authors who conducted the most influential studies on patient safety in nursing is given in Figure 4.
The number of citations per publication is an important indicator that measures the scientific impact of each article of an author. In this context, Kalisch B.J. has the highest rate of citations per publication with 119.36 citations/article. This shows that each of Kalisch B.J.'s 11 articles, which received a total of 1313 citations, is highly influential and frequently referenced. The second highest publication belongs to Griffiths P. and the rate of citations per article is 55.79. This shows that each of Griffiths P.'s 19 articles, which received a total of 1060 citations, were highly influential and frequently referenced. Additionally, the author with the highest total number of citations and publications may also have had a significant impact. In this context, Chaboyer W. has the highest total number of citations and publications, with a total of 1426 citations and 45 publications. These high numbers show that Chaboyer W has carried out studies on a broad scope and made a significant impact in this field. In the analysis, Aiken L.H. is among the noteworthy authors. These authors have created a significant scientific impact both in terms of their number of publications and the rate of citations per publication.

3.1.4. Most Cited Journals

Table 2 gives the first 20 article publishing journals on patient safety in nursing, with h-index ranking. They constitute 43.51% (2380/5470) of the total articles. Criteria such as h-index, g-index, total publication number, total citation number, average citation per publication (TC/NP), and the year of first publication of the journals in the table allow us to evaluate the academic activity, impact and publication profiles of these journals [9].
"International Journal of Nursing Studies" is the topmost ranking h-index and g-index journal with a h-index of 48 and g-index with 79. It is also the leading journal in terms of total citation amount with 7538 citations. This shows that the journal's publications are frequently referenced by a wide audience and it effectively contributes to the literature. However, the journal with the most publications is "Journal of Clinical Nursing" with 338 articles.
The journal's average number of citations per publication (TC/NP) shows how influential a journal's publications could be. "Nursing Outlook" is the journal with the highest average citation ratio, with 50.7 citations/article. This shows that each of the journal's articles is highly influential and frequently referenced by a wide audience.
The first publication year of a journal reflects the academic history and experience of a journal. "Journal of Nursing Administration" and "Nurse Education Today" journals were first published in 1996 and 1995, showing their long history.
For the identification of the most cited articles, and the connections in-between, citation analysis is performed. Citation analyzes are generally employed to examine the intellectual structure and developmental dynamics underlying the field of the study. The topmost 20 cited articles on the patient safety in nursing are given in Table 3.

3.1.5. Keyword Frequency

Keywords are used to describe the article and reflect the main focus points and important concepts of the studies. It is noteworthy to make analysis of keywords to identify the topic and content of the field under study. Keyword repetition rate of the patient safety in nursing is extracted by means of Bibliometrix. The word cloud is a graphical representation of the latest concepts [30]in the field of patient safety in nursing review. Through the word cloud, it becomes easier to identify areas that are intertwined and to analyze the trend words of these areas over the years [31,32]. The more the keywords appear in the data set, the more frequently they are used [33]. The first 50 of the most frequently occurring keywords are presented in the form of word clouds and the first 15 in the form of frequencies in Table 4. The most frequently used term is “patient safety” and is mentioned 2219 times in total. This indicates that studies in the literature generally focus on patient safety. The term Nursing is mentioned 691 times and generally refers broadly to research in the field of nursing.
The term Nurses appears 377 times and generally refers to studies on the role, responsibilities and contributions of nurses. The term Communication is used 233 times and emphasizes the importance of communication in the context of patient safety. The terms Medication Errors and Quality Improvement appear 171 and 169 times, respectively. The terms "Nursing Education" and "Nursing Care" appear 167 and 153 times, respectively. These terms focus on research related to the education of nurses and improving the quality of patient care.
Figure 5 gives the popular keywords according to years. In a year, at least five times used two keywords are given. It appears that there have been significant changes in the focus of studies on patient safety in nursing over time. The highlighted keywords vary from year to year, and it is understood that the keywords emphasized between 2006 and 2010 have been replaced by new and more contemporary topics today. Among the keywords that stood out between 2006 and 2010 were Electronic Fetal Monitoring, Clinical Risk Management, Oxytocin, Human Error, Cardiac Surgery and Intrapartum Care. These terms could be reflecting the focus of research in patient safety and nursing at the time.
Recently, it is seen that the prominent keywords show a dynamic change. Terms such as Pandemic, Covid-19 Pandemic, Covid-19, Clinical Judgment, Missed Nursing Care, Workforce and Nurses reflect the priority issues today. These terms emphasize issues such as clinical assessment, incomplete nursing care, workforce and the role of nurses, especially related to global epidemics. This change shows how both developments in the health sector and social events affect research focuses. Today's keywords focus on issues such as challenges in healthcare, the role of nurses, and pandemic management, especially in the context of the Covid-19 pandemic. These changing emphases can be considered a reflection of current and pressing issues in the nursing literature.

3.2. Collaboration Network Analysis

Collaboration Network Analysis is a type of analysis that examines the collaboration relationships between actors in a research or study field. This analysis is often based on a network theory and used to examine the interactions, connections, and level of collaboration between actors. In this context, "actors" often represent individuals, institutions, researchers, authors, or groups. Louvain clustering algorithm was used in the analyses. The results of the cross-country cooperation analysis (Countries Collaboration Network) are visualized in Figure 6. In the analysis, 30 node points were taken as basis and the Louvain Algorithm was used. Each ellipse represents a country. Regarding the patient safety in nursing literature, it is seen that there are three clusters on a country basis. The green cluster consists of 13 countries, the blue cluster 9 countries and the red cluster 8 countries. The green cluster is the one with centrality and the most countries are in this cluster; however, the country with the most cooperation is the USA (USA) in the red cluster. The strongest cooperation is between England and Australia, USA and China, and USA and Canada. Türkiye, as a country, has created a cooperation network in the green cluster. The green cluster includes several European countries. These countries are Brazil, Spain, Italy, Belgium, Türkiye, Netherlands, Denmark, Portugal, Ireland, Switzerland, Germany, Israel and Greece. These countries are generally European countries and they cooperate with each other. The blue cluster includes Australia, England, Switzerland, Iran, Norway, Finland, Japan, New Zealand and Singapore. These countries cooperate among themselves, but they do not have as intense interaction as the red cluster. The red cluster includes large and influential countries. USA, China, Canada, Korea, Saudi Arabia and Thailand are in strong cooperation with each other. The United States, in particular, has the highest level of cooperation in the network. This cluster occupies an important position in the overall network.

3.3. Thematic Analysis

Figure 7 gives The Thematic Map containing each sub-period of patient safety research in nursing created by Bibliometrix using at least 3 times repeated keywords in the first 150,000 authors. Theme clusters are constituted by the most repeated keywords. Each cluster is represented by the first 3 words with the highest number of repetitions. Clustering was done using the Louvain clustering algorithm. There is no word combining. The frequency of the keywords constitutes the size of the circles. Thematic analysis is a research method that aims to examine a text, document or data set around specific themes, topics or motivators. The objective of this type of analysis is to discover patterns and meanings in texts [34].
The themes are presented in four segments. Each segment is evaluated in its own content. Centrality and density are the two parameters in which density corresponds to y and centrality corresponds to the x axis. If the selected theme becomes central, it means it is more important whereas if it becomes dense than it means it is more developed [35]. Basic Themes, which are highly examined and have low density and high centrality with well-developed internal ties, are the fourth quadrant theme in the lower right part of the thematic map [36].
The basic themes consist of 3 clusters. The first cluster includes Patient Safety, Medication Errors and Nursing Care. In the second cluster, the keywords Nursing, Systematic Review and in the third cluster, Nursing Education, Simulation and Nursing Students are represented.

4. Discussion

This study integrates existing international knowledge using the Bibliometric analysis of 5470 articles on patient safety in nursing in the WoS database. The analysis reflects an extensive literature, rapid growth trend and a wide international collaboration network.
The study shows that in order to ensure patient safety, an important issue in healthcare all over the world, researchers have generally collaborated at the international level and have investigated issues that are critical for patient safety. In addition, it is also seen that research on patient safety in nursing has a rapid increase. The annual growth rate of the analysis was determined shows that research on patient safety in nursing is rapidly increasing. The article average per year reflects that research on the subject topic has generally been conducted in recent years. The huge number of different keywords shows that a wide range of topics were covered in the analysis. The international collaboration rate shows that researchers generally collaborate at the international level. The topmost appearance of the keyword “patient safety” indicates that studies in the literature in this topic generally focus on patient safety. This term encompasses a range of research on various strategies and practices to improve patient safety in healthcare. Second ranked keyword “nursing” encompasses a wide range of literature focusing on the nursing profession. The other most frequently searched keywords used were nurses, nursing care, communication, medication errors, quality improvement, nursing education and teamwork, showing that there are multiple and interrelated factors that may cause patient to get harmed. Even in just a single patient safety violation, multiple factors may often be involved [37].
Thematic analysis shows active research topics of today and that these themes include important research topics. According to this information, the possible topics that need to be studied regarding patient safety in nursing in the coming years may be as follows: The role and applications of technology, emergency and intensive care relationship, training and simulation, nursing education, leadership and work environment, patient participation and communication quality improvement and evidence-based practices. By conducting more research in these areas, practices that will contribute to patient safety can be identified and disseminated.
In general, an increasing trend is observed every year except 1994 and 1997. There has been a significant increase, especially since the early 2000s. Only one article was published in 1992 and 1993. However, the number of articles began to increase in 1995, and there has been a significant increase especially since the mid-2000s. The highest article rate is in 2021, a total of 535 articles were published that year. This increasing trend in the total number of articles shows that interest in patient safety in nursing and research in this field has increased significantly. These data reveal the growth trend in the scientific literature on the subject topic and show that researchers' interest in the subject is increasing.
It has been determined that the USA is in a leading position in research conducted in the field of patient safety in nursing and that there is a great deal of academic interest in these studies. The increase in the number of research may be interpreted as a search for a solution to the negativities experienced regarding patient safety. The literature shows that 1.5 million people are injured every year in the USA due to medical errors and more than a quarter (26%) of hospital readmissions are potentially preventable [18]. Studies conducted in many countries such as Australia, England and Canada have attracted great attention and achieved significant success in terms of the total number of citations to publications.
Author Beatrice J. Kalisch, who has done the most effective work by researching strategies to prevent negligence and errors for the quality of nursing care, which is an important element in ensuring patient safety, has 1313 citations. Her 11 articles appeared to be highly effective and frequently referenced. This situation may, of course, be related to the academic activity and publication profiles of the published journal. In fact, it is important to provide evidence-based information to ensure patient safety in healthcare delivery. "International Journal of Nursing Studies" with an h-index of 48, frequently publishes on patient safety in nursing. This shows that the journal's publications are frequently referenced by a wide audience with 7538 citations and contribute effectively to the literature. However, "Journal of Clinical Nursing" is the journal with the highest number of publications on patient safety in nursing with 338 articles, while "Nursing Outlook" is the one with the highest average citation rate with 50.7 citations/article.
Training nurses to increase their knowledge about patient safety, cooperation and teamwork in the performance of duties, reducing workloads, providing appropriate equipment and electronic systems for communication and information sharing and standardization of care processes will help increase nurses' commitment to patient safety principles [19]. To achieve a qualified and reliable healthcare system, with minimized incidence and maximized safety, patient safety principles are defined and employed [30,31]. Trust in corporate leaders and management will improve positive communication between managers and employees as well as increasing employee support. Additionally, empowering employees will lead to eliminating the fear of blame for providing accurate data regarding patient care and reporting errors [32].
Using artificial intelligence technologies to obtain accurate information and data regarding patient care is one of the important issues regarding patient safety. Artificial intelligence-supported medical technologies such as health information systems, wearable devices, and telemedicine creating big data, allows data to be collected from multiple sources and enables use of artificial intelligence in practices such as diagnosis of the disease [34]. Filling out these documents automatically reduces the administrative burden on nurses, by saving time and making use of time more efficient. Reducing this time is one of the positive factors that will increase focusing on patient care [35]. Additionally, it has been demonstrated that the participation of patients and their families in healthcare services is of critical importance in ensuring patient safety. In a study conducted with leaders and managers of healthcare services, it was reported that less than 50% of their patients had a high level of participation in treatment plans [36]. Increasing patients' participation in healthcare will lead to improvements in health outcomes and patient satisfaction and a decrease in the level of medical errors [37].
Although important results are obtained in this study, there are limitations common to some bibliometric analyses. First of all, only Web-of-Science research database is used. Another limitation may be the analysis of articles published in English, in well-known journals.

5. Conclusions

This bibliometric study aimed to identify and characterize the subjects of focuse, structure, and development of nursing literature in terms of patient safety. At the same time, the study has contributed to enrich the literature on patient safety for nursing researchers and practitioners by evaluating critical areas of the nursing research field and creating significant implications to enlighten for future works in this area. Because nurses have great responsibilities, especially in patient care and treatment practices, in terms of patient safety, they should be well trained with the results deduced from knowledge and understanding from research.

Author Contributions

For research articles with several authors, a short paragraph specifying their individual contributions must be provided. The following statements should be used “Conceptualization, X.X. and Y.Y.; methodology, X.X.; software, X.X.; validation, X.X., Y.Y. and Z.Z.; formal analysis, X.X.; investigation, X.X.; resources, X.X.; data curation, X.X.; writing—original draft preparation, X.X.; writing—review and editing, X.X.; visualization, X.X.; supervision, X.X.; project administration, X.X.; funding acquisition, Y.Y. All authors have read and agreed to the published version of the manuscript.” Please turn to the CRediT taxonomy for the term explanation. Authorship must be limited to those who have contributed substantially to the work reported.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Science Mapping Workflow.
Figure 1. Science Mapping Workflow.
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Figure 2. Annual Scientific Production.
Figure 2. Annual Scientific Production.
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Figure 3. Most Cited Countries.
Figure 3. Most Cited Countries.
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Figure 4. Number of Publications and Total Citations.
Figure 4. Number of Publications and Total Citations.
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Figure 5. Word Cloud and Frequency Created by Authors' Keywords.
Figure 5. Word Cloud and Frequency Created by Authors' Keywords.
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Figure 6. Intercountry Cooperation Network.
Figure 6. Intercountry Cooperation Network.
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Figure 7. Thematic Analysis.
Figure 7. Thematic Analysis.
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Table 1. Basic Information.
Table 1. Basic Information.
Main Information Results Author(s) Collaboration Results
Sources (Journals, Books, etc.,) 187 Single Author 568
Documents 5470 Co-Authors per article 4.05
Annual Growth Rate % 22.41 International co-authorships % 14.48
Document Average Age 7.07 Document Type
Average citations per doc. 13.92 article 4076
References 115901 article; early access 815
Document Contents article; proceedings paper 20
Keywords Plus (ID) 4129 article; retracted publication 2
Author's Keywords (DE) 8161 review 408
Authors review; early access 149
Authors 15855
Authors of single-authored docs 510
Timespan 1992-2023.
Table 2. Source Local Effect.
Table 2. Source Local Effect.
Source H-Index G-Index TC NP TC/NP PY_start
INTERNATIONAL JOURNAL OF NURSING STUDIES 48 79 7538 168 44,9 2000
JOURNAL OF CLINICAL NURSING 36 52 5629 338 16,7 1998
JOURNAL OF NURSING MANAGEMENT 36 51 4853 282 17,2 2008
JOURNAL OF ADVANCED NURSING 35 58 4591 200 23,0 1999
JOURNAL OF NURSING ADMINISTRATION 30 54 3517 144 24,4 1996
NURSE EDUCATION TODAY 30 42 2811 161 17,5 1995
JOURNAL OF NURSING CARE QUALITY 27 42 3093 237 13,1 1998
JOURNAL OF NURSING SCHOLARSHIP 23 43 1929 58 33,3 2001
BMC NURSING 22 34 1487 131 11,4 2006
NURSE EDUCATION IN PRACTICE 22 34 1444 92 15,7 2013
JOURNAL OF NURSING EDUCATION 20 32 1270 73 17,4 2004
INTERNATIONAL NURSING REVIEW 19 31 1095 62 17,7 2008
NURSING OUTLOOK 19 38 1926 38 50,7 2001
REVISTA LATINO-AMERICANA DE ENFERMAGEM 18 25 1016 86 11,8 2009
WESTERN JOURNAL OF NURSING RESEARCH 18 30 972 47 20,7 2006
CIN-COMPUTERS INFORMATICS NURSING 17 24 946 92 10,3 2006
JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING 17 26 778 47 16,6 2004
AMERICAN JOURNAL OF CRITICAL CARE 16 24 607 32 19,0 2010
INTERNATIONAL EMERGENCY NURSING 16 21 578 60 9,6 2013
JOURNAL OF PROFESSIONAL NURSING 16 27 761 32 23,8 2004
NP = Number of publications, TC = Total citations, TC/NP = Citations per paper, PY_start = Publication year starting.
Table 3. Most Locally Cited articles.
Table 3. Most Locally Cited articles.
Document YP LC LC/YYP GC GC/YYP LC/GC Ratio%
CRONENWETT L, 2007, NURS OUTLOOK [10] 2007 120 7,059 704 41,412 17,05
SAMMER CE, 2010, J NURS SCHOLARSHIP [11] 2010 79 5,643 289 20,643 27,34
LASCHINGER HKS, 2006, J NURS ADMIN [12] 2006 76 4,222 446 24,778 17,04
KIRWAN M, 2013, INT J NURS STUD [13] 2013 71 6,455 169 15,364 42,01
KALISCH BJ, 2009, J ADV NURS [14] 2009 66 4,400 360 24,000 18,33
MAYO AM, 2004, J NURS CARE QUAL [15] 2004 59 2,950 188 9,400 31,38
BALL JE, 2018, INT J NURS STUD [16] 2018 57 9,500 263 43,833 21,67
AIKEN LH, 2013, INT J NURS STUD [17] 2013 54 4,909 414 37,636 13,04
GRIFFITHS P, 2018, J ADV NURS [18] 2018 53 8,833 269 44,833 19,70
AMMOURI AA, 2015, INT NURS REV [19] 2015 48 5,333 110 12,222 43,64
EBRIGHT PR, 2003, J NURS ADMIN [20] 2003 44 2,095 201 9,571 21,89
TELLA S, 2014, J NURS EDUC [21] 2014 44 4,400 71 7,100 61,97
RIESENBERG LA, 2010, AM J NURS [22] 2010 43 3,071 195 13,929 22,05
FENG XQ, 2008, J ADV NURS [23] 2008 42 2,625 82 5,125 51,22
TANG FI, 2007, J CLIN NURS [24] 2007 39 2,294 159 9,353 24,53
WANG X, 2014, INT J NURS STUD [25] 2014 38 3,800 89 8,900 42,70
AUSSERHOFER D, 2013, INT J NURS STUD [26] 2013 37 3,364 139 12,636 26,62
STEVEN A, 2014, NURS EDUC TODAY [27] 2014 37 3,700 74 7,400 50,00
VAN BOGAERT P, 2014, INT J NURS STUD [28] 2014 36 3,600 193 19,300 18,65
ANDERSON J, 2015, J CLIN NURS [29] 2015 35 3,889 88 9,778 39,77
Year of Publication (YP), YYP= Year 2024-Year of Publication, Global Citations (GC), Local Citations (LC).
Table 4. Word Cloud and Frequency Created by Authors' Keywords.
Table 4. Word Cloud and Frequency Created by Authors' Keywords.
Terms Frequency
patient safety 2219
nursing 691
nurses 377
communication 233
medication errors 171
quality improvement 169
nursing education 167
nursing care 153
safety 138
nurse 136
simulation 136
qualitative research 123
education 119
nursing students 118
teamwork 114
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