Barriers and Facilitators of Nursing Error Reporting: Literature Review

Ahmed Raja, RN-BSN Student

Al Quds University

May 2017
 Introduction

Patient safety is a key component of quality care and is a critical concern in any

healthcare system. Errors, on the other hand, are an integral part of human and professional life.

Although nursing errors are common and unavoidable, they are serious and are a major threat to

patient’s safety. Around the world, the incidence of errors in healthcare systems is high and

medical errors affect about one out of every 10 hospitalized patients. Moreover, nearly 7% of

these errors are fatal (citation).

The term “error” involves “deviation from correctness” (citation) and “taking the wrong

path” (citation). Lewis et al (2013) described nurses’ involvement in errors as a vague problem

that needs to be clarified. nursing errors occur when nurse make the wrong decision or use the

wrong procedure. Criminal law defines medical errors as the failure to meet diagnostic,

therapeutic and care standards (Lewis et al. 2013). Individuals studied by Sanagoo et al. (2012)

defined medical error as an act endangering the patient’s life or causing any kind of harm to the

patient. This is drastically different from the legal definition. Nursing aims to help vulnerable

people. Caring is thus an entirely moral action. An incorrect act will cause additional harm to a

vulnerable person. Since detrimental actions create turmoil in the minds of nurses, they try to

avoid such actions (Sanagoo et al. 2012?).

Nursing error has been defined as “an unintended act (either of omission or commission)

or one that does not achieve its intended outcome, the failure of a planned action to be completed

as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of

planning), or a deviation from the process of care that may or may not cause harm to the patient.
Patient harm from medical error can occur at the individual or system level. The taxonomy of

errors is expanding to better categorize preventable factors and events”. (US National Patient

Safety Foundation, 2014)

During 2013, Centers for Disease Control and Prevention(CDC) reported that 611,105

people died of heart disease, 584,881 died of cancer and 149,205 died of chronic respiratory

disease, which are the main causes of death in the United States (CDC, 2013). The newly

calculated figure put medical errors behind cancer but ahead of respiratory disease. The

healthcare system is a complex structure that is prone to human error. But it’s even more than

that. Whenever an estimate of how many deaths are “deaths by medicine,”, According to the

CDC, of the 251 thousand deaths that occur every year in the U.S., if Makary’s estimates are

correct, 15% of all hospital deaths are due to medical errors. (Makary, 2016)
 Although evidence shows that recurrence of errors can be prevented by utilization of an

error reporting system, errors continue to be overwhelmingly underreported. An estimated 50 to

96% of all errors are left unreported (Wu, 2011), indicating that up to 96% of errors that occur in

healthcare cannot be evaluated or prevented from happening again in the future.

Several studies have been conducted on the topic of utilization of the error reporting

system and nurses’ perceived barriers in regards to these systems. Barriers that have been

identified for nurses include time to complete the error report, lack of knowledge that an error
occurred, nurses’ belief of the necessity to report an error, realization or denial that the nurse has

committed an error, and embarrassment or fear of retribution for making an error (US

Department of Health and Human Services, 2012). Studies consistently report a lack of

knowledge regarding errors or reportable errors as a common barrier. According to a report by

the Department of Health and Human Services (2012) in US “Hospital staff did not report 86

percent of events to incident reporting systems, partly because of staff misconceptions about

what constitutes patient harm” (p.12). These numbers prove, further evaluation and education for

healthcare professionals regarding the necessity to utilize error reporting systems must become a

priority.

Statement of the Problem

Understanding the underlying causes of why theseoccur is needed in order to prevent

repeat occurrences of the same error. However, in order to fully understand the underlying cause

of the error, first and foremost, it must be reported. The number of medical errors that occur in

hospitals is unacceptable, due to the potential for harm. Therefore, decreasing the incidence of

errors must take priority in order to improve patient safety (Leapfrog Group, 2013). Evaluating

the barriers to utilization of an error reporting system and addressing these issues is a crucial step

towards decreasing nursing error and improving patient safety.

Identifying addressing the error reporting perceptions and barriers for nurse are important

steps to address the needs when evaluating utilization of the error reporting system. Nursing are

key in medical error reduction efforts. Developing a clear understanding of nurse’s perceptions

of and barriers to error reporting is crucial in developing a plan of action for increasing

utilization of these error reporting systems.

Using the Agency for Healthcare Research and Quality (AHRQ) safety indicators, Zhan & Miller

(2003) estimated that increased length of stay for postoperative sepsis could be as long as 11

days and could cost hospitals up to $60,000 per patient. More data regarding issues now being

referred to as “never events” are being published in both the healthcare literature and in the

media which has driven the public and payers to demand these issues be addressed.

Significance of the Problem

It is estimated that there are over three million “preventable adverse events” that occur in

hospitals each year (Agency for Healthcare Research and Quality, 2013, p. 129).

Medical errors represent an important public health problem and pose a serious threat to

patient safety. The growing awareness of the importance of reporting medical error and its

causes help to prevent consequences of error in medicine reinforces an imperative to improve our

understanding of the problem and to devise workable solutions and prevention strategies.

So this study will investigate barrier for reporting nursing error, understanding barriers of

nursing error reporting will help nurses and policymakers in establishing a reporting system that

encourages reporting and overcoming barriers to error reporting. Historical Perspective on

Patient Safety

Small and Barach (2002) noted inadvertent patient harm appeared as an infrequent topic

in 20th Century medical journals, beginning as far back as Beecher and Todd (1954). Recurrence

for inadvertent patient harm continues in the literature even during the first decade of the 21st

Century (Hosford, 2008). Beecher and Todd (1954) published one of the first seminal articles

that compiled data from over 500,000 operative cases. Their five-year-study followed ten

surgical teams where they examined and assessed all deaths that occurred during the study.
Through data analysis, Beecher and Todd (1954) concluded that death from anesthesia was of

sufficient enormity to represent a public health problem.

Barker and McConnell (1962) demonstrated a medication error rate of sixteen

errors per one-hundred doses of medication, which led to developing guidelines of

conduct for medication error research.

Over the next two decades (1970s and 1980s), evidence continued to accumulate that

pointed to adverse events among patients, including medical injury (Brennan et al., 1991).

Laws were created to affect the frequency and severity of malpractice claims

(Cassirer & Anderson, 2004). Despite these efforts, data collected after those laws were

implemented offered little evidence the legislative changes affected the primary problem:

nursing errors (Kinney, 1995).

Purpose of the Study

The purpose of this study is to identify the barriers and facilitator that affect nursing error

reporting in health care facilities through reviewing research published during the last 7 years.

Research Questions

What are the barriers that influence nursing report of nursing error?

What are the Facilitators that affect nursing report of nursing error?

Definition of Terms

For purposes of this study, the following terms are defined as listed.

Error reporting is the process utilized in a healthcare facility to report actual errors that

occur or close calls. These errors are generally reported through an institutional internal system

called an “error reporting system”. The error reporting system is often voluntary.
 A voluntary reporting system is an error reporting system that is not mandated, and is

voluntarily completed by the individual that recognizes an error occurred.

Different types of errors can be reported. An adverse event is an error that has caused

harm to the patient (Wu, 2011).

A medication administration error is a medical error that specifically involves

medications. A medication administration error can fall into two categories which include either

an adverse event or a close call.

Near miss, close call and good catch: are terms that are used interchangeably to define an

error that did not actually reach the patient. The mistake was therefore noticed before it could

cause harm to a patient (Cooper, 2012). Near miss is a term used by the aviation industry, the

aviation industry provides a framework for many of healthcare’s safety practices. Some argue

that there is a negative connotation to the term near miss and have chosen to adopt the terms

close call or good catch to encourage reporting of these types of errors (Wu, 2011).

Just culture is a concept created to promote a culture of safety within healthcare. It is

meant to hold individuals accountable for their actions while also encouraging error reporting.

Root cause analysis is a quality improvement technique that provides a process for

analyzing errors and the precipitating events that led to the occurrence of error. This process

takes into account that not all errors are solely caused by the individual; rather errors are often

part of a bigger system deficiency (Harris, &Roussel, 2010). A root cause analysis evaluates and

identifies deficiencies with both the individual and the complex system.

Attitude is an individual or group sentiment that is a positive or negative. Attitudes are

related to perceptions or viewpoints that are based on past experiences or acquired knowledge
(Mohanty, 2014). Attitudes can play a role in patient safety by affecting healthcare team

behaviors when choosing to report nursing errors.

Adverse event: “… an injury caused by medical management rather than the underlying

condition of the patient” (Kohn et al., 2000).

Error: “…the failure of a planned action to be completed as intended (i.e., error of execution) or

the use of a wrong plan to achieve an aim (i.e., error of planning)” (Kohn et al., 2000).

Harm: “…death or impairment of a body function or structure requiring intervention” (Agency

for Healthcare Research and Quality, 2003).

Incident: “…occurrences that are significant or pivotal, in either a desirable or an undesirable

way … significant or pivotal means that there was significant potential for harm (or actual harm),

but also that the event has the potential to reveal important hazards in the organization [and]

provide valuable opportunities to learn about individual and organizational factors that can be

remedied to prevent similar incidents in the future” (Agency for Healthcare Research and

Quality, 2008).

Incident reporting: “…a process used to document occurrences that are not consistent

with routine hospital operation or patient care” (National Patient Safety Foundation (NPSF),

1997).

Licensed nurse: “an individual licensed by a state to perform nursing duties [and

includes] both registered nurses (RNs) and licensed practical or vocational nurses (PNs

or LVNs)” (ANA, 2004).

Nursing error: a “…mistake made in the process of care that results in or has the potential

to result in harm to patients. … [error can] include the failure of a planned action to be

completed as intended or the use of a wrong plan to achieve an aim [and] can be the result of an
action that is taken (error of commission) or an action that is not taken (error of omission)”

(Agency for Healthcare Research and Quality, 2008).

Methods

A literature study is “a critical review of knowledge from written sources and a summary

of these with discussion”. (citation?) Literature review develops one’s understanding of the

literature in a field of study through a synthesis of critical analysis and a narrative defined by

guiding concepts (citation).

The Search

Systematic search of the literature performed to obtain original studies that investigated

barrier and facilitator of documenting nursing error. The relevant studies were identified by the

use of the PubMed database and EBSCO host. In our primary search, two different strategies

used with the following key words: first, documentation of nursing error; and second, barrier and

facilitator toward documenting nursing error. Afterwards, we attempted additional search using a

combination that included the following key words as well: factor affect documentation of

nursing error.

Systematic review included original studies written in English. Thus, reviews, editorials,

letters, books and case reports were excluded from our study. Studies included in the review

contained quantitative and qualitative research regarding the association barrier and facilitator of

reporting nursing error. Moreover, studies that examined the factors affect nursing error

reporting are included. Limitations not use regarding any study sample size did, study design,

and specific measures of outcomes used in the various studies. Finally, we did not include

studies that focused on the evaluation of reporting nursing error.

Data extraction
 From the studies that were included in this review, data extracted regarding the date of

publication, the type of the study, the setting of the study, the study population, the aim of the

study, the follow-up period, the method used to assess and measure barrier and facilitator of

nursing error.

When we searching for literature through, we faced lots of challenges. One was finding

full text versions of the articles. The second challenge was finding articles that were not older

than 10 years. The third challenge was worrying all the time whether we chose the right articles;

did they relate to our topic? Finding the time to search the Internet for articles was very difficult

for us . And most of the articles are factor that lead to nursing error and others are not founded in

full text or while others are not in English while it’s the only language we know beside Arabic.

Theoretical Framework

The theory of reasoned action (TRA) was cited as a theoretical framework, utilized in the

study by Pfeiffer, Manser&Wehner (2010) to help form an understanding of error reporting

behaviors. There is a lack of nursing theory related to motivators for error reporting (Pfeiffer,

Manser&Wehner, 2010).

Because of this lack of nursing theory many studies did not discuss a specific theoretical

framework that guided their research, however, several did cite various attitudes in relation to

error reporting barriers.

Theory of reasoned action (TRA). The TRA defines an individual’s perceived intention

to perform desired behaviors based on attitudes and subjective norms (Pender, Murdaugh&

Parsons, 2011). TRA suggests that an individual shows intention to perform a behavior based on

the perceptions of positive or negative outcomes as well as perceived societal norms (Pender,

Murdaugh& Parsons, 2011; Butts & Rich, 2015). Ajzen (1991) believed TRA was only
appropriate for behaviors where the individual has complete volitional control or personal choice

over the behavior. Therefore, he expanded the model of TRA and developed the theory of

planned behavior (TPB) to include the construct of perceived behavioral control, which accounts

for behaviors that are affected by outside influences (Montano &Kasprzyk, 2008).

Theory of planned behavior (TPB). Ajzen (1991) suggests the inclusion of perceived

behavioral control to the theory of reasoned action to create the TPB (Pender, Murdaugh&

Parsons, 2011). Ajzen (1991) suggests that the stronger a person’s intention to perform a specific

behavior the stronger the correlation is for the person to actually perform this behavior.

Perceived behavioral control is the individual’s perceptions of ease or difficulty when

completing a behavior (Ajzen, 1991). Perceived behavioral control is influenced by the

individual’s confidence that he can complete the behavior and is often based on past experiences

(Villarruel, et al, 2001). Utilizing the TPB can help predict a person’s behavioral intention, such

as utilizing error reporting systems.

Pfeiffer, Manser&Wehner (2010) utilized the TRA to help predict an individual’s intent

to report a nurisng error. By utilizing the TRA as a guideline as well as incorporating the social

identity theory and psychological safety these authors created a theoretical framework of their

own to predict intent to report. The social identity theory acknowledges all of the roles the

healthcare provider manages when caring for patients. This theory suggests internal conflict

between the roles may affect the act of error reporting (Pfeiffer,et al, 2010).

Psychological safety is based on the perceived invulnerability of the clinician when

reporting errors (Pfeiffer, Manser&Wehner, 2010). It could be argued that the TRA is not an

appropriate theory to utilize in evaluating the behavior of error reporting. There are multiple
outside influences that affect this behavior; therefore performing the behavior is not in the

individual’s complete volitional control.

Both TRA and TPB depend on the constructs of individuals’ attitude and subjective

norm. Behavioral intention is formed based on individual perceptions regarding the positive and

negative outcomes of the behavior and societal pressures (Montano &Kasprzyk, 2008). These

theories directly correlate with perceived barriers to utilize an error reporting system. If health

care providers perceive negative retribution for admitting an error or have knowledge or negative

experiences with reporting errors, then they are not going to be as likely to utilize an error

reporting system.
The literature

Ahmed Alduais, et al (2014) conduct study in KSA about Barriers and strategies of reporting
medical errors in public hospitals in Riyadh city that aim to find out the barriers preventing staff
from reporting medical errors and identifying the strategies which might encourage the staff
reporting the medical errors at Riyadh, Saudi Arabia.

They use quantitative method, questionnaire where random sampling was used to represent the
hospitals of Riyadh city, a represented sample of 467 clinical staff (physicians , nurses) from 9
different hospitals.

The result show there were actually no gender significant differences―Saudi and non-Saudi,
physicians and nurses regarding response to barriers and the strategies. There were also no
significant differences between types of hospitals regarding barriers and strategies reporting.
r=.482>.05 and r = .701>.05. However, there was a significance difference between age
structures regarding the barriers reporting. r=.000<.05 where the age range between 31-40 years
provided more responses to reporting the barriers than the 41-50 years and 50 and above. There
were also significant differences between levels of education regarding the strategies reporting.
r=.012<.05 where the board provided more response to reporting the barriers than the diploma.
Besides, there were significant differences between years of experience regarding the barriers
reporting. r=.000<.05 where the 0-10 years and 11-20 experience provided more responses to
reporting the barriers than both (21-30 years) and (31years and above).

The most common barriers preventing the staff from reporting the medical errors are: fear of
being blamed, fear of being punished, difficulty in filling the form, lack of knowledge of what
should be reported, medical errors reporting are inadequate, lack procedures on reporting
medical errors. On the other hand, the most common strategies improving reporting medical
errors are: there should be a clear guidelines and procedures for reporting errors, forms and other
documentation should be clear, staff should be trained on reporting medical errors, staff should
always be encouraged to report medical errors.

Hashemi, Nasrabadi & Asghari, (2012) conducted a study assessing the factors associated
with reporting nursing errors in Iran. In this study, ‘the nurses complained about some factors as
inhibitors in reporting the errors which were placed in the barriers category’,
(biomedcentral.com, 2014). The researchers explored the factors associated with reporting the
nursing errors. Some factors associated with nurses, organization, and the nurses’ awareness of
the incidence and consequences of the error were stated as the main barriers in reporting the
errors .The study was conducted in the hospitals allied to Shiraz and Tehran universities of
Medical Sciences.Sample of study was around 115 nurses with different experience to focus role
of experience in reporting the errors. Results of this study stated that ‘professional errors are
indicative of flawed systems and indicate the lack of safety culture and poor working conditions
for nurses. System problems can be prevented through reporting of all types of errors. Besides,
‘training the nurses as well as the nursing managers regarding the objectives of error reporting
and method of using the information of the occurred errors is suggested in order to improve the
patient safety and the quality of care in nursing domains. In this case, patient safety and work
safety for nurses are improved.

One more study is by Chiang & Ginette (2006) assessing the barriers to nurses reporting
of medication administration errors in Taiwan. The study described nurses’ perceptions of
reporting barriers to reporting medication administration errors (MAE) and to examine the
relationship between the barriers to MAE reporting and cultural factors and nursing work
environment in Taiwan. ‘Nurses are the front line of defense to cut off and report medication
errors. Learning from errors by depending ‘on voluntary error reporting is the strategy in use to
improve medication safety and to modify system vulnerabilities. Understanding of nurses’
perceived barriers to MAE reporting is a primary step to strengthen medication safety.The
‘linkage between nursing work environment and medication safety is noticeable. Nurses can
provide safer patient care through quality management and work environment transformation. A
mail survey using the total design method. Were used in this study. The sample of study was 727
nurses who received the questionnaires but the retuned were only 597 from the total sample.
Findings indicated that ‘fear and administrative barriers were the top two perceived barriers to
MAE reporting also provide new knowledge for design of medication administration safety
practices. Overall barriers to MAE reporting in the study hospital were mostly explained by
power hierarchy and face-saving concern. Work environment factors such as quality
management and peer relations modestly contributed to the barriers. Overall barriers to MAE
reporting that were perceived as significant were fear and administrative barriers. ‘Building a
voluntary reporting system without barriers is one of the first steps. According to these findings,
‘reducing the power hierarchy and modifying persona attitudes toward MAE reporting are
suggested.

Kagan & Barnoy (2013) conducted a study about organizational safety culture and
medical error reporting by Israeli nurses to investigate ‘the association between patient safety
culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses. Findings
indicated that ‘most nurses encountered medical errors from a daily to a weekly basis. Of the
total sample, 6% never reported their own errors, while half reported their own errors―rarely or
sometimes.Senior healthcare executives and managers can make a major impact on safety culture
development by creating and promoting a vision and strategy for quality and safety and fostering
their employee’s motivation to implement improvement programs at the departmental and
individual levels.

Cook et al. (2004) used multi-method research over three years to study the
organizational processes used to recognize medical errors. Participants agreed that errors were
commonplace in healthcare settings; however, perceptions of errors were highly influenced by
preconceived notions of what constitutes an error and what kind of events should be reported.
Nurses expressed feelings of being unable to question physician judgment due to perceived lack
of similar level of knowledge; therefore, they were uncomfortable reporting a medical error if a
physician was involved.

Overall, Cook et al. found that participants agreed that errors were commonplace in the
healthcare settings. Of all respondents, 78% believed that error reporting was primarily nursing’s
responsibility, and less than one-quarter of all respondents (22%) believed that the responsibility
for patient safety should be shared equally among the healthcare team. Results of Cook et al. are
difficult to interpret given the multiple modes and variety of responses to the tools used.
Responses covered a wide variety of topics aside from reporting, and only the ‘when’ and ‘how’
issues of reporting were explored, not the ‘why.’ Since nurses were not the primary focus of
Cook et al.’s study, little information is applicable to nursing practice.

Spears (2002) used phenomenology to study nurses’ experiences with error reporting.
Purposeful sampling led to one-on-one interviews with 12 registered nurses. Results identified
six categories of themes (1) nurses are affected emotionally by the error, experiencing such
things as anxiety, loss of trust, and embarrassment; (2) errors are multi-factorial; (3) nurses feel
responsible for errors, including themes of self-blame, ownership, and accountability; (4) nurses
learn and make changes as a result of an error; (5) nurses describe errors as inevitable; and (6)
nurses have high expectations of their performance. Findings from this small sample study
pertain to post-error reporting and communication but did not include any discussion of specific
issues that affected a nurse’s initial decision to report or not to report the error.

Crigger and Meek (2007) used grounded theory to explore nurses’ responses to making
mistakes. Ten nurses were interviewed, and four categories of ‘selfreconciliation’ were
identified. The reconciliation encompassed coming to terms with the reality of the mistake
(‘reality hitting’); determining or weighing the need to report the mistake (‘weighing in’);
deciding on the best trajectory for responding (‘acting’); and finally, evaluating (‘resolving’) the
event. In the ‘reality hitting’ phase, the initial shock of realizing an error had occurred was
followed by remorse and second-guessing. Nurses mentally compared their actions with the
social standards and personal ideals of the intended actions. In the ‘weighing in’ stage, the nurse
determined the time and method of reporting, if indeed a report were made. As part of this
process, participants determined whether the mistake was one they identified as a “real mistake”
or a “non-mistake.” A real mistake was one the participants thought should be reported because
the primary indicator was that the mistake resulted or could have resulted in harm to the patient.
The next stage, ‘acting,’ depended on whether the mistake was reported or not, which led to two
distinct trajectories: one for an error that was publically reported and one that was not publically
reported. Reporting, if done, was usually to an immediate supervisor or physician. The study’s
participants voiced an expectation of punitive responses to reports. In the final stage, ‘resolving,’
the nurses evaluated the harm that had or had not occurred because of their action and expressed
feelings of uncertainty of their ability to provide adequate care to patients. The participants also
described feelings of remorse and a heightened awareness of their practice for an extended time
following the error event.

Crigger and Meek’s (2007) study was limited in size to (n=10) nurses who were not
expected to file a formal report as long as reporting to a supervisor had occurred. The authors
admitted that they had not previously explored the trajectory of unreported errors; thus, their
understanding of the process was limited. However, the authors discovered a new concept,
“weighing in,” which holds potential for further study to add to the knowledge base of how
decisions to report errors are made.

Elder et al. (2008) explored the use of focus groups in the medical error decision making
practices regarding (a) formal reporting, (b) telling someone else about a mistake, or (c) keeping
silent. Their study’s convenience sample (n=33) included nurses from four hospitals. Responses
were compared and contrasted with results of a safety culture survey completed by a random
sample of nurses (n=92) from those same units. The authors did not identify how the
participants, if any, were divided into groups; therefore, the reader cannot know if cross
participation existed between the written surveys and interviews.

Responses to the anonymous safety culture survey revealed ‘socially desirable’ answers,
with the majority of nurses indicating that they usually or always reported errors and received
feedback. Results of the focus group discussions were, however, distinctly different. In the focus
groups, nurses gave time pressures and the presence or absence of patient harm as priorities to
determine if formal report of the error was made. The nurses were also likely to take into
consideration the hierarchal relationship between themselves and the other persons involved
when reporting an error. Nurses were only likely to report an error to the physician if harm to the
patient had occurred, and nurses described the use of a complex language designed to circumvent
actually telling the physician outright that a mistake had been made. Participants were often
cognizant of which physicians were more receptive to hearing about errors and would wait until
the ‘right’ physician was available to report the error.

Elder et al. (2008) determined from the focus groups that the nursing culture in the units
under study still emphasized personal failure as a cause of error, especially when considering
reporting an error made by others. Despite the results of the safety culture survey indicating
nurses received feedback, reactions in the focus groups indicated this was not consistent with
experience. Focus group members indicated that feedback was oblique and not directed at the
actual event; rather, feedback was guised in terms of ‘staff education’ or in the form of new
standards or guidelines. Elder et al.’s study demonstrated how information can be gained through
use of combined methodologies and discussed the influence of factors that affect error reporting
decisions; however, the findings did not hone in specifically as to what factors in which
circumstances played a role in the decision making process to report an error. Study criteria did
not hold respondents accountable to make formal error reports; instead, the authors focused on
verbal reports to parties involved in the error.

Scott et al. (2009) focused their research about experience with medical errors from the
standpoint of healthcare providers being ‘second victims’ of the errors. The term “second victim”
was coined by Wu (2000) as a description of the impact of medical errors on physicians. Scott et
al. (2009) interviewed 31 healthcare professionals (10 physicians, 11 nurses, and 10 other
healthcare professionals) regarding their involvement with a patient safety event and the
aftereffects of the experience. Six stages of recovery were identified. The recovery encompassed
identifying the moment the event was detected (‘chaos and accident response’); feeling internal
inadequacy and isolation (‘intrusive reflection’); seeking support from a trusted individual
(‘restoring personal integrity’); wondering about repercussions affecting job security (‘enduring
the inquisition’); attempting to decide in whom they were ‘safe’ to confide (‘obtaining emotional
first aid’) and finally, retaining memories of the event in their future practice (‘moving on’). In
the ‘chaos and accident response’’ phase, the realization of an event was followed by both
internal and external turmoil. In the ‘intrusive reflection’ stage, the participants described asking
themselves multiple ‘what if’ questions as a means to understand the event. The next stage,
‘restoring personal integrity,’ focused on the individual’s feeling of self-doubt and lack of
clinical confidence. While ‘enduring the inquisition’ the focus was on the individual’s concern
about job security and personal liability in a litigation situation. The stage ‘obtaining emotional
first aid’ focused on participants’ attempts to confide in someone about the error but having
concerns about the privacy and legal considerations of relating the error event. In the final stage,
‘moving on,’ the participants described pressures both internal and external to put the event
behind them. Three potential paths of ‘moving on’ were discovered: dropping out (leaving
nursing), surviving (returning to previous performance levels), or thriving (making something
good come from the event).

The Scott et al. (2009) study demonstrated a larger-than-average sample size (n=31) for
qualitative interviewing studies; however, only one-third of the participants were nurses. The
presence of other healthcare professionals in the data confounds the ability to apply the results to
nursing in more general terms. The study made no mention regarding the types of units from
which the participants were selected; therefore, no opportunity exists to examine the effects of an
intensive care versus non-intensive care environment in their findings. However, the author’s
application of the ‘second victim’ phenomena to the medical error experience is unique to
research into medical errors and holds potential for further study to add to the knowledge base of
the aftermath of errors.

Lewis et al. (2013) performed an integrative literature review of the effects of medical
errors on nurses. The integrative literature review was structured according to standardized
methodology and yielded 21 articles for analysis. Findings were examined to determine specific
variables related to nurses’ responses to medical errors in terms of the system, nurse
characteristics, interventions, or nurse outcomes. Findings demonstrated that characteristics of
the work unit such as the overall work environment and the nurse manager were important to
nurses’ experiences with medical errors. Increased anxiety following an error resulted from a
punitive work environment, and nursing managers exerted either a positive or a negative impact
on the experience depending on the level of support perceived by the nurse. The number of years
in nursing affected a nurse’s experience with errors. Novice nurses were concerned about their
self-image after an error, and veteran nurses were more likely to make constructive changes after
an error. Interventions such as disclosing the error to the patient and feeling supported after the
error also affected nurses’ experiences. Nurses believed that telling the patient about the error
was part of “making the medical error right” (p. 156) and allowed nurses to feel closure. Support
following the error, both formal and informal, was important to the nurse's restoration of
personal integrity following an error. Lewis et al. identified four outcomes following nurses’
experiences with errors in their literature review: burnout, moral distress, intention to leave, and
constructive change. From their findings, they proposed a model of nurses’ experiences with
medical errors. The model showed that interventions of disclosure and support to nurses after
medical errors are moderated by system characteristics (work unit) and nurse characteristics
(number of work years), both of which affect nurse outcomes (burnout, moral distress, intention
to leave and constructive change). These interactions suggest a dynamic process is in operation;
therefore, Lewis et al. suggested that more research is necessary to test the proposed reciprocal
relationships. The integrative literature review by Lewis et al., (2013) may have failed to capture
all relevant studies using the standardized structured method. The review also highlighted the
multitude of research methodologies and the wide variety of settings used to explore this newly
developing area of research; therefore, further exploration of the topic by direct interviewing of
nurses would be beneficial.

Attree (2007) used grounded theory to explore factors that influenced nurses’ decisions to
raise concerns about standards of practice. Situated in England, the study included semi-
structured interviews with 132 nurses across a variety of disciplines. Analysis yielded one core
category, ‘professional dissonance,’ which was comprised of three subcategories: (a)
professional discrepancies, (b) professional discontent and disquiet, and (c) professional
dilemmas and decisions. All of these were identified as conflicts that arose between nurses’ duty
to raise concerns and their fear that negative consequences would result. Raising concerns was
seen as a “high-risk: low-benefit” act. Facilitating factors were described as an ideal culture that
was open, where raising concerns was perceived as a professional duty and responsibility, and
where reported concerns were perceived as positive and constructive. None of the nurses
interviewed believed that they worked in that type of environment. Attree’s (2007) study has a
larger sample size than other previously discussed qualitative studies. The data represented a
wide range of nursing experiences, which identified similar problems reported in other studies.
The data supports the assertion that nurses believe they continue to work in a punitive
environment. A more specific discussion about how that environment influences decisions about
error reporting was missing.
 Running header: NURSING ERROR REPORTING BARRIERS AND FACILITATORS 22

References Title Aim Personnel Method Attitudes and Barriers to Medical Error
involved/Setting Reporting

Uribe CL1, Perceived explored the factors 56 physicians and 66 Qualitative; nominal group Barriers for physicians; not knowing the usefulness of
Schweikhart SB, barriers to that affect medical- nurses/ University technique  the report, workload , the lack of information on how to
Pathak DS, Dow medical-error error reporting among hospital, USA Quantitative; descriptive report an error, thinking that reporting has little
M, Marsh GB. reporting: an physicians and nurses survey design contribution for improvement of quality of
exploratory at a large academic care.Barriers for nurses; time involved in documenting
investigation. medical center located an error, is not anonymous, extra work involved in
in the midwest United reporting , hesitancy regarding “telling” on somebady
States. else, it is unnecessary to report the error and fear of
lawsuits.

S M Evans1, J G Attitudes and To assess awareness 587 nurses from Descriptive: survey design the incident form taking too long to complete and a
Berry2, B J barriers to and use of the current diverse clinical belief that the incident was unimportant. Major barriers
Smith3, A incident incident reporting settings in six South to reporting for nurses were lack of feedback a belief
Esterman4, P reporting: a system and to identify Australian hospitals that there was no point in reporting near misses and
Selim3, J collaborative factors inhibiting forgetting to make a report when the ward is busy.
O’Shaughnessy3, hospital study reporting of incidents
M DeWit3 in hospitals.
2006

Hui-Ying Chiang, Barriers to To describe nurses' 597 Descriptive cross-sectional, The major perceived barrier was fear. Regression
Ginette A. Pepper Nurses' perceptions of nurses/University correlational design analysis showed that power hierarchy, face-saving
2011 Reporting of reporting barriers to Hospital concern, and work environment factors (e.g., quality
Medication reporting nursing error management and peer relations) accounted for 54.6%
Administration variance in the barriers. Age, educational background,
Errors in Taiwan working experience, experience of having made MAEs,
and failure to report MAEs were not associated with the
barriers.
 NURSING ERROR REPORTING BARRIERS AND FACILITATORS 23

MAJD T. Rate, causes and The aim of the study 799 nurses/Various Comparative descriptive Exposure to disciplinary action and the fear of losing
MRAYYAN PhD, reporting of was to describe hospitals survey design their jobs .
RN, medication errors Jordanian nurses’
KAWKAB in Jordan: perceptions about
SHISHANI PhD, nurses’ various issues related
RN, perspectives to medication errors.
IBRAHIM AL-
FAOURI PhD,
RN

2012
Ulanimo VM1, Nurses' to describes nurses' 61 nurse/Medical Descriptive; survey design  Descriptive indicated in barriers; fear of the reaction
O'Leary-Kelley perceptions of perceptions about Center they would receive from the nurse manager  and their
C, Connolly PM. causes of medication errors and peers
medication errors reporting system.
2012 and barriers to
reporting.

Espin S, To report or not exploring ICU nurses’ 37 nurses/Intensive Qualitative; semi-structured Lack of time, fear and lack of management feedback.
Griffithsb AW, to report: A perceptions of error care units questions with individual When the patient wasn’t harmed nurses dont prefer to
Wilson M, descriptive study and error reporting. interviews do reporting.
Lingardd L Intensive and Critical
(2010) Care Nursing.
Okuyama A, The relationship To identify The 430 nurses/Hospitals Descriptive; A self- Incidents were reported more frequently when the
Sasaki M, Kanda between incident relationship between in various regions administered survey potential consequences were considered severe for the
K reporting by incident reporting by patient. when nurses and safety managers on wards
2010 nurses and safety nurses and safety discuss incidents and their root causes, nurses feel less
management in management in afraid of incident reporting.
hospitals. hospitals.
Almutary HH, Nurses’ study examined the 62 nurses/University Descriptive; survey design The most important factor in nursing management
Lewis PA, Cert willingness to likelihood of registered hospital responses, another factor is the feeling of fear of legal
CC (2012) report nurses (RNs) reporting action as a result of reporting.
medication MAEs when working
administration in Saudi Arabia.
errors in Saudi
Arabia.
 NURSING ERROR REPORTING BARRIERS AND FACILITATORS 24

Hartnell N, Identifying, The under-reporting of Nine doctors, 14 Qualitative; focus group Barriers to medication error reporting were thematised
MacKinnon N, understanding medication errors can nurses, seven interviews five categories: reporter workload, Professional
Sketris I, Fleming and overcoming compromise patient pharmacists/Four identity, information gap, organisational factors and
M barriers to safety. community hospitals fear. Facilitators to encourage medication error
(2012) medication error in Nova Scotia, reporting were classified three categories: reducing
reporting in Canada. reporter workload, closing the communication gap and
hospitals: educating

Bayazidi S, Medication error to explore medication 733 Descriptive; survey design Blame and fear of punishment in addition nurses
Zarezadeh Y, reporting rate error reporting rate and nurses/University identified no need to report if no harm to patient.
Zamanzadeh V, and its barriers its barriers and hospital
Parvan K and facilitators facilitators among
(2012) among nurses. nurses in teaching
hospitals of Urmia
University of Medical
Sciences (Iran)
Wagner LM, Barriers and To explore Barriers 1180 Nurse/Nursing Descriptive; cross sectional Risk of being harmed to confidence in the
Damianakis T, facilitators to and facilitators to Homes design competencies and reporting is difficult for nurses
Pho L, communicating communicating
Tourangeau A nursing errors in nursing errors in long-
(2013) long-term care term care settings.
settings.
Hashemi F, Factors to clarify the factors 115 nurse/University Qualitative; focus group Fear of legal procedures, threats of job, fear of losing
Nasrabadi AN, associated with associated with hospital interviews respectability, lack of information, lack of skills to
Asghari F (2012) reporting nursing reporting the nursing error management,unwillingness to accept
errors in Iran: a errors through the responsibility for errors, and the manager's response is
qualitative study. experiences of clinical inappropriate.
nurses and nursing
managers.
Reeva Lederman, Electronic error- This research asks 30 nurse/Private and Qualitative; (in-depth barriers identified in the questionnaire; lack of training
PhD'Corresponde reporting whether the electronic tertiary hospitals interviews) and descriptive in reporting system, workload, lack of access to
nce information systems: A case media creates survey design computers, the fear of being monitored, reporting of the
about the author study into the additional barriers to form very detailed.
PhD Reeva impact on nurse error reporting, and, if
LedermanEmail reporting of so, what practical steps
the author PhD medical errors can all hospitals take to
Reeva Lederman, reduce these barriers.
 NURSING ERROR REPORTING BARRIERS AND FACILITATORS 25

Suelette Dreyfus,
PhD, Jessica
Matchan, BIS
(Hons), Jonathan
C. Knott, PhD,
Simon K. Milton,
PhD
2013
Nursing error reporting barriers and attitudes towards researches.
Running header: NURSING ERROR REPORTING BARRIERS AND FACILITATORS 26

Chapted five: Discussion

The reporting of medical errors is the focal point of the effort for reducing the incidence of
these errors. The evaluation of the types and frequency of errors, and their effects on patients,
have critical importance in the determination of the root causes of errors, and for the
development of attempts toward the reduction and prevention of these errors [42,43]. Despite
the critical importance of error reporting, healthcare professionals do not sufficiently report
errors due to specific barriers.

It has been determined in studies that investigate the attitudes and perceptions towards
medical error reporting that more reporting is done when the outcomes of the errors are at the
level of severe damage; in parallel with this, less reporting is done when the potential
outcome is harmless or only slightly harmful. The types and severity of medical errors are
perceived differently among healthcare professionals. However, despite a common
terminology related to the severity, types and outcomes of errors having been developed by
international patient safety authorities, it was seen that this terminology is still not used and
conceptualized as basic information by healthcare professionals.

based on the attitudes and perceptions of the participants of this study, organization safety
culture is among the factors influencing the nurses' decisions to report the professional errors.
In fact, lack of or defected safety culture hinder error reporting, while existence of safety
culture will strengthen the nurses’ motivation to report the errors. The factors reducing the
safety culture in this study were authorities' and colleagues' intolerance of error, lack of
professional support, blaming and shaming the one who committed the error, putting an
individual at the sharp end of an event, lack of support for the error reporters by the
authorities, the authorities' blaming and punishing the reporters, and lack of the physicians'
cooperation as well as team accountability. Wolf et al. also believe that the clinicians who
work in a system of blaming and punishing do not report errors due to the fear of being
punished. A long standing tradition in healthcare domain is repeating a common expressions
of “your name, you are guilty, you're ashamed”. Fear of retaliation and punishment leads to
silence, while silence is destructive. In fact, healthcare professionals need to put the important
issues and problems of their working environment, such as errors and unsafe actions of their
colleagues.
NURSING ERROR REPORTING BARRIERS AND FACILITATORS 27

Error reporting can be increased by the authorities' support of those who report the errors and
training the staff about the objectives of error reporting. To increase error reporting, health
care providers and others should know that first, reporting without penalty leads to improving
safety and second, errors are primarily the product of the organizations' flaws. In addition,
perfect communication and collaboration between healthcare providers are requirements of a
safe environment and in a safe culture; open communications, error reporting, and team
accountability among all healthcare providers are facilitated and will be considered as a rule.

Different fears, such as fear of legal action and job threats, fear of economic losses, fear of
honor and dignity, and fear of reporting outcomes, and also some personal characteristics of
nurses, such as lack of professional responsibility and accountability and lack of knowledge
and skill in how to report errors, are the most prominent barriers in reporting the errors in the
sub-class of factors related to nurses. Therefore, conscience, commitment, sense of personal
responsibility, and the authorities' not considering the nursing errors as crimes, supporting the
error reporters, and not reinforcing fear in those who have committed an error will increase
reporting the errors. Training and encouraging the nurses to identify and report the working
errors in a non-punitive milieu will increase error reporting, as well.

Factors associated with errors are among the other identified sub-classes in the main theme of
barriers in reporting the errors. Although the participants of the present study did not have a
universal agreement on the effect of these factors, the majority considered the impacts and
consequences of errors as important issues in the nurses' decision to report or not,

Barriers in reporting the errors

In this study, the nurses complained about some factors as inhibitors in reporting the errors,
which were placed in the barriers class. For example, the factors associated with nurses,
organization, and the nurses’ perception of the incidence and consequences of the error were
stated as the main barriers in reporting the errors.

1. a) Factors associated with nurses: factors include fear of legal action and job threats,
fear of economic losses, fear of honor and dignity, weakness of knowledge, weakness
of nursing skills in error management, and unwillingness to accept the responsibility
of the errors. A selection of the participants’ statements from qualitative study is as
follows: “If we report errors, they will be used against us. There will be no legal
NURSING ERROR REPORTING BARRIERS AND FACILITATORS 28

protection. They threaten us. Our problems will be examined in the Medical Council.
Physicians will vote against us and in favor of their own interest. We are afraid of
being ousted from our job. Continuous warning comes from the nursing office”.

2. b) Nurses’ perception of the incidence and consequences of the errors: These factors
included the impact degree as well as the severity of the error, not having adverse
events, and ambiguity in the notion of the error. 

3. Organizational factors: including the managers, physicians, and colleagues, and also
the inappropriate reaction of the manager regarding the impact and intensity of the
error lead to under-reporting the errors and covering them up. Another major concept
associated with the organization which stopped the nurses from reporting the errors
was shortcomings in the safety culture, which appeared in the form of the limited
threshold of fault tolerance, nonexistence of team response, assigning one person at
the sharp end, and name, blame, and shame culture. In this regard, the authorities',
physicians', managers', and other team members' flying into rage and shirking from
the error responsibilities as well as the nurses' being responsible, being beaten by the
patients’ loved ones, going to court, being at the sharp end, being named, blamed, and
shamed, and being humiliated were expressed by the participants.

4. Work pressure/high load of responsibility: perceptions of high work load and pressure
as well as the responsibilities of the nurses which caused the errors to go unreported.
These factors include the personnel’s lack of time and the reporting process.

5. Also The long duration of the reporting process, the belief that reporting errors that
are not harmful to the patient is unnecessary and meaningless, the type of harm and
severity of the error, lack of education, lack of feedback about reporting, the fact that
the error is not perceived as an error, and lack of knowledge about the importance of
error reporting were found to be other reporting barriers.

Motivators in error reporting

NURSING ERROR REPORTING BARRIERS AND FACILITATORS 29

1. a) Factors associated with nurses: These factors include the nurses' knowledge and
skills in managing the errors, responsibility, professional commitment, and
professional accountability.

2. b) Factors related to errors: Here, a clear definition of error, its consequences and
negative adverse events, and the profitability of the reports for the patients were
considered as motivators.

3. Organizational factors: Based on the participants' experiences, the factors of this class
were related to their work place and facilitated reporting the errors. Dominant
supportive atmosphere, no authority and physician shirking from the responsibility of
the practiced error.

4. error reporting profitability in various fields, such as adjusting its consequences,

improving patient safety, and learning opportunities, was considered as the motivator.

Recommendations

Development of health care personnel awareness about error types and severity, reportable
errors and the importance of reporting.

 Dissolution of the atmosphere of fear and potential risks as a consequence of reporting, 

Delivery of constructive feedback in a reasonable amount of time, shortening of the reporting

duration, and development of strategies to encourage reporting by administrators emerged

Conclusion:

Despite the fact that nursing error reporting has been accepted as a basic attempt for the
improvement of patient safety, error reporting barriers continue to be one of the most
important healthcare problems worldwide. Since the reporting barriers determined by the
literature review are similar, a common terminology that includes these barriers (similar to
the classification of errors and their outcomes) could be developed. Via the development of
measurement tools that include this terminology, worldwide standardization could be
provided and could shed light on the attempts at proof-based reporting.

The fear of individual accusation and administrator reactions took the place at the top of the
list of obstacles. Other reporting barriers among nurses, in the order of significance, were
NURSING ERROR REPORTING BARRIERS AND FACILITATORS 30

found to be: being thought of as incompetent, patients’ negative attitudes, the stigma of
incompetence, unsupportive work environment, long reporting process, the idea that
reporting errors that do not damage the patient is unnecessary, not knowing the importance of
error reporting, and lack of education, lack of feedback on reporting and not perceiving the
error as an error.

in order to increase the medical error reporting rate of healthcare personnel were presented
most often in the qualitative studies. Increasing the nurses’ knowledge, ability, undertaking,
and accountability aspects, encouraging a scientific environment, an anonymous reporting
system and lack of authority, clinicians and administrators learning from their mistakes,
patient education, determining the basic ethical duties for reporting and encouraging the
employees were all leading motivational factors for error reporting.

Implications for Practice and Future Research

This investigation presents up-to-date information about medical error reporting barriers, and
the features of effective error reporting systems for nurse administrators, quality and risk
management workers, institution administrators, and researchers. When evaluated within the
scope of the investigated research questions, along with descriptive studies toward reporting
barriers, more experimental studies are required. The constitution of error reporting systems,
evaluation of its usage by healthcare workers, and sharing of the results will contribute to the
literature in this field. Especially, studies that investigate the reporting barriers determined by
the research and healthcare workers’ suggestions, comprehensively, from a practical
perspective, are thought to be beneficial.

By using the results of this review, nurse administrators could collaborate with system
designers to develop effective, creative error reporting systems. At the same time, these
results could contribute to the development of strategies that improve and encourage error
reporting, with the aim of developing the awareness of error reporting and patient safety. The
development of positive attitudes and behaviors of clinical nurses within a healthcare team,
who have the potential and strength to be agents of change, would affect other team
members. Accordingly, effective team cooperation, which is necessary for qualified patient
care, will be provided, contributing to the leadership strength of nursing.