Archives of

1. Introduction
edical errors are the preventable adverse
effect of care that may include incorrect
or incomplete diagnosis or treatment
[1]. The prevalence estimates ranged
from 2% to 94% [2]. Ramia and Zeenny
found that 73% of patients had incomplete therapeutic/
safety laboratory-test monitoring tests [3]. Preventable
adverse medication events were estimated as 15/1000
individuals/years [4]. In Iran, a systematic review study
highlighted that medical errors are approximately 50%
[5]. This frequency of medical errors can lead to several
complications [6].
Multiple studies have reported the consequences of
medical errors. Medical errors have direct and indirect
impacts. Immediate results include patient harm as well
as increased healthcare costs. Indirect effects include
damage to nurses regarding professional and personal
status, confidence, and practice [7]. Although most errors
are minor, there is a considerable spectrum, and
some are fatal. It is estimated that medical error is the
third cause of death in the USA [8]. A study reported
that the number of deaths related to U.S medical error is
44000-98000 cases annually [8]. Approximately 1%-3%
of pediatric hospital admissions are complicated by medical
error [9]. Therefore, medical errors must be caught
in time, and their reasons are revealed if solutions are
found for their prevention [10].
The first step in preventing medical errors is identifying
the causes of medical errors using the medical error
reporting system. If medical errors are well reported
by health system staff, health managers can identify the
causes of medical errors; thereby, they can plan and
implement operational programs to prevent the causes
[11]. The medical error reporting system is the essential
method that can be used to identify errors in healthcare
services. This measure is aimed to save patients from
being harmed by such errors and reduce these errors
altogether [10]. Despite the medical error reporting system’s
importance, some health workers refuse to report
the mistakes. Estimates suggest that 50%-96% of
adverse events are never reported [12], while about half
of them are considered preventable [13]. Identifying the
facilitators and barriers to reporting medical errors can
enhance medical error reporting to identify and prevent
the causes of medical errors [14].
A large body of literature from different contexts has
reported the facilitators and barriers to reporting medical
errors. Of the surveys published in the literature,
most have been conducted in the U.S., Australia, and
the United Kingdom (U.K.), with findings of barriers
towards reporting, including the fear of adverse consequences
following reporting [15-17] disagreement over
error [18, 19], identifying the lack of knowledge and
awareness [20], and the lack of feedback [21]. Despite
numerous studies on facilitators and barriers to reporting
medical errors, a limited number of these studies are
related to healthcare delivery systems in Iran. The managing
system of healthcare in Iran is different from other
countries [22]. Furthermore, the culture of Iranian health
workers is different from other countries [23]. Therefore,
facilitators and barriers to reporting medical errors in
Iran can differ from other countries. This study aimed to
explore the barriers and facilitators of reporting medical
errors in Iranian hospitals.
2. Materials and Methods
A qualitative study design with a conventional content
analysis approach was used. The qualitative content
analysis examines participants’ experiences [24]. The
study setting included the teaching hospitals of Tehran
and Qom Provinces, Iran. The study participants were
selected using the purposive sampling method [25]. As
per Table 1, 13 clinical staff members were invited to
participate in the study. The examined participants differed
concerning the level of education (B.A. degree),
job positions (nurse, head nurse, midwife, anesthesiologist,
& physician), workplaces (maternity ward, operating
room, intensive care unit), and work experience
(ranged: 2-21 years).
The study’s inclusion criteria included at least one
year of work experience in the clinical setting and the
informed consent of the participants to participate in the
study. The study participants who dropped out of the
study at each study stage were excluded. Sampling was
performed by the purposive method. For this purpose,
the subject who met the inclusion criteria and could express
their experiences were considered. In-depth interviews
were used to gather information; that the study
participants could have more freedom of action and freely
discuss the topic of the study. Before the interview, the
study participants were permitted to record the interview
and ensure that their information was confidential. These
interviews were conducted where participants could feel
comfortable about their mistakes, such as the clinical
governance office. The interview was conducted in Persian.
Sampling continued until the data were saturated.
After providing voluntary information, the interviews
began with a general question about the barrier medical
error report. Next, we used adequate questions to under-
M
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stand the participants’ experiences better. No pre-defined
definition of medical error is provided. The research
participants were requested to talk about what they were
experiencing and identify them as medical errors. The
interview was semi-structured. Some of the interview
questions were as follows: Please tell me about your mistakes
in providing care. What do you do when you have
a medical error? After commenting on the importance
of the error, a participant was asked. Do you remember
what the barriers/facilitators to error reporting were?
Furthermore, research questions were asked to ask for
more details or clarification.
To validate the findings, member checking was applied
to the research participants. Moreover, the research team
triangulation results for checking and establishing the
validity of finding by analyzing a research question from
multiple perspectives to arrive at consistency across data
sources or approaches. Moreover, codes and categories
were checked and confirmed by two experts in qualitative
study design by two colleagues. The peer reviewers
were not involved in this study. The qualitative data
analysis was based on the content analysis method, and
its results were presented in the form of a theme, subcategories,
and categories.
Conducting the interviews took 20 to 45 min, was
audio-recorded. Subsequently, they were immediately
transcribed to the paper, following which they were analyzed
using descriptive qualitative analysis. In this study,
the coding of the interviewees, including the Midwife
(M), Nurse (N), Anesthesia Nurse (AN), the Operating
Room Nurse (ORN), and the work experience with (E)
and the age of the employees (Y) were determined. For
example, a nurse with 18 work experience, 42 years old,
was written in the figure below (N, E18.42Y).
The interviews were concurrently recorded, transcribed
verbatim, coded, and analyzed. In the initial step,
interviews were read and re-read to understand what
the participants had talked about. Then, the texts about
the study participants’ experiences were extracted and
brought together into one text as a unit of analysis. The
meaning units were identified, condensed, abstracted,
and labeled with codes in this text. Based on differences
and similarities, the various codes were sorted into 16
subcategories and six categories [26].
The study participants are voluntary for cooperation in
the study, and the study’s purposes were described for
them. Therefore, all participants were informed about
the study’s protocol, and confidentiality was assured
and maintained for all of them. Moreover, verbal consent
was obtained from recruited subjects. Furthermore,
the research team described to the participants that they
were free to withdraw from the study if they felt embarrassed
at any time. The anonymity of the participants
was ensured by taking cod to the subjects during the interviews.
The recording of the discussion was conducted
with the consent of the interviewees.
3. Results
According to the study data, most individual, organizational,
and social barriers to medical error reporting were
raised. Besides, the staff provided training and organizational
and cultural facilities to create the obstacles to
error reporting by creating facilitators. The executor did
not use the sample list of obstacles and facilitators during
the in-depth interviews. This is because there was much
discussion with the participants, s they reacted to each
other’s experiences, especially when they had to think of
facilitators. In total, 3 categories of barriers and 3 classes
of facilitators were identified.
Barriers
The barriers involved 3 categories of individual, organizational,
and social (Table 2):
Individual
Two sub-headings, including the lack of staff time to
report medical errors, the lack of awareness of medical
error definition, no job commitment was related to individual
barriers.
Lack of staff time to report medical errors
Excessive workload and responsibility prevent staff
from reporting errors. Nursing experts said: "...Due to
the overload, and when the ward gets crowded, I forget
to report the error" (N, E2,25Y).
Lack of awareness of medical error definition
The lack of awareness was one of the cases that participants
cited as a barrier to reporting. The lack of awareness
was reported primarily on the newly graduated
nurses; a nurse said: “Sometimes we do not have enough
knowledge about the error, and we do not know what is
wrong and need to report it (N, E2,25Y). The nurse from
the operating room said: "Do not know the error definition
and does not know to report the error (AN, E8,32Y).
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Organizational
Four sub-heading, including notification from the direct
supervisor, useless medical error report, negative attitude
responsible department, exposed to charges, were
related to organizational barriers.
Notification from the direct supervisor
Most study participants were referred to reprisals and
did not report errors due to fear of reprisal. Midwife... I
am not aware of the fear of reprimand or remorse for the
mistake committed (M, E10,33Y). Another nurse said
we were reprimanded for the error and told us that you
had increased the error rate (N, E16,39). Another nurse
mentioned... When an error occurs, authorities look for
the offender (N, E14,37Y). Also, I am not reporting the
error due to the terrible attitude of the person in charge of
the department and because of the mistake of going to the
nursing office (N, E2,25Y)…I fear that job stigma and inappropriate
treatment of the head of the department cannot
be misreported. That mistake will not be erased from the
past (AN, E9, 33).
Useless medical error report
One consequence of failing to report medical errors is
that the error is unimportant, which seems to be due to
a lack of awareness of the error:…Many mistakes are
trivial in terms of personnel and not worth telling (M,
E10,33Y). If it does not harm the patient, the nurse said
any error reporting is required (N, E14,41Y). Another
Table 1. Characteristics of study participants (n=13)
Variables No. (%)
Gender
Female 13(100)
Male 0(0)
Marital
Single 1(7.6)
Married 12(92.3)
Age, y (Mean±SD) 34±5.2 -
Clinical experience, y (Mean±SD) 10.3±3.5 -
Education
Bachelor 12(92.3)
Specialist 1(7.6)
Workplaces
Intensive care unit 3(23.07)
Childbirth block 2(15.3)
Surgery room 2(15.3)
Job position
Physician 1(7.6)
Nurse 4(30.7)
Supervisor 1(7.6)
Midwife 2(15.3)
Operating Room Technician 2(15.3)
Head Nurse 3(23.07)
Practice experiences, y
<10 1(7.6)
10-20 8(61.5)
>20 4(30.7)
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nurse…In the past, employees felt responsible, but now
the opposite is exact (N, E18, 42Y). …We are no longer
motivated to work at all. If I say we are not encouraged,
it is useless (AN, E9, 33)…. What is the result of recording
the error? What will happen? (M, E16,43Y).
Negative attitude responsible department
Most research participants were unhappy with the shift
in viewpoints of the lineage officials and were barriers
that could not easily report their error.
Nurse…If staff members report an error, their comments
about the person will be wrong (N, E16,39Y).
Midwife…The fear of incorrect view of department responsible
who does not allow error to be declared everyone
else in the error department will blame me.
Eexposed to charges
An examination of the staff revealed that they would
be impeachment if they made a mistake…When I make
a mistake, I feel like others are infamous (N, E14,37Y).
Another nurse...only when you say the mistake does the
person in charge of the worse part stress you out (N,
E6,33Y)…Whenever you make a mistake, the feedback
you receive is essential. Everyone understands. They become
curious, You are just being punished, For example,
salaries are reduced, pay attention to the error, You are
insulted, This is discouraging)N, E20,44Y).
Social
Four sub-heading, including humiliation and blame the
staff, legal issues, distrust, and losing a reputation or a
job, were related to organizational barriers
Humiliation and blame the staff
Being punished or reprimanded in the organization
increases the anxiety and stress of the nurse, resulting
in an increased error and no reporting. Midwifery…I
once reported a mistake. I was humiliated by my boss
and treated me harshly, and she treated me very harshly.
Insulted my personality (M, E10,33Y)...
Well, it depends on whether the error is large or small
... it is more about maintaining prestige. Furthermore, a
more experienced nurse is waiting to see our error (N,
E14,37Y).
Legal issues
According to the importance of patients’ rights, the legal
issue of medical errors has become common. Moreover,
employees are reluctant to report errors for fear of cost
overruns and consequences….When the error is said, it
has trouble Bored of not following up; also, I am terrified
that I will be forced to pay compensation (N, E6,33Y).
Distrust
Nurses seem to report their mistakes when they feel safe
and confident that error reporting is not a bad outcome
for them. ... There is no sense of security (M, E10,33Y)
…There are no supporters. First, they say report the error,
but in the end, you have to go to the committee and
explain. (N,E6,33Y).
Losing a reputation or a job
Error detection is often a complicated process. Accordingly,
the reason for not reporting errors is damage to the
professional position and reputation of the service provider…...
If we report an error, our Work reputation will
be damaged (ORN, E10,33Y).
Facilities
Facilities created the 3 categories of education, organizational,
and cultural (Table 3):
F.1. Education
Two sub-headings, including “education how to report
errors, and patient safety training based on patient safety
standards”, were related to Education
F.1.1: Education on how to report errors
Most participants noted the necessity of training in this
regard….It is a good idea to learn more about how to
report an error and how to report it to. Let’s talk about
what they say is wrong, how to say it (N, E2,25Y). Continuous
training should be given to the staff because it
causes sensitivity and accuracy and affects the patient’s
safety (N, E18,42Y).
F.1.2. Patient safety training based on patient safety
standards
The institutionalization of patient safety standards in
medical centers requires establishing standards. Most
of the study participants mentioned this issue…. Try to
remind the staff frequently of the standards and safety
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issues should be valued more (ORN, E10,33Y).…. If we
know the instructions, we will recognize what the error
is and report it. Most of these are for patient safety… Patients
often do not know the standard, and we think We
are exemplary and not wrong (M, E16, 43Y).
F.2. Organizational
Three sub-heading, including “Reward payment, supporting
individuals in disclose, medical errors were related
to the administrative aspect:
F.2.1. Reward payment
Most research participants were dissatisfied with not
being encouraged to take the right action and reporting
medical errors. They pointed to motivational factors, e.g.,
using an incentive approach and rewarding…Encourage
the staff to be happy because it will make the mistakes
clear and not be repeated (M, E10,33Y)….Give employees
the right encouragement and do not lie (M, E12,
43Y)…I think employees should be encouraged financially
and in the case( N, E2,25Y). Another nurse Written
encouragement and special privileges are much better for
the error reporter. It affects staff because of the encouragement
he received. That mistake did not leave his mind
(N, E16,39Y)…Encourage any personnel who pose
the most significant error. The kids in that section have
a sense of attention from the managers(AN, E9, 33)…
Encouragement in exchange for a mistake increases the
motivation to work (N, E14,41Y)…. Encourage the person
as a gift that the hospital considers (ORN, E10,33Y).
F.2.2. Supporting individuals to disclose medical errors
In the treatment system, employees require further support.
Thus, the study participants tend to be supported by
managers if they make a mistake…. The gynecologist
said. Do not just look for the cause of the error to support.
I announce the error when I know it will be supported.
I try to work better (G, E2,35Y) …… I expect them
to support me and make me confident (M, E12,43Y).
F.2.3. Creating an error reporting system
Regarding identifying and reporting errors, most employees
referred to issues, such as conditions and the characteristics
of reporting, confidentiality, and the necessity
of having a system for monitoring and recording errors in
the organization...The error registration process should be
concise and short, and the staff should have easy access
(M, E12,43Y)…The error report becomes systematic and
is confidential and without a name. There is no need to
write the error name ( AN, E9,33)… Leave a separate box
to monitor for errors and give feedback to the person so
they know the outcome of their work. (M,E10,33Y).
F.3. Cultural
Two sub-headings, including “Organizational learning
and learning errors, a culture of encouragement versus
inspection and punishment was related to the cultural
dimension:
F.3.1. Organizational learning and learning errors
Most study participants cited such issues as error feedback
and corrective action to learn from mistakes…..I
made a mistake in finding a solution to the error in the
body participation session so that it stays in my mind,
and I do not repeat the danger (M, E12,43Y) ….The
wrongdoer should be guided by the superior, not punishment
and reprimand so that he learns from the mistake
(N, E2,25Y) ….On the other hand, if the result of the
Table 2. Barriers to reporting medical error
Categories Sub-category
Individual barriers Lack of staff time to report medical errors
Lack of awareness of medical error definition
Organizational barriers
Notification from the direct supervisor
Useless medical error report
Negative attitude responsible department
exposed to charges
Social barriers
Humiliation and blame the staff
Legal issues
Distrust
Losing a reputation or a job
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error is sent to the department, it will be experienced by
everyone, and they will learn to ask (N, E16,39Y).
F.3.2. A culture of encouragement versus inspection
and punishment
Encouragement seems to impact reporting medical
errors significantly. Furthermore, stress-relieving
staff can articulate their misconceptions about the fear
of reprimanding and punishing the majority of participants…
Encourage the staff to be encouraged because it
will make the mistakes clear and not be repeated…(M,
E10,33Y) Honest encouragement of the body no lies at
work (M, E12,43Y) …
Employees should be encouraged both financially and
in a case-by-case manner rather than by abusive behavior
or inspection (N, E2,25Y)…. written encouragement.
Visa score is much better for the error reporter and affects
the staff because of his encouragement (N, E16,39Y)…
Encouragement in exchange for a mistake increases the
motivation to work...
Body motivation Raise the staff’s self-confidence Reassure
the body of non-punishment and reprimand (N,
E14,41Y)…… Encouragement to the person as a gift
that the hospital considers ORN, E10,33Y).
4. Discussion
The present study aimed to investigate barriers and facilitators
in reporting medical errors. The obtained findings
were classified into 6 categories and 16 subcategories.
The present study data revealed that the barriers to
reporting medical errors included individual, organizational,
and social aspects. Besides, the first barrier to reporting
medical errors is individual barriers. Individual
barriers to reporting medical errors included the lack of
staff’s time to report medical errors and lack of awareness
of medical error definition. This finding is consistent
with previous studies [27, 28]. Studies conducted
in Iran [29, 30], Taiwan [31], and Germany [32] also
signified that the first barrier to reporting medical errors
is the high workload of healthcare workers. Due to the
increased work shifts and the high ratio of patients to
nurses in Iran, nurses lack adequate time to participate in
in-service training classes actively and learn the basics
of error reporting. Additionally, the lack of time has led
nurses who know the basics of medical error reporting to
refrain from doing so.
These results indicate the significance of improving
health workers’ ratio to patients and improving health
workers’ knowledge about the importance of medical error
reporting in increasing medical error reporting.
The achieved results demonstrated that the second barrier
to reporting medical errors is organizational barriers.
Organizational obstacles to reporting medical error included
notification from the direct supervisor, useless medical
error report, negative attitude responsible department
exposed to charges. Stratton reported that senior managers
focus on the person who committed errors rather than a system
where medical errors can be registered and analyzed
[19]. Moreover, Soydemir et al. argued that the employees’
perceptions of preventing the medical reporting error
included the lack of belief in the need for such a system,
unawareness about medical errors, considering errors normal,
and not considering it as an error [10].
These results indicate that the medical error reporting
process will not be appropriately performed until an adequate
error reporting system is established. In a fair error
reporting system, managers understand the importance
of paying attention to the reported errors, managing the
individuals who reported the mistake and accompanying
the error reporter to find the root causes of the error and
the method of preventing its recurrence. In this system,
instead of focusing on the erring individual, it focuses on
a set of individual and organizational factors that can be
effective in causing the error.
Table 3. The facilitators for reporting medical error
Categories Sub-category
Education Education how to report errors
Patient safety training based on patient safety standards
Organizational
Reward payment
Supporting people to disclose medical errors
Creation error reporting system
Cultural Organizational learning and learning errors
A culture of encouragement versus inspection and punishment
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The results show that the third barrier to reporting medical
error concerns social aspects. Social barriers to reporting
medical errors included humiliation and blame to
the staff, legal issues, distrust, and losing a reputation or a
job. Bayazidi S et al. stated that the most critical barriers
of reporting medication errors were blaming individuals
instead of the system, the consequences of reporting mistakes,
and fear of reprimand and punishment [33].
In another study, the most significant obstacles to error
reporting in both cohorts consisted of the fear of reprimand,
poor communication, and hierarchy [34]. Qalandarpuratar
et al. and Helmchen et al. also argued that
some health system employees do not report medical
errors due to the fear of adverse consequences, such as
malpractice lawsuits, the loss of patient trust, and emotional
reactions of patients and their relatives, or the loss
of job [35, 36]. Accordingly, following the reporting of
an error, the authorities should hold the entire treatment
team responsible for the occurrence of this error. Without
punishing or stigmatizing the person reporting the
error, they should search a set of factors contributing to
the error. In a system with adequate error reporting, not
only is the reporting person not punished but individuals
who report errors to identify existing gaps (which can be
effective in creating systematic errors) are encouraged.
The collected results outlined that the facilities of medical
error reporting included education, organizational, and
cultural facilities. Moreover, the first facilitator of medical
error reporting is education that provides education on reporting
errors and patient safety training based on patient
safety standards. Elder et al. and Pattison et al. found that
improving workers’ information about the error reporting
process and devoting educational resources can improve
medical error reporting [37]. Therefore, in creating
a quality error reporting system, one of the first steps is
to educate healthcare workers about the importance and
process of error reporting. If healthcare workers know
that reporting their errors can help identify similar gaps
and challenges and prevent similar mistakes, they will undoubtedly
be more interested in reporting errors. There
should also be straightforward error reporting processes
so that healthcare workers can register their errors in the
shortest amount of time, despite their busy schedules.
This study indicated that the second facilitator of medical
error reporting is organizational that includes reward
payment, supporting individuals to disclose medical errors,
and creating an error reporting system. Evidence revealed
that a fault recording system could be considered
a powerful tool for further detecting faults and risk factors
and may help prevent the occurrence of preventable
side effects [38]. In line with the results of this study,
Varjavand found that light workload, optimal working
conditions, effective systems, sound policies, and procedures
are the fascinators of medical error reporting.
These findings also indicate the importance of an incentive
organization in increasing medical error reporting.
The error reporting system should be designed with an
incentive approach so that health care providers are more
willing to participate in error reporting.
The third facilitator of medical error reporting is cultural,
i.e., organizational learning and learning errors and a culture
of encouragement versus inspection and punishment.
Pattison Jet al. concluded that a just and trusting culture
should enhance the likelihood of reporting medical errors.
Improved reporting, in turn, should improve patient safety
[39]. Another study concluded that instead of punishment,
it should be used as a facilitator in the training system’s
error report and employee encouragement. With a culture
that encourages reporting errors and learning, clear guidelines
should be communicated [40]. Participants may not
be willing to report their mistakes, a cultural issue.
Organizational culture should be easy to inform and
support when medical errors occur [41]. These findings
confirm that it is impossible to provide a medical
error reporting mechanism without considering the organization’s
culture. In an organizational climate where
the individual reporting the error is regarded as a culprit,
health workers cannot be expected to report their
errors. Health managers should create an environment
in which the offender can easily register their mistake
without fear of being punished, stigmatized, or fired, and
help the health system identify and eliminate factors that
could be effective in repeating the errors. This study was
conducted only in the maternity ward, operating room,
an intensive care unit. Therefore, the results can not be
generalized to other sections.
5. Conclusion
The present study results signified that the barriers to
reporting medical errors included individual, organizational,
and social aspects. Additionally, according to the
results of this study, the facility of medical error reporting
had education, administrative, and cultural facilities.
Findings indicate the necessity for support and security
for employees and consideration of facilities to prevent
the nonreporting of errors. Managers must provide the
necessary personal, professional, and legal support to
employees to remove barriers to encourage them to report
the mistakes effectively.
Asgarian A, et al. Barriers of Reporting Medical Errors in a Hospital.A rch Hyg Sci. 2021; 10(4):279-288.
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Ethical Considerations
Compliance with ethical guidelines
The Ethics Committee of Qom University of Medical
Sciences approved the study (Code: I.R.MUQ.
REC.1398.025).
Funding
This research did not receive any grant from funding
agencies in the public, commercial, or non-profit sectors.
Authors' contributions
All authors equally contributed to preparing this article.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgments
The researchers would like to thank the Deputy of Research
and Development Technology, Qom University
of Medical Sciences.
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