| Koehn et al., 2016 [2] United States |
To explore licensed nurses' decision-making with regards to reporting medical errors. |
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The process of “learning lessons from the error” consist of five stages. 1) The first stage “being off killer” discuss on the antecedents responsible for causing the error. 2) The second stage “living the error” discussed on nurses' emotional stage having to undergo and reconcile with the error. 3) The third stage “reporting/telling about the error” concerns with various considerations that lead to nurses deciding on whether to report error. 4) The fourth stage “living the aftermath” discussed about how nurses were constantly plagued by memories following reporting. 5) The fifth stage “lurking in your mind” discussed on how nurses' were taunted and having to live memories of the error over time that would influence their practices. |
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| Soydemir et al., 2017 [11] Turkey |
To determine what barriers to error reporting exist for physicians and nurses. |
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Both nurses and physicians does not report medical error which they had experienced or witnessed.
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Barriers towards error reporting by nurses were grouped into four themes: 1) fear – fear of being blamed, fear of sanctioning and losing their job; 2)attitude of administrations – negative and/or lack of feedback after reporting, management not keen to investigate the causes despite reporting, focusing on pinpointing blame; 3) barriers related to the system – complexity of the reporting system, lack of anonymity; 4) the employees' perception of the error – lack of awareness to mandatory reporting, perceived severity of error leading to selective reporting.
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| Peyrovi et al., 2016 [15] Iran |
To explore the barriers to reporting nursing errors in intensive care units in Iranian hospitals. |
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Barriers perceived by nurses in error reporting: 1)wanting to preserved professional reputation and preventing stigma; 2) afraid of consequences – punishment, legal repercussion and the experience of organizational misconduct; 3) feelings of insecurity – pointing a finger at (experiencing presumed blame) nurses and lack of managerial support; 4) management not investigating error root causes, leading to lack of motivation of reporting. |
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| Lee et al., 2018 [20] South Korea |
To clarify the barriers to reporting patient safety incidents among nurses and resident physicians working in hospitals with reporting systems. |
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Four categories of the identified barriers to reporting were: 1) “incidents and reporters”; 2) “reporting procedures and systems”; 3) “feedbacks”; 4)“reporting culture”.
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Additional reasons identified by nurses for not reporting error were: 1) manifestation of feelings of pressure or guilt; 2) lack of feedback after reporting; 3) the perception of potential blame; 4) stigmatization resulting from reporting.
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| Lederman et al., 2013 [28] Australia |
To examine error reporting by nurses in hospitals using electronic media |
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Mixed-methods case study and survey.
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Questionnaire and interview.
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30 nurses completed the survey. 18 nurses participated in the interview.
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Top barriers to error reporting identified in the survey were, lack of training to the electronic reporting system (53%), busy with work (52%), lack of access to computer (45%), afraid of being tracked (40%), lack of feedback (36%), excessive detail required in filling the reporting form (32%).
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Four categories of barriers to error reporting identified through interview were: 1) training and education (lack of training); 2) technology acceptance; 3) organization structure and culture (lack of time, individual blame and lack of feedback); 4) access (confidentiality and anonymous reporting).
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| Espin et al., 2010 [53] Canada |
To explore the emergent factors influencing nurses' error reporting preferences, scenarios were developed to probe reporting situations in the intensive care unit. |
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Most (81%) nurses reported that they will engage in error reporting based on the scenarios discussed.
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Majority of nurses were more inclined towards informal reporting.
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Reasons given by nurses for not reporting were: 1)error that does not results in patient's harm; 2) not consider the commission as an error; 3) not wanting to engage in whistleblowing of other people's error; 4) lack of time; 5) fear of reprisal; 6) lack of management response.
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| Choi et al., 2019 [54] South Korea |
To determine nurses' perceptions of the DPSI |
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Most participants felt that DPSI is necessary because of its effectiveness and their ethical obligation to do so.
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Barriers towards DPSI as perceived by nurses were, a closed organizational culture (blame and negative management response), fear of deteriorating relationship with patients and seeing DPSI as additional work burden.
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Provision of clear guidelines and improving hospital organization culture would drive DPSI.
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| Haw et al., 2014 [55] United Kingdom |
To explore the reasons given by inpatient psychiatric nurses for not reporting a medication error made by a colleague and to determine the perceived barriers to near miss reporting. |
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Generic qualitative using clinical vignette.
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Semi-structured interview.
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50 nurses working in acute psychiatric setting.
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Less than half of participants would report an error made by a colleague (48%) or a near-miss involving themselves (40%).
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Barriers to reporting of errors and near missed: 1)patients not harmed; 2)forgetting; 3)fear in loss of status; 4) fear of being stigmatize by colleagues/loss of trust by colleagues; 5) disciplinary consequences.
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Reasons not reporting error made by colleagues:
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passing the buck; 2) being a one-off event and not occur again; 3) empathy; 4) not worth reporting; 5) empathy and wanting to support them and not wanting them to face punishment.
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| Hewitt et al., 2017 [56] Canada |
To investigate the frames that enable and inhibit self-reporting and peer reporting among physicians and nurses. |
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Three inhibiting frames for self-reporting were fear of blame, incompetence, and career progression. For peer reporting, they were tattletale, locus of responsibility, and professional boundaries.
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Three enabling frames for self-reporting were professional accountability, trust in the system, and learning from error. For peer reporting, they were, severity of incident or repeated errors by a health professional, learning from errors, and anonymity.
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| Hashemi et al., 2012 [57] Iran |
To explore the factors associated with reporting the nursing errors. |
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Three approaches of error perception by nurses. 1) Persons: nurses to be responsible and punished for committing error in viewing error commission as unacceptable to profession (self-regulation). 2) System: view nurses as susceptible to error commission and see error commission as flaws in organization system. 3) Combination: view error commission as multi-factorial, and both nurses and organization are accountable for it.
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Barriers of error reporting were: fear of legal repercussion, job threats, economic losses, fear of honor and dignity, weakness of knowledge and nursing skills in error management, past unpleasant encounter with organization, high workload.
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