Evidence Table, [Error Reporting and Disclosure]. - Patient Safety and Quality

Evidence Table

Error Reporting and Disclosure

Source	Safety Issue Related to Clinical Practice	Design Type	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Balas 2004¹²⁹	Error reporting Reporting near errors	Cross-sectional study	Qualitative, voluntary, anonymous, self- reported recording of 14-days of shift work, sleep, and errors using a journal (Level 4)	119 full-time hospital registered nurses (RNs). Note: subset of the larger study with 393 full-time RNs described in other articles.	None	58% of reported errors and 59% of near misses were medication related. 73 nurses reported 1 error, while 45 reported making between 2 and 5 errors during the study period.
Blegen 2004¹³⁸	Barriers to reporting medication administration errors (MAEs) and near misses	Cross-sectional study	Survey, including falls and MAEs, near misses, staff injury, and reporting barriers (Level 4)	1,105 RN respondents in 25 acute care hospitals nationally	None	Reporting rates varied, with 47% errors reported overall; intravenous MAEs highest rate overall. Reporting inhibited by fear of being blamed, peer reactions, patients becoming negative, reprimands by physicians, losing license, and public reporting. Reporting of MAEs was higher in units with quality management processes. Errors resulting in patient and staff injuries were underreported.
Chiang 2006¹⁴⁷	Barriers to error reporting	Cross-sectional study	Self-administered survey of barriers to reporting MAEs (Level 4)	597 nurses in 1 hospital in Taiwan	None	Fear was the main barrier to reporting MAEs, significantly associated with organizational power hierarchy and face- saving concerns.
Cook 2004⁵⁸	Responsibility for errors Defining medical errors	Cross-sectional study	Assessed hospital data and administered the “Close Call Pilot Culture Assessment,” error reports, staff patient safety instrument, e- mailed questionnaires, staff patient-safety survey, case studies, and telephone interviews (Level 4)	485 clinicians (305 nurses, 49 physicians, and others) in 29 hospitals in 9 States	None	Majority agreed that hospital administrators did not punish error reporters. Staff have learned and would like to continue to learn from mistakes of others. Most agreed that the hospital culture recognized that mistakes could be made (64%) and that error reporting could be done by all employees (86%). Majority felt comfortable (65%) or somewhat comfortable (32%) discussing medical errors. Attempts to maintain collegiality and their belief about lacking authority prevented nurses from questioning physicians. Pharmacists were more confident in their ability to recognize errors. Nurses reported most frequent problem was unclear or confusing patient orders. Nonphysicians attributed many errors to nursing practices. 96% of nurses and more than 90% of physicians, administers, and pharmacists assigned patient safety responsibility to nurses. 22% of respondents believed that clinicians and administrators shared equal responsibility for patient safety. Nurses reported that they were responsible for reporting errors (99%), educating themselves (98%), recommending changes in procedures (88%) and policy (86%), reviewing reported events (79%), and participating in investigations of errors (72%). However fewer than half had participated in investigating, reviewing, or analyzing errors.
Costello 2007¹¹⁹	Error reporting	Pretest and post-test	Retrospectively assessed error reports, then again assessed error reports after several interventions (Level 4)	Physicians and nurses in a pediatric critical care center	Introduction of clinical pharmacists to raise awareness of medication safety and encourage reporting of all errors	Medication error reporting increased overall, but reports from nurses remained relatively constant and the reports from physicians decreased. The pharmacist did not change the error reporting culture.
Day 2004¹³⁴	Reporting adverse events	Cross-sectional study	Administered a retrospective questionnaire about experience in reporting errors (Level 4)	32 physicians, 175 nurses, and 44 others (a 43% response rate) in 1 hospital in Utah	None	Physicians and nurses reported similar reporting experiences, but nurses reported 27% more. 34% of ICU staff reported errors. Physicians reported more major events while nurses reported more minor events; nurses had a more “inclusive view.” Physicians and nurses reported more near misses. 47% reported time and 27% reported fear of punitive actions as the major barriers to reporting.
Elder 2007¹³¹	Barriers to error reporting Reasons to report errors	Cross-sectional study	Conducted focus groups on errors related to testing, issues involved in error reporting, and the effects of error reporting on office systems (Level 4)	Physicians, nurse practitioners, physician assistants, office staff, and nurses in 8 family physicians offices	None	Majority of reporting barriers were a lack of time, forgetfulness, and confusion about what to and who should report. Most common reported reason for reporting errors was a perceived benefit.
Espin 2006⁸¹	Error disclosure and reporting	Cross-sectional study	Questionnaire using 4 scenarios	9 surgeons, 9 nurses, 10 anesthesiologists in operating rooms at 2 teaching hospitals	None	Patients want full disclosure, while physicians and nurses want to disclose only what happened. Nurses (the only clinician type asked) were less likely to want to report errors than patients.
Espin 2007¹³⁰	Error reporting	Cross-sectional study	Administered 4 error scenarios to nurses	13 perioperative nurses at 1 hospital in Canada	None	58% of theoretical errors were identified as errors, only 26.7% of which would have been reported by the nurses. Nurses perceived error reporting as a profession-specific responsibility; nurses should report errors made by nurses. The presence of a negative outcome appeared to be a secondary consideration for nurse error reporting. Nurses had a greater tendency to report errors informally with a nurse colleague or nurse manager.
Evans 2006¹⁰⁶	Barriers to error reporting	Cross-sectional study	Anonymous survey of physicians and nurses about their knowledge of their organizations’ reporting system, how often they reported errors, and reasons why errors were not reported (Level 4)	70.7 response rate for physicians and 73.6% for nurses in hospitals in southern Australia	None	98.3% of physicians and nurses were aware of the incident reporting system. Nurses were more likely to know how to submit an error report (88.3%), to have completed an error report (89.2%), and to know where to submit an error report (81.9%).
Evans 2007¹²⁰	Error reporting	Nonrandomized trial	Comparison of incident reporting rates between 1 control and 1 intervention hospital (Level 3)	2 hospitals in Australia	Educational intervention was combined with a revised reporting system, with an option for a call center.	Reporting increased throughout the hospitals. More reports were initiated by physicians in EDs and were anonymous. Nurses generated 84% of error reports.
Fein 2005⁹¹	Error disclosure	Case control study	Focus group interviews, on ethical perceptions and details of error disclosure (Level 4)	Hospital personnel and former patients (n = 240), 25 focus groups: separate stakeholder groups of attending physicians, residents, nurses, administrators, former patients	None	All agreed that errors should be disclosed when patients are harmed. Degree of harm caused by error and whether patients and others were aware of errors were characteristics related to disclosure. Institutional culture (perceived tolerance for error and supportive infrastructure) was important to disclosure decision. Patient factors were health care sophistication, desire for information, and rapport with provider. Provider factors included fears of malpractice, reputation, job threat, and change in rapport with the patient, as well as perceived professional responsibility, medical training, lack of confidence in disclosure skills, and personal discomfort.
Fernald 2004¹²¹	Error reporting in ambulatory settings	Cross-sectional study	Collected and analyzed error reports from clinicians and staff, using a voluntary reporting system (Level 4)	2 practice-based research networks	Implemented a voluntary reporting system	47% of reported errors were associated with diagnostic tests, 35.4% with medications, and 13.6% with both medication and a diagnostic test; 70.8% of error reports were associated with communication errors. Confidential reports were more complete than anonymous reports. Reporting different types of patient harm did not vary between anonymous and confidential reports.
France 2003¹²²	Reporting system	Quality improvement	Assessed utilization of a voluntary reporting system and provider- initiated improvements (Level 4)	1 hospital in Tennessee	Implemented a voluntary reporting system	Nurse reporting significantly decreased after implementation, while pharmacy reporting significantly increased.
Furukawa 2003¹²³	Reporting medication errors	Cross-sectional study	Errors reported using a Web-based system during a 2-year period (Level 4)	Physicians, nurses, pharmacists, technologists, and others in 1 hospital in Japan	None	Nurses reported 78% of errors, an average of 2.2 reports per nurse. The majority of error reports submitted by nurses and pharmacists were considered minor. Physicians were found to report errors only when detected and prevented by nurses or pharmacists.
Harper 2005¹⁴⁴	Barriers to error reporting	Cross-sectional study	Self-report survey (Reporting Culture Survey) on mandatory reporting system in hospitals transitioning to close-call reporting system: scaled and open-ended items (Level 4)	858 nurses and physicians (a 41% response rate) at 2 hospitals in Texas	None	Less than 10% of respondents had knowledge of the mandatory reporting system, but less than half of nurses and 20% of physicians reported using the system. Physicians and nurses were not positive about the effectiveness of a hospital-based reporting system. Physicians reported that nurses were responsible for reporting errors. 40% of physicians and 30% of nurses were concerned about the anonymity of reporters, yet 86% of nurses and 81% of physicians favored feedback on corrective action taken in response to the report. 40% of physicians and 30% of nurses were concerned that the reporting system would be used punitively.
Harris 2007¹³³	Error reporting	Prospective cohort study	Assessment of error reports once a new reporting system had been put in place (Level 4)	3 ICUs in a 1,371-bed urban teaching hospital	A new, card- based reporting program to encourage anonymous reporting of errors	Nurses submitted 67.1% of error reports, followed by 23.1% by physicians and 9.5% by other reporters. Of the reports where errors did not reach the patient, 31.1% were from nurses, 36.2% from other staff, and 17% from physicians. Of the reports were errors harmed patients, 33.9% were from physicians, 27.2% from nurses, and 13% from other staff.
Hirose 2007¹²⁴	Error reporting	Cross-sectional study	Evaluation of lag time of submission of 6,880 reports filed by nurses and physicians during a 3-year period (Level 3)	Reports submitted by nurses and physicians in 1 hospital in central Japan	None	Nurses filed 93.3% of the reports, 99.5% of which were categorized as minor incidents. Physicians submitted 32 reports (an annual reporting rate of 0.26 per physician), while nurses submitted 31 reports (an annual reporting rate of 3.43 per nurse) for major errors. Lag time was 18% shorter for major events than minor, and 75% longer for physicians.
Hobgood 2004¹⁰⁰	Error disclosure Error reporting	Cross-sectional study	Retrospective survey of health care providers’ experiences with disclosing medical errors (Level 4)	41 EMTs, 33 RNs, and 42 physicians in 1 tertiary care academic medical center	None	Disclosure to patients was associated with provider type (19% EMTs, 23% RNs, and 74% physicians). 59% of physicians reported observing another provider disclose an error.
Hobgood 2006⁹²	Error disclosure Error reporting	Cross-sectional study	Survey using 10 clinical vignettes (Level 4)	40 physicians, 26 nurses, and 35 EMTs in 1 tertiary care academic emergency department	None	Physicians were more likely (71%) to disclose an error than were nurses (59%), but nurses were more likely (68%) to report the error than were physicians (54%).
Inoue 2004¹²⁵	Types of error reports	Cross-sectional study	Retrospective analysis of errors reported through incident reports (Level 4)	Incident reports submitted by nurses in 6 urban hospitals in Japan	None	Error rates were high for prevention of problematic behavior, prevention of suicide, safeguarding against falls, and subcutaneous injections of insulin. Error rates that were high in some hospitals, but not all, were maintenance of dialysis, endoscopy preparation and assistance, administration of preoperative treatments, and blood transfusions. Error rates were higher in hemodialysis patients, those with problematic types of behavior, and the elderly. Incidence of errors was associated with rule violations, management practices, and nonstandardized nursing practices.
Jeffe 2004¹³²	Perceptions of error reporting Barriers to error reporting	Cross-sectional study	Verbatim transcribed focus groups, recommendations for systems change to improve reporting, including awareness of provider status, benefits of feedback, and culture change (Level 4)	9 focus groups with 49 nurses, 10 nurse managers, and 30 physicians in 20 community and academic hospitals	None	Culture change might be accomplished as providers’ concern and responses were considered in systems changes to improve reporting and policy revisions; how best to improve error reporting and disseminate information about errors might benefit when considering perceived barriers to reporting and including front-line providers’ perspectives on clear guidelines on what to report, education on reporting mechanisms, anonymous reporting mechanisms, personnel, and routine followup of error reports for education and hospital action. Nurses were more knowledgeable about how to report errors. All mentioned barriers—fear of reprisals, lack of confidentiality, time, and feedback after an error—are reported. Both physicians and nurses agreed that reporting was intended to change practice and policy to promote patient safety.
Jones 2004¹¹⁶	Error reporting	Quality improvement	Standardized voluntary medication reporting form and database, compared with MEDMARX; NCC MERP severity index was used to categorize severity of harm to the patient (Level 4)	10 critical access hospitals	Conducted education workshops about nature of errors, the design of safety systems, and best practices in medication safety; provided quarterly reports from the error reports the hospitals	Most errors were not harmful; greater availability of pharmacists associated with reporting greater proportions of Category A errors (circumstances have the capacity to cause error) and Category B errors (an error occurred, but the error did not reach the patient). Nurses submitted 97% of error reports.
Kim 2006¹⁵⁷	Electronic error reporting	Cross-sectional study	Structured interview (Level 4)	Chairs of nursing departments (a 35% response rate) throughout Korea	None	Only 3% of hospitals used health information technology (HIT); HIT mainly used for medication administration, order entry, and radiology.
Kim 2007¹³⁹	Error reporting Barriers to error reporting	Cross-sectional study	AHRQ’s patient safety culture survey (Level 4)	886 nurses (a 92.3% response rate) in 8 teaching hospitals in Korea	None	67% of nurses reported always reporting errors resulting in patient harm. About half were unclear about what should be reported. 32% worried that their errors were kept in files. 52% reported having been given feedback and informed about errors made. 48% reported speaking out if they saw something negative, and 38% would voice opinions that differed from those in authority. 66% felt that their suggestions to improve patient safety were ignored. 83% felt that more errors should have happened than did, and 52% reported their units had serious patient safety problems. 56% reported problems talking with physicians. Frequency of reporting errors was higher among nurses with 5 to 10 years experience. Head nurses reported errors more frequently than did staff.
King 2001¹⁵³	Error reporting	Cross-sectional study	Mailed surveys of error scenarios to RNs to elicit error reporting behaviors (Level 4)	372 nurses in the Midwest	None	Nurses were able to differentiate between intentional wrongdoing, which was related to questionable behavior. The perception of severity determined whether the error was reported. Unintentional errors would not be reported.
Lata 2004¹²⁶	Improving adverse drug event (ADE) reporting	Cross-sectional study	Determine whether nurse case managers and pharmacists increase reporting of serious ADEs (Level 4)	1 community hospital in rural Wisconsin	Nurse case managers were educated that they were expected to report ADEs.	Nurse case managers reported 62% of ADEs, compared to 17% by pharmacists, and 75% of serious adverse drug reactions.
Lawton 2002⁴⁶	Barriers to error reporting	Cross-sectional study	Questionnaire about willingness to report errors of others; included error scenarios (Level 4)	73 physicians, 145 nurses, and 92 midwives (a 53% response rate) in 3 NHS trusts in England	None	Reporting was more likely if there was a bad outcome. Physicians were less likely to make a report than were nurses or midwives. Health care professionals were less likely to report errors of senior colleagues. Physicians were unlikely to report violations of clinical protocols, whereas nurses and midwives were more likely.
Mayo 2004¹⁴²	Error reporting	Cross-sectional study	Random sample of RNs surveyed about perceived causes of medication errors, percentage of medication errors reported to nurse managers, types of reportable incidents, and reporting behaviors, including medication errors scenarios (Level 4)	983 RNs (20% response rate) in the United Nurses Association of California/ Union of Health Care Professionals	None	When the dose was withheld or omitted, the majority would report the event to the physician, but few would have completed an incident report for the withheld medication, compared to about half for the omitted dose. Nurses working in neonatal intensive care units perceived higher reported errors (52.5%) than did those working in medical/surgical units (35.3%). The mean perceived percentage of reported errors was 45.6%. 92.6% reported knowing what a medication error was, and 91.3% reported knowing when to use an incident report. Reporting barriers were fear of manager reactions (76.9%), fear of coworker reactions (61.4%), and considering error was not serious enough to warrant reporting (52.9%).
Mick 2007¹⁵⁴	Reporting Errors	Cross-sectional study	Assessed error reports	300 employees (out of a possible 800) in 5 inpatient units	New close call error reporting program, called the Good Catch Program with periodic feedback to staff.	The new program resulted in a 1,468% increase (from 175 before to 2,744 afterwards) in the number of reports. Reports facilitated the targeting of interventions to improve patient safety.
Nuckols 2007¹²⁷	Reporting errors	Cross-sectional study	Analyzed 3,875 reports from 2 hospitals (Level 4)	1 academic tertiary referral hospital and 1 affiliated community hospital in Southern California	None	The majority of reports were for errors involving medications, operations, falls, and procedures. 89% of incident reports were from nurses. 48% of incidents occurred on general floors, 21% in ICUs, and 14% in operating rooms. Nurses were involved in 43% of the potentially preventable events, while physicians were involved in 16%.
Osborne 1999⁶⁹	Perceptions of errors Reporting medication errors Barriers to error reporting	Cross-sectional study	Survey to RNs about perceived causes of medication errors (Level 4)	57 RNs (61.9% response rate) on medical- surgical units in a 700-bed community hospital in South Florida	None	43.9% of respondents reported that only 25% of medication errors were reported. 84.2% of respondents indicated that they knew what defined an error, and 86% that medication errors were not reported because of fear. 57.9% reported that they did not report a medication error when they did not consider it serious. There was no difference in perceptions associated with age, years of experience, or level of education.
Osmon 2004¹³⁷	Reporting errors	Cross-sectional study	Prospective analysis following implementation of a new error reporting process, specific to the hospital (Level 4)	1 urban teaching hospital in Missouri	Implementation of new hospital-based error reporting system using the SAFE reporting cards	Reporting rate for medical events was 31.9 per 100 ICU patient admissions. Nurses reported the majority of events (59.1%), followed by medical students (27.2%) and ICU attending physicians (2.6%). Most reports involved delays or omissions (e.g., medications, diagnostic tests, or necessary/planned procedures (36.5%)), medication errors (20.2%), and malfunctioning equipment (7.9%). 9.9% of events required life-sustaining interventions, and 3% may have led to the patient’s death. 60.9% of life-sustaining interventions were a result of delays/omission of prescribed nonmedication treatments and necessary planned procedures.
Rathert 2007¹⁴⁶	Reporting errors	Cross-sectional study	Survey measuring patient-centered climate, perceived medication error frequency, job satisfaction, comfort reporting own errors and pointing out the errors of others (Level 4)	307 nurses (a 57% response rate) in 3 acute care hospitals in the eastern United States	None	Nurses are more comfortable reporting their own errors in a patient-centered care climate than they are pointing out the errors made by others.
Rudman 2005¹¹²	Error reporting systems	Cross-sectional study	Comparative description of baseline paper-based medication errors with postintervention Web- based reports; increased medication error reports, increased intercepted medication error threats, and staff access to post error interventions (Level 3)	Hospital reported errors: pre (average = 434.5/mo.) vs. post (average = 79.9/mo.)	Web-based, anonymous medication error reporting system on all personal computers and work stations	Staff accessed reports, noting immediate actions taken. Error reports and intercepted error threats increased. Intercepted nurse, physician, and pharmacist medication errors increased. Errors attributed to physicians increased as nurses’ and pharmacists’ decreased. Details of cause-of-error reporting.
Schuerer 2006¹³⁶	Error reporting systems	Prospective cohort study	Assessment of error reporting using a prospective analysis following implementation, withdrawal, and then reintroduction of a new error reporting process, specific to the hospital (Level 4)	Nurses, physicians and other health care workers in 1 24- bed surgical ICU	A card-based reporting system (SAFE)	Physician reporting increased from 0.3 to 5.8 reports per 1,000 patient days, and nurses from 18 to 39 reports per 1,000 patient days. When reporting cards were removed, physician reporting decreased to 0 per 1,000 patient days, then increased to 8.1 reports when the cards were reintroduced. A higher proportion of events reported by physicians were for events that caused harm, while the higher proportion of events reported by nurses were for events that did not cause harm to patients.
Stratton 2004¹⁴¹	Perceptions on error reporting	Cross-sectional study	Survey of pediatric and adult hospital nurses on their perceptions of the proportion of reported medication errors and why errors are not reported (Level 4)	57 pediatric and 227 adult nurses (a 40% response rate) in 33 acute care units in 11 hospitals (in rural Midwestern States, urban areas in the Rocky Mountain region of the United States)	None	Pediatric nurses estimated that 67% of medication errors were reported; adult nurses estimated 56%. Error rates per 1,000 patient-days were 14.80 in pediatric units and 5.66 in adult units. Medication errors are underreported by pediatric and adult nurses, with more reported on pediatric units. The more strongly nurses on pediatric units agreed with management-related and individual/personal reasons for not reporting errors, the lower the estimates of errors reported. Pediatric nurses agreed that nurses fear consequences from reporting and believe peers will think of the reporters as incompetent.
Throckmorton 2007¹⁴⁰	Error reporting	Cross-sectional study	Survey about the environment and reasons why nurses do not report errors (Level 4)	435 nurses (a 10% response rate) licensed to practice in Texas	None	Knowledge of the nurse practice act was not associated with intent to report. Nurses providing direct care to patients were more likely to report. Nurses would report both errors that harmed patients and those that did not.
Tuttle 2004¹³⁵	Error reporting system	Prospective cohort study	Implementation of a voluntary, electronic reporting system (ERS) for safety events involving patients or visitors (Level 4)	1 teaching hospital in New York	Implemented new confidential ERS for safety events and provided multifaceted education program to promote safety awareness and how to use the ERS.	Nurses reported 73% of the 2,843 safety events; physicians reported 2%. Of the events reported: - 16% were unsafe conditions or near misses; 22% were adverse events where patient was harmed; and 39% were not reported correctly. - 40% were medication/infusion events, 30% were adverse clinical events, and 24% were falls.
Uribe 2002¹⁴⁹	Barriers to reporting errors	Cross-sectional study	Survey on perceived barriers to reporting and likelihood they could be modified (Level 4)	56 physicians and 66 nurses (17.3% response rate) in a Midwest academic hospital	None	Major barriers to error reporting were time and work involved in documenting an error; not being able to report anonymously; thinking that errors with no negative outcomes should not be reported; fear of legal actions; and hesitancy to “tell” on someone else. Modifiable barriers were identified as the structure and processes for reporting errors and education. Least modifiable barriers were fear of lawsuits, fear of being blamed, and motivational issues. Physicians identified twice as many barriers to reporting than did nurses; both identified time and extra work involved in documenting an error. Nurses were more concerned about anonymity, “telling” on someone else, fear of lawsuits, and the necessity of reporting errors that did not result in patient harm.
Vojir 2003¹⁴⁵	Error reporting	Cross-sectional study	Surveyed nurses about their estimates of reported medication administration errors (Level 4)	1,214 nurses in 205 adult patient care units in 26 hospitals	None	Differences in staff definitions of reportable error, occurrence data not widely shared with staff nurses, staff nurses rely on personal experience to estimate unit medication administration errors.
Wakefield 1996⁷⁰	Barriers to reporting medication errors	Cross-sectional study	Survey of medication administration errors and reasons nurses do not report errors, oriented to reporting process (Level 4)	RNs (n = 1,384) in 24 acute care hospitals; nonrandomly selected convenience sample	None	Fear, disagreement over whether an error occurred, administrative responses to medication errors, and effort required to report MAE are reasons nurses may not report errors. Fear inhibits reporting; organizational culture change needed to support reliable, valid, complete error reporting; too much emphasis placed on medication errors as measure of quality nursing care.
Wakefield 1999¹⁵⁰	Barriers to reporting MAEs Perceived causes of MAEs Estimated MAEs reported	Cross-sectional study	Survey assessing perceived reasons for not reporting MAEs (Level 4)	Staff nurses and supervisors in 29 acute care hospitals in Iowa	None	There was some agreement on fear and administrative response as barriers to error reporting, but the barriers are associated with individual characteristics and management practices. The degree of agreement between staff and their supervisors about why errors are not reported varied considerably. Supervisors were more likely to view fear of administrative response as a barrier to error reporting, whereas staff nurses did view fear as a barrier.
Wakefield 2001¹⁵¹	Barriers to reporting MAEs	Cross-sectional study	Questionnaire on organizational culture, implementation of clinical quality improvement (CQI), and nurses’ perceptions of MAE reporting (Level 4)	292 nurses from 6 Midwest hospitals	None	Hospital culture types varied: smaller institutions tended to have group-oriented cultures, larger institutions tended to be more hierarchal in nature. The extent of CQI implementation increased with bed size of the hospital, and perceived rate of MAE reporting decreased. The greater the number of barriers, the lower the reporting of errors. The presence of a group-oriented culture and higher levels of CQI implementation were positively but not significantly associated with reporting errors. Hierarchical or rational-type cultures were negatively associated with reporting errors.
Wakefield 2005¹⁴⁸ (Note: This includes findings of Wakefield 1996, 1999, 2001⁷⁰^,¹⁵⁰^,¹⁵¹)	Barriers to reporting medication errors	Cross-sectional study	Scale development, content validity (face), construct validity (factorial), concurrent validity; internal consistency, and test- retest reliability (Level 4)	RNs (n =1,384 in 1994, 1,428 in 1996, 862 in 1998, and 295 in 2001) in hospitals (n = 24 in 1994, 29 in 1996, 21 in 1998, and 16 in 2001)	None	The reported reasons why MAEs were not reported were due to disagreement with the definitions, the burden of the reporting effort, fear (e.g., judgment from peers, patients, and their families, physician reprimand, adverse consequences, and being blamed for patient harm), and administrative response (e.g., no positive feedback, individual blame, and response not matching the severity of the error).
Weingart 2000³⁶	Error reporting	Cross-sectional study	Compared house officer reports with incident reports and patients’ medical records, using confidential peer interviews to identify errors and substandard quality care (Level 3)	Medical house officers, nurses, social workers, physical therapists, and case managers in 1 hospital in Boston	None	Of the errors verbally reported by the house officer and confirmed in the patient’s medical record, only one was recorded in the hospitals’ incident reporting system. Nurses recorded the majority of incident reports, whereas only 1 incident report was submitted by a house officer.
Wild 2005¹⁴³	Perceptions and attitudes about error reporting Knowledge and use of error reporting systems	Cross-sectional study	Self-administered survey on the knowledge and use of the hospital error reporting system and attitudes and perceptions about hospital culture regarding error reporting (Level 4).	24 resident physicians (a 96% response rate) and 36 nurses (a 60% response rate) in 1 community hospital in Connecticut	None	54% of residents and 97% of nurses knew of the hospital’s error reporting system; 13% of residents and 72% of nurses were likely to use it. Residents were more likely to perceive the culture as more threatening and nonsupportive; 29% of residents and 64% of nurses reported being comfortable discussing mistakes. 42% of residents and 44% of nurses were uncomfortable discussing errors with patients. 64% of nurses were comfortable discussing mistakes with supervisors. 54% of residents and 91% of nurses reported being more likely to report an error, either their own or someone else’s. 25% of residents and 1% of nurses were more likely to report an error if they did not like the person who caused the error.
Yamagishi 2003¹²⁸	Reporting adverse events Reporting method	Cross-sectional study	Adverse event data obtained from incident reports, logs, checklists, nurse interviews, medication error questionnaires, urine leucocyte tests, patient interviews, and medical records. Patients were interviewed about the events (Level 3).	Event reports by 115 staff nurses in 6 wards in 1 hospital in Tokyo, Japan	None	Actual events and reported events were similar when using incident reports, checklists, nurse interviews, urine leucocyte tests, and questionnaires of medication errors. Falls were not always reported, depending on whether patients were independent with activities of daily living or under standardized care protocols. Restraint use was usually not documented in patient record.

From: Chapter 35, Error Reporting and Disclosure

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Hughes RG, editor.

Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

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