In the current study the reasons for and the manner in which clinical errors occur and are identified in a teaching hospital were elicited through the interviewing of Medical and nursing groups. Among the nursing staff, the most significant obstacle impeding the reporting of clinical errors was that related to hospital systems which in the study was categorized as Organizational problems, while among Physicians this was identified as external problems related to the governing of the health care system and there beyond the confines of the hospital itself.
In most cases, nurses sought to change the prevailing attitude and practices. However, the doctors expected a modification in the policies related to the dealing with clinical errors in teaching hospitals on a governmental level. All the interviewees also requested a method for resolving the dealing with individual attitudes and concurrent training in the identifying of clinical errors and methods of self-reporting.
The two main categories of individual and organizational problems were determined as being the main problems identified in the interviews carried out among all members of the treatment group. The medical staff of operating theatres and nursing staff had the highest rate of individual problems especially regarding a lack of information about various errors due to the extensiveness of clinical errors and defects in concurrent training carried out at hospitals.
Acording to a study in Iran, 73% of lack of reporting clinical errors was due to the lack of awareness of the error itself [26]. Nurses lack of awareness of the definition of hospital errors is mentioned as the main cause for the lack of reporting clinical errors [27]. Also in other studies, one of the main barrier to reporting and disclosing errors was: lack of a unified and standard definition regarding the seriousness of errors and their eligibility for reporting and disclosing[28,29]Some studies have shown that the number of clinical errors reports filed by the staff is far less than those reported after the staff has received training on how to identify hospital errors [1, 26]. Alijanzadeh et al and Beiranvand et al has recommended training of hospital staff in identifying common clinical errors in hospitals [17,30]. The training of medical staff during their undergraduate period and during concurrent training courses in hospitals in the area of common and life threatening clinical errors and methods for dealing and informing patients of the error and efficiently reporting the clinical error will aid in the development of a culture of self- reporting clinical errors and will ultimately result into a diminishing of such errors in the hospital.
In the nursing team, the significant codes categorized under one's personal perspective regarding the obstacles hindering the reporting of clinical errors were the fear of losing one's job, concern regarding the consequences of reporting errors, the inherent tendency to conceal one's errors and the striving to maintain one's social status all elements which have been discussed in previous studies. Heidari states that 38% of the not reporting clinical errors are due to the person's fear of losing his/her job [26]. In another study performed in teaching hospitals in Iran, 46% of the lack of reporting of clinical errors occurred as a result of one's fear of jeopardizing his/her job [2]. In addition, Nurses reported that disclosing and reporting practice errors could damage patients’ trust in nurses’ competencies and might lead to litigation [31].Based on the aforementioned reasons, one may conclude that in order to minimize the personal perspective of the staff in medical and treatment centers regarding clinical errors, a systematic approach must be instigated in order the increase the reporting of clinical errors in such centers.
The interviews carried out on the issue of organizational problems indicated that this category has a number of major issues among which the motivational factors for reporting clinical errors; organizational problems and managerial problems were all considered as subcategorizes. Most of the interviewees indicated that their speech and comprehension of what is required from them as being a type of organizational problem and they considered this aspect as being one of the main reasons for the occurrence of clinical errors.
Nurses stated that the lack of any sort of feedback after reporting a clinical error is another reason for the lack of reporting clinical errors in hospitals. This issue was categorized under motivational problems in reporting clinical errors. In a study carried out in Southern Australia by Evans it was seen that the lack of sort of feedback after the disclosure of a clinical error resulted in further reporting of clinical errors [32]. Some nurses believed that positive feedback could be initiated in the form of a financial reward; others mentioned receiving incentives such as complimentary leave, yet others indicated the implementing of change in order to minimize clinical errors as a sign of suitable feedback.In a study carried out by Elder it has been observed that receiving financial rewards motivates the reporting of clinical errors [14].With due regards to the fact that reporting clinical errors in the health system is an effective means for the identifying of clinical errors and the resolving of them in the hospital, it is believed that by creating the necessary motivational factors for nurses to report clinical errors or whom offer solutions to reduce or eliminate clinical errors the necessary environment for reporting such errors will develop and will affect the development of a systematic approach in health and treatment centers.
Wagner et al. noticed several barriers in reporting and disclosing practice errors including negative reactions and feedbacks by nurse leaders, encouragement of selective reporting of incidents, ignoring nurses’ clinical reasoning and judgment in handling error reports, anonymity and confidentiality issues, concerns over being sued and reprimanded by administrators at the workplace, and endangering nurses’ professional reputation [28]. nurse leaders are responsible for encouraging error disclosure through policy making, creation of a supportive culture, and encouraging nurses to consider ethical values via provision of care, education, and mentorship [33]. It should be noted that by converting negative feedback into positive feedback, it is possible to provide the basis for voluntary error reporting by medical care staff.
Another influential factor in the lack of reporting of clinical errors was the lack of an HSE manager on hand in the hospital in order to supervise the implementing of the necessary scope of services related to the safety and well-being of the patient, and to initiate training in the reporting of clinical errors in addition to the following up of such reports. These were categorized as structural problems during the analysis carried out by the panel and which have not been discussed in most studies. In recent years and based on the evaluation standards implemented in hospitals throughout the country it has been advised that an HSE department be established; however due to staffing problems, the majority of hospitals have not been able to establish such a department. Seidi in a study on nurses' perspectives regarding impediments in the reporting of clinical errors states that most of the participants reported that forgetting to report the clinical error was the main reason for the error not being reported. This in itself is related to the lack of an official responsible for the supervising of such reports and recording of the number of reports in hospitals [34].
The lack of a standard reporting procedure for reporting clinical errors was another important obstacle mentioned by the health care staffs hindering adequate reporting of clinical errors in our study. Unclear process for reporting clinical errors is maintained in other studies in Iran [17 ,34]. In addition, lack of knowledge of existing reporting process and not trusting in current digital systems for reporting has identified as other barriers to error reporting [28,29]. It seems, through new accreditation system platform, that is proceeding in last decade by ministry of health, establishing a unified effective process for reporting medical errors will not be far from reach. By creating a standard system to record and track clinical errors by senior physicians, there will be a reduction in the type of reporting carried out on the basis of personal taste by other medical professionals and the health care system which in itself will reduce clinical errors. Moreover, it will aid in the identifying of high-risk areas that most surgical assistants cause a clinical error to occur and thus create the necessary foundation for their future training.
In 2004, to mark the fifth anniversary of the establishment of The Institute for Reporting Medical Errors in the United States the Five Principles of Patient Safety were reviewed and amended, among which the most important was the amending of the second principal related to the method for systematically reporting clinical errors [35].Such an action in itself indicates the importance of error reporting systems in reducing clinical errors. Shams al-Din has proposed that the establishing of effective systems for the recording and reporting of errors is a practical means to effectively reduce such errors [36]. In other studies the creating of a rapid response system for reporting clinical errors has been advocated [14].
Managerial problems such as a hospital's managerial level's lack of active participation in the controlling of errors and also the self –centered perspective afforded by most of the aforementioned officials to clinical errors has also been considered as an obstacle to the reporting of errors in the past and are categorized under the heading administrative problems. The lack of active participation on part of the hospital's administrative staff regarding the controlling of clinical errors was not evaluated in prior investigations ,while these investigations did emphasis the self-centered perspective of managers [2, 27].Furthermore, the lack of a suitable reaction on part of the existing administrative structure when clinical errors were reported, as has been indicated to throughout this study and other previous studies, is has been associated to the inactive participation of high level managers in controlling clinical errors.
In an interview conducted with surgical assistants’ clinical errors were regarded as a major problems in the healthcare system, and other obstacles such as the lack of emphasis on ethics, the inability to communicate effectively with patients and the lack of a precise definition for the probable types of errors manifest in surgical residency training were categorized as "training problems " which in themselves are a sub-category of "individual problems."
Kuhpayehzadeh investigated the perspective of medical residents at Tehran University of Medical Sciences regarding the self-reporting of clinical errors and found that % 91 the medical residents preferred to learn how to identify and report clinical errors [37]. Senior physicians believe that training and the holding of self- expression sessions with the purpose of creating an atmosphere of reporting clinical errors in addition to the sharing of one's personal experiences, and the teaching of professional ethics will aid medical assistants after graduation towards a reporting and rectifying of clinical errors in the workplace. In the same category, the using of Specialist consultants has been recommended in critical conditions [37].
The brusque treatment of patients by Senior physicians is among the other codes specified at the level of the hospital. Prior studies show that % 68 percent of residents fear conflict with senior physicians and do not therefore report clinical errors [37].However, Most senior physicians in training hospitals believe that the lack of reporting of clinical errors is due to the lack of support by high-ranking officials in the education systems and the existing legal loopholes with is in contrast to the educational mission of training hospitals where surgical assistant should be taught what to do at the bedside of a patient. It is believed that policy-makers on the upper echelons of the health care system must alleviate the fear of reporting clinical errors in order to enhance the patient's well-being and rectify the legal short comings and modify the existing laws accordingly.
Limitations
One of the limitations of this study was that it was conducted in only one hospital; hence it needs to be cautious to generalize the results. Participants' inadequate time for interviews was another limitation of this study.