Quantitative phase
Demographic characteristics
In this study, 491 questionnaires were analyzed. The compiled demographic information revealed that the average age of participants was 33; 88% of the research subjects turned to be female while 60% of them had 10 years of experience and worked with rotating shift schedules; the majority of the participants were married and had an undergraduate degree (See Table 1).
Barriers of reporting error
Concerning the participants' perceptions, education factors (64 %), motivational factors (64 %), managerial factors (64%), error consequences (62%), and error reporting mechanism (48%) had respectively the most important role in non-reporting error. Statistical results approved that there is a significant correlation between error-reporting mechanisms, education, and consequences of reporting errors domains and independent variables such as age, sex, and work experience, respectively (See Table 2). The relationship between various domains’ non-reporting error examined by the SEM analysis is shown in Figure 1, after calculation of coefficient regression (C.R.), structural model revealed that all paths were of absolute value less than z-score (1.96) which indicates that there is no significant difference between them. In sum, the most important perceived barriers with the highest impacts were educational and motivational domains (See Table 3).
Qualitative phase
Twenty-two nurses were recruited to the study. All of the participants held a Bachelor of Science in Nursing. Their average age and work experience were 36 and 10 years, respectively. They were interviewed according to the designed scenario and responded to the questions revolving around the five scenarios. They expressed various points about error, reporting and disclosure error in each scenario. We provided a brief description of the emergent themes related to error reporting or disclosing in Table 4.
Error perception
The nurses’ perceptions of the error were directed toward the type and consequences of error for the patient. In fact, 55% of nurses identified the errors in scenarios (see Table 5). They defined errors as “deviation from the standards, policy procedure, and protocols and from a physician’s order ". In Scenario 3, the nurses interpreted errors as “deviation from the implementation of safety standards in blood transfusions such as lack of patient identification and control of vital signs in the first 15 minutes of blood transfusion”. Nurses mentioned protocols such as safe patient transportation, patient assessment, emergency trolley checking and so on. Distortion from protocol in each scenario was also identified as an error by nurses. However, professional and communication skills were ignored in scenarios by most of the participants. A participant who respond “communication is a part of patient care, I think communication among personnel is not very good, we keep silent after understanding a professional error”. Another said, “If I understand a problem or harm created by a physician for patient, I will likely prefer not to confront with the doctor; I will just be silent as saving their reputation is very important among others (physicians, managers, nurses, patients). It is clear all the time professional reputation and others’ reactions are very important” (Participant 4). It seems there is an ambiguity in error definition; in scenarios one and two, more than half of nurses did not detect the errors and marked the scenario as error-free. One of the nurses stated, “In the first year that I started my project I did not commit any error” (Participant 7). Participants identified negative outcomes in most of the scenarios but they did not consider them to have the potential for real harm, therefore, according to the viewpoint, there is no need for reporting an error. When care-giver act out side of their task did not consider as an error by some of nurses.
Participants emphasized on recruiting less-experienced medical staff particularly in high risk wards such as intensive care and emergency wards, high number of patients to nurse, and keeping patients with critical situation in general wards without standard nurse-to-patient ratios as main reason of not reporting error . One of the participants expressed, “you are expected to work flawlessly in a very busy environment as we are enforced to take care of intubated patients in general wards instead of ICU”. Another nurse stated, “in some of my working shifts, I have to take care of around 15 patients, I don’t simply have time to give patients their medicines, let alone to report the errors. You know, error reporting goes for standard nurse-patient ratios. In such a messy situation, it’s very probable for me to do serial errors.” (Participant 13). Generally, while most of the participants were under time pressure, only a few referred to lack of time as a barrier. Error-reporting mechanism was not stated as a factor in not reporting. One of the nurses believed, "I think it’s the system duty to teach a nurse who is newly introduced into the workplace with less experience. You know adequate monitoring should also be implemented in place. I think weak nursing performance is a sign of weaknesses of nursing education especially in Continuing Education Centers at hospitals“(Participant 1).
Reporting error system (formal vs informal)
Paper-based reporting system was used in studied hospital. The results showed that 66 percent of participants would report the error in scenarios but not exactly through formal reporting system because they believed they received no feedback when they formally disclosed a mistake (especially an error without harm); this would reinforce the perception that reporting is not important. In other words, nurses prefer to report the errors to their head nurse rather than to hospital incident reporting system. In addition, the nurses strongly believed that there was no need to report erroneous incidents without harm. Another participant said, “The head-nurse may prefer not to disclose the errors off the ward” (Participant 2). Error reporting is influenced by participants’ perception and the possible consequences; for instance, if a scenario illustrated an error that did not lead to a harm in patients, the nurses believed that they choose not to report the error. The majority of participants agreed on concerns of inappropriate reaction and lack of support by the hospital authorities especially the nursing manager. One other participant maintained “I believe that the system doesn’t look for roots of error, but wants to find a nurse to blame.’ A nurse stated, “Once I participated in a meeting of morbidity committee for an inadvertent error, I can remember that I was treated so badly that I felt insulted as a human being (Participant 6). In scenario 1, a participant commented that he would not report the scenario, “Because nothing has happened”. It seems that error-reporting often varies depending on how much nurses trust others within the team. A nurse said, “Once I reported an error, the nursing manager decreased my evaluation score and my payment. I’ve come to the conclusion that there is no need to report an error which wouldn’t cause a harm to a patient” (Participant 4). The majority of respondents agreed on “nurses’ insufficient familiarization with error documentation”, “fear of the legal liability”, and “concern for financial losses are not the reason for non-reporting error. But nurses would face some workplace penalties such as changing their ward and increase in payroll deductions which can postpone the procedures of being a head-nurse, supervisor or nursing manager.
Disclosure of medical errors to patients
While describing the affairs in scenarios, nearly half of the participants did not provide disclosure while 37% disclosed partially (see table 5). There are a common disagreement (83%) toward full disclosing (explain what happened and how) the medical errors to patients especially when there is no serious harm caused to the patient. Although the majority of respondents agreed that this is a patient’s right to know about any errors occurred at hospital, they tended to conceal errors to prevent any possible consequences after disclosures. Some reasons were listed as missing patient trust, reactions from patients or their family, damage to professional reputation and the possibility that a patient might sue or reprimand the nurse. Some participants agreed with partial disclosure (just to describe what had happened without specific details); they believed that providing details could disrupt the relationships between the medical professionals and the public, but partial disclosure might result in improved communication in a positive way. One of the participants said, “I committed a medication and I told the patient about it; I assured him that it had no side effect and was not risky. However, I was so desperate by the reaction of the patient and his family who asked the head-nurse to change the faulty nurse so that I had to leave my workplace that day, I felt so bad for a while” (Participant 13). In sum, respondents were not likely to provide full details of errors.