Received: 8 August 2022 | Revised: 2 December 2022 | Accepted: 4 January 2023

DOI: 10.1111/jocn.16622

REVIEW

Factors contributing to patient safety during triage process in

the emergency department: A systematic review

Zvonka Fekonja RN, BSc, MSc, PhD Student, Teaching Assistant1 | Sergej Kmetec RN, BSc,
1
MSc, PhD Student, Teaching Assistant | Urška Fekonja RN, BSc, MSc, PhD Student,
2
Registered Nurse | Nataša Mlinar Reljić RN, BSc, MSc, PhD, Assistant Professor1 |
1
Majda Pajnkihar RN, BSc, MSc, PhD, FAAN, FEANS, Professor | Matej Strnad MD, PhD,
2,3,4
Associate Professor

1
Faculty of Health Science, University of
Maribor, Maribor, Slovenia Abstract
Background: Triage is a dynamic environment in which large numbers of people can
2
Emergency Department, University
Clinical Centre Maribor, Maribor, Slovenia
3
present. It presents a vulnerable assessment point, as a triage nurse must assess a
Faculty of Medicine, University of
Maribor, Maribor, Slovenia patient's urgency level and analyse their health status and expected resource needs.
4
Prehospital Unit, Department for Given the critical nature of triage, it is necessary to understand the factors contribut-
Emergency Medicine, Community
ing to patient safety.
Healthcare Center Maribor, Maribor,
Slovenia Objectives: To identify and examine the factors contributing to patient safety during
the triage process.
Correspondence
Zvonka Fekonja, Faculty of Health Methods: A systematic review of the literature was undertaken, and a thematic analy-
Sciences, University of Maribor, Žitna ulica
sis of the factors contributing to patient safety during the triage process. PubMed,
15, 2000 Maribor, Slovenia.
Email: zvonka.fekonja@um.si CINAHL, Web of Sciences, Science Direct, SAGE, EMBASE and reference lists of rel-
evant studies published in English until March 2022 were searched for relevant stud-
ies. The search protocol has been registered at the PROSPERO (CRD42019146616),
and the review was conducted using the PRISMA criteria.
Results: Out of 5366 records, we included 11 papers for thematic synthesis. Identified
factors contributing to patient safety in triage are related to the emergency's work
environment, such as patient assessment, high workload, frequent interruptions and
staffing, and personal factors such as nurse traits, experience, knowledge, triage fa-
tigue and work schedule.
Conclusions: This review shows that patient safety is influenced by the attitude, ca-
pabilities and experiences of triage nurses, the time when nurses can dedicate them-
selves to the patient and triage the patient without disruption. It is necessary to raise
awareness among nursing administrators and healthcare professionals to provide a
safe triage environment for patients.

Patient or public contribution: No patient or public contribution was required to design or undertake this review.

PROSPERO registration number: CRD42019146616 (https://www.crd.york.ac.uk/prosp​ero/displ​ay_record.php?Recor​dID=146616).

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited and is not used for commercial purposes.
© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.

J Clin Nurs. 2023;32:5461–5477.  wileyonlinelibrary.com/journal/jocn | 5461

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5462 FEKONJA et al.

Relevance to Clinical Practice: This review highlights the evidence on the factors con-
tributing to patient safety in the triage process. Further research is needed for this
cohort of triage nurses in the emergency department concerning ensuring patient
safety.
Patient or Public Contribution: No patient or public contribution was required to de-
sign or undertake this review.

KEYWORDS
contributing factors, emergency department, nurses, patient safety, review, triage

1 | I NTRO D U C TI O N
Patient safety forms the key aspect of healthcare quality and is a
serious global public health concern (Tevžič et al., 2021). The safety
of patients is influenced by several factors and varies depending on
the level of the healthcare system (Klemenc-­Ketiš et al., 2020). As
an entry point to the healthcare system, the emergency department
serves a critical role and is an essential contributor to the health of
a population (Marcozzi et al., 2018). The clinical environment of the
emergency department is highly susceptible to patient safety risks
due to its fastest-­paced, complex and dynamic environment (Durgun
& Kaya, 2018). The number of patients in emergency departments
worldwide is growing and often exceeds the capacity to provide all
the help needed on an ongoing basis (Wireklint et al., 2018). To al-
locate limited resources as efficiently as possible, triage has become
a commonly used working tool (Wireklint et al., 2018). Good triage
presents a central emergency department task and enables undis-
turbed activity (Alumran et al., 2020; Bijani & Khaleghi, 2019). It is
a complex and urgent process that is crucial for the safety and ef-
ficiency of emergency patient care (Burström et al., 2014). When
patients arrive at the emergency department, the triage nurses ho-
listically assess their clinical conditions (Fekonja & Pajnkihar, 2016)
as patient's medical history, the clinical presentation of symptoms,
personal data, vital signs, transportation mode, the presence and
time-­frame of presented symptoms and patient's general appear-
ance (Reay et al., 2020). In this way, we can provide the patient with
timely health care and reduce the risk of poor health prognosis due
to excessive waiting for treatment (Alumran et al., 2020). The cor-
rectness of triage is crucial and a way to ensure patient safety (Moon
et al., 2019), as neither undertriage (underestimation of patients of
urgency or severity of disease) nor overtriage (overestimation of pa-
tient urgency or severity of disease) are nondesirable outcomes of
triage (Ausserhofer et al., 2021).
Various triage systems based on a well-­developed methodology
and protocols have been developed worldwide to increase patient
safety (Reay et al., 2020). An effective triage system regulates the
length of patient waiting times in the emergency department by
combining immediate health status assessment and interventions
(Forsman et al., 2012). In the triage systems, nurses are essential for
properly assessing patient urgency and reducing errors (Ausserhofer
et al., 2021). The nurse's interview technique and ability to accurately
What does this paper contribute to the wider
global community?
• Patient safety during the triage process can be under-
stood within the environmental and personal domain of
the reciprocal determinism framework.
• The clinical environment, which includes triage perfor-
mance and the workplace, is associated with the be-
haviour of triage nurses to contribute to patient safety
through their characteristics, experience, knowledge,
triage fatigue and work schedule.
• The review identifies factors associated with patient
safety during the triage process in the emergency de-
partment; some of them need to be deeply examined in
further intervention and longitudinal studies.
assess patient health based on observation also contribute to pa-
tient safety at triage and systemic issues related to greater patient
flow through the emergency department, interdisciplinary team
communication and different nurse competencies in triage (Reay
et al., 2020). Thus, triage is influenced by the personality traits of
the individual triage nurse, the patient and the specific urgent work
environment (Ausserhofer et al., 2021). Given the critical nature of
triage in enabling emergency department functions, factors that af-
fect the ability of triage nurses to ensure patient safety in the triage
process need to be identified and understood. Therefore, this sys-
tematic review aims to identify and examine the factors contributing
to patient safety during the triage process in the emergency depart-
ment, guided by the theoretical framework of Bandura's model of
reciprocal determinism.
1.1 | Theoretical framework
For this review, Bandura's model of reciprocal determinism was cho-
sen as the guiding and organising framework to explore contributing
factors underlying patient safety in the triage process. Moreover,
it allows the inclusion of the environment and external factors that
affect patient safety, allowing for the discovery of barriers and

FEKONJA et al.
facilitators of safety issues within the triage process. Reciprocal
determinism is supported by some studies (Eshete et al., 2019;
Parry et al., 2015; Sepp, 2021), and its domains have been recom-
mended for patient safety-­related topics (Cooper, 2000). Bandura's
reciprocal determinism presents a central premise of social learning
theory where three domains: (1) behaviour, (2) personality factors
and (3) the environment work as interacting determinants that af-
fect each other (Wood & Bandura, 1989). The model assumes that
change results from the interaction between the person and their
environment as a reciprocal process (Baranowski et al., 2002). A
person refers to an individual's unique personality, set of experi-
ences, personal values, attitudes, cognition, thinking and more.
Environmental factors are anything outside the person, such as
working setting, equipment, material things, gadgets and politics.
The environment thus includes social factors such as family, friends
and community (Bandura, 1999). In the framework, patient safety
was regarded as the aspect of behaviour and is the result of our
interest.
2 | M E TH O D S
A systematic review of the literature was undertaken. The process
of searching and data extraction of the studies and displaying the
results were guided by the Preferred Reporting Items for Systematic
Reviews (PRISMA) (Moher et al., 2009) guidelines (Appendix S1).
2.1 | Research question
The research question of this review was as follows: What factors
in the triage process contribute to patient safety in the emergency
department?
TA B L E 1 Research strategy containing inclusion and exclusion criteria
Databases PubMed, ScienceDirect, Web of Science, CINAHL, SAGE, EMBASE
Inclusion criteria
Participants/ Triage nurse working in the emergency department
setting
Intervention/ Triage in the emergency department
Treatment
Outcome Factors that influence patient safety through the triage
process in the emergency department
Types of Research article (Quantitative, qualitative or mixed methods
research empirical studies)
Search limits
Timeframe Until March 2022
Language English
Availability of None limit
articles
|
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5463
2.2 | Search strategy
A systematic review was conducted to identify relevant literature. A
computerised literature search was carried out across the following
databases: PubMed (including Medline), CINAHL, Web of Sciences,
ScienceDirect, SAGE and EMBASE. The reference list of each final
article was considered for inclusion to identify any other literature
not previously identified and was manually searched. The search
was performed using the search terms that contained a combination
of keywords: adult, patient safety, emergency department, triage
and using their synonyms. These keywords were used in combina-
tion with Boolean operators (OR/AND) to identify all relevant pa-
pers. We used the same search terms, limits, inclusion and exclusion
criteria in all the databases (See Appendix S2 for the search results
in individual databases).
2.3 | Eligibility criteria
To focus the systematic review on patient safety in the triage pro-
cess, inclusion and exclusion criteria were established to provide
consistency and rigour to the literature review (Table 1). Inclusion
criteria for the search were as follows: (1) focused on the factors of
patient safety in the triage process, (2) published in scientific journals
and (3) triage nurses' involvement. Exclusion criteria were as follows:
(1) studies not related to the topic, (2) related solely to professions
other than emergency triage nursing and (3) no empirical data.
2.4 | Methodological quality assessment
Studies included in the final analysis were independently and criti-
cally evaluated for methodological quality by two authors (first
Exclusion criteria
Healthcare practitioners or nurses not performing triage
process in the emergency department; patients
Handover, admission without triage or care of the patient in the
emergency department; telephone triage; ambulance and
paramedics services
Not assessing factors that influence patient safety through the
triage process in the emergency department
Systematic review articles or other types of reviews
Duplicates, commentaries, editorials, conferences and research
protocols
 |
5464
and second authors) using the ‘Joanna Briggs Institute Critical
Appraisal Checklist’ (Aromataris & Munn 2020). After complet-
ing a separate critical assessment, both authors compared their
results. Disagreements between reviewers were discussed, and
the consensus was reached with the help of a third author. To as-
sess the quality of the articles, we used the JBI Critical Appraisal
Checklist for (1) qualitative research (Lockwood et al., 2015) and (2)
analytical cross-­s ectional research (Moola et al., 2020). JBI qual-
ity assessment tools include methodological appraisal questions
that help authors determine the methodological rigour of included
studies. For each of the checklists used, the answers were scored:
‘Yes’ with one point, ‘No’ and ‘Unclear’ got zero points. After the
assessment, we calculated the sum and percentage of all points
for each study. Based on the authors of Camp and Legge (2018)
recommendation, we evaluated and divided the studies into four
groups: low quality (60%–­69%), medium quality (70%–­79%), high
quality (80%–­89%) and excellent quality (more than 90%). Each
study had to have at least 60% compliance with the JBI standard
before its inclusion in the review process. The ‘Quality Score’ col-
umn also shows the points achieved and the percentage for each
study.
2.5 | Data extraction and synthesis of data
Data were collated by one reviewer and checked by other review-
ers using predefined data extraction criteria that included the au-
thors name, date of publication, country, objectives, design and
data collection methods, sample and setting, and a summary of
the main findings of the study. Disagreements were resolved by
discussion and consensus. Each included study was presented in
Table 2 with predefined data extraction criteria and quality ap-
praisal score.
Thematic analysis and synthesis were performed to examine
the literature using Bandura's (1986) reciprocal determinism the-
ory as an organising framework. To synthesise the data emerging
from the results of the final selection of studies, the Thomas and
Harden (2008) thematic approach was adopted: (1) Line by line
coding to identify free codes, (2) organising free codes into de-
scriptive primary and secondary level subthemes, and (3) develop-
ing main themes. Thematic synthesis has been reviewed by other
authors, and any disagreements were resolved through discussion
and consensus.
3 | R E S U LT S
3.1 | Study identification and selection
In accordance with the eligibility criteria (Table 1), the literature was
searched until March 2022. Initial database searches resulted in re-
trieving 5366 records. All 5366 identified records were imported into
the EndNote X9.2 reference software manager, and 170 duplicates
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FEKONJA et al.
were removed. After excluding all duplicated records, 5196 records
were imported into an Excel 2016 file, where the first author began
reviewing the titles and abstract. Records (n = 5196) were excluded
because they were not thematically related to our research topic
and did not meet the inclusion criteria. Then, the remaining stud-
ies' full texts (n = 96) were screened independently for eligibility.
After reading the full text, 86 records were excluded. Therefore, 12
studies were finally included in the critical appraisal. One of all stud-
ies was excluded due to quality (Johnson et al., 2014); therefore, 11
were retained in the final analysis and synthesis despite their meth-
odological bias (see Appendix S3 for a list of excluded papers with
reasons for their exclusion). The literature identification process is
summarised and presented in the PRISMA flow diagram in Figure 1
(Moher et al., 2009).
3.2 | Study characteristic
Of the 11 included articles, seven used a qualitative design and
five utilised a quantitative design. Three studies were conducted in
the United States, three in Sweden and one each in Iran, Taiwan,
Australia, South Corea and Canada. In the qualitative studies, three
used focus groups, three interviews and one unstructured observer-­
only observation. In quantitative designs, two studies used ques-
tionnaires for data collection, one assessment tool and one review
of medical records. Detailed descriptions of individual studies can
be seen in Table 2.
3.3 | Methodological quality assessment
Using the JBI helped identify each article's methodological strengths
and weaknesses. The quality results of the studies are reported in
Table 3. Seven studies were evaluated with a moderate-­quality
score, one as high and three as excellent.
3.4 | Results of data synthesis
The line-­by-­line coding of selected papers established free codes
(n = 231). Free codes were then organised into 13 descriptive pri-
mary level subthemes, and after their analysis and comparison, sec-
ondary level subthemes were developed (n = 4). All themes were
synthesised and classified around an established theoretical frame-
work (Bandura, 1986), from which we identified one main topic:
Patient safety factors during the triage process (Figure 2). Using the
patient's safety in triage as the outcome of behaviour, the domains
of environment and person (Bandura, 1986) have synthesised the
selected studies' findings.
Analysis of the literature revealed four secondary level sub-
themes that could be described as patient safety factors during the
triage process. Within the domain of personal factors were iden-
tified: (1) Triage nurses' attributes (Andersson et al., 2006; Bijani &
 TA B L E 2 Characteristics of the included studies

References and Research design, data Quality

country Aim collection method Sample, setting Main findings assessment
FEKONJA et al.

Andersson To describe how nurses work with Qualitative 45 nurses in ED of a • Experienced nurses bring a sense of security to the triage team, 7/10 (70%)
et al. (2006) triage on patients' arrival as well Semi-­structured county hospital as younger –­not so experienced triage nurses are happy to turn
Sweden as the factors considered when interview to older colleagues for advice and support.
prioritising and in connection with • Due to the overcrowding and physical exertion, incorrect triage
nurses' decision-­making occurs, and thus the safety of the patient is endangered
• Nurses point out that knowledge is an essential virtue in the
triage of the patient
Bijani and To investigate the challenges and Qualitative 18 triage nurses and • Factors related to the triage nurse and factors related to 7/10 (70%)
Khaleghi (2019) barriers affecting the quality of Semi-­structured four emergency emergency management are important for quality and safe
Iran triage in an educational hospital interview and focus medicine specialists triage.
group working in the ED • The triage nurses have insufficient clinical competencies and
Two focus groups with insufficient psychological capacity.
seven triage nurses • For organisational factors, are mentioned, human resources,
structural and triage challenges
Chen et al. (2010) To gain an understanding of the Quantitative 279 triage nurses in ED • Triage training hours are the most important factor in the 6/8 (75%)
Taiwan accuracy of acuity assessment Questionnaire of 14 hospitals accuracy of triage nurses' assessment (b = 0.74; p = .000)
made by the emergency • Years of experience in emergency work (p = .001), hours of
department triage nurses, to triage training (p = .001), type of medical institution (p = .002)
compare the differences between and triage method (p = .002) are significantly related to the
the characteristics of triage results of an accurate triage assessment
nurses according to hospital • Among triage nurses, a high proportion of the inaccurate
variables and the accuracy of assessment of patient condition was found –­24.3% of triage
acuity ratings, and to explore the decisions were undertriage, and 19.7% were over-­triage
influence of nursing variables on
the judgement of triages
Forsman To describe nurse's perception of the Quantitative 74 triage nurses in • The Manchester triage system contributes to patient safety 8/8 (100%)
et al. (2012) impact of experience and safety Questionnaire four ED (R = .65, R2 = .42), but as more reliable and relevant in ensuring
Sweden of the Manchester triage system patient safety, nurses' experience was assessed/selected.
have on patient safety • Nurses' experiences increased patient safety (R = .73, R2 = .54),
which was further enhanced by years of working experience
and experience working as triage nurse (R = .33, R2 = .11).
• The level of patient safety increased at times when the triage
nurse also had more time for assessment and triage (R = .24,
R2 = .06) and enough time for further analysis of the condition
(R = .26, R2 = .68).
• The skills of the triage nurse, the Manchester triage system and
additional organisational factors together represent 65% of the
guaranteed patient safety (R2 = .65) in the triage process
| 5465

(Continues)

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 TA B L E 2 (Continued)
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References and Research design, data Quality

country Aim collection method Sample, setting Main findings assessment

Hitchcock To explore and describe the triage Qualitative Staff working in the • The key factors for safe triage are the education, knowledge 7/10 (70%)
et al. (2014) process in the Emergency Unstructured observer-­ ED setting that and experience of nurses
Australia Department to identify problems only observation, were involved in • Triage waiting line, extended time to triage and longer time to
and potential vulnerabilities that field notes, the triage process, health status assessment and treatment can slow patient care
may affect the triage process informal and formal including triage and potentially jeopardise their safety
interviews nurses, emergency • Lack of experience with the work of a triage nurse is associated
nurses, shift with compromised patient safety.
leaders, medical • The less knowledge and experience a triage nurse has, the
officers, ambulance greater the risk of endangering patient safety.
officers and clerical • Communication, collaboration and teamwork were highlighted
staff as key to the triage process
Johnson To describe the interruptions Quantitative Two adult emergency • Interruptions during triage can cause delays and hinder safe and 7/8 (87.5%)
et al. (2018) occurring during triage and their Tool –­TIAT (Triage departments. efficient patient care.
United States impact on the triage process and Interruptions The sample consists of • Triage was most often interrupted by other nurses with a direct
patient outcomes Assessment Tool) 8 triage nurses conversation and by patients who answered the phone during
triage.
• The interrupted triage interview lasted longer, namely 29 min,
while the continuous triage interview lasted on average 10 min
Källberg To describe emergency department Qualitative Ten physicians and 10 • A large number of patients has been identified as a risk to 10/10 (100%)
et al. (2017) clinicians' experience with regards Semi-­structured registered nurses compromised safety and the occurrence of errors, but at the
Sweden to patient safety risks interviews in two emergency same time, it can develop into a long waiting period, which can
departments for also delay the basic primary triage of the patient.
adults • Interruptions or disorders have been identified by nurses as
a threat to working performance, as disruptions during peak
patient times and strains can cause certain (even important)
things to be forgotten.
• Disruptions and interruptions in work have made it difficult for
nurses to concentrate and focus on their work, which in turn
endangers patient safety
• Unclear organisational responsibility has been described as
a risk factor for patient safety, as it can lead to uncertainty
about who was responsible for the patient and delay before the
patient receives adequate care.
• Staff shortage is also a risk to patient safety
McMahon To determine how the length of triage Quantitative 28 triage nurses in • The optimal triage duration should be 4 h to avoid a significant 6/8 (75%)
et al. (2017) shifts affect perceived fatigue Questionnaire the Emergency increase in fatigue.
United States levels among triage nurses department at a • The large workload and the associated higher fatigue levels
university-­affiliated among triage nurses are present between the fourth and eighth
community hospital working hours.
• There is a strong positive association between nurses' time in
triage and fatigue (p < .01)
FEKONJA et al.

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 TA B L E 2 (Continued)

References and Research design, data Quality

country Aim collection method Sample, setting Main findings assessment
FEKONJA et al.

Moon et al. (2019) To identify emergency department Quantitative 1267 systematically • Patient safety can be improved by developing a training 8/8 (100%)
South Korea triage accuracy and evaluate the Review of medical selected records program for nurses according to the cause of the wrong triage
causes of mistriage records of the adult decision.
patient admitted • Presence of incorrect triage due to incorrect decision: 55
to two emergency (29.6%) cases were over triage (overestimation of severity) and
departments 131 (70.4%) cases of undertriage (underestimation of severity).
• The most common reason for safety concerns was incorrect use
of the pain scale and misjudgment of the physical symptoms
associated with the patient's main complaint
Reay et al. (2020) To identify factors impeding triage Qualitative 11 trained triage • Sometimes, the most critical patients do not receive care and 7/10 (70%)
Canada decision-­making. Focus group nurses in four have to wait in the waiting room for a free bed in front of less
urban tertiary care acute patients who are already being treated in the fast track
teaching hospitals area of the emergency department.
• The number of patients has a severe and sometimes
detrimental effect on triage decision-­making
• Effective triage is affected by the length of the shift, the
number of consecutive shifts, the number of triage shifts per
week and the number of triage nurses per shift.
• The potential safety of patients is affected by the personal
capacity of triage nurses; more patients triage within one
category and the relationship between triage nurses and
paramedics.
• Too many shifts in a row or too long shifts in triage affect triage
nurses decisions and interactions with patients
Wolf et al. (2018) To explore emergency nurses' Qualitative 26 nurses working in • The main identifiable barriers to effective triage are inadequate 7/10 (70%)
United States understanding of and experience Focus group the emergency use of technology, inadequate staff, lack of time, language
with the triage process and to department barriers, lack of education and experience, burnout and lack of
identify facilitators and barriers to nursing care.
accurate acuity assignation • Environmental conditions (e.g. lack of staff and limited time)
and personal conditions (e.g. education, burnout/compassion
fatigue) hamper the quality and safety of care for triage
patients
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5468
Records idenfied through
database searching
PubMed (n = 543 )
CINAHL (n = 167)
Science direct (n = 1996 )
Web of Sciences (n = 171 )
SAGE (n = 1630 )
EMBASE (n = 859)
Records aer duplicates removed
(n = 5366 )
Records assessed based on tle and
abstract for eligibility
(n = 5196)
Full text assessed for eligibility
(n = 96)
Addional records
idenfied through
hand search
(n = 2)
Studies retained for crical
appraisal
(n = 12 )
Studies included in literature
review (n = 11 )
F I G U R E 1 Flow diagram of papers selection.
Khaleghi, 2019; Chen et al., 2010; Forsman et al., 2012; Hitchcock
et al., 2014; Källberg et al., 2017; Moon et al., 2019; Reay et al., 2020;
Wolf et al., 2018); (2) Lived experience of triage (Andersson et al., 2006;
Bijani & Khaleghi, 2019; Källberg et al., 2017; McMahon et al., 2017;
Reay et al., 2020; Wolf et al., 2018). In the domain of Environment
were identified; (3) Triage performance (Andersson et al., 2006; Bijani
& Khaleghi, 2019; Chen et al., 2010; Forsman et al., 2012; Hitchcock
et al., 2014; Johnson et al., 2018; Källberg et al., 2017; Moon
et al., 2019; Reay et al., 2020; Wolf et al., 2018); and (4) Workplace
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FEKONJA et al.
Remove duplicates
(n = 170 )
Records excluded as tle and abstract showed
that study was not primarily focused on safety
of paent and triage process in an emergency
department
(n = 5100)
Full-text arcles excluded, with reasons (n = 86)
Intervenon/treatment:
- Type of Errors or adverse events (n = 5)
- Comparing, usage or auding triage systems (n = 11);
- Not include the triage process (n = 33)
Outcomes:
- Not include the factors of paent safety (n = 32)
Type of study (n = 5 )
Record excluded due to very low quality
JBI appraisal checklist < 60 %
(n = 1 )
(Andersson et al., 2006; Forsman et al., 2012; Hitchcock et al., 2014;
Källberg et al., 2017; Reay et al., 2020; Wolf et al., 2018).
4 | D O M A I N : PE R S O N A L FAC TO R S
Two secondary level subthemes emerge in the domain of personal
factors: (1) Triage nurses' attributes and (2) Lived experience of
triage.
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FEKONJA et al. 5469

TA B L E 3 Critical assessment of included papers

JBI CA checklist ACS

Including papers (n = 5) 1 2 3 4 5 6 7 8

Chen et al. (2010) Y Y Y U Y N Y Y

Forsman et al. (2012) Y Y Y Y Y Y Y Y
Johnson et al. (2018) Y Y Y Y Y U Y Y
McMahon et al. (2017) Y Y Y Y U U Y Y
Moon et al. (2019) Y Y Y Y Y Y Y Y

JBI CA checklist QR

Including papers (n = 7) 1 2 3 4 5 6 7 8 9 10

Andersson et al. (2006) U Y Y Y Y N N Y Y Y

Bijani and Khaleghi (2019) U Y Y Y Y N N Y Y Y
Hitchcock et al. (2014) U Y Y Y Y U N Y Y Y
Källberg et al. (2017) Y Y Y Y Y Y Y Y Y Y
Johnson et al. (2014) U U U U U N N Y N N
Reay et al. (2020) U Y Y Y Y N N Y Y Y
Wolf et al. (2018) Y Y Y Y Y N N Y N Y

Note: JBI CA checklist ACS –­1. Were the criteria for inclusion in the sample clearly defined? 2. Were the study subjects and the setting described
in detail? 3. Was the exposure measured in a valid and reliable way? 4. Were objective, standard criteria used for measurement of the condition? 5.
Were confounding factors identified? 6. Were strategies to deal with confounding factors stated? 7. Were the outcomes measured in a valid and
reliable way? 8. Was appropriate statistical analysis used? JBI CA checklist QR: 1. Is there congruity between the stated philosophical perspective
and the research methodology? 2. Is there congruity between the research methodology and the research question or objectives? 3. Is there
congruity between the research methodology and the methods used to collect data? 4. Is there congruity between the research methodology and
the representation and analysis of data? 5. Is there congruity between the research methodology and the interpretation of results? 6. Is there a
statement locating the researcher culturally or theoretically? 7. Is the influence of the researcher on the research, and vice-­versa, addressed? 8.
Are participants, and their voices, adequately represented? 9. Is the research ethical according to current criteria or, for recent studies, and is there
evidence of ethical approval by an appropriate body? 10. Do the conclusions drawn in the research report flow from the analysis, or interpretation, of
the data?
Abbreviations: ACS, analytical cross-­sectional studies; CA, critical appraisal; N, no; NA, not applicable; QR, qualitative research; U, unclear; Y, yes.

4.1 | Triage nurses' attributes
The subtheme of triage nurses' attributes included three elements:
(1) Personality traits, (2) clinical and practical capability and (3)
experience.
behaviours (Bijani & Khaleghi, 2019). In some studies, (Andersson
et al., 2006; Bijani & Khaleghi, 2019; Forsman et al., 2012; Wolf
et al., 2018), triage nurses have also highlighted the importance of
intuition for safe triage patient care.

4.1.2 | Clinical and practical capability

4.1.1 | Personality trait
The potential safety of patients is influenced by the personal ca-
pabilities of the triage nurses (Reay et al., 2020), such as emotional
stability, high tolerances (Bijani & Khaleghi, 2019), skills, intelligence
and empathy (Forsman et al., 2012), which allow the triage nurses
to adapt to difficult emergency situations (Andersson et al., 2006;
Källberg et al., 2017; Wolf et al., 2018). Long triage lines require the
triage nurses to manage the crowd and resolve conflicts. However,
the ability to do so is often self-­t aught and dependent on individual
personalities (Reay et al., 2020). Triage requires from the nurse a
great deal of courage and belief in the correctness of her decision
(Andersson et al., 2006), high tolerance, critical thinking and inter-
professional communication skills, calmness and maintaining men-
tal concentration in critical situations, and controlling emotional
Education, knowledge and clinical capability of the triage nurses
(Andersson et al., 2006; Bijani & Khaleghi, 2019; Chen et al., 2010;
Forsman et al., 2012; Hitchcock et al., 2014; Wolf et al., 2018) are
crucial for patient safety in the triage process. Differences in the
level of knowledge are sometimes reflected in the decisions of tri-
age nurses (Hitchcock et al., 2014; Wolf et al., 2018); therefore, tri-
age education and nurse preparation for the triage role (Hitchcock
et al., 2014) are vital. In support of this, Wolf et al. (2018) found
that measuring knowledge in the triage process can be challenging
because some nurses find it difficult to accept criticism and are not
suited to learning specific triage skills. The skill level of triage nurses
directly affects the triage process, namely the accuracy of patient
assessment, which means that it can provide patients with adequate
quality triage care or otherwise jeopardise their safety (Hitchcock
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5470 FEKONJA et al.

F I G U R E 2 Schematic model of
the contributory factors of findings
Behaviour from selected studies within each
Patient safety in triage domain. [Colour figure can be viewed at
wileyonlinelibrary.com]

Triadic
reciprocality

Environment
Personal factors
Triage performance
Triage nurses‘ attributes Assessment
Personaly trait Workload
Clinical and practical capability Staffing
Triage experience Interruptions

Lived experience of triage

Fatigue/Burnout
Workplace
Mentoring/supervision
Shift scheduling Teamwork and communication
Unit organisation and leadership

et al., 2014). Knowledge and skills in the triage process mostly refer
to knowledge of triaging the patient, sufficient clinical knowledge in
the field of the physiopathology of diseases and emergencies, clini-
cal skills to perform correct and rapid clinical measures, the ability
to check patient history and perform physical examinations (Bijani
& Khaleghi, 2019; Hitchcock et al., 2014; Moon et al., 2019). Patient
safety can be improved by developing educational programs (Moon
et al., 2019) and continuous training and competency assessment
to facilitate triage accuracy and effective decision-­making (Wolf
et al., 2018). Training must highlight the negative consequences of
mistriage, including undertriage (Moon et al., 2019). The higher the
level of knowledge and experience indicated by the triage nurse, the
more respect and trust from nursing and medical colleagues have
been perceived (Hitchcock et al., 2014).
out that people used not to get to go to triage unless they had been a
nurse down there for many years. In support of this, Hitchcock et al.
(2014) found that at least 3 or 4 years post nursing degree work ex-
perience is required to perform triage activity safely. Similarly, Wolf
et al. (2018) indicated at least 2 years of work in the emergency de-
partment for triage nurses. Experienced nurses see themselves as
having more courage and faith in themselves and bringing a sense
of ‘security’ to the triage team (Andersson et al., 2006); nevertheless
according to Reay et al. (2020), experience is intangible, and yet, a key
component of a nurse's ability to make triage decisions. Experiences
give nurses the ability to know when individual patients are at higher
risk, when immediate intervention is needed, or when there is a mis-
match between their assessment findings and the information pro-
vided by the patient (Hitchcock et al., 2014; Reay et al., 2020).

4.1.3 | Triage experiences 4.2 | Lived experience of triage

Triage nurses' lack of experience is linked to patient safety threats
(Chen et al., 2010; Hitchcock et al., 2014; Wolf et al., 2018), as depth
and breadth of clinical experience are needed to identify an already
seemingly ill patient (Wolf et al., 2018). The experience was consid-
ered to improve the patient's safety (R = .73, R 2 = .54, p < .05), which
is further increased with the longer the nurse had worked with triage
(R = .33, R 2 = .11, p < .05) (Forsman et al., 2012). Experience is seen
as an important prerequisite for triage skills; Wolf et al. (2018) point
In relation to the Lived experience of triage, two subthemes emerged,
namely (1) Fatigue and Burnout and (2) Shift scheduling.
4.2.1 | Fatigue and burnout
The triage unit represents a very stressful environment with high
workload, fatigue and overload (Bijani & Khaleghi, 2019; McMahon

FEKONJA et al.
et al., 2017). Triage nurses often feel stressed and under pressure,
uncertain or concerned about the decision regarding the correct-
ness of prioritisation of the patients and the timeliness of treatment
of critically ill patients (Andersson et al., 2006; Källberg et al., 2017;
Reay et al., 2020). Wolf et al. (2018) reported that triage nurses
often do not even know they are burned out. However, their sur-
roundings report their irritability, impatience to co-­workers and
patients, negativity towards everything, leaking empty triage and
carelessly triage. Triage nurses indicated burnout as a major im-
pediment to safe and effective triage of patients (Reay et al., 2020;
Wolf et al., 2018). Within the phenomenon of burnout, fatigue has
been identified (Andersson et al., 2006; Reay et al., 2020; Wolf
et al., 2018). Triage fatigue was exposed when triage nurses were
in multiple consecutive shifts during busy times (Reay et al., 2020).
In addition, McMahon et al. (2017) found out that there is a strong
positive association between the time nurses spend in triage and
fatigue (p < .01). Triage nurses point out that a 12-­h workday af-
fects their decision-­making and increases fatigue and, thus, patient
safety (Reay et al., 2020). McMahon et al. (2017) found that the av-
erage triage fatigue in a 12-­h shift increases by 64.4%–­75.2%, with
a maximum percentage increase between 4 and 8 a.m., which can
provide guidance on the time a nurse should take to survive in tri-
age. Therefore, the maximum load and thus the increased level of
fatigue are present in triage nurses between the fourth and eighth
hours of work, so the optimal triage duration would be 4 h to avoid
a significant increase in fatigue.
4.2.2 | Shift scheduling
Reay et al. (2020) found that the length of the shift influences the
ability to safe and effective triage, the number of shifts and the num-
ber of consecutive shifts on triage. Further, Reay et al. (2020) indi-
cated that too many shifts in a row or too long-­lasting triage shifts
affect their decisions and interactions with patients, making patients
feel devalued and unwilling to disclose relevant information regard-
ing their health. McMahon et al. (2017) stated that the optimal tri-
age duration would be 4 h, while Wolf et al. (2018) pointed out that
changing triaging nurses constantly on 2 h is needed for the quick
and smooth running of the triage function.
5 | D O M A I N : E N V I RO N M E NT
We identified two primary level subthemes within the domain envi-
ronment: (1) Triage performance and (2) Workplace.
5.1 | Triage performance
In relation to triage performance, we identified four subthemes: (1)
Assessment, (2) Workload, (3) Staffing and (4) Interruptions.
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5471
5.1.1 | Assessment
In the course of assessment, the use of triage systems (Hitchcock
et al., 2014) and technology (Wolf et al., 2018) helps to increase pa-
tient safety by reducing the risk of overlooking important param-
eters (Forsman et al., 2012; Hitchcock et al., 2014). However, triage
systems as additional support contributed to the early finding and
identifying patients with life-­threatening conditions and reduced
the risk of overlooking important parameters in health assessment
(Forsman et al., 2012; Hitchcock et al., 2014; Reay et al., 2020). For
safe triage, in addition to the use of the triage system, vital signs can
be used, as according to Wolf et al. (2018), methods of triage that
do not include vital signs may not adequately reflect the urgency of
the patient. In the triage process, the nurse must assess clinical sta-
tus before making a triage decision and prioritising the patient (Reay
et al., 2020). Hitchcock et al. (2014) find that triage is a somewhat
subjective process and very person dependent rather than process-­
dependent (Wolf et al., 2018). However, some studies have indicated
that many disagreements and problems have arisen when making
triage assessments. Problems mainly relate to over and undertriage
(Chen et al., 2010; Forsman et al., 2012; Hitchcock et al., 2014; Moon
et al., 2019; Wolf et al., 2018), which prolongs medical waiting and
treatment (Hitchcock et al., 2014). Triage nurses face this problem
when co-­workers direct them to raise or lower the patient's triage
category because a particular area of the emergency department is
full or empty (Wolf et al., 2018). According to the findings of Moon
et al. (2019) and Chen et al. (2010), underestimating the severity of a
health condition (under triaging) is higher than overestimating the se-
verity (over triaging). On the contrary, several patients are often tri-
aged within one category (Andersson et al., 2006; Reay et al., 2020),
which produces a priority within priority (Andersson et al., 2006).
Hence, in these cases, the triage nurse must look and see whether
there is someone who needs to be cared for before others. Forsman
et al. (2012) found that the level of patient safety increased at times
when the triage nurse also had more time for assessment and triage
(R = .24, R 2 = .06, p < .05) and enough time for further analysis of
the condition (R = .26, R 2 = .68, p < .05). Conversely, time to triage
(Andersson et al., 2006; Hitchcock et al., 2014; Reay et al., 2020)
and longer time to assess health status (Andersson et al., 2006; Wolf
et al., 2018) can slow patient care and potentially compromise their
safety.
5.1.2 | Workload
Patient overcrowding (Andersson et al., 2006; Hitchcock et al., 2014;
Källberg et al., 2017; Moon et al., 2019; Reay et al., 2020) is recog-
nised as a serious risk to patient safety because it has a severe and
sometimes detrimental effect on triage decision-­making (Andersson
et al., 2006; Källberg et al., 2017), working relations and safe patient
handover (Reay et al., 2020). The large volume of patients affects
waiting times, delays or disrupts the patient flow and consequent
 |
5472
triage as well (Hitchcock et al., 2014; Källberg et al., 2017). Long tri-
age lines require nurses to be able to manage a crowd and resolve
confrontations (Reay et al., 2020). Moon et al. (2019) found that
crowding may affect the triage process but not the accuracy of tri-
age. The number of patients per hour was not related to the accurate
determination of triage categories.
5.1.3 | Staffing
Three studies explored the impact of staff shortage on triage pa-
tient safety. Wolf et al. (2018) and Källberg et al. (2017) found that
an insufficient number of staff in relation to the number of patients
significantly prolong the waiting time until treatment and reduce the
quality of health services (Bijani & Khaleghi, 2019).
5.1.4 | Interruptions
Interruptions or disorders in triage (Andersson et al., 2006; Johnson
et al., 2018; Källberg et al., 2017) are recognised by triage nurses as
a factor that limits the provision of safe and effective triage of pa-
tients. Most commonly affect the work performance of triage nurses
(Andersson et al., 2006; Johnson et al., 2018; Källberg et al., 2017),
discourage nurses from collecting relevant triage data (Johnson
et al., 2018), cause nurses to make bad triage decisions (Andersson
et al., 2006), and make it difficult for nurses to focus and concen-
trate on their work (Källberg et al., 2017). According to Johnson
et al. (2018) and Andersson et al. (2006), triage was most often inter-
rupted by other nurses, paramedics, phone calls, patients and rela-
tives. Workflow interruptions also posed an increased risk of errors
in team communication itself and thus loss of important information
(Källberg et al., 2017).
5.2 | Workplace
Within the workplace, three subthemes were identified as con-
tributing factors to triage patient safety, namely (1) Mentoring and
supervision, (2) Teamwork and communication, and (3) Unit organi-
sation and leadership.
5.2.1 | Mentoring and supervision
A sense of security in the triage team is introduced by the possibility
of younger triage nurses consulting with older colleagues (Andersson
et al., 2006; Hitchcock et al., 2014). Younger, not-­so-­experienced
triage nurses gladly turn to older co-­workers for support, guidance
and advice (Andersson et al., 2006; Forsman et al., 2012; Hitchcock
et al., 2014). Forsman et al. (2012) reported that patient safety also
increased when the organisation offered peer support to the triage
nurse (R = .31, R 2 = .10, p < .05).
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FEKONJA et al.
5.2.2 | Teamwork and communication
Teamwork and communication have been shown to be crucial to the
triage process in maintaining patient safety (Hitchcock et al., 2014;
Källberg et al., 2017). Furthermore, Hitchcock et al. (2014), Källberg
et al. (2017) and Reay et al. (2020) pointed out that interaction be-
tween members of the interdisciplinary emergency department team
is important for ensuring continuous care and the continuous flow of
patients through the triage process. According to Källberg et al. (2017)
and Reay et al. (2020), the lack of information on transfers of patients
from other hospitals could seriously jeopardise patient safety in the
form of long waiting times and misjudged patient health status.
5.2.3 | Unit organisation and leadership
Unclear organisational responsibility has been described as a risk fac-
tor for patient safety, as it can lead to uncertainty about who was
responsible for the patient and delay before the patient receives ap-
propriate care (Källberg et al., 2017). Reay et al. (2020) indicated that
the organisational system's focus on maintaining the flow of patients
by the emergency management and not taking into account the com-
plex nature of the emergency environment proved to be the most
threatening to patient safety. Wolf et al. (2018) indicate that triage
cannot be adapted to the situation in the emergency department and
staff occupancy; you have to triage for the patient. For patients' safe
and efficient care at the initial patient triage encounter, it is necessary
to include management, which should be apprised of the situational
workload in the triage area. The management of patients through
the emergency department is essential. Therefore, fast track areas
for less acute patients are used in many emergency departments
(Hitchcock et al., 2014; Reay et al., 2020; Wolf et al., 2018) which,
in practice, means that sometimes the most critical patients do not
receive care immediately and have to wait in the waiting room for a
free bed in front of less acute patients who received care first (Reay
et al., 2020). Furthermore, it must understand and meet the needs of
educational, human and other resources. Administration involvement
is particularly important when it comes to issues of appropriate staff-
ing and skill mix in triage areas that can provide adequate staffing and
educational resources (Wolf et al., 2018).
6 | DISCUSSION
This review synthesised studies examining the factors connected
with behaviour to ensure patient safety in the triage process.
Evidence from summarised studies has highlighted the four factors
contributing to behaviour related to patient safety during the tri-
age process and shows the interconnection between the person, the
environment and behaviour within reciprocal determinism. These
interconnections between person, environment and behaviour
were identified as triage nurse attributes and lived triage experi-
ence (within personal factors), as triage performance and workplace

FEKONJA et al.
(within the environment) and are related to triage nurse behaviour
for increased patient safety.
Triage is identified as the most error-­prone area of the emer-
gency department, which possibly impacts patient outcomes
(Calder et al., 2012) and, consequently, its safety. Our review found
that triage nurse attributes are an important factor influencing pa-
tient safety. This factor is influenced by personal traits, clinical and
practical capability and triage experience. Safe, proper and fast tri-
age is a professionally demanding and responsible job. We found
it requires a wide range of triage nurses' attributes like personal-
ity traits, clinical and practical capability, and experience. A similar
finding also emerged in a study by Sutriningsih et al. (2020), where
the triage nurses should possess a wide range of professional skills,
good judgement, flexibility, objectivity, work experience and crit-
ical decision-­making skills, which are deemed as essential charac-
teristics of a competent triage nurse. Furthermore, triage nurses
must appropriately, quickly and correctly prioritise patients, pro-
vide education, and a safe environment in the waiting room and
throughout the emergency department (Bijani et al., 2020). Nursing
expertise and experience are central to patient safety in triage in
general (Mistry et al., 2018) because more experienced workers,
according to Tevžič et al. (2021), might be more aware of potential
safety problems. Conversely, Hardy and Calleja (2019) indicated
that experience could make decisions fallible as experienced nurses
may become cynical and allow their own biases to influence their
triage decisions (McNair, 2005). Our results have shown that ex-
periences are an important prerequisite for patient safety, as this
factor has been exposed by six studies (Andersson et al., 2006;
Chen et al., 2010; Forsman et al., 2012; Hitchcock et al., 2014; Reay
et al., 2020; Wolf et al., 2018). There is conflicting evidence in the lit-
erature about the required years of experience before starting to tri-
age, as different years of experience have been highlighted, mostly
ranging from one (EUSEN, 2022), 2–­4 years (Hitchcock et al., 2014;
Sutriningsih et al., 2020; Wolf et al., 2018) or even 2–­10 years ac-
cording to Cotič-­Anderle (2011). In contrast, some studies stressed
that inexperienced nurses must complete specialised training be-
fore performing patient triage (Hitchcock et al., 2014). Experience
and knowledge are often grouped together, as experience can be
attributed to knowledge in some situations (Hitchcock et al., 2014);
therefore, as Reblora et al. (2020) stress, relevant experiences help
recognise and understand the condition of presented patients in the
triage area. In support of this, Andersson et al. (2006) and Hitchcock
et al. (2014) found that the less knowledge and experience the triage
nurse possesses, the more the patient's safety is jeopardised. In this
regard, triage skill education and training are important aspects of
nurses' preparedness for different emergency situations (Delnavaz
et al., 2018). Triage educational programs must take into consider-
ation the nurse's characteristics, experience and level of learning
style the nurse, containing the theoretical knowledge of nursing
(Smith, 2013) in the form of written case scenarios, cues such as
video footage and photographs (Hammad et al., 2017) and provided
by an instructor, who is very familiar with the triage system (Tam
et al., 2018). The management should conduct continuous triage ed-
ucation and training (Reblora et al., 2020).
|
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5473
The second factor within the personal factors is the live experi-
ence of triage, which is affected by shift working and the shortage of
nurses. According to Reay et al. (2020), the ability to perform effec-
tive triage is influenced by the length of shift, the number of shifts in
a row and a number of shifts at a triage area. Limited evidence sup-
ports the optimal triage shift, as only three studies have addressed
this phenomenon with limited data. McMahon et al. (2017) found
that triage shift length should be limited from 2 (Wolf et al., 2018)
to 4 h (McMahon et al., 2017). This limitation would avoid signif-
icant gradual increases in triage fatigue (McMahon et al., 2017;
Reay et al., 2020), as increasing shift length and fatigue may reduce
cognitive abilities (Rosa et al., 2019), influence interaction with pa-
tients (Reay et al., 2020) and lead to less accurate triage assessments
(McMahon et al., 2017; Reay et al., 2020). Given the lack of evidence,
further research is needed to find the optimal triage shift length, the
time sequence of work shifts and crowding impact on triage fatigue.
The synthesis of identified studies found environmental factors
as an important component of patient safety in the triage process.
The emergency department represents a challenging work environ-
ment for nurses (Bambi et al., 2016). This work environment also in-
cludes triage performance for timely and accurate patient treatment,
representing one of the identified factors influencing patient safety.
It is described as resource-­limited, unpredictable and full of interrup-
tions (Stone, 2019), which are also common in the triage area (Bambi
et al., 2016; Johnson et al., 2014). Interruption is defined as any activ-
ity which requires the triage nurse to turn his or her attention away
from the patient being triaged or any activity that causes the nurse
to leave the triage area (Johnson et al., 2014). Triage interruptions
lead to incorrect triage decisions, missed symptom identification, in-
complete assessment or unasked questions, and can potentially delay
care, resulting in significant morbidity or mortality (Kwon et al., 2021)
and are caused mostly by other healthcare workers, paramedics,
phone calls, patients and relatives (Andersson et al., 2006; Johnson
et al., 2014, 2021). At the time of occurrence, triage nurses need to
be able quickly and efficiently to determine whether an interruption
is critical enough to take precedence over the current task being
performed (Johnson et al., 2021). Moreover, triage performance is
directly related to the appropriate response of the triage staff and
the triage system (Burgess et al., 2019). The triage system must guide
the nurses to ensure the most accurate and precise triage priority is
obtained from a patient's acuity (Dippenaar & Bruijns, 2016). Studies
(Hitchcock et al., 2014; Reblora et al., 2020) emphasise that con-
tinuous education and mentorship programs are essential for nov-
ice nurses in the emergency department to learn about triage, use
triage guidelines and perform it effectively. We found peer support
to novice nurses is essential in triaging a patient, as the experienced
nurse brings a sense of safety to the triage team. Novice triage nurses
should work together with experienced nurses during high patient
density times to build skill and competency (Cetin et al., 2020) at least
two clinical shifts (Varndell et al., 2019). In addition (Smith, 2013), em-
phasises the importance of rotating novice nurses through various
clinical settings, which helps build a repertoire of experiences for safe
patient triage. Therefore, according to evidence from summarised
studies, we can conclude that patient safety relies upon emergency
 |
5474
triage nurses' experience, education and training. In addition, triage is
a very person-­dependent process (Wolf et al., 2018), and the usage of
triage systems reduces subjectivity and provides a valid and reliable
system (Dippenaar & Bruijns, 2016; Hammad et al., 2017; Hitchcock
et al., 2014; McMahon et al., 2017; Reay et al., 2020). The applied
triage system must distinguish between a stable and an unstable pa-
tient, as the inability to do so may lead to severe consequences for
the patient (Wireklint et al., 2018). The effect of an invalid triage sys-
tem may be the mistriage of the patient in the manner of overtriage
or undertriage (Najafi et al., 2019), which is not a desirable outcome
of the triage process (Ausserhofer et al., 2021). Mistriage leads to un-
necessary delays in patient care, prolonged workup, length of stay
in the emergency department and inappropriate use of resources
(Ausserhofer et al., 2021; Chen et al., 2010; O'Connor et al., 2020).
Overtriage and undertriage of the patient were mentioned in five
studies (Chen et al., 2010; Forsman et al., 2012; Hitchcock et al., 2014;
Moon et al., 2019), while many studies have reported this threat while
establishing the validity and reliability of the triage system.
The above factors are best understood based on Bandura's
theoretical framework of reciprocal determinism. According to re-
ciprocal determinism, any human behaviour results from environ-
mental factors (through social stimuli) and internal personal factors
(through cognitive processes). In our study, internal personal factors
include the attributes of the triage nurse and the experience of the
triage process. Environmental factors include the performance of
triage and the workplace. The safety of patients during the triage
process is reciprocally (bidirectionally) influenced by personal and
environmental factors, as shown in Figure 2. In our review, the clini-
cal environment, which includes patient assessment, high workload,
frequent interruptions and staffing, is associated with the behaviour
of triage nurses to contribute to patient safety through their charac-
teristics, experience, knowledge, triage fatigue and work schedule.
6.1 | Limitations of the review
The current review has some limitations that need to be acknowl-
edged. Although we had access to a wide range of articles, some
important articles were probably excluded based on our inclusion
criteria and because we were looking for papers written in English.
Relevant publications published in languages other than English
could be missed. The weakness is that we may not have reviewed
all the relevant literature because additional other search synonyms
could be used and because the key criterion for inclusion in our re-
view was that the records explicitly use the words ‘patient safety’,
‘emergency department’ and ‘triage’ in the title or the results sec-
tion. Papers describing patient safety based on the reliability or
validity of the measurement of individual triage systems were not
included. We also have not included papers reporting medical errors
and adverse events during the triage process. Furthermore, there is
also an absence of correlational data between the factors identified
in this systematic review and the occurrence of medical errors and
adverse events. There is considerable concern about the insufficient
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FEKONJA et al.
quantitative data to confirm an increase in the number of safety
events due to these factors or a decrease when interventions are
implemented. Including these data in our review would be very in-
teresting and important. In addition, the factors we identified during
our review, such as patient assessment, heavy workload, frequent
interruptions, staff and individual characteristics of nurses such
as characteristics, experience, knowledge, triage fatigue and work
schedule, should be further investigated the impact of these factors
on the patient safety during the triage. This next step will improve
the quality of triage care and patient safety and build on the existing
body of knowledge for developing evidence-­based triage care.
Nevertheless, we have identified sufficient numerical records to
prove and support our results. The whole initial review of the liter-
ature selection was conducted by one author, which may influence
the selection of the included studies. Given that the first author has
expertise in patient triage and in-­depth knowledge of pre-­existing lit-
erature, this was reasonable from a practical point of view; however,
given the subjective nature of the review process, there is a possibility
that the study would be excluded from the review by others. Despite
some limitations and weaknesses, we believe we have provided in-
sight into the importance of ensuring patient safety in the triage pro-
cess. We argue that this knowledge is very important for key factors
such as emergency nurses, managers and health policymakers. In ad-
dition, the new knowledge gained on the factors that contribute to
patient safety in the triage process adds an important contribution to
the existing body of knowledge in the field of emergency care.
7 | CO N C LU S I O N
This paper presents the factors associated with patient safety during
the triage process in an emergency department. Triage is a pillar of
emergency and vital in patient safety management; therefore, all the
safety-­related factors involved in its process should be known. The
findings show that many different environmental and personal fac-
tors contribute to patient safety during the triage process. Patient
safety is the consequence of the behaviour of the triage nurse de-
pending on environmental and personal factors. It is ensured and in-
creased in cases where those factors are identified; thus, knowledge
of risks and errors is gained to prevent harm to the patient before it
occurs. Investigating the correlation between the factors identified
in the systematic review and the occurrence of medical errors and
adverse events remains an interesting topic for further research.
8 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
Our findings have valuable implications for improving patient safety
in the triage process. Management should know how important and
demanding the triage area is in ensuring patient safety. The triage area
represents an environment where bottlenecks occur and cause a delay
in patient urgency assessment. Additional nurse resources should be
added to solve the overcrowding issue in triage and, at the same time,

FEKONJA et al.
reduce triage fatigue and improve care quality and safety. Special care
is also needed when planning the work schedule for nurses working in
the emergency department, especially for the triage site. The variabil-
ity in required education, preparation, training, skills and experiences
for triage nurses is present worldwide and requires special attention.
Therefore, nursing administration involvement is significant when it
comes to issues of appropriate staffing, deployment of novice nurses
and planning of education and training for efficient and safe care in
the triage. Triage requires a professionally trained person and a good
coordinator between patient, triage nurse and physicians; therefore,
effective communication and good interpersonal relationships among
healthcare workers and patients contribute to the safety of triage and
which needs to be emphasised. Management should make teambuild-
ing development programmes and activities for improving communica-
tion and teamwork among all employees in the emergency department.
F U N D I N G I N FO R M AT I O N
This research received no specific grant from any funding agency in
the public, commercial or not-­for-­profit sectors.
C O N FL I C T O F I N T E R E S T
The authors declare that there is no conflict of interest.
DATA AVA I L A B I L I T Y S TAT E M E N T
Additional data from this review are not publicly available but can be
provided on request.
ORCID
Zvonka Fekonja https://orcid.org/0000-0002-4224-8843
Sergej Kmetec https://orcid.org/0000-0002-5601-0940
Urška Fekonja https://orcid.org/0000-0002-1576-3022
Nataša Mlinar Reljić https://orcid.org/0000-0003-1148-0831
Majda Pajnkihar https://orcid.org/0000-0002-6298-045X
Matej Strnad https://orcid.org/0000-0002-4505-557X
REFERENCES
Alumran, A., Alkhaldi, O., Aldroorah, Z., Alsayegh, Z., Alsafwani, F., &
Almaghraby, N. (2020). Utilization of an electronic triage system
by emergency department nurses. Journal of Multidisciplinary
Healthcare, 13, 339–­3 44. https://doi.org/10.2147/jmdh.S250962
Andersson, A.-­K ., Omberg, M., & Svedlund, M. (2006). Triage in the emer-
gency department –­A qualitative study of the factors which nurses
consider when making decisions. Nursing in Critical Care, 11(3), 136–­
145. https://doi.org/10.1111/j.1362-­1017.2006.00162.x
Aromataris, E., & Munn, Z. (Eds) (2020). JBI Manual for Evidence Synthesis.
JBI. https://synthesismanual.jbi.global.https://doi.org/10.46658/
JBIMES-20-01
Ausserhofer, D., Zaboli, A., Pfeifer, N., Solazzo, P., Magnarelli, G.,
Marsoner, T., Siller, M., & Turcato, G. (2021). Errors in nurse-­led tri-
age: An observational study. International Journal of Nursing Studies,
113, 103788. https://doi.org/10.1016/j.ijnur​stu.2020.103788
Bambi, S., Ruggeri, M., Sansolino, S., Gabellieri, M., Tellini, S., Giusti, M.,
Ciulli, E., Franchi, F., Petrocchi, L., Olivi, M., Gravili, R. C., Biancalana,
P., Millanti, A., Martini, L., & Sgrevi, P. (2016). Emergency depart-
ment triage performance timing. A regional multicenter descriptive
study in Italy. International Emergency Nursing, 29, 32–­37. https://
doi.org/10.1016/j.ienj.2015.10.005
Bandura, A. (1986). Social foundation of thought and action. Prentice Hall.
|
13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16622 by University Of Maribor, Wiley Online Library on [21/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
5475
Bandura, A. (1999). Social cognitive theory: An agentic perspec-
tive. Asian Journal of Social Psychology, 2(1), 21–­41. https://doi.
org/10.1111/1467-­839X.00024
Baranowski, T., Perry, C. L., & Parcel, G. S. (2002). How individuals, en-
vironments, and health behavior interact. In K. Glanz, B. K. Rimer,
& F. M. Lewis (Eds.), Health behavior and health education: Theory,
research, and practice (Vol. 3, pp. 165–­184). Jossey-­Bass.
Bijani, M., & Khaleghi, A. A. (2019). Challenges and barriers affecting the
quality of triage in emergency departments: A qualitative study.
Galen Medical Journal, 8, e1619. https://doi.org/10.31661/​gmj.
v8i0.1619
Bijani, M., Rakhshan, M., Fararouei, M., & Torabizadeh, C. (2020).
Development and psychometric assessment of the triage nurses'
professional capability questionnaire in the emergency depart-
ment. BMC Nursing, 19(1), 82. https://doi.org/10.1186/s1291​2-­
020-­0 0476​-­0
Burgess, L., Kynoch, K., & Hines, S. (2019). Implementing best prac-
tice into the emergency department triage process. International
Journal of Evidence-­ Based Healthcare, 17(1), 27–­35. https://doi.
org/10.1097/xeb.00000​0 0000​0 00144
Burström, L., Letterstål, A., Engström, M. L., Berglund, A., & Enlund,
M. (2014). The patient safety culture as perceived by staff at two
different emergency departments before and after introducing a
flow-­oriented working model with team triage and lean principles:
A repeated cross-­sectional study. BMC Health Services Research, 14,
296. https://doi.org/10.1186/1472-­6963-­14-­296
Calder, L. A., Forster, A. J., Stiell, I. G., Carr, L. K., Perry, J. J., Vaillancourt,
C., & Brehaut, J. (2012). Mapping out the emergency department
disposition decision for high-­acuity patients. Annals of Emergency
Medicine, 60(5), 567–­576.e564. https://doi.org/10.1016/j.annem​
ergmed.2012.04.013
Camp, S., & Legge, T. (2018). Simulation as a tool for clinical remediation:
An integrative review. Clinical Simulation in Nursing, 16, 48–­61.
Cetin, S. B., Eray, O., Cebeci, F., Coskun, M., & Gozkaya, M. (2020).
Factors affecting the accuracy of nurse triage in tertiary care emer-
gency departments. Turkish Journal of Emergency Medicine, 20(4),
163–­167. https://doi.org/10.4103/2452-­2473.297462
Chen, S.-­S., Chen, J.-­C ., Ng, C.-­J., Chen, P.-­L ., Lee, P.-­H., & Chang, W.-­
Y. (2010). Factors that influence the accuracy of triage nurses'
judgement in emergency departments. Emergency Medicine Journal,
27(6), 451–­455. https://doi.org/10.1136/emj.2008.059311
Cooper, M. D. (2000). Towards a model of safety culture. Safety Science,
36(2), 111–­136. https://doi.org/10.1016/S0925​-­7535(00)00035​-­7
Cotič-­Anderle, M. (2011). Izvajanje triaže pri rednem delu urgentnih ambu-
lant = Triage in routine work on emergency department. Paper pre-
sented at the Urgentna medicina: Izbrana poglavja 2011: Zbornik =
Emergency medicine: Selected topics [2011]: Proceedings, Ljubljana.
Delnavaz, S., Hassankhani, H., Roshangar, F., Dadashzadeh, A., Sarbakhsh,
P., Ghafourifard, M., & Fathiazar, E. (2018). Comparison of scenario
based triage education by lecture and role playing on knowledge
and practice of nursing students. Nurse Education Today, 70, 54–­59.
https://doi.org/10.1016/j.nedt.2018.08.006
Dippenaar, E., & Bruijns, S. (2016). Triage is easy, said no triage nurse
ever. International Emergency Nursing, 29, 1–­2.
Durgun, H., & Kaya, H. (2018). The attitudes of emergency department
nurses towards patient safety. International Emergency Nursing, 40,
29–­32. https://doi.org/10.1016/j.ienj.2017.11.001
Eshete, M. T., Baeumler, P. I., Siebeck, M., Tesfaye, M., Wonde, D.,
Haileamlak, A., Michael, G. G., Ayele, Y., & Irnich, D. (2019). The
views of patients, healthcare professionals and hospital officials on
barriers to and facilitators of quality pain management in Ethiopian
hospitals: A qualitative study. PLoS One, 14(3), e0213644. https://
doi.org/10.1371/journ​al.pone.0213644
EUSEN. (2022). Agreed position statement. http://eusen.org/?page_id=21
Fekonja, Z., & Pajnkihar, M. (2016). Implementation of Manchester triage
system in an emergency department in Slovenia. Health Academy,
7(3), 151–­158.
 |
5476
Forsman, B., Forsgren, S., & Carlström, E. D. (2012). Nurses working with
Manchester triage –­ The impact of experience on patient security.
Australasian Emergency Nursing Journal, 15(2), 100–­107. https://doi.
org/10.1016/j.aenj.2012.02.001
Hammad, K., Peng, L., Anikeeva, O., Arbon, P., Du, H., & Li, Y. (2017).
Emergency nurses' knowledge and experience with the triage pro-
cess in Hunan Province, China. International Emergency Nursing, 35,
25–­29. https://doi.org/10.1016/j.ienj.2017.05.007
Hardy, A., & Calleja, P. (2019). Triage education in rural remote settings:
A scoping review. International Emergency Nursing, 43, 119–­125.
https://doi.org/10.1016/j.ienj.2018.09.001
Hitchcock, M., Gillespie, B., Crilly, J., & Chaboyer, W. (2014). Triage: An
investigation of the process and potential vulnerabilities. Journal
of advanced nursing, 70(7), 1532–­1541. https://doi.org/10.1111/
jan.12304
Johnson, K. D., Gillespie, G. L., & Vance, K. (2018). Effects of interrup-
tions on triage process in emergency department: A prospective,
observational study. Journal of Nursing Care Quality, 33(4), 375–­381.
https://doi.org/10.1097/NCQ.00000​0 0000​0 00314
Johnson, K. D., Motavalli, M., Gray, D., & Kuehn, C. (2014). Causes
and occurrences of interruptions during ED triage. Journal of
Emergency Nursing, 40(5), 434–­439. https://doi.org/10.1016/j.
jen.2013.06.019
Johnson, K. D., Schumacher, D., & Lee, R. C. (2021). Identifying strategies
for the management of interruptions for novice triage nurses using
an online modified Delphi method. Journal of Nursing Scholarship,
53(6), 718–­726. https://doi.org/10.1111/jnu.12683
Källberg, A.-­S., Ehrenberg, A., Florin, J., Östergren, J., & Göransson, K. E.
(2017). Physicians' and nurses' perceptions of patient safety risks
in the emergency department. International Emergency Nursing, 33,
14–­19. https://doi.org/10.1016/j.ienj.2017.01.002
Klemenc-­Ketiš, Z., Makivić, I., & Poplas-­S usič, A. (2020). The psycho-
metric properties of the Slovenian version of the medical office
survey on patient safety culture. Acta Medico-­B iotechnica, 13(2),
38–­45.
Kwon, Y. E., Kim, M., & Choi, S. (2021). Degree of interruptions experi-
enced by emergency department nurses and interruption related
factors. International Emergency Nursing, 58, 101036. https://doi.
org/10.1016/j.ienj.2021.101036
Lockwood, C., Munn, Z., & Porritt, K. (2015). Qualitative research syn-
thesis: Methodological guidance for systematic reviewers utilizing
meta-­aggregation. International Journal of Evidence-­Based Healthcare,
13(3), 179–­187. https://doi.org/10.1097/xeb.00000​0 0000​0 00062
Marcozzi, D., Carr, B., Liferidge, A., Baehr, N., & Browne, B. (2018). Trends
in the contribution of emergency departments to the provision of
hospital-­associated health care in the USA. International Journal
of Health Services, 48(2), 267–­288. https://doi.org/10.1177/00207​
31417​734498
McMahon, B., Hudson, J., Prewitt, J., Carman, M. J., & Engleson, M.
(2017). Measuring fatigue in triage: A pilot study. Advanced
Emergency Nursing Journal, 39(2), 114–­122. https://doi.org/10.1097/
TME.00000​0 0000​0 00143
McNair, R. S. (2005). It takes more than string to fly a kite: 5-­Level acuity
scales are effective, but education, clinical expertise, and compas-
sion are still essential. Journal of Emergency Nursing, 31(6), 600–­
603. https://doi.org/10.1016/j.jen.2005.07.061
Mistry, B., Balhara, K. S., Hinson, J. S., Anton, X., Othman, I. Y., E'nouz,
M. A. L., Avila, N. A., Henry, S., Levin, S., & De Ramirez, S. S. (2018).
Nursing perceptions of the Emergency Severity Index as a triage
tool in the United Arab Emirates: A qualitative analysis. Journal
of Emergency Nursing, 44(4), 360–­367. https://doi.org/10.1016/j.
jen.2017.10.012
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred
reporting items for systematic reviews and meta-analyses: the
PRISMA statement. BMJ, 339, b2535. https://doi.org/10.1136/bmj.
b2535
13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16622 by University Of Maribor, Wiley Online Library on [21/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
FEKONJA et al.
Moola, S., Munn, Z., Tufanaru, C., Aromataris, E., Sears, K., Sfetcu, R.,
Currie, M., Lisy, K., Qureshi, R., Mattis, P., & Mu, P. (2020). Chapter
7: Systematic reviews of etiology and risk. In E. Aromataris & Z.
Munn (Eds.), JBI manual for evidence synthesis (pp. 217–­269). JBI.
Moon, S.-­H., Shim, J. L., Park, K.-­S., & Park, C.-­S. (2019). Triage accu-
racy and causes of mistriage using the Korean Triage and Acuity
Scale. PLoS One, 14(9), e0216972. https://doi.org/10.1371/journ​
al.pone.0216972
Najafi, Z., Abbaszadeh, A., Zakeri, H., & Mirhaghi, A. (2019). Determination
of mis-­triage in trauma patients: A systematic review. European
Journal of Trauma and Emergency Surgery, 45(5), 821–­839. https://
doi.org/10.1007/s0006​8-­019-­01097​-­2
O'Connor, L., Larkin, C., Ibrahim, A. F., Allen, M., Wang, B., & Boudreaux,
E. D. (2020). Development and pilot study of simple suicide risk
rulers for use in the emergency department. General Hospital
Psychiatry, 63, 97–­102. https://doi.org/10.1016/j.genho​sppsy​
ch.2018.08.004
Parry, A. M., Barriball, K. L., & While, A. E. (2015). Factors contribut-
ing to registered nurse medication administration error: A narra-
tive review. International Journal of Nursing Studies, 52(1), 403–­420.
https://doi.org/10.1016/j.ijnur​stu.2014.07.003
Reay, G., Smith-­MacDonald, L., Then, K. L., Hall, M., & Rankin, J. A.
(2020). Triage emergency nurse decision-­making: Incidental find-
ings from a focus group study. International Emergency Nursing, 48,
100791. https://doi.org/10.1016/j.ienj.2019.100791
Reblora, J. M., Lopez, V., & Goh, Y.-­S. (2020). Experiences of nurses work-
ing in a triage area: An integrative review. Australian Critical Care,
33(6), 567–­575. https://doi.org/10.1016/j.aucc.2020.01.005
Rosa, D., Terzoni, S., Dellafiore, F., & Destrebecq, A. (2019). Systematic
review of shift work and nurses' health. Occupational Medicine,
69(4), 237–­243. https://doi.org/10.1093/occme​d/kqz063
Sepp, J. (2021). Development of a reciprocal health care model for deter-
mination of safety level in the nursing homes in Estonia. European
Journal of Economics and Business Studies, 4(3), 114–­122. https://doi.
org/10.2478/ejes-­2018-­0 065
Smith, A. (2013). Using a theory to understand triage decision mak-
ing. International Emergency Nursing, 21(2), 113–­117. https://doi.
org/10.1016/j.ienj.2012.03.003
Stone, E. L. (2019). Clinical decision support systems in the emergency
department: Opportunities to improve triage accuracy. Journal of
Emergency Nursing, 45(2), 220–­222.
Sutriningsih, A., Wahyuni, C. U., & Haksama, S. (2020). Factors affect-
ing emergency nurses' perceptions of the triage systems. Journal
of Public Health Research, 9(2), 1808. https://doi.org/10.4081/
jphr.2020.1808
Tam, L. H., Chung, S. F., & Lou, C. K. (2018). A review of triage accuracy
and future direction. BMC Emergency Medicine, 18, 58. https://doi.
org/10.1186/s1287​3-­018-­0215-­0
Tevžič, Š., Poplas-­Susič, A., & Klemenc-­Ketiš, Z. (2021). The safety cul-
ture of the Ljubljana Community Health Centre's employees.
Zdravstveno Varstvo, 60(3), 145–­151. https://doi.org/10.2478/
sjph-­2021-­0 021
Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of
qualitative research in systematic reviews. BMC Medical Research
Methodology, 8(1), 45. https://doi.org/10.1186/1471-­2288-­8-­45
Varndell, W., Hodge, A., & Fry, M. (2019). Triage in Australian emergency
departments: Results of a New South Wales survey. Australasian
Emergency Care, 22(2), 81–­86. https://doi.org/10.1016/j.
auec.2019.01.003
Wireklint, S. C., Elmqvist, C., Parenti, N., & Göransson, K. E. (2018). A
descriptive study of registered nurses' application of the triage
scale RETTS©; a Swedish reliability study. International Emergency
Nursing, 38, 21–­28. https://doi.org/10.1016/j.ienj.2017.12.003
Wolf, L. A., Delao, A. M., Perhats, C., Moon, M. D., & Zavotsky, K. E.
(2018). Triaging the emergency department, not the patient: United
States emergency nurses' experience of the triage process. Journal
 |

13652702, 2023, 17-18, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.16622 by University Of Maribor, Wiley Online Library on [21/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
FEKONJA et al. 5477

of Emergency Nursing, 44(3), 258–­266. https://doi.org/10.1016/j.

jen.2017.06.010 How to cite this article: Fekonja, Z., Kmetec, S., Fekonja, U.,
Wood, R., & Bandura, A. (1989). Impact of conceptions of ability on self-­
Mlinar Reljić, N., Pajnkihar, M., & Strnad, M. (2023). Factors
regulatory mechanisms and complex decision making. Journal of
Personality and Social Psychology, 56(3), 407–­415. contributing to patient safety during triage process in the
emergency department: A systematic review. Journal of Clinical
Nursing, 32, 5461–5477. https://doi.org/10.1111/jocn.16622
S U P P O R T I N G I N FO R M AT I O N
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