Barriers of Reporting Errors among Nurses in a Tertiary Hospital Publication History :

Backgroun d: Reporting errors in healthcare organizations is aimed to detect patient safety and quality of care issues. Reporting errors is frequently used as a general term for patient safety event reporting systems, which depend on those involved in events to provide detailed information. This study aimed to identify barriers of reporting errors at one tertiaryhospital in Saudi Arabia from the perspective of nurses themselves. Methodology: A descriptive cross-sectional study was conducted. The data were collected by a questionnaire that was distributed among 154 nurses varying between male and female staff nurses working at the tertiary hospital. A descriptive statistical analysis was used to analyze the data. Results: Nurses revealed that there are several barriers to report incidents; however, lack of time and complexity of works were the main barriers for nurses to report incidents within the hospital units particularly for nurses who have 11-20 years of experience. Conclusion: Conducting this study has several advantages. Firstly, to identify the common barriers of reporting errors in clinical practice among nurses. Secondly, identifying the barriers and strategies of reporting incidents will enhance the patient safety across the organization and encourage the staff to report the errors. Barriers of Reporting Errors among Nurses in a Tertiary Hospital Publication History: Received: July 20, 2017 Accepted: August 05, 2017 Published: August 07, 2017


Introduction
Reporting errors in clinical practice is critical to enhance patient safety and improve the quality of care [1].The aim of reporting errorsis to gather allthe required information onpatient safety reported by healthcare professionals as well as to enable health care organizations to use this information to understand system errors and create changes to reduce the likelihood of the reoccurrence of the error [2].Therefore, reporting all types of errors by healthcare professionals is crucial [3].
Medical errors can be reported through mandatory or voluntary reporting systems.Mandatory reporting system is aimed to report injuries or illnesses related to the misuse of particular medical devices [4].On the other hand, voluntary reporting system is aimed to provide detailed information about the occurrence of errors and their causes.Moreover, the frontline practitioners have the opportunity toreport the occurrence of errorsas a complete story without fear,these stories aresignificant to understand the occurrence of errors [4].Thus, the voluntary reporting system is most commonly used in healthcare organizations than mandatory reporting system as practitioners must not be forced to report the occurrence of errors; however, practitioners need free blame culture and freedom from punishment, which is found with a voluntary reporting system [4].
Several evidences have suggested that healthcare professionals under report errors as a result of a number of barriers that have been identified and need to be taken into account within healthcare organizations.For example, despite the attempts to encourage a more proactive attitude to maintaining safety in healthcare organizations, the fear of disciplinary action and thinking that error reporting is unnecessary because no harm has been incurred have both been considered barriers to nurses in reporting patient safety incidents [2].In a study conducted in the US, the nominal group technique was used to develop a survey tool to identify barriers to incident reporting in clinical practice among physicians and nurses.The group involved one in-patient assistant nurse manager, staff nurses (n = 3), one out-patient nurse manager, physicians (n = 3) and one non-clinical administrator in order to list the factors that could be barriers to reporting errors in clinical practice and then to vote for the most important factors contributing to the underreporting of errors.After distributing a total of 122 validated questionnaires the researchers subsequently found that 30% of nurses were anxious about reporting errors due to lack of anonymity and the potential for punitive outcomes [2].No assurance of the anonymity of reporters considers high frequency barriers by 10% as an organizational factor.
A further study was carried outto explore the factors that facilitate the operation of patient safety incident reporting systems.According to the study results, nurses reported that the poor design of incident reporting systems including a lack of anonymity was the most frequent perceived barrier to report errors [5].The data of this study were collected from 42 nurses at 42 general hospitals in Korea via face-to-face interviews [5].
It should be noted that there are significant differences between nurses and physicians regarding their opinion about barriers of reporting errors.In USa study aimed to identify potential barriers of using the reporting system [6].The researcher distributed surveys among nurses and physicians (n = 858, response rate 41%) who reported that fears of reporting any incidents would be used against them.This issue appeared to 40% with physicians and 30% of nurses.Hence, this study clearly pointed out to the importance of having protection in reporting errors among healthcare providers.Furthermore, another study published in the UK reported that health care professionals especially doctors are reluctant to report adverse event to a superior; however, physicians are most likely to report an incident to a colleague [7].Both studies showed that doctors thought the reporting of errors is the responsibility of the nurse who is providing the care for the patient at the time of the event.
Similarly, a survey of Korean nurses demonstrated that 32% were concerned that a record of any errors would be kept on their personal files [8].Researchers in this study aimed to describe nurses' perceptions of the frequency of error reporting by emailing patient safety culture questionnaires to 960 nurses in Korean teaching hospitals.However, in an earlier review of medication errors documented on standard report forms completed between April 1994 and August 1999 in a UK teaching hospital, nurses considered errors only required reporting when the outcome would be analyzed to prevent further recurrence [9].
In Saudi Arabia, 63% of registered nurses raised their concerns about their willingness to report Medication Administration Errors [10].Major barriers to nurses reporting medication administration errors in this study included fear of reporting and receiving negative feedback from nursing administration, lack of awareness regarding the reporting policy and finally the complicated bureaucratic process of reporting incidents.Likewise, a further study revealed three main reasons for barriers to reporting an error in public hospitals: 1. Lack of awareness among healthcare providers regarding the incident reporting policy, 2. Workload leading to time pressures and an associated inability to report errors and finally 3. The non-availability of report forms on the ward [11].The factors were each highlighted by different healthcare professionals (including nurses) (n = 106, 57.5% response rate) in response to a questionnaire regarding their experience of medication errors in Saudi Arabia [11].Thus, error reporting is an organizational issue that should be an integral part of an organization's culture.However, nurses involved in errors seemed to be treated in a punitive way (named, blamed and shamed).Hence, the fear of negative consequences and feedback, lack of awareness of reporting incidents and blaming individual nurses were the main barriers to nurses reporting errors in clinical practice across various healthcare organizations.
In South Australia, a qualitative studydemonstratedthat the common barriers to report incidents were inadequate time and feedback,deficiencies in knowledge, unsatisfactory processes, beliefs about risk, cultural norms, lack of value in the process and cultural differences between doctors and nurses [12].In this study, the data was collected by using five focus groupswith 19 nurses and 14 medical staff from different clinical wards (two medical wards, one surgical ward, one intensive care unit and emergency department) [12].
In Jordan, a descriptive study aimed to examine the awareness of Jordanian nurses and physicians in reporting the incidentsand barriers to report incidents [13].The authors reported that the awareness of reporting incident among nurses was more than physicians.However, a total of 42.6% of nurses reported the occurrence ofincidents within the last month while only 24.6% of physicians reported the incidents in the last month.The major barriers to reporting incidents were: (1)nurses' and physicians' beliefs that reportingnear misses is not important, (2) fear of disciplinary actions and (3) lack of feedback regarding the errors with a significant difference between physicians and nurses.A total of 66.7% was of concern for nurses' and physicians' belief that reporting errors would not lead to change within the system.Moreover, the errors perceived by physicians.Additionally, about (71.3% of physicians n = 82 vs. 37.7% of nurses n = 93) did not know whose responsibility to report incident.Thus, it should be noted that there issignificant differences between nurses and physicians regarding their awareness of reporting error [13].belief that junior staff were blamed in the occurrence of errors was the most significant barrier of reporting errors perceived by physicians.Additionally, about (71.3% of physicians n = 82 vs. 37.7% of nurses n = 93) did not know whose responsibility to report incident.Thus, it should be noted that there issignificant differences between nurses and physicians regarding their awareness of reporting error [13].
Reporting the errors have been found as an effective strategy to reduce the reoccurrence of errors.For example, more than 90% of healthcare workers believe that they should report errors,and safety organizationsrecommend incident reporting to better understand errors and their contributing factors [3] .In a period between November 2001 and June 2003 a cross sectional survey of doctors and nurses was taken to assess the percentage of awareness, the use of incident reporting system and to identify barriers inhibiting reporting of incidents in hospitals [36].Hospitals sampled included three referral hospitals: one major referral hospital, and two rural base hospitals in South Australia.A nameless survey of 587 nurses and 186 doctors was used in six hospitals in South Australia (response rate 72.8%).Lack of feedback (57.7%) was found as the major barriers to reporterrors amongphysicians, complete the incident form is taking too long (54.2%), and finally a belief that the type of incident is minor and not causing harm (51.2%).However, nurses reported that the major barriers to report errors among nurses were lack of feedback (61.8%), a belief that there was no need in reporting near misses (49.0%), and when there is a workload nurses forget to report errors (48.1%).
The result of the above studies demonstrated that there are several barriers of reporting incidents reported by all healthcare professionals, such as fear of disciplinary action and thinking error reporting is unnecessary, lack of anonymity and the potential for punitive outcomes which indicate the most frequently perceived barrier to incident reporting.Additionally, there is inadequate time and negative feedback, deficiencies in knowledge, cultural norms and beliefs about risk.However, no studies have been found to identify the barriers of reporting errors in nursing practice from the perception of nurses themselveswithin the context of Saudi Arabia.Hence, this study is important to measure the knowledge and the awareness of nurses about the reporting system, and found the barriers that prevent them from reporting errors in nursing practice and finally to maintain high safety measures for the patients.

Materials and Methods
This study was conducted by using a non-experimental descriptive cross-sectional research design.This research design was chosen in order to identify barriers of reporting errors in nursing practice within a tertiary hospital to find out what are the barriers that inhibit reporting errors [14].This study employed a purposive sampling to select the target population.The decision regarding the selection of participants was based on the need to access those nurses whom are most knowledgeable about reporting incidents.Thus, the decision has been made to include both head nurses and staff nurses working in general care words and have experience for more than three years [14].The sample size of this study was calculated in the rocs of data collection.However, the minimum sample size recommended for survey is 154 of 95% confidence level, varying between male and female nursing staff.

Setting
The research was conducted inone tertiary hospital in Jeddah, Saudi Arabiawithin the following clinical wards: medical and surgical general pediatric wards, male and female medical,male and female surgical general wards and emergency ward and department.

Data collection
The data were collected by using an adapted questionnaire from "Barriers and strategies of reporting medical errors in public hospitals in Riyadh city: A survey-study" conducted by Alduaiset al. (2014) [15] to collect data from staff nurses and head nurses.The survey is about the barriers of reporting the medical errors which consists of three parts.The first one is demographic part which include gender, age, nationality, level of education and experience while the second part is more about statements of barriers to report medical errors, the last part shows strategies that could be used to improve the reporting of medical errors.The reliability of the questionnaire was measured by using Cronbachalpha (0.9).
Ethical approvals of this study were obtained from the targeted hospital.The participant information sheet stated clearly and provided all information about the study as well as the voluntary participation for the participants.Additionally, the questionnaire distributed on the participants depending on inclusion criteria.The process of protecting participants' names involved removing their names and ascribing them codes during the analysis and reporting phases, so that data cannot be traced back to particular individuals.In addition, it was clearly stated that participants have the right to refuse participate, without giving a reason.Prior to commencing data collection, participants had the opportunity to ask any questions, and then if they agree to participate, they completed and signed the study consent form.

Data analysis
A descriptive analysis used to analyze the data of this study using IBM SPSS Statistics for Windows, Version 20 (IBM Corp., Armonk, NY USA) to identify percentage, frequency and standard deviation.The relation between barriers and years of experience was tested by using ANOVA.Moreover, Cross tab was also used to identify the relation between years of experience groups and barriers.

Barriers of reporting incidents
Table 2 demonstrates the barriers of reporting nursing errors with the percentage range from 20.2% to 1.2%.According to the below table, the study participants strongly agreed that lack of time 20.2% (n = 17) was the major barrier of underreporting errors in different clinical wards.Moreover, complexity of work 16.7% (n = 14) is also highlighted by study participants as barriers of reporting errors in different clinical wards within the hospital.Conversely, a total of 84 participants disagreed that lack of knowledge 23.8% and lack of procedures 29.8% were considered as barriers of reporting errors in different clinical wards within the hospital.In addition, the majority of study participants reported that the following statements within the questionnaire were not found as barriers of reporting errors in this hospital which are: 'reporting errors in not my responsibility' 42.9% (n = 36), 'reporting errors is not a priority' 46.4% (n = 39), 'reporting errors will not make any improvement' 48.8% (n = 41), 'reporting system is inadequate' 59.5% (n = 50) and ' difficulty in filling the form' 46.4% (n = 39).Importantly, a total of 84 participants reported that fear of being blamed 35.7% (n = 30), fear of being punished 35.7% (n = 30) and 48.8% reporting errors is not anonymous (n = 41) were not perceived as barriers of reporting errors within the hospital clinical wards.

Strategies of reporting errors
Table 3 presents several strategies that were strongly agreed by study participants to improve the reporting system within the hospital.A total of 48.8 % (n = 41) strongly agreed that using a computerized system to report medical errors is a strategy to improve the reporting the hospital clinical wards.Furthermore, study participants strongly agreed that reporting errors should not be used against reporter 51.2% (n = 43), encourage the staff to report errors 54.8% (n = 46), staff should be trained on reporting medical errors 50.0%(n = 42) and there should be a clear guidelines and procedures for reporting errors 54.8% (n = 46).Table 4 shows the relationship between nurses' years of experience and number of barriers to report errors.The below table revealed that there were no significant differences between nurses' years of experience and number of barriers to report errors, except with two variables which show significant relationship, lack of time (P= 0.045 <0.05) and complexity of work (P=0.024<0.05).
The result in the above Table 5 showed the years of experience between 11-20 years were complaining of lack of time and complexity of work.Furthermore, nurses have 20 years and above experience lesser reported these barriers.While junior nurses did not consider them as major barriers.

Discussion
This study aimed to identify the barriers of reporting errors in nursing practice in one teaching hospital.In this study, the results revealed that lack of time and complexity of works are the main barriers for nurses to report incident within the hospital units.
Lack of time was the major barrier faced nurses to report incidents within hospital units, which has a negative impact on the patient care.Lack of time in the study context is caused by heavy workload due to staff shortage as encountered by nurses in particular within the general care wards.Therefore, lack of time was found as a burden to report such simple type of errors.This result is in agreement with a further studywhich demonstrated that patient care left undone or missed duo to lack of time especially when nurses assigned on a shift with high number of patients [16].
Complexity of work is another important barrier.In nursing, the complexity of work has received increased attention since the Institute of Medicine (IOM) issued its report on medical errors in 2000.Nurses who experience work overload in the unit have difficulties to report incidents that negatively effect on their work because of pressure in the main priority of work.Complexity of work was mentioned as one of the most common reporting barrier in a study who reported that workload leading to time pressures and an associated inability to report errors [11].
Surprisingly, this study revealed that fear of being blame was not reported by nurses as a barrier of reporting incidents within the hospital units.However, this result of the current study does not support the previous research.Fear of being blamed considered a main barrier in several studies [17].Additionally, blamingnurses were the main barriers for nurses to report errors inclinical practice across various healthcare organizations in Saudi Arabia [11].Similarly, the results show that fear of being punished was not considered by nurses as a barrier to report errors in the hospital units.However, fear of being punished in the literature was found as a major barrier of reporting incidents not only monopoly to nurses, but also junior staff were blamed most of the time for incidents [13].Moreover, it was demonstrated that the healthcare providers are fears to report any incidentswould be used against them [6].This issue appeared to 40% with physiciansand 30% of nurses.A possible explanation for this is that the targeted healthcare organization is encouraging a nonblaming culture among their staff.
The strategies of reporting medical errors practice were described in different studies.For example, the most common strategies that help in reporting medical errors are: Use computerized system, reporting errors shouldn't be used against reporters and staff should always be provided by feedback on what has been reported [13].Similarly, in the present study the result showed similar strategies helping in reporting nursing errors.Moreover, this study reported that the staff should always be encouraged to report medical errors and there should be a clear guidelines and procedures for reporting errors.
This study shows no significance differences between nurses' years of experience and number of barriers to report incidents, except in lack of time and complexity of work particularly with nurses their experience between 11-20 years.Nurses might perceive that get more experience could be related to their underreporting incidents report.This could attributed to the previous clarification in this study that nurses lack of time and complexity of work made the perception in reporting incidents and deal with these barriers sound difficult particularly in nurses with low level of experience.That could be supported by a study who reported that nurses less than 20 years of experience were facing barriers to report incidents [13].

Conclusion
An understanding of the health care professionals' awareness of reporting nursing errors can promote more effective to protect patients.This study is important to measure the knowledge and the awareness of nurses about the reporting system, and found the barriers that prevent them from reporting errors.Nurses demonstrated that lack of time and complexity of work were the major barriers to report errors.However, fear of being blamed and fear of being punched were not considered as a barriers of reporting incidents among nurses as the targeted hospital is encouraging the non-blaming culture.Healthcare leaders can make a major impact of organizational safety by increase the number of staff and nurses working at this hospital sequenced to decrease nurse patient ratio.Additionally, nurse managers should prevent their staff nurses to do a non-nursing work in order to enhance patient safety firstly and reduce nurses' workload secondary.Moreover, this study was conducted only in one teaching hospital and with small sample size.Therefore, the results of this study cannot be generalized to other healthcare organizations.Thus, a further research is needed to identify the barriers of reporting errors in nursing practice across different healthcare organization, considering large sample size.

Table 3 :
Strategies to reporting the medical errors.