Patient Safety Engagement in Practice: Determinants, Relational Mechanisms, and System-level Influences-A Scoping...

Patient safety engagement has been widely promoted within contemporary health care systems; however, conceptual clarity and explanatory integration remain limited. This scoping review synthesizes how patient safety engagement has been defined and examines the determinants, mediating mechanisms, and system-level influences shaping engagement behaviors. A comprehensive search of PubMed/MEDLINE, Scopus, Web of Science, and CINAHL (January 2000-February 2026) identified empirical studies linking patient engagement to safety-related processes. A total of 137 studies were included. Engagement was conceptualized in 4 dominant ways: compliance-oriented (23% of studies), behavioral participation (41%), partnership-based involvement (24%), and shared responsibility (12%). Determinants operated across 4 levels: patient-level (n=112 studies), provider-level (n=98), organizational-level (n=76), and system-level (n=54). However, engagement behaviors were not directly determined by these factors alone; rather, they were mediated through 4 recurring mechanisms: relational-interactional (present in 89 studies), cognitive-informational (n=67), communication-driven (n=81), and behavioral acceptability (n=58). Communication quality, perceived legitimacy of participation, trust dynamics, cognitive load, and workflow pressures consistently shaped engagement variability. A behavioral acceptability gradient was observed, with patients more willing to engage in low-confrontation behaviors than high-challenge actions such as questioning clinical decisions. These findings suggest that patient safety engagement is best understood as a relationally mediated and systems-sensitive practice rather than a stable individual attribute. Interventions focusing solely on education are unlikely to achieve sustained impact. System-oriented strategies that strengthen relational legitimacy, embed engagement within routine workflows, and address structural constraints may be more effective in translating willingness into meaningful safety participation.