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.
Aziz et al. (Mon,) studied this question.