Domain	Barrier	Driver
Event Related Issues	Someone Else’s Mistake	System Error
	“Human Error”	Harm or Potential to Harm
	Reported in Another Forum	Reckless Behavior
		Recurrent or Repeatable Event
Institutional & Cultural Issues	Differences in MD & RN Perspective	Potential for Improvement
	Blame-based System	Attending Encouragement
	“Waste of Time”/Inefficacious
	Culture of Low Expectations
Reporting System/Process Issues	Lack of Anonymity	Follow-up on Reports
	Difficult Reporting System	Visible Changes to System
	Lack of Transparency of Process & Consequences
	Inappropriate Follow-up
	Witnessed or Experienced Negative Consequences