Nursing Students' Reports of Patient Safety Incidents and Reasons During Clinical Placements: A Secondary Analysis of the International Data

ABSTRACT

Clinical placements expose nursing students to patient safety incidents and provide important opportunities for learning about safe care. This study explored how nursing students in four countries recognized and interpreted patient safety incidents encountered or witnessed during clinical practice, including perceived contributing factors. A secondary qualitative content analysis was conducted using narrative data from 1442 undergraduate nursing students in the Czech Republic, Italy, Slovakia, and Türkiye. In total, 287 incident descriptions and 263 explanations of perceived reasons were analyzed using an inductive–deductive approach supported by descriptive frequency counts. Medication safety incidents and patient falls were most frequently reported, alongside infection prevention breaches, missed or inadequate care, communication failures, adverse outcomes, and environmental hazards. Students described incidents as multifactorial, involving patient and contextual factors, organizational and system conditions, and human and professional factors. Cross‐country differences reflected patterns within the analyzed narratives rather than differences in incident prevalence or quality of care. The findings support practice‐integrated patient safety education, effective supervision, structured reflection and debriefing, clear reporting pathways, and psychologically and emotionally safe, nonpunitive learning environments.

Keypoints

• Nursing students most frequently reported medication safety incidents and patient falls during clinical placements across four European countries.

• Reported incidents were multifactorial, involving patient and contextual factors, organizational and system factors, and human and professional factors.

• Variations across countries regarding the patient's incident witnessed or encountered and their contributing factors.

• Strengthening education, clinical supervision, organizational support, and nonpunitive learning environments is essential to promote patient safety incidents recognition and interpretation of their contributing factors among nursing students during clinical placements.

1. Introduction

Patient safety remains a major global priority in healthcare and nursing education. Despite sustained international efforts to reduce preventable harm, adverse events continue to occur across healthcare settings and may affect patients, healthcare professionals, students, and organizations. Unsafe care has been described as a substantial source of morbidity, mortality, and economic burden worldwide, and international policy documents emphasize the need to strengthen patient safety competencies through education and training of future healthcare professionals (World Health Organization ²⁰²⁴). As the largest group of healthcare professionals, nurses play a central role in preventing harm; therefore, undergraduate nursing education represents a critical period for developing the knowledge, skills, attitudes, and professional values required for safe practice (Steven et al. 2014; Wang et al. ²⁰²⁶).

Clinical placements are an essential component of nursing education because they enable students to apply theoretical knowledge in real‐world care environments and to develop clinical judgment, communication, teamwork, and professional responsibility. However, clinical practice is also a complex and emotionally demanding learning environment in which students may witness, become involved in, or reflect on events that compromise patient safety (Espin and Meikle 2014; Fisher and Kiernan ²⁰¹⁹; Steven et al. ²⁰¹⁴). Previous research suggests that students' experiences of patient safety are shaped not only by formal education, but also by the quality of supervision, the teamwork culture, and the hidden curriculum of practice‐based learning (Atakro et al. 2019; Fagan et al. ²⁰²¹; Steven et al. ²⁰²³).

A persistent challenge in patient safety education is the gap between what students learn in academic settings and what they observe or experience during clinical placements. Although students may be familiar with basic safety principles, such as hand hygiene, infection prevention, medication safety, and patient identification, they may feel insufficiently prepared to recognize, interpret, discuss, or report adverse events in practice (Bocaut and Cusack 2016; Vaismoradi et al. ²⁰¹¹). Recent evidence also indicates that nursing students often perceive stronger patient safety competence in classroom settings than in clinical settings, suggesting that theoretical knowledge does not always translate easily into practice (Wang et al. 2026). In this context, adverse events may become powerful but challenging learning experiences, particularly when students lack support, confidence, or opportunities for guided reflection.

Students' encounters with adverse events are frequently accompanied by strong emotional responses. The fear, guilt, shame, confusion, helplessness, shock, anxiety, and loss of confidence among students who witness or are involved in patient safety incidents have been described (Gradišnik et al. 2024; Kang and Cho ²⁰²³; Zieber and Williams ²⁰¹⁵). These emotions may be intensified by fear of blame, negative evaluation, disrupted relationships with clinical staff, or being perceived as incompetent (Fagan et al. 2021; Fisher and Kiernan ²⁰¹⁹; Roman Jones et al. ²⁰²²). As a result, students may hesitate to speak up or report concerns, even when they recognize unsafe practice. Such silence may deepen the tension between professional values learned in academic settings and the realities of clinical practice, contributing to cognitive dissonance and emotional distress (Fagan et al. 2021; Ghasempour et al. ²⁰²³).

The role of mentors, supervisors, and clinical teams is therefore crucial in shaping how students learn from adverse events. Supportive supervision can help students make sense of safety incidents, reflect on contributing factors, and transform difficult experiences into professional learning. Conversely, poor supervision, humiliation, dismissal of concerns, or lack of constructive feedback may undermine students' emotional safety and confidence (Javornická et al. 2024; Luhanga et al. ²⁰⁰⁸; Steven et al. ²⁰¹⁴). In a Czech qualitative study using the SLIPPS Learning Event Recording Tool, supervisory relationships were conceptualized through the contrasting experiences of “clinical and emotional companionship” and “clinical and emotional abandonment.” Clinical and emotional companionship was associated with feeling welcomed, respected, heard, trusted, and supported, whereas abandonment was linked to vulnerability, fear, loneliness, and reduced confidence (Javornická et al. 2024).

Reflection has been identified as an important strategy for supporting patient safety learning during clinical placements. The SLIPPS Learning Event Recording Tool (SLERT) was developed to enable healthcare students to document and reflect on real patient safety‐related events encountered in practice. The tool prompts students to describe the event, consider those involved, identify contributing factors and outcomes, reflect on emotions and learning, and classify the event as an adverse event, near miss, hazard, or good practice (Steven et al. 2023). In the Czech study, the Czech version of SLERT was used to collect students' written reflective narratives of patient safety learning events during clinical placements (Javornická et al. 2024). In a later qualitative study conducted in Iran, the Persian version of SLERT was found to support students' reflection on real patient safety events and to promote learning about event classification, event outcomes, possible causes, solutions, and factors influencing learning (Mirzaei et al. 2025).

Although previous studies have examined nursing students' patient safety competencies, emotional responses, supervision, and reporting behaviors, less is known about how students themselves recognize and interpret the types of patient safety incidents they encounter or witness during clinical practice. Exploring students' free‐text responses may provide insight into their understanding of patient safety risks, their interpretation of contributing factors, and the extent to which they connect clinical events with individual, organizational, educational, or communication‐related causes. Such knowledge can inform patient safety education, strengthen clinical supervision, and support learning cultures in which patient safety incidents are discussed openly and used as opportunities for improvement rather than blame (Fisher and Kiernan 2019; Javornická et al. ²⁰²⁴; Mirzaei et al. ²⁰²⁵).

Therefore, the aim of this study was to explore how nursing students from Czech Republic, Italy, Slovakia, and Türkiye recognize and interpret patient safety incidents they experienced or witnessed during clinical practice, including their perceived contributing factors.

The study addressed the following research questions:

1. What types of patient safety incidents do nursing students report experiencing or witnessing during clinical practice?

2. How do nursing students explain the perceived reasons or contributing factors associated with these incidents?

3. What similarities and differences are evident in the reported incident types and perceived contributing factors across Czech Republic, Italy, Slovakia, and Türkiye?

2. Methods

2.1. Design

This study employed a secondary qualitative content analysis of narrative data derived from a multinational cross‐sectional study investigating nursing students' experiences during clinical placements. The primary study collected both quantitative and qualitative data; however, this secondary analysis focused exclusively on students' free‐text reports of patient safety incidents and their perceived reasons. Secondary analysis was considered appropriate to enable a more in‐depth exploration of incident characteristics and reasons as contributing factors that were not fully addressed in the primary analysis (O'Connor ²⁰²⁰). The analysis followed an inductive–deductive qualitative content analysis approach, aiming to identify patterns in incident types and contributing factors across countries. A completed STROBE checklist for the underlying multinational cross‐sectional study is provided as Supporting Information 1.

2.2. Data Source

The data originated from a larger multinational cross‐sectional study conducted among undergraduate nursing students in Czech Republic, Italy, Slovakia, and Türkiye between February and December 2025. Participants in the primary study were recruited using convenience sampling from academic institutions providing nursing education. The primary dataset included 1442 nursing students, of whom 579 reported exposures to a patient safety incident during clinical practice.

For this secondary analysis, only free‐text responses related to patient safety incidents and their contributing factors were extracted and analyzed.

2.2.1. Eligible Data and Collection

Narrative data were collected using an open‐ended section within the study questionnaire, which invited students to describe patient safety incidents encountered during clinical placements. Students were encouraged to provide brief descriptions of the incident and, where applicable, the perceived reasons for its occurrence. The questionnaire contained one free‐text field for the incident description and one for its perceived reasons; individual responses could nevertheless contain more than one distinct incident or contributing factor. These responses were collected alongside structured survey data but analyzed independently in this secondary analysis.

Narratives were eligible when they referred to a patient safety incident encountered during clinical placement and contained sufficient information to allow meaningful interpretation and coding. Blank responses, responses unrelated to patient safety or clinical placement, and narratives containing insufficient information for analysis were excluded. Eligibility assessment was independently performed by two researchers and subsequently cross‐checked during a consensus meeting, where any inconsistencies were discussed and resolved. Thus, 287 eligible incident descriptions were available for analysis, while 263 also included an analyzable explanation of the perceived reasons or contributing factors. Therefore, all these eligible responses were included to ensure comprehensive coverage of reported experiences; no additional selection or subsampling of eligible incident descriptions was undertaken. No country‐specific quotas or balancing procedures were applied; therefore, the number of incident descriptions from each country reflected all eligible responses available in the respective national dataset. The derivation of the final analytical sample is presented in Figure 1.

FIGURE 1.

Flowchart of the derivation of the final analytical sample.

2.3. Data Analysis

The analysis followed Mayring's qualitative content analysis framework, combining inductive category development with deductive organization informed by the patient safety literature (Mayring 2014). The inductive component involved open coding of students' free‐text regrading incident descriptions, allowing initial codes, subcategories, and categories to emerge directly from the data without applying a predefined coding framework. This approach was important for capturing the specific types of patient safety incidents and students' own explanations of why these incidents occurred. The deductive component was applied during the subsequent phase of abstraction and organization when the emergent categories were compared with and structured in relation to broader concepts established in the patient safety literature. Thus, the analysis combined data‐driven category development with theoretically informed organization to enhance conceptual clarity and support comparison across the four national datasets.

The analytical process followed a structured and iterative approach. First, all incident descriptions were repeatedly read to achieve data familiarization and gain an overall understanding of their content and context. Each free‐text response constituted the initial unit of analysis. When a response contained more than one distinct incident or contributing factor, it was divided into separate meaning units. During the inductive phase, concise descriptive codes were assigned as closely as possible to the original meaning of the students' narratives. Codes expressing conceptually similar content were compared within each national dataset and grouped into provisional subcategories and categories. The country‐specific coding structures were subsequently compared across the four datasets to harmonize category labels, definitions, and boundaries. During the deductive phase, the resulting categories were abstracted and organized in relation to broader concepts established in the patient safety literature. Multiple preliminary codes could be assigned when a narrative contained several relevant elements; however, for the descriptive frequency analysis, each distinct incident and each reported reason was assigned to one final category according to its predominant meaning.

Ambiguous responses and differences in coding or category assignment were discussed by the research team, with repeated reference to the original narratives of incident descriptions, until consensus was reached. To enhance analytical rigor, an analytical matrix was maintained to document the progression from the original narrative response through meaning units and descriptive codes to provisional categories and higher‐order domains. Category labels, definitions, and boundaries were repeatedly reviewed across the four national datasets and refined through constant comparison and team discussion. The final category system therefore reflected both the original narrative content and a consistently applied analytical structure across countries. These procedures contributed to the credibility and dependability of the analysis.

After the category system had been finalized, representative participant quotations were selected to illustrate the meaning and range of each higher‐order analytical domain and to demonstrate the relationship between the original narratives and the researchers' interpretations. Quotations are identified by the respondent's country while preserving participant anonymity.

To complement the qualitative analysis, category frequencies and within‐country percentages were calculated as a descriptive component of the content analysis (Mayring 2014). The cross‐country comparison was exploratory and was used to identify similarities and differences in reporting patterns across the four national datasets. Its purpose was to examine convergence and divergence in the types of incidents and perceived contributing factors represented within each dataset, rather than to compare national incident rates or rank the participating countries. Because the number of eligible narratives of incident descriptions differed across countries, absolute frequencies were interpreted together with within‐country percentages. No inferential statistical testing was performed, and the findings were not interpreted as estimates of the incidence or prevalence of patient safety incidents in the participating countries. Moreover, Because the national datasets differed in size, the cross‐country findings are presented as descriptive patterns within the analyzed narratives. Differences in absolute frequencies should therefore be interpreted together with the corresponding within‐country distributions and not as direct indicators of differences in the occurrence of patient safety incidents or the quality of care between countries.

Narratives were analyzed in the original languages by the respective national research teams. Quotations selected for publication were translated into English and checked by bilingual members of the research team to preserve semantic equivalence.

2.4. Ethical Considerations

The study was approved by the Ethics Committee of the Constantine the Philosopher University in Nitra, Slovakia (ref. no. UKF/370/2025/191013:008), by the Institutional review board of Department of Medicine, Italy (ref. no. 162/2025 Tit III cl 13 fasc.24/2025), by the Ethic Committee of the Faculty of Health Sciences, Palacký University in Olomouc (UPOL‐4946/1030S‐2025). Participation in the study was voluntary, and written informed consent was obtained from all respondents. Participants were informed of their right to withdraw at any time. Data were processed anonymously in accordance with GDPR regulations (GDPR.eu, 2021).

The study complied with the International Conference on Harmonization/Good Clinical Practice (ICH/GCP) guidelines, the Declaration of Helsinki (October 2024), and relevant legislation. Permission to conduct the research was obtained from the management of participating nursing education institutions. No identifying information (e.g., name, date, or place of birth) was collected. Sociodemographic data (age, education, years of experience) were reported only in aggregated form to ensure participant and institutional anonymity. Data collection, storage, and analysis adhered to applicable data protection regulations.

3. Results

The narratives of incident descriptions reflected diverse clinical contexts and patient populations. Reports included incidents involving adult and older patients, pediatric and neonatal care, mental health and behavioral situations, and acute, critical, perioperative, and procedure‐related contexts.

3.1. Frequency and Types of Patient Safety Incidents

A total of 287 incidents were analyzed across four countries (Figure 1): the Czech Republic (N = 98), Italy (N = 101), Slovakia (N = 32), and Türkiye (N = 56). At a higher level of abstraction, the incident categories were organized into four broader domains: clinical safety, infection prevention and care quality, patient and organizational, and environmental or outcome‐related safety. The distribution of incidents revealed a clear concentration within a limited number of categories, with most events consistently clustered around clinical safety issues (Table 1).

TABLE 1.

Distribution of patient safety incidents by category and country.

Category of incidents	Czech Republic (N = 98)	Italy (N = 101)	Slovakia (N = 32)	Türkiye (N = 56)	Total (N = 287)
Medication safety incidents	47 (48.0%)	44 (43.5%)	5 (15.6%)	25 (44.6%)	125 (43.6%)
Patient falls and fall‐related events	13 (13.3%)	30 (29.7%)	9 (28.1%)	14 (25.0%)	62 (21.6%)
Patient identification errors	12 (12.3%)	4 (4.0%)	3 (9.4%)	2 (3.6%)	21 (7.4%)
Infection prevention and control	4 (4.1%)	2 (2.0%)	4 (12.5%)	1 (1.8%)	11 (3.8%)
Fundamental care/missed care	7 (7.1%)	4 (4.0%)	2 (6.3%)	3 (5.4%)	16 (5.6%)
Clinical procedures and technical errors	2 (2.0%)	4 (4.0%)	3 (9.4%)	2 (3.6%)	11 (3.8%)
Patient behavior/safety risks	7 (7.1%)	6 (5.9%)	2 (6.3%)	4 (7.1%)	19 (6.6%)
Communication and organizational factors	1 (1.0%)	2 (2.0%)	1 (3.1%)	3 (5.4%)	7 (2.4%)
Occupational/environmental safety	1 (1.0%)	3 (2.9%)	2 (6.2%)	1 (1.8%)	7 (2.4%)
Adverse outcomes/complications	4 (4.1%)	2 (2.0%)	1 (3.1%)	1 (1.8%)	8 (2.8%)

Abbreviations: N, number; %, percentage.

Medication safety incidents were the most frequently reported category overall and were identified across all countries, although with variability in frequency (Czech Republic N = 47, Italy N = 44, Slovakia N = 5, Türkiye N = 25). These incidents included incorrect medication administration, wrong dosage, administration to the wrong patient, and omission of medication, as well as near‐miss events. Importantly, medication‐related incidents frequently co‐occurred with other types of errors, particularly patient misidentification and documentation failures, suggesting that they are rarely isolated events but rather reflect broader systemic vulnerabilities in care processes. Across all countries, patient falls and fall‐related events represented one of the two most frequently reported types of incidents. Patient falls and fall‐related events also represented a prominent incident category across all four national datasets (Czech Republic N = 13, Italy N = 30, Slovakia N = 9, Türkiye N = 14). Falls occurred in a wide range of situations, including during mobilization, hygiene care, toileting, and unsupervised patient activity, and were often associated with contributing factors such as inadequate supervision, improper use of restraints, or failure to adhere to safety protocols. Representative accounts of clinical safety incidents included “Morning insulin administered at night” (Czech Republic) and “The patient fell out of bed and removed his Peripherical Venous Catheter” (Italy).

Incidents related to infection prevention and control and fundamental nursing care formed a secondary but consistently present group across all datasets. These included breaches of aseptic technique, inadequate hygiene practices, and failures in isolation procedures, alongside omissions in basic care such as insufficient monitoring, improper positioning, and unmet patient needs. While these incidents were less frequent than falls and medication errors, they were notably more extensively reported in the Czech Republic and Italy, where descriptions of missed care and care omissions were more detailed and varied, compared to the more limited representation observed in Slovakia and Türkiye. This domain was illustrated by statements such as “Use of restraints; inadequate hygiene—patient left all day in a diaper soiled with stool” (Czech Republic) and “Non‐adherence to principles of sepsis and asepsis in wound care” (Slovakia).

Across all countries, incidents were also shaped by patient‐related and organizational factors, including patient behavior (e.g., delirium, agitation, noncompliance) and communication or coordination failures among healthcare professionals. These factors were rarely reported as standalone incidents; instead, they appeared embedded within more complex events, particularly falls and medication errors, highlighting their role as underlying contributors to patient safety risks. The Turkish dataset uniquely included explicit reports of violence, aggression, and external interference by relatives, indicating the presence of context‐specific safety challenges related to security and patient–family interactions. Representative narratives included “The patient escaped from the ward and nobody noticed” (Italy) and “Verbal and physical violence against the patient by the patient's relative” (Türkiye).

Less frequent but clinically significant were incidents involving adverse outcomes and complications, such as patient death, aspiration, and clinical deterioration, which were reported primarily in the Czech Republic and Italy. Similarly, occupational and environmental hazards, including sharps injuries and unsafe physical conditions, were reported at low frequency across all countries but were often implicated as contributing factors to patient harm. These incidents were reflected in accounts such as “A radiator detached from the wall and fell; delayed staff response to call bell; assistance provided by a student from another ward” (Czech Republic) and “A doctor did not attach importance to a patient's high troponin levels; the 60‐year‐old patient died during the night” (Italy).

3.2. Reasons for the Occurrence of Patient Safety Incidents

A total of 263 reasons for the occurrence of patient safety incidents were identified across the Czech Republic (N = 98), Slovakia (N = 22), Italy (N = 95), and Türkiye (N = 48). The analysis revealed that reasons were not evenly distributed, but rather clustered into three overarching domains: organizational and system factors, human and professional factors, and patient and contextual factors, with clear cross‐country similarities in their relative contribution (Table 2).

TABLE 2.

Distribution of reasons for patient safety incidents by category and country.

Category of reasons	Slovakia (N = 22)	Czech Republic (N = 98)	Italy (N = 95)	Türkiye (N = 48)	Total (N = 263)
Organizational and system factors	11 (50.0%)	29 (29.6%)	28 (29.5%)	19 (39.6%)	87 (33.1%)
Human and professional factors	6 (27.3%)	9 (9.2%)	10 (10.5%)	10 (20.8%)	35 (13.3%)
Patient and contextual factors	5 (22.7%)	60 (61.2%)	57 (60.0%)	19 (39.6%)	141 (53.6%)

Abbreviations: N, number; %, percentage.

The largest domain comprised patient and contextual factors and encompassed patient‐related characteristics, environmental conditions, and situational influences. Patient‐related factors such as confusion, delirium, cognitive impairment, noncompliance, and impaired mobility were consistently reported across all countries and were particularly prominent in the Czech Republic (N = 7) and Italy (N = 10). These factors frequently contributed to falls and other safety incidents, especially when combined with inadequate supervision. Environmental and material factors, including unsafe equipment, wet floors, or inappropriate footwear, were less frequently reported but present in all datasets. In Italy and Türkiye, additional contextual influences were identified, such as cultural factors, patient autonomy, and family involvement, indicating a broader conceptualization of safety determinants in these settings. Patient and contextual influences were reflected in narratives such as “A noncollaborative and disoriented hospitalized patient fell down” (Italy) and “Interfering with healthcare professionals due to the patient's religious sensitivities” (Türkiye). Across all countries, organizational and system factors constituted the second largest domain of reported reasons. These included staff shortages, high workload, time pressure, and organizational inefficiencies such as chaotic handovers, lack of beds, and insufficient supervision. Such factors were consistently reported in all datasets, though they were most extensively described in the Czech Republic (N = 12) and Italy (N = 10), compared to Slovakia (N = 7) and Türkiye (N = 4). Importantly, organizational constraints were frequently linked to downstream failures in care processes, including inadequate monitoring, missed preventive measures, and nonadherence to safety protocols, indicating that system‐level pressures directly shaped the conditions under which incidents occurred. Organizational and system‐related conditions were illustrated by accounts such as “A radiator detached from the wall and fell; delayed staff response to call bell; assistance provided by a student from another ward” (Czech Republic) and “Leaving a patient without adequate supervision at night” (Slovakia).

Human and professional factors represented the smallest domain of reported reasons overall, although they were present across all countries. These included insufficient competencies, lack of knowledge, inattention, negligence, and errors in judgment or decision‐making. The Czech Republic (N = 9) and Italy (N = 10) again demonstrated a broader range of such factors, including student‐related errors and failures to recognize patient deterioration, while Slovakia (N = 6) and Türkiye (N = 10) highlighted similar issues primarily in terms of inattention, carelessness, and inadequate training. Across datasets, human factors were rarely isolated; rather, they were often embedded within contexts of high workload and organizational strain, suggesting that individual performance deficits were closely intertwined with systemic conditions. Furthermore, a subset of reasons was explicitly described as multifactorial, particularly in the Czech Republic and Italy, reflecting the complex interaction of organizational, human, and patient‐related elements. Human and professional factors were evident in statements such as “An internship student administered the wrong medication” (Italy) and “The medication was administered twice because the first administration had not been documented” (Italy).

4. Discussion

4.1. Methodological Discussion

The present secondary qualitative content analysis provides insight into how nursing students recognize and interpret patient safety incidents encountered or witnessed during clinical placements across four European countries. Students' narratives and reported reasons indicate that patient safety incidents are understood as emerging from the interaction of patient and contextual factors, organizational and system factors, and human and professional factors. Such a multifactorial phenomenon aligns with studies showing that nursing students encounter adverse events, near misses, hazards, and unsafe conditions embedded in everyday clinical practice (Gradišnik et al. 2024; Li et al. ²⁰²¹; Stevanin et al. ²⁰¹⁸).

The unequal numbers of incident descriptions narratives contributed by the four countries require cautious interpretation. The higher absolute frequencies observed in the Czech Republic and Italy may partly reflect the larger numbers of eligible free‐text responses available in these national datasets rather than a higher occurrence of patient safety incidents. Differences in reporting patterns may also have been influenced by students' willingness to disclose incidents, their familiarity with patient safety terminology, the organization and intensity of clinical placements, and the emphasis placed on patient safety and incident reporting within nursing education. Cultural norms related to professional hierarchy, speaking up, blame, patient autonomy, and family involvement may likewise have shaped which events students recognized as safety incidents and how they described them. However, these educational and cultural factors were not measured directly in the present study; therefore, they should be regarded as plausible contextual explanations rather than demonstrated causes of the observed cross‐country differences. Accordingly, the reported frequencies describe patterns within the analyzed narratives and should not be interpreted as epidemiological estimates of incident occurrence or as direct indicators of differences in care quality between the participating countries.

4.2. Frequency and Types of Patient Safety Incidents

Medication safety incidents and patient falls represented the most prominent incident categories. Medication‐related incidents are consistently identified as frequent and educationally significant patient safety events involving nursing students (Bickel et al. 2020; Gunes et al. ²⁰²⁰; Li et al. ²⁰²¹; Musharyanti et al. ²⁰¹⁹; Schroers et al. ²⁰²²). Consistent with Musharyanti et al. (2019), our findings indicate that these incidents were not isolated technical failures but were linked to verification, documentation, patient identification, supervision, workload, and communication. Students' perceptions of medication‐related risks may also be shaped by knowledge, fear, self‐efficacy, anxiety, fatigue, communication skills, and clinical confidence (Roman Jones et al. 2022). Medication safety education should therefore extend beyond the traditional “rights” of medication administration and address system factors, interruptions, supervision, and simulation‐based preparation (Schroers et al. 2022).

Patient falls were also frequently reported. Although this differs from studies in which medication errors clearly dominated student‐reported events (Bickel et al. 2020; Li et al. ²⁰²¹; Stevanin et al. ²⁰¹⁸), it is consistent with the broader patient safety literature identifying falls as common adverse events in nursing care (García‐Gámez et al. ²⁰²⁰; Gradišnik et al. ²⁰²⁴). Their prominence may reflect their visibility during routine activities such as mobilization, toileting, hygiene care, and unsupervised patient movement. Falls were frequently connected with impaired mobility, confusion, delirium, agitation, noncompliance, environmental hazards, and inadequate supervision.

While many studies on nursing students' patient safety focus mainly on medication errors, reporting behavior, or emotional responses, our results highlight the centrality of patient vulnerability and situational complexity. These factors constitute the clinical reality in which students must learn to recognize risk, priorities care and respond to changing patient conditions. This is particularly relevant for falls, missed care, infection prevention and control, and patient behavior/safety risks, where harm may develop gradually rather than through a single discrete error. Similar concerns have been raised in studies describing clinical placements as learning environment shaped by formal teaching, hidden curriculum, supervision, and observed professional behavior (Steven et al. 2014, 2023). Kang and Cho (2023) also emphasized that students experience safety threats in a dual role: as learners exposed to risk and as emerging professionals expected to protect patient safety.

4.3. Reasons for the Occurrence of Patient Safety Incidents

According to the students' narratives, although organizational and system factors did not constitute the largest domain overall, they remain essential. Staff shortages, high workload, time pressure, insufficient supervision, chaotic handovers, and lack of beds can amplify patient and contextual risks. Li et al. (2021) found that nursing adverse events among students were associated with safety culture, professional behavior experience, educational level, and hospital region. Similarly, Musharyanti et al. (2019) showed that high workload reduced nurses' capacity to supervise students and model safe medication practices. Organizational and system factors therefore help explain when patient vulnerability becomes unsafe. Human and professional factors also require attention. Students identified inattention, carelessness, lack of knowledge, inadequate training, and errors in judgment, yet these factors should not be read through a blame‐oriented lens. Vaismoradi et al. (2011) argued that students require support to internalize patient safety principles and move beyond theoretical knowledge toward safe care in clinical practice. Likewise, Li et al. (2021) noted that confidence in implementing patient safety may decline when students enter the clinical environment. Human and professional factors therefore indicate areas where students need stronger preparation, supervision, feedback, and guided reflection. At the same time, educators and preceptors must identify unsafe practice early, set clear expectations, and provide structured support (Luhanga et al. 2008).

Students recognized that patient safety incidents were rarely attributable to a single cause and instead reflected interactions between patient vulnerability, professional actions, staffing and workload pressures, supervision, communication, and organizational processes. This indicates that students are able to identify not only visible clinical errors but also less visible conditions that shaped their occurrence. Particularly relevant was the apparent discrepancy between formally established safety procedures and their inconsistent implementation in everyday clinical practice. Repeated exposure to such discrepancies may influence students' professional socialization and contribute to the normalization of deviations from recommended safety practices.

Communication failures were a cross‐cutting issue. Students described unclear handovers, poor communication among healthcare professionals, and documentation omissions. Similar patterns were reported by Gradišnik et al. (2024), while Noland and Carmack (2015) showed that students' narratives of medical errors are shaped by communication norms, silence, and attempts to preserve relationships within clinical teams. Communication is therefore not only a technical skill, but also a relational and cultural practice. This aligns with Fagan et al. (2021), who described speaking up as shaped by students' subordinate position, fear of consequences, and inconsistencies between what is taught at university and what is observed in practice.

Violence, aggression, and interference by patients' relatives were explicitly reported only in the Turkish dataset. This finding should be interpreted cautiously, as it may reflect differences in clinical exposure, placement settings, or reporting practices rather than a higher prevalence in Türkiye. Nevertheless, workplace violence can adversely affect nurses' well‐being, performance, and retention, while nursing students may be particularly vulnerable because of their limited experience and preparedness (Çiriş Yildiz et al. 2026). Family involvement should not, however, be viewed solely as a safety threat. When supported by clear communication, respectful partnerships, and defined roles, relatives can contribute to risk identification and the prevention of adverse events (Correia et al. 2023; Ravaghi et al. ²⁰²⁵). Further cross‐country research is required before these findings can be interpreted as context‐specific differences.

The findings are also connected with literature on reporting, disclosure, psychological safety, and emotional safety for learning. Fisher and Kiernan (2019) described how raising concerns is shaped by safety culture, power relations, and staff responses. Lyman and Mendon (2021) showed that psychological safety enables students to ask questions, engage in care, and learn from experience, while Steven et al. (2023) conceptualized emotional safety for learning as a condition that allows students to discuss uncertainty and patient safety events without fear. Without such safety, students may remain silent even when they recognize unsafe practice (Fagan et al. 2021; Lyman and Mendon ²⁰²¹; Steven et al. ²⁰²³). Although the present analysis did not directly examine whether students formally reported the incidents or the reasons for nonreporting, the organizational, supervisory, and communication factors identified in their narratives underline the importance of a clinical learning environment in which students feel able to discuss safety concerns. Where students anticipate blame, dismissal, negative evaluation, or damage to relationships with clinical staff, opportunities for reporting and learning may be reduced. The emotional dimension of patient safety incidents should also be acknowledged. Gradišnik et al. (2024) found that students experienced fear, guilt, confusion, embarrassment, and shock after patient safety incidents, while Zieber and Williams (2015) described making mistakes in clinical practice as traumatic. Hood and Copeland (2024) further emphasized the need for preparation, debriefing, support, and follow‐up after critical events. Students' incident narratives should therefore be understood not only as records of clinical events, but also as accounts of how patient safety events are recognized, interpreted, and transformed into learning experiences.

Similar incident categories across Slovakia, the Czech Republic, Italy, and Türkiye suggest shared vulnerabilities in clinical placements, particularly medication safety incidents and falls. Variation in reported reasons may reflect differences in placement structures, reporting cultures, supervision models, and locally visible risks. Palese et al. (2018) showed that students' disclosure of patient safety concerns is influenced by program‐level learning opportunities, tutorial strategies, safety culture, and regional variation. Therefore, cross‐country differences should be interpreted as possible reflections of learning cultures and clinical environments rather than direct indicators of care quality.

4.3.1. Implications for Nursing Education and Clinical Practice

Overall, the present study contributes to the international literature by showing that nursing students' narratives provide insight into both visible adverse events and the less visible conditions shaping safety during clinical placements. Findings have direct implications for nurse educators, clinical mentors, and nursing leaders. First, patient safety education should be longitudinal, practice‐integrated, and explicitly connected to real incidents, near misses, and hazards encountered during clinical placements. It should also explicitly develop students' ability to analyze why incidents occur and to distinguish individual actions from the organizational and system conditions that influence clinical practice. Moreover, strengthening patient safety education requires supervised, psychologically safe, emotionally safe, and reflective clinical learning environments in which students can recognize patient and contextual risks, communicate concerns, report incidents, and learn from errors without fear of blame. Given the role of patients and contextual factors, students need to develop competence in assessing patient vulnerability, anticipating risks, recognizing deterioration or behavioral risks, and responding to environmental and family‐related safety challenges.

Specifically, patient safety education should enable students not only to recognize and classify incidents but also to analyze contributing factors at the patient, professional, team, organizational, and system levels. Structured reflection, case‐based discussion, and debriefing may help students examine why safety procedures were not followed without reducing the explanation to individual blame. Clinical mentors should support students in discussing discrepancies between expected and observed practice, while nursing leaders should promote adequate supervision, constructive feedback, and reporting processes that enable students to raise safety concerns. Curricula should therefore integrate systems‐oriented analysis of authentic clinical events throughout undergraduate nursing education. Moreover, nursing education and clinical supervision should therefore prepare students both to engage families as safety partners and to manage aggression, conflict, or inappropriate interference.

Medication safety education should extend beyond the “rights” of medication administration to include interruptions, workload, documentation, patient identification, role modeling, supervision, and interprofessional communication. Structured reflection tools may support students in recognizing and interpreting incidents, identifying contributing factors, processing emotional responses, and transforming patient safety incidents into learning opportunities. However, such tools must be embedded in nonblaming and nonpunitive cultures that encourage reporting, feedback, and shared learning, transforming such experiences into patient safety learning. Nurse educators, clinical mentors, and nursing leaders should establish clear and accessible processes through which students can raise concerns, receive timely feedback, and participate in reflective debriefing without fear of punitive consequences.

Clinical placement providers and educational institutions should also clarify reporting pathways for students, define whom they should approach when a safety concern arises, and ensure that concerns are acknowledged and followed by constructive feedback. Such processes are necessary to support psychological safety and prevent uncertainty, hierarchy, or fear of negative evaluation from limiting students' participation in patient safety learning.

4.4. Study Limitations

This study has several limitations. First, the secondary analysis of qualitative data limited control over the scope and depth of the narratives, and the use of brief free‐text responses may have constrained the richness of the data. Second, the findings are based on self‐reported student experiences and may be subject to recall bias and subjective interpretation. Third, convenience sampling from selected institutions may limit generalizability. Variability in response length across countries may also have affected the depth and comparability of the analysis. The number of eligible narratives differed across the four countries; consequently, the cross‐country findings reflect patterns within the analyzed national datasets and should not be generalized as population‐level differences in incident occurrence, safety culture, or quality of care. These factors also limit the transferability of the country‐specific comparisons. Moreover, country‐specific educational characteristics, cultural norms, and attitudes toward reporting or speaking up were not measured. The observed differences between national datasets therefore cannot be attributed directly to cultural or educational factors. In addition, the clinical setting was not recorded as a separate structured variable for each incident; therefore, the distribution of incidents across specific placement contexts could not be quantified. Finally, although methodological rigor was ensured, the categorization process involved a degree of interpretative judgment.

5. Conclusion

This secondary analysis provides insights into how nursing students recognize and interpret patient safety incidents encountered during clinical placements across different European contexts. The findings indicate that patient safety incidents are predominantly concentrated in a limited number of categories, particularly medication safety incidents and patient falls, and that their occurrence is largely multifactorial. Patient and contextual factors, organizational and system factors, and human and professional factors were identified as key contributors, highlighting the complex interaction between patient vulnerability, clinical context, system‐level conditions, and professional performance. These results highlight the need to strengthen patient safety education, enhance clinical supervision, and promote supportive learning environments that encourage reflection and open discussion of safety incidents. Integrating structured reflection tools and fostering a nonpunitive culture in clinical settings may further support students in developing patient safety competencies. Future research should explore interventions aimed at bridging the gap between theoretical knowledge and clinical practice and examine how educational and organizational strategies can better support safe learning environments.

Author Contributions

Dominika Kohanová: conceptualization, investigation, writing – original draft, methodology, writing – review and editing, formal analysis, resources. Elena Gurková: conceptualization, investigation, writing – review and editing. Alvisa Palese: investigation, writing – review and editing, supervision. Daniela Bartoníčková: investigation, writing – original draft, methodology, writing – review and editing, formal analysis, resources. Lenka Mazalová: investigation, writing – review and editing. Aysel Özsaban: investigation, writing – review and editing, formal analysis. Aysun Bayram: investigation, writing – review and editing, formal analysis. Seher Basaran‐Acil: investigation, formal analysis, writing – review and editing. Öznur Ispir Demir: investigation, writing – review and editing, formal analysis. Chiara Moreal: conceptualization, writing – review and editing. Stefania Chiappinotto: investigation, formal analysis, supervision, writing – review and editing.

Funding

The authors have nothing to report.

Disclosure

The research team declares there was no artificial intelligence or AI‐assisted technology used during any point of this study.

Conflicts of Interest

Alvisa Palese is an Associate Editor for Nursing & Health Sciences and a co‐author of this article. The manuscript was managed by editors unaffiliated with the author or her institution and was carefully monitored to ensure that there was no peer review bias. The other authors declare no conflicts of interest.

Supporting information

Data S1: Supporting Information.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.