Chapter 35. Error Reporting and Disclosure 

Zane Robinson Wolf, Ronda G. Hughes 

Background 

This chapter examines reporting of health care errors (e.g., verbal, written, or other form of 

communication and/or recording of near miss and patient safety events that generally involves 

some form of reporting system) and these events’ disclosure (e.g., communication of errors to 

patients and their families), including the ethical aspects of error-reporting mechanisms. The 

potential benefits of intrainstitutional and Web-based databases might assist nurses and other 

providers to prevent similar hazards and improve patient safety. Clinicians’ fears of lawsuits and 

their self-perceptions of incompetence could be dispelled by organizational cultures emphasizing 

safety rather than blame. This chapter focuses on the assertion that reporting errors that result in 

patient harm as well as seemingly trivial errors and near misses has the potential to strengthen 

processes of care and improve the quality of care afforded patients. 

Reporting Errors 

Reporting errors is fundamental to error prevention. The focus on medical errors that 

followed the release of the Institute of Medicine’s (IOM) report To Err Is Human: Building a 

Safer Health System1 centered on the suggestion that preventable adverse events in hospital were 

a leading cause of death in the United States. This report emphasized findings from the Harvard 

Medical Practice Study that found that more than 70 percent of errors resulting in adverse events 

were considered to be secondary to negligence, and more than 90 percent were judged to be 

preventable.2, 3 The IOM report also emphasized the importance of reporting errors, using 

systems to “hold providers accountable for performance,” and “provide information that leads to 

improved safety.” Conceptually these purposes are not incompatible, but in reality they can 

prove difficult to satisfy simultaneously1

 (p. 156). Nonetheless, reporting potentially harmful 

errors that were intercepted before harm was done, errors that did not cause harm, and near-miss 

errors is as important as reporting the ones that do harm patients. Patient safety initiatives target 

systems-related failures that contribute to errors within the complex environment of health care. 

Because many errors are never reported voluntarily or captured through other mechanisms, these 

improvement efforts may fail. 

Errors that occur either do or do not harm patients and reflect numerous problems in the 

system,4

 such as a culture not driven toward safety and the presence of unfavorable working 

conditions for nurses. To effectively avoid future errors that can cause patient harm, 

improvements must be made on the underlying, more-common and less-harmful systems 

problems5 most often associated with near misses. Systems problems can be detected through 

reports of errors that harm patients, errors that occur but do not result in patient harm, and errors 

that could have caused harm but were mitigated in some manner before they ever reached the 

patient. Reporting near misses (i.e., an event/occurrence where harm to the patient was avoided), 

which can occur 300 times more frequently than adverse events, can provide invaluable 

information for proactively reducing errors.6 Analysis of reported errors have revealed many 

“hidden dangers” (near misses, dangerous situations, and deviations or variations) that point to 

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

system vulnerabilities, not intentional acts of clinician performance that may eventually cause 

patients harm.7

Opinions and experiences of hospital leaders about State reporting systems were solicited 

from chief executive and chief operating officers of hospitals in six States with a variety of 

reporting systems: mandatory, nonconfidential; mandatory, confidential; and voluntary systems.8

Questionnaires addressed perceptions of the effect of mandatory systems on error reporting, 

since it was thought that they reduced the frequency of error reports. Items elicited perceptions 

on the likelihood of lawsuits, overall patient safety, attitudes regarding release of incident reports 

to the public, and likelihood of reporting incidents to the States or affected patients based on 

hypothetical clinical vignettes varying in type and severity of patient injury. Safety was a high 

priority across hospitals. Most hospital leaders reported that a mandatory, nonconfidential 

reporting system run by the State deterred reporting of patient safety incidents to internal 

reporting systems. The majority thought that a mandatory, nonconfidential system encouraged 

lawsuits. Over half indicated that patients should learn details of errors on request by patients or 

families. They preferred that individual practitioner and hospital names be kept confidential and 

that incidents involving serious injury be reported to the State. Most indicated that the State 

should not release information to patients under certain circumstances. Definitions of reportable 

events varied by State, bringing hospital leaders to call for specific, national definitions of errors. 

Just because an error did not result in a serious or potentially serious event does not negate 

the fact that it was and still is an error. Since reporting both errors and near misses has been key 

for many industries to improve safety,6

 health care organizations and the patients they serve can 

benefit from enabling reporting. Reporting sets up a process so that errors and near misses can be 

communicated to key stakeholders. Once data are compiled, health care agencies can then 

evaluate causes and revise and create processes to reduce the risk of errors. As such, 

organizations have implemented strategies, such as staff education, elicitation of staff advice, 

and budget appropriations, to ease the implementation of patient safety systems and to improve 

internal (e.g., intrainstitutional) reporting and disclosure to patients and families. 

The ramifications of errors that do cause patient harm can provide critical information to 

inform the modification or creation of policies and procedures for averting similar errors from 

harming future patients. The position taken by the Joint Commission is that once errors are 

identified and the underlying factors/problems or “root causes” are identified, similar errors can 

be reduced and patient safety increased. When both errors and near misses are reported, the 

information can help organizations better understand exactly what happened, identify the 

combination of factors that caused the error/near miss to occur, determine its frequency, and 

predict whether it could happen again. Underreporting and failure to report errors and near 

misses prevents efforts to avoid future errors and thwarts the organization’s and clinicians’ 

obligation to inform/disclose to patients about the error. 

As patients become more aware of actual and potential errors, they not only want to be 

informed, they want to know that quality improvement efforts supported by shared learning will 

prevent similar future errors.9

 Patients and the public support error reporting,10, 11 particularly 

mandatory reporting,12 and want to know that clinicians and organizations acknowledge errors13

to leaders, managers, and peers, and that errors are reported as soon as they are detected.14 

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Error Reporting & Disclosure

Ethical Implications of Reporting and Disclosure 

Health care providers are typically so devastated and embarrassed by their mistakes that they 

may attempt to conceal them or defend themselves by shifting the blame to someone or 

something else.15 Some attribute failure of honestly acknowledging health care mistakes to 

providers’ personal difficulty with admitting mistakes and incriminating other providers.16–19

Ethical frameworks operate when health care mistakes are made.20 Respect for patient autonomy 

is paramount, as is the importance of veracity. Fidelity, beneficence, and nonmaleficence are all 

principles that orient reporting and disclosure policies. Providers might benefit from accepting 

responsibility for errors, reporting and discussing errors with colleagues, and disclosing errors to 

patients and apologizing to them.21

When providers tell the truth, practitioners and patients share trust. The fiduciary 

responsibility of institutions exists in patients’ and families’ trust that providers will take care of 

them. If providers cover up errors and mistakes, they do not necessarily stay hidden and often 

result in compromising the mission of health care organizations. Consistent with their mission, 

institutions have an ethical obligation to admit clinical mistakes. Professional and organizational 

policies and procedures, risk management, and performance improvement initiatives demand 

prompt reporting. When patients, families, and communities do not trust health care agencies, 

suspicion and adversarial relationships result.18 Likewise, the breach of the principle of fidelity 

or truthfulness by deception damages provider-patient relationships.22 Fidelity and trust, implicit 

to the provider-patient relationship, do not coexist with deception.23

Physicians, nurses, and other health care providers have legal and ethical obligation to report 

risks, benefits, and alternative treatments through informed consent mandates. Legal self-interest 

and vulnerability after errors are committed must be tempered by the principle of fidelity 

(truthfulness and loyalty).24–26 This ethical principle has been reinforced by practical lessons 

learned from errors; especially when an adverse event causes serious harm or even death, there is 

an ethical and moral obligation to disclose information.27, 28 Candid reports and disclosure of 

errors by physicians as well as other health care providers (or institutional leadership if the 

physician refuses to disclose)19 might result in greater patient trust and less litigation.29

Furthermore, it is essential to act after errors are reported, with interventions aimed at protecting 

the welfare of patients by targeting iatrogenic problems and documenting the care given. 

Additionally, the ethical principles of beneficence (doing good) and nonmaleficence 

(preventing harm) are violated when errors are not reported or disclosed. These ethical 

principles, beneficence and nonmaleficence, shape caring nursing practice, and caring 

presupposes that nurses act in the best interests of patients. For example, sharing information and 

preventing harm to patients through truth telling, regardless of good or bad news, build 

relationships between elder residents and nursing home staff.30 Putting residents’ interests first 

represents nurse caring and characterizes relationships in which sharing information, rather than 

hiding it, surrenders nurses’ control related to withholding information. Thus, failure to disclose 

health care mistakes can be viewed from the perspective of provider control over the rights of 

patients or residents. 

Error-Reporting Mechanisms

Traditional mechanisms have utilized verbal reports and paper-based incident reports to 

detect and document clinically significant medical errors; yet the correlation with actual errors 

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

has been low.31 The benefits of these reports are dependent upon the design of the system, how 

and what information is collected, and whether the information is used to inform a sophisticated 

investigation of specific errors to understand the nature and magnitude of the problem. 

Additionally, reports can reflect the clinician’s ability to recognize an error and willingness to 

report it, whether through formal reporting mechanisms or documentation in patient records. A 

consistent finding in the literature is that nurses and physicians can identify error events, but 

nurses are more likely to submit written reports or use error-reporting systems than are 

physicians. 

Many types of errors that involve medications, health care acquired infections, and medical 

devices have been targeted for reporting and dissemination mechanisms.32 In the case of 

medication errors, errors made by nurses during the administration of medications to patients are 

more likely to be reported in incident reports than are errors made by the prescribers (e.g., 

physicians) or distributors (e.g., pharmacists).33 That said, it is important to note that physicians 

do not necessarily use incident-reporting systems.31

Error-reporting mechanisms may capture only a fraction of actual errors. Research has 

approached potential errors using direct observation, which, while expensive and not necessarily 

practical in all practice settings, generates more accurate error reports.34 More recent approaches 

have been focusing on increasing and simplifying error reporting, and automating the detection 

of errors, including creating Web-based forms or adapted standard spreadsheets to reveal 

patterns of errors.35 Many of these efforts have focused on improving physician participation and 

emphasize voluntary31 and confidential reporting.36 Most have encouraged reports of errors and 

near misses and shared occurrences with risk managers, other agency leaders, and patient safety 

specialists.37 Perhaps a combination of reporting mechanisms, both concurrent and retrospective, 

might improve reporting and ideally result in safer processes. 

Some of the challenges in using error-reporting mechanisms are associated with the lack of 

standard definitions, gaining easy access to databases, and the associated cost of electronic 

applications.38 The capability of health care organizations’ networks and hardware, the existing 

policies and reporting processes, including reporting actual errors and near misses, and whether 

the new system will provide error details to assist quality improvement initiatives must be 

evaluated. 

Patients can also be a source of information for reports about the occurrence of adverse 

effects associated with medical interventions. In institutional settings, patients can provide 

information on new symptoms that may not be readily detected by clinician observation or 

testing. In outpatient settings, it could be argued that when there is no direct communication 

between patients and their outpatient clinicians, some unplanned emergency department (ED) 

visits and hospitalizations have been used to determine patients with significant, reportable, and 

actionable adverse drug reactions (ADRs). Two studies of patients in an outpatient setting found 

that patients reported more information about ADRs, the majority of which did not warrant an 

ED visit or hospitalization, when specifically asked, providing clinicians the opportunity to make 

changes in the patient’s medication therapy. Without the patient’s report of an ADR, clinicians 

would not know about the majority of ADRs affecting patients.39, 40 

Voluntary Versus Mandatory Reporting 

The IOM differentiated between mandatory and voluntary reporting of health care errors.41

Voluntary reports may encourage practitioners to report near misses and errors, thus producing 

4
Error Reporting & Disclosure

important information that might reduce future errors. However, there is concern that with 

voluntary reporting, the true error frequency may be many times greater than what is actually 

reported.42 Both of these types of reporting programs can be Web-based and nationally 

representative. Mandatory and voluntary reporting systems differ in relation to the details 

required in the information that is reported. 

Mandatory reporting systems, usually enacted under State law, generally require reporting of 

sentinel events, such as specific errors, adverse events causing patient harm, and unanticipated 

outcomes (e.g., serious patient injury or death. It is estimated that less than half the States have 

some form of mandatory reporting system for adverse events—a number that is expected to grow 

in the next few years. One such State-mandated system is created by Pennsylvania’s Medical 

Care Availability and Reduction of Error (MCARE) Act of 2002 (on the Web at 

www.mcare.state.pa.us/mclf/lib/mclf/hb1802.pdf). Another example is the New York Patient 

Occurrence Reporting and Tracking System (NYPORTS), a Web-based, external, confidential, 

mandatory reporting system that has been in existence since 1998. The focus of NYPORTS is on 

serious complications of acute disease, tests, and treatments. The system has 9 occurrence 

categories (aspiration, embolic, burns/falls, intravascular catheter related, laparoscopic, 

medication errors, perioperative/periprocedural, procedure related, and other statutory events) 

and 54 specific event codes.43, 44 

Sentinel events, such as serious medication errors resulting in deaths, are incidents that can 

be voluntarily submitted to the Joint Commission in accordance with their Sentinel Event Policy 

(accessible at www.jointcommission.org/SentinelEvents/PolicyandProcedures), which is based 

on root-cause analyses. Root-cause analysis is a systematic investigation of the reported event to 

discover the underlying causes. The Joint Commission’s position on mandatory reporting is that 

providers who are forced to report errors may not describe the details of the event, since they are 

motivated by a requirement. Nationally, the Joint Commission’s Sentinel Alerts provide 

electronic access to selected sentinel events, identify common underlying causes, and 

recommend steps to prevent future events. The alerts provide clinicians the opportunity to learn 

about root causes of errors. Sentinel event statistics are available for clinicians to note error 

trends and root causes. 

An example of voluntary external reporting mechanisms, specifically a Web-based, 

anonymous/confidential system, is the Medication Errors Reporting Program (MERP) of the 

United States Pharmacopoeia and the Institute for Safe Medication Practices (assessable at 

www.usp.org/hqi/patientSafety/mer). Reported errors make up the MEDMARX® database, 

which subscribing hospitals and health care systems can use as part of their quality improvement 

initiatives. Employees of subscriber organizations enter, review, and release data to a central data 

repository that is then available for all subscribers to search. Comparisons can be made within 

institutions of a single health care system and across participating health care systems. The 

sharing of data allows medication error types, locations in agencies, level of staff involved, 

products, and facts contributing to errors to be known and serves to alert clinicians to safety 

hazards. Actual, intercepted, and potential errors are all included. MEDMARX® examines the 

medication use process, systems, and technologies rather than individual blame and emphasizes 

the Joint Commission’s framework for root-cause analysis. 

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

Barriers to Error Reporting 

Many errors go unreported by health care workers.45 The major concern they have is that 

self-reporting will result in repercussions.46–48 Providers’ emotional responses to errors inhibit 

reporting, yet some are relieved when they share the events of the error with patients.49 Health 

care professionals report feeling worried, guilty, and depressed following serious errors, as well 

as being concerned for patient safety and fearful of disciplinary actions. They also are aware of 

their direct responsibility for errors.16, 50 Many nurses accept responsibility and blame themselves 

for serious-outcome errors.51 Similarly, physicians responded to memorable mistakes with selfdoubt, self-blame, and shame.52 The need of clinicians for support may be fulfilled by discussing 

their mistake with another person. However, many received support most often from spouses 

rather than colleagues. Instead of bearing the pain of mistakes in silence, clinicians should admit 

them, share them with peers, and dispel the myth of perfect practice. However, this support 

might keep disclosure within the disciplinary culture and practice of medicine rather than 

bringing mistakes to multidisciplinary teams. 

Self-reporting errors can be thwarted by several factors. First, clinicians fear careerthreatening disciplinary actions and possible malpractice litigation and liability.22, 24, 53, 54 Health 

care leaders who do not protect reporters of errors from negative consequences reinforce this 

fear,8, 55 as does the criminalization of fatal health care mistakes.56, 57 Fear of these negative 

consequences can lead to reporting errors only when a patient is harmed or when the error could 

not be “covered up”;58 yet more health care providers are vulnerable to legal action if detailed 

error reports are documented for events that could formerly be concealed.27, 28 Additionally, the 

moral residue of previous mistakes may also restrict disclosure of errors.59 This residue could be 

replaced in providers’ memories by efforts encouraging reporting in a nonpunitive milieu60 and 

incorporating the systems improvements that follow. Clinicians do not want to intentionally 

harm patients; yet when they conceal errors, they place patients at increased risk of some type of 

harm. 

Second, clinicians working in a culture of blame and punishment do not report all errors, 

primarily because they fear punishment. A long-held tradition in health care is the “name you, 

blame you, shame you”61 mantra. Many organizations have been challenged to provide an 

environment in which it is safe to admit errors and understand why the errors occurred.41 Fears 

of reprisal and punishment have led to a norm of silence. But silence kills, and health care 

professionals need to have conversations about their concerns at work, including errors and 

dangerous behavior of coworkers.62 Among health care providers, especially nurses, individual 

blame has been the predominant reaction for errors.63 When individuals and organizations are 

able to move from individual blame toward a culture of safety, where the blame and shame of 

errors is eliminated and reporting is rewarded, organizations are enabled to institutionalize 

reporting systems and increase reporting of all types of errors.64, 65 To do so, clinicians and others 

must know that safety can be improved by nonpunitive reporting of error and that organizational 

flaws cause errors.1

 As communication, collaboration, and safety are inextricably linked in the 

pursuit of quality care, risk managers, safety officers, and other leaders in health care institutions 

are encouraging the development of a culture of safety. In a culture of safety, open 

communication facilitates reporting and disclosure among stakeholders and is considered the 

norm.20 Yet even in organizations with a culture of safety, creating a nonpunitive environment is 

a work in progress.66

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Error Reporting & Disclosure

Third, there is significant variation in how errors are defined, what information is reported, 

and who should be involved in reporting and mitigating the effects of errors. Differing 

definitions of errors and near misses and significant differences in reporting—among health care 

providers working in the same institution and across health care systems—make it difficult to act 

and prevent similar errors. One of the greatest challenges confronting the patient safety 

movement is agreeing on standard definitions of what constitutes errors.67 Reporting near misses 

can facilitate a blame-free approach (a hallmark of a culture of safety) and fewer cultural and 

psychological barriers. Yet, clinicians who believe that an error or near miss was unimportant or 

caused no harm, especially if intercepted, might decide that a report of a near miss is not 

warranted;68–70 near misses are not frequently reported.71

Lastly, error reports are difficult to complete, and feedback about needed system changes to 

improve safety is not commonly given.55 The lack of standardization in the information that is 

reported and collected makes comparisons and trending as well as preventing future errors 

difficult. Implementing and using standardized reports of error events, such as those available in 

hospital databases, is just one example of an open communication strategy, benefiting both 

clinicians and ultimately the patients they serve.72 However, the process for reviewing events is 

not consistently applied nor conducted in matter conducive to providing feedback and improving 

safety.73 

These and other barriers to reporting and disclosing errors must be breached to accomplish 

safer health care.25 Reporting errors and near misses through established systems provides 

opportunities to prevent future similar, and perhaps even more serious, errors. Failure to report 

and speak up about errors and near misses is unacceptable because the welfare of patients is at 

stake. Investigations into the reporting behaviors of clinicians have found that clinicians are more 

likely to report an error if the patient was not harmed.74 Clinicians would also be likely to report 

an error made by a colleague regardless of patient harm.74

Several factors are necessary to increase error reporting: having leadership committed to 

patient safety; eliminating a punitive culture and institutionalizing a culture of safety; increasing 

reporting of near misses; providing timely feedback and followup actions and improvements to 

avert future errors; and having a multidisciplinary approach to reporting.64, 65 Only through 

reporting errors can nurses and other health care providers learn which system design and 

operational failures contribute to human fallibilities and subsequently improve the quality of 

care. Additionally, one study found that physicians, pharmacists, advanced practitioners, and 

nurses considered the following to be modifiable barriers to reporting: lack of error reporting 

system or forms, lack of information on how to report an error, and lack of feedback to the 

reporter.75

Error Disclosure 

Disclosure of health care errors is not only another type of error reporting, it is also an 

account of a mistake. It involves an admission that a mistake was made and typically, but not 

exclusively, refers to a provider telling a patient about mistakes or unanticipated outcomes. 

Disclosure addresses the needs of the recipient of care (including patients and family members) 

and is often delivered by attending physicians and chief nurse executives. However, while 

physicians’ willingness to disclose errors may be stimulated by accountability, honesty, trust, 

and reducing risk of malpractice, physicians may hesitate to disclose because of professional 

repercussions, humiliation, guilt, and lack of anonymity.76

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

Disclosure also sometimes calls for a formal verbal apology, in some institutions presented in 

writing by patient safety officers. Often the providers involved in the error apologize. The central 

element of disclosure is the trust relationship between patients (or residents of long-term care 

facilities) and health care providers. Agency policies specify the disclosure approach and identify 

the person—for example, the primary care provider or safety officer—who communicates the 

error, adverse event, or unanticipated outcome to the patient or resident, or family member. 

Some institutions make error disclosure mandatory, and some disclose errors on a voluntary 

basis. 

Providers were concerned about disclosure. They felt shame and fear about their mistakes. 

“Medical missteps” were transformed into clinical mistakes after practice standards were 

developed; next, malpractice suits followed. As a result, mistakes were subsequently hidden, 

creating a negative cycle of events.72 Furthermore, physicians’ anxiety about malpractice 

litigation and liability and their defensive behavior toward patients have blocked individual and 

group strategies for preventing and reducing medical errors, thus hindering error reduction 

attempts.22 Hiding errors at times resulted in providers being involved in litigation. The 

association between hiding errors and reducing costs seemed less certain than formerly 

believed.29

When patients’ concerns are not addressed, they are more unwilling to return for future care 

needs77and follow medical advice, and are more likely to seek malpractice lawsuits.78–80 Several 

surveys of patients and the general public have found that they believe health care to be only 

moderately safe and that they are concerned about errors affecting them if the seek care in 

hospitals.54, 81–84 Specifically, patients are concerned about misdiagnoses, physician errors,85

medication errors, nursing errors,77, 85 wrong test/procedure errors, 85 and problems with medical 

equipment.77 

Another dimension of reporting and disclosing errors is the role patients can have. Patients 

can understand, perceive the risk of, and are concerned about health care errors. As more is 

learned about errors, patients and clinicians have opportunities to improve health care quality. 

Patients want full disclosure86 and to know everything about medical errors that impact them. 

Disclosure can avert patients seeking another physician and can improve patient satisfaction, 

trust, and positive emotional response to an error, as well as decrease the likelihood of patients 

seeking legal advice following the error.87 Patients have the right to know; patients and the 

public strongly desire disclosure.86, 87 Failure to disclose mistakes and unanticipated outcomes 

limits opportunities for evaluation of systems and processes, and for sharing knowledge gained 

by publishing safety alerts across organizations, conducting educational sessions, modifying 

practice, and offering opportunities for improved performance.88 Disclosure is also an element 

that contributes to the creation of a culture of safety89 and as such must be accepted as a strategy 

in health care institutions interested in becoming high-reliability organizations, “those in which 

error seldom occurs even in dangerous environments”90 (p. 121).

A significant barrier to disclosing errors is the clinicians’ willingness to do so. This may in 

part be due to the lack of clarity as to exactly what should be disclosed, when the discussion 

should take place, and who (e.g., a hospital administrator, physician, or nurse) should disclose 

the error. When it comes to what should be disclosed, research has found that physicians and 

nurses want to disclose only what had happened,81 but there are no universal rules for doing so.86

Decisions to disclose or not to disclose are complex and depend on how errors are defined and if 

they are recognized or detected. Health care providers are heavily influenced by their perceived 

8
Error Reporting & Disclosure

professional responsibility, fears, and training, while patients are influenced by their desire for 

information, their level of health care sophistication, and their rapport with their provider.91 

Both health care providers and patients seem to agree that errors disclosure should take place 

when patients are harmed and that corrective action should involve systems improvement.91

Other research has found that the likelihood of disclosure increased for physicians, nurses, and 

emergency medical technicians (EMTs) as the severity of the error increased.92 Somewhat 

conflicting with this is the assertion that patients would suffer additional harm when 

“unnecessary” information was shared about a mistake.30 Unfortunately, this line of reasoning 

has its roots in the dubious contention that patients might be more harmed when told the truth as 

compared with disclosing the mistake. 

Physicians have argued that they should be responsible for disclosing errors to the patient.93

This is borne out in some research that has shown that in practice, at least among emergency care 

providers, nurses were less likely (23 percent to 54 percent) to disclose an error than were 

physicians (71 percent to 74 percent).92, 94

Because there are instances when error disclosure has been followed by the “victims” 

seeking further action, the disclosure of errors in practice may not reflect all errors that have 

harmed patients,95–97 nor all those that could or should have been disclosed. In many instances, 

patients may be less likely to seek legal action if the error is disclosed by the physician82, 83 and if 

they do not suspect a cover-up.78 However, it is not known if there is a causal relationship 

between disclosure of errors and adverse consequences such as litigation.87

Disclosure policies. Written policies on disclosing health care mistakes stand to benefit 

institutions because they can reduce idiosyncratic responses of reporters.19 Specific policies and 

systems of error disclosure are preferred over position statements.98, 99 This is because policies 

stipulate health care personnel to be notified, patient care to be given following the mistake, and 

the content of the disclosure notification. Plans to care for the patient are also included. “True 

informed consent can only be as a result of discussion between a patient and 

physician”19 (p. 155). Such a policy fits within a systemwide approach to quality and safety. 

Underreporting may be addressed by a standardized patient safety event form, integration of 

databases for event reporting, ongoing education to reinforce the need for providers to report, 

and patient and family involvement in care delivery processes.100

A disclosure policy implemented by the Veterans Affairs (VA) Medical Center in Lexington, 

Kentucky,91 resulted in liability payments that were more moderate than such payments at 

similar facilities. The policy required disclosure to patients of unanticipated outcomes (accidents 

or medical negligence).101 This developing, national VA initiative continued its focus on research 

and policy related to health care error, error-reporting systems and analysis, and feedback 

methods. Improving systems of care was the target of the ongoing initiative.102 The VA’s 

disclosure policy included reporting details of incidents, expressing institutional regret, and 

identifying corrective actions. Comparable liability payments resulted when contrasted with 

other VA hospitals. Another solution instituted was the granting of a waiver for practitioners 

who reported errors. Many voluntary adverse event/health care error-reporting systems created 

for acute care hospitals have built on the VA reporting system.44 Nonetheless, many health care 

organizations may not disclose errors to patients,53 although virtually all have traditionally 

reported errors through paper incident reports that remained internal and confidential. Errorcommunication strategies are changing, since several States have mandated that health care 

institutions notify patients about unanticipated outcomes.103 

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

Policies can be supported by advisories, which have historically relied on relatively few 

contributions from patients. Patients’ responses to drafts of advisories were explored best with 

Medicare beneficiaries.104 While not specifying advisory content on disclosure of health care 

errors, recommendations included the involvement of patients and providers. Discussions on 

patient roles in safety enhancement and the development of protocols for inclusion in safety 

advisories were encouraged. 

The development and implementation of disclosure policies should be part of an 

organization-wide effort predicated on cultural change that includes open communication, truth 

telling, and no blame.20, 60 Debate regarding the assignment of blame has not negated the 

importance of counseling some clinicians when policies are intentionally violated—or 

prosecuted in the case of criminal behavior. Policies on disclosure, including apologies to 

patients and families, have been justified; respect for patients and their autonomy prevails as a 

source and support of patients’ right to information about health care errors. The aforementioned 

changes for disclosure policies—for example, open communication, truth telling, and no 

blame—apply to error-reporting systems as well. 

Differences between reporting and disclosure. It is important to place health care errorcommunication strategies, specifically definitions of reporting and disclosure, in context (see 

Figure 1). The process of reporting errors is sometimes referred to as disclosure of errors, 

causing confusion. A report of a health care error is defined as an account of the mistake that 

conveys details of the occurrences, at times implicating health care providers, patients, or family 

members in error events. Both clinicians and patients can detect and report errors.105 Each report 

of a health care error can be communicated through established and informal systems existing in 

health care agencies (internal) and outside organizations (external), and may be written (e.g., 

electronic or paper) or verbal, voluntary or mandatory (policy driven). The core value supporting 

reporting is nonmaleficence, do no harm, or preventing the recurrence of errors. 

An error report may be transmitted internally to health care agency administrators, managers, 

physicians, nurses, pharmacists, laboratory technicians, other caregivers, and agency legal 

counsel. Reporting is often directly related to risk management activities intended to prevent 

actual or potential threats of harm. Intrainstitutional or internal reporting examples are incident 

reports, nurses’ notes, safety committee reports, patient care rounds, and change-of-shift reports. 

Intrainstitutional reports have increased since the initial IOM report and the elimination of the 

culture of blame in many health care agencies. Of these, the most common means of reporting 

serious errors for nurses has been through incident reports, a mechanism that has been criticized 

as being subjective and ineffective in improving patient safety.106, 107

Extrainstitutional or external reporting systems include accounts submitted to agencies such 

as the Medical Event Reporting System for Transfusion Medicine (MERS-TM), MERP, the Joint 

Commission, and various State departments of health, as well databases such as United States 

Pharmacopeia’s MEDMARX® Reporting System (U.S. Pharmacopeial Convention 2006), as 

illustrated in Figure 1. Additional reporting methods have been called for, such as databases that 

allow for analysis and communication of alerts to key stakeholders in single agencies and across 

systems. 

10
Error Reporting & Disclosure

Figure 1. Heath Care Error-Communication Strategies 

Healthcare Error Communication Strategies

Reporting Errors Disclosure

Verbal, Written

Mandatory, Voluntary

Intrainstitutional

(Nurses, physicians, pharmacists, 

other caregivers, managers, 

administrators, risk, quality, and 

safety officers, board of trustees, 

other agency staff, etc.)

Extrainstitutional

(State, JCAHO, 

professional organizations, 

community, Nation, etc.)

Patients, Families

Reporting (providing accounts of mistakes) and disclosing (sharing with patients and 

significant others) actual errors and near misses provide opportunities to reduce the effects of 

errors and prevent the likelihood of future errors by, in effect, warning others about the potential 

risk of harm. Reporting reduces the number of future errors, diminishing personal suffering108

and decreasing financial costs. In contrast, disclosure is thought to benefit patients and providers 

by supplying them with immediate answers about errors and reducing lengthy litigation.109

Although clinicians and health care managers and administrators feel uncomfortable with 

disclosure, disclosure is a duty. 

Error Reporting and Detecting Strategies 

Several strategies have been used to improve error reporting. In a literature review of 

incident-reporting research published between 1990 and 2000, the effectiveness of chart reviews, 

computer monitoring, and voluntary reporting were compared. The investigators found that the 

most adverse drug events were identified through chart reviews; the least effective method was 

voluntary reporting. The most efficient method of understanding errors was computer-based 

monitoring because more adverse drug events were found than with voluntary reporting and it 

took less time than chart reviews.110

A strategy tested in another project, developed within a hospital, used an electronic, 

anonymous paper report to increase close call (i.e., near miss) incident reporting. Close call 

categories included blood/transfusions, diagnostic tests/procedures, falls, medications, other 

treatments, surgery, and therapeutic procedures. The final template included five main screens 

and was received very positively by providers. A clinical analyst assisted in communicating 

feedback and describing the etiology of close call situations, and urgent close calls were rapidly 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

communicated. The investigators found that improved reporting systems may encourage 

providers to report near misses. Once identified and shared with front-line providers, errors may 

be prevented.111

Several Web-based systems have also been used in hospitals to improve error reporting. One 

study investigated reported errors, intercepted errors, and data quality after a Web-based 

software application was introduced for medication error event internal reporting. The reporting 

system generated occurrence reports, documented anonymously submitted reports, and allowed 

for the possibility of real-time reporting and more rapid investigation of contributing factors. The 

investigators found that error reports increased as well as intercepted error threats (near misses), 

and intercepted nurse, physician, and pharmacist medication errors increased. The details of 

cause-of-error reporting also increased as did the participation of hospital leadership.112 In 

another study, Wu and colleagues113 described the use of Web-based internal reporting in the 

intensive care unit setting. The researchers found that analyzing and disseminating error and near 

miss data, so that providers are alerted to safety risks, could reduce errors. Additionally, patient 

safety would most likely improve when providers see the benefits of reporting through systems 

improvements.113 One other project occurred when leaders at Baylor Medical Center at 

Grapevine partnered with DoctorQuality to create a Web-based form for reporting errors.114 At 

the same time, they implemented strategies to change the culture of the organization, supported 

by education on the use of the reporting system, incident reporting, communication, and 

feedback information about errors. Investigators found that event reporting doubled, suggesting 

that even with increased reporting, the actual number of errors may not be identified. Proactive 

risk management allowed for timely followup, the percentage of errors submitted increased after 

implementation, and the average days from event to submission shortened.115

Using a voluntary, regional external reporting database and United States Pharmacopeia’s 

MEDMARX® database increased medication error reports across critical access hospitals.116

Most errors reported to the regional database and MEDMARX® did not result in harm to 

patients. However, significant differences existed in severity, phase, and types of error when 

comparing the two external reporting systems. More error reports from the critical access 

hospital database (Nebraska Center for Rural Health Research) reached patients than did 

MEDMARX® errors. Increased reporting of potential and near-miss errors by nursing and 

pharmacy personnel was associated with easily accessible pharmacist availability. 

Another strategy to improve awareness of errors is the assessment of medical records to 

detect errors that were not otherwise reported. Two prospective, cross-sectional studies 

compared facilitated incident monitoring to retrospective review of patient medical records in 

hospitals. The first117 compared medical record review to physician reporting prompts by daily 

electronic reminders for 3,146 medical patients in an urban teaching hospital. The investigators 

found that the physician reporting method identified nearly the same number (2.7 percent) of 

adverse events as did the retrospective medical record review (2.8 percent), but the electronic 

reminders detected more preventable adverse events (62.5 percent vs. 32.9 percent), was less 

costly than the record review ($15,000 vs. $54,000), and could be integrated in the daily routine 

through electronic health information technology. The second, smaller study118 compared 

facilitated discussions to medical record review in one 12-bed intensive care unit (ICU) with 164 

patients in an Australian hospital with an established incident reporting system. The investigators 

found that facilitated discussions, in addition to the incident reporting system, identified more 

preventable incidents than retrospective medical record review and was not as resource intensive 

12
Error Reporting & Disclosure

as medical record reviews (50 hours vs. 65 hours). However, medical record review detected 

some incidents not captured by the incident reporting system. 

Research Evidence 

Over the past 11 years, research on the reporting of errors among nurses targeted four key 

areas: (1) description of who reports errors and what errors are and perceived to be reported; (2) 

barriers to error reporting; (3) disclosure preferences; and (4) reporting systems and frameworks, 

including the development of effective reporting systems. The researchers used different 

methods to assess reporting preferences and what was reported, including surveys, 

retrospectively assessed error reports,116, 119–128 a 2-week journal,129 error scenarios,81, 92, 130 and 

focus groups.91, 131, 132 One study used a mixture of methods.58 Most of the research included in 

this analysis involved discussions of reporting involving health care providers using existing 

systems, while 11 studies assessed the effects of new or revised error-reporting systems. 

Who Is Reporting 

Verbal, paper-based, electronic, and Web-based error-reporting mechanisms have been used 

to capture, record, and communicate errors. Nurses were found to report the majority of errors. 

The proportion of error report submitted by nurses ranged from 67.1 percent133 to 93.3 

percent.124 Nurses reported 27 percent more errors than did physicians.134 Physicians submitted 2 

percent135 to 23.1 percent, and 9.5 percent were submitted by others.133 Considering the 11 

surveys included in this analysis that investigated who submitted error reports, all found that 

nurses reported the majority of incident reports.36, 46, 106, 120, 123, 124, 133–137 

Factors that have influenced the submission of error reports included believing it was 

beneficial to do so131 and having quality management processes in place.138 Feeling comfortable 

reporting, working in a climate of patient-centered care, job satisfaction, and the serious nature 

of the error enabled error reporting.131 In terms of characteristics associated with those likely to 

report errors, nurses with more than 5 years of experience were more likely to believe there was 

no value in reporting near misses.106 This contradicts findings from another survey where the 

frequency of error reporting was found to be higher among nurses with 5 to 10 years of 

experience.139 Another finding that complicates this notion is that in one survey, nurse managers 

reported more errors than did staff nurses,139 but this could have been associated with 

organizational structure rather than ability of staff nurses. Additional characteristics were that 

nurses providing direct patient care were more likely to report,140 and that pediatric nurses 

reported medication errors more frequently than adult nurses.141

Compared to physicians, nurses seemed to have more knowledge/awareness of the reporting 

process/system,106, 132 know what should be reported,69, 142 know when the error should be 

reported,142 be more likely to have submitted an error/incident report, know how to use an 

incident report form, and know where to submit the report.106 One survey found that while 98.3 

percent of physicians and nurses knew about incident reporting systems within their 

organizations, nurses were more likely to know how to submit an error report, have experience 

with submitting an error report, and know where to submit the report.106 Another survey found 

that 54 percent of residents and 97 percent of nurses knew about their hospital’s error-reporting 

system, and 13 percent of residents and 72 percent of nurses were likely to use the reporting 

system.143 Conversely, another survey found that less than 10 percent of physicians and nurses 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

were aware of their State’s mandatory reporting system, and only a small subset of the ones 

familiar with the system (less than 50 percent of nurses and 20 percent of physicians) had 

actually submitted a report using the mandatory system.144

Who reported was also be associated with their understanding of what should be reported. 

One survey of medication administration errors found that nurses acknowledged differences in 

how reportable errors were defined among staff.145 Similar findings were found in another survey 

of nurses in Korea, where nurses were not clear as to what should be reported.139

Nurses tended to be more likely to report errors, considering it a professional obligation. One 

survey of nurses in rural hospitals found that nurses believed they were responsible for reporting 

errors, getting needed education, recommending changes in policies and procedures to prevent 

future errors, and participating in investigations of the causes of errors.58 Another found that 

physicians believed that nurses were responsible for reporting errors.144 Similar findings were 

found using error scenarios, where nurses believed that error reporting was a professional 

responsibility and that nurses should report the errors made by other nurses if they did not do so 

themselves.130 However, another survey found that nurses were more comfortable reporting their 

own errors than they were of those of colleagues.146 Another found that 54 percent of residents 

and 91 percent of nurses believed that they would report their own error or someone else’s, and 

25 percent of residents and 1 percent of nurses would report the errors of others if they did not 

like the person who caused the error.143 

What Is Reported 

What is reported could depend upon the understanding of nurses as to what should be 

reported, which is associated with how reportable errors and near misses are defined. If nurses, 

nurse managers, and physicians question the value of reporting because they did not see 

improved patient safety in practice and policies,132 few errors may be reported. If nurses did not 

understand the definition of errors and near misses, they were not able to identify or differentiate 

errors and near misses when they occurred. For example, one very small study gave four error 

scenarios to 13 perioperative nurses to assess whether they could detect errors and their reporting 

preferences. The investigators found that 58 percent of the theoretical errors were identified as 

errors, but only 26.7 percent of them would have been reported.130 However, when nurses were 

given definitions of errors and near misses, one study indicated that nurses reported 58 percent of 

errors and 59 percent of near misses.129 Among the respondents, 61 percent reported one error 

and 38 percent reported making between two and five errors during a 2-week period. 

The severity of errors and who is doing the reporting influence which errors are reported. 

One survey found that 58 percent of nurses did not report minor medication errors.69 Another 

survey found that while nurses reported 27 percent more errors than physicians, physicians 

reported more major events and nurses reported more minor events because they had a more 

“inclusive view.” Both physicians and nurses reported near misses.134 Analysis of error reports in 

Japan found similar differences in error reporting among different types of clinicians. One study 

found that nurses and pharmacists submitted more reports of events that were considered minor, 

while physicians submitted reports when errors were detected and prevented by nurses or 

pharmacists.123 The other study of error reports submitted by physicians and nurses in a hospital 

found that 99.5 percent of the reports—the majority of which were submitted by nurses—were 

for what were considered minor incidents. Additionally, the lag time for reporting major events 

14
Error Reporting & Disclosure

was 18 percent shorter than it was for minor reports, but 75 percent longer when physicians 

submitted the error report.124

Several surveys assessed whether errors that resulted in harm to patients were reported. One 

survey of physicians and nurses in England found that error reporting was more likely if the error 

harmed a patient, yet physicians were less likely to report errors than were nurses or midwives. 

Clinicians were less likely to report errors made by senior colleagues, and physicians in 

particular were unlikely to report violations of clinical protocols, whereas nurses and midwives 

would.46 A review of error reports found that when an error harmed a patient, 34 percent of the 

reports were submitted by physicians and 27 percent of the reports were submitted by nurses. 

When errors did not harm patients, 31 percent of the reports were submitted by nurses and 17 

percent were submitted by physicians.133 One survey found that nurses would report errors 

whether they harmed the patient or not.140 A survey in Korea found that 67 percent of nurses 

believed they always reported errors that harmed patients.139 A very small study found that 

reporting errors that harmed patients was a secondary concern for nurses; nurses believed that 

errors that fell outside the scope of the nurse’s practice should be reported by the responsible 

individual (i.e., not the nurse).130 A related study found that errors resulting in either patient harm 

or worker injury were underreported.138 Thus, events that may harm patients are at risk for not 

being reported. 

What is reported may also be associated with whether the reports are confidential or 

anonymous. Informal reporting mechanisms were used by both nurses and physicians. One 

survey found that nurses also informally reported to physicians when a dose was withheld or 

omitted, but they were less likely to formally report the missed dose as an error.142 Nurses also 

had a greater tendency to informally report errors to nurse colleagues.130 Reviewers found that 

confidential reports were more complete than anonymous ones, but the types of patient harm did 

not vary between anonymous and confidential reports.121 Since voluntary reporting depends on 

health care professionals to report medication errors so that the more realistic frequency and type 

of errors that happened can be known, several surveys encouraged anonymous responses to 

identify the barriers to reporting medication administration errors.58, 69, 142, 147–149 While only brief 

descriptions of the survey instruments were discussed in each of the studies, the surveys did 

capture error reports that may not have been communicated or known otherwise. 

Type of Errors Reported 

An analysis of error reports found that the most serious reports involved rule violations, 

management practices, and nonstandardized nursing practices.125 One study found that the 

majority of error reports involved delays or omissions of medications, diagnostic tests, or 

necessary/planned procedures; medication errors, and malfunctioning equipment. Ten percent of 

the reported errors required life-sustaining interventions (61 percent of which resulted from 

delays/omissions of prescribed nonmedication treatments and necessary planned procedures), 

and 3 percent might have caused the patient’s death.137

In a study of surgical ICUs, the type of events reported were related to medications, tests, 

treatments, or procedures.136 Researchers in another study found that 47 percent of reported 

errors were associated with diagnostic tests, 35 percent with medications, and 14 percent with 

both diagnostic tests and medications. The investigators believed that 71 percent of these errors 

were associated with communication breakdowns.121 One study found that nurses generally were 

more likely to report patient falls than pressure ulcers or near-miss medication errors, and nurses 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

with fewer than 5 years experience were more likely to report deep vein thrombosis.106 Another 

retrospective analysis of error reports in six Japanese hospitals found that reported error rates 

were high for prevention of problematic behavior, patient suicide, patient falls, and subcutaneous 

injections of insulin. A high number of error reports in some hospitals were associated with 

maintenance of dialysis, endoscopy preparation and assistance, administration of preoperative 

treatments, and blood transfusions. There were more reported errors in the elderly, hemodialysis 

patients, and those with problematic types of behavior.125 Another study found that the major 

types of errors reported were for unsafe conditions or near misses, adverse events that harmed 

patients, medication/infusion errors, and patient falls.135 In yet another study, researchers found 

that the majority of reports involved medication errors, surgical errors, falls, and problems with 

procedures.127

Additionally, the type of errors reported can be associated with characteristics of the patient 

population. For example, the findings from one survey indicated that medication error rates, 

which were computed from actual occurrence reports, were higher on pediatric units than adult 

units.141 Children’s vulnerability to adverse outcomes from medication errors was attributed to 

weight-based drug dosing, dilution of stock solutions, and immature physiological buffering 

systems, situations that are unique to children. 

Estimations and Perceptions of Error Reporting 

Several surveys asked nurses to estimate how many and what types of errors were reported 

by colleagues and themselves. There was significant variation when nurses were asked to 

estimate how many errors were reported. Respondents in one survey estimated that an average of 

45.6 percent of errors were reported.142 Nurses may not easily estimate how many errors are 

reported, as indicated in one study where staff nurses were not consistent estimators of 

medication administration errors.145 Another study of medication errors in 29 rural hospitals in 

nine States found that less than half of nurses believed that all medication errors were reported,58

while another study found that 44 percent of nurses estimated that 25 percent of medication 

errors were reported.69 Another survey found that nurses estimated that less than half of all 

medication administration errors were reported,138 an estimate that is lower than those in other 

surveys.70, 150–152

Estimation may also reflect where one works as well as one’s experience. In terms of where 

nurses work, one survey found that nurses working in neonatal ICUs perceived higher reported 

errors than did those working in medical/surgical units. The mean perceived percentage of 

reported errors was 46 percent.142 Another survey found that pediatric nurses estimated that 67 

percent of medication errors were reported, while adult nurses estimated 56 percent. The stronger 

the agreement with management-related and individual/personal reasons for not reporting errors, 

the lower the estimates of errors reported by pediatric nurses.141 In terms of experience, one 

survey found that staff nurses relied on personal experience to estimate medication 

administration errors on their unit.145

Other surveys investigated what nurses thought should be reported. One study divided nurses 

into high- and low-reporting rates; groups differed by definition of what makes up a reportable 

error, by personal experience when estimating unit error reporting, and by willingness to share 

occurrence data with other nurses. Also, nurses were surveyed on the perspectives of types of 

errors that should be reported, the proportion of errors reported, worker safety, and opinions 

about the work environment and job satisfaction.138 Although nurses indicated that all errors 

16
Error Reporting & Disclosure

except near misses should be reported, less than half of medication administration errors were 

reported. Intravenous medication errors were the highest percentage reported events; patient falls 

were associated with major injuries. Not reporting medication errors was attributed to nurses’ 

concerns about administrative responses and personal fears such as imagining the poor opinion 

of their coworkers. Sharps injuries, exposure to body fluids, and back injuries threatened nurse 

safety. Some questioned hospitals’ quality management processes. 

The perceived rates of error reporting may be associated with organizational characteristics. 

For example, the perceived rates of medication administration error reporting were compared by 

organizational cultures of hospitals and extent of applied continuous quality improvement (CQI) 

philosophy and principles.151 As bed size increased, perceived rate of medication administration 

error reporting decreased. Larger hospitals tended to be more hierarchical in nature. Grouporiented hospital culture (norms and values associated with affiliation and trust, flexibility, a 

people-oriented culture with concerned and supportive leadership) and higher levels of CQI 

implementation were positively associated with the estimated overall percentage of medication 

administration errors reported. 

Perceived Barriers to Reporting Medication Errors 

There were 15 identified studies that surveyed nurses about their perceptions of what factors 

(e.g., organizational, process, individual) precluded them from reporting errors. Fourteen of these 

studies used cross-sectional surveys of nurses,69, 70, 106, 120, 131, 138, 141, 142, 147–151, 153 and all but one 

of the surveys131 were in hospitals. Of the two studies that used focus groups, one interviewed 

clinicians in 20 community hospitals,132 the other in ambulatory care settings.131 Several themes 

emerged from these studies, as illustrated in Table 1. The types of responses given by nurses may 

have depended upon the questions asked, but that is not known. In all, research findings seem to 

indicate that, as Wakefield and colleagues151 found, the greater the number of barriers, the lower 

the reporting of errors. 

One survey of nurses in the Midwest found that nurses were able to recognize errors and 

events associated with intentional wrongdoing related to questionable behavior. Nurses were 

more apt to report serious errors but not unintentional errors.153

Other clinicians are concerned about reporting barriers as well. In one survey of physicians 

and nurses, physicians identified twice as many barriers to reporting than did nurses; both 

identified time and extra work involved in documenting an error. However, 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.149

Additional barriers were identified as well. One survey in a State with mandatory reporting 

found that both physicians (40 percent) and nurses (30 percent) were concerned about the lack of 

anonymity of reports and that the reports would be used punitively against the individual who 

submitted the report.144 Another survey of nurses in Korea found that 32 percent were worried 

that their errors were kept in files; 66 percent felt that their suggestions to improve patient safety 

were ignored; 83 percent felt that it was by chance that more errors did not happen; 52 percent 

believed their units had serious patient safety problems; and 56 percent reported problems 

talking with physicians.139 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Table 1. Reasons why clinicians do not report and disclose errors and near misses

Reporting Barriers 

Fear 

Fear69, 138, 148, 150, 151

Fear of being blamed for negative patient outcome70, 147

Fear other providers will consider provider who made the error incompetent70, 138, 141, 142, 147

Fear of reprimand from physician(s)70, 147, 148

Fear patients will develop negative attitudes70, 147

Fear of legal liability, belief that disclosure of errors to patients results in lawsuits149

Fear of “telling” on someone else149

Fear of adverse consequences from reporting70, 141, 147, 148

Fear of reporting that is not anonymous149

Understanding 

Confusion over definition of errors and near misses70

Disagreement with the organizations’ definition of error70, 148, 151

Providers unaware that errors occurred70, 142, 147

Providers’ bias about which incidents should be reported70, 149, 153

Some incidents, i.e., near misses, thought too trivial/unimportant to report106

No perceived benefit131, 149

Administrative/Management/Organizational 

Administrative response138, 142, 148, 150, 151

Lack of feedback on reported errors70, 120, 147, 148

Persistence of the culture of blame/shame, blaming the individual70

Excessive emphasis on medication error rates as quality measure of care70, 147

Poor match of administrative response to errors with severity of errors70, 148

Burden of Effort148

Incident reports take too long to complete70, 131, 147, 149, 151

Verbal reports to physicians take too long or contacting the doctor takes too much time 70

Providers forget to make a report, too busy106, 131

Extra work involved in reporting149

Five studies provided additional information about reporting barriers for nurses. In a survey 

of nurses in Taiwan, nurses did not vary in their concerns about the effects of reporting barriers 

based on factors such as the age of the nurse, type of education, length of experiences, and length 

of employment. Yet nurses who perceived more error reporting barriers also believed that errors 

were over- or underreported, compared to nurses who reported that the error reporting rates were 

accurate. In this study, factors that could thwart error reporting were positively correlated with 

the power hierarchy and face-saving concern. On the other hand, the better the work 

environment, quality management, and relationships with peers, the fewer the perceived barriers 

for error reporting.147

Factors about the organization’s culture may be barriers to error reporting. In one survey of 

clinicians in rural hospitals, the majority agreed that hospital administrators did not punish error 

reporters. Most agreed that the hospital culture recognized that mistakes could be made (64 

percent) and that error reporting could be done by all employees (86 percent). The majority felt 

comfortable (65 percent) or somewhat comfortable (32 percent) discussing medical errors, and 

18
Error Reporting & Disclosure

have learned and would like to continue to learn from the mistakes of others. Attempts to 

maintain collegiality and their belief about lacking authority prevented nurses from questioning 

physicians. Nonphysicians attributed many errors to nursing practices. In fact, if an error 

occurred, 96 percent of nurses and more than 90 percent of physicians, administrators, and 

pharmacists would have assigned patient safety responsibility to nurses. Only 22 percent of 

respondents believed that clinicians and administrators shared equal responsibility for patient 

safety.58

Three studies by Wakefield and colleagues70, 150, 151 asked nurses about organizational and 

leadership/management factors that could thwart error reporting. Staff nurses believed that 

having an organizational culture that did not support error reporting70 and management practices 

and beliefs (e.g., supervisors not viewing fear of an administrative response as a barrier to error 

reporting)150 thwarted error reporting. Wakefield and colleagues151 found in another survey that 

hospital culture types varied; smaller institutions tended to have group-oriented cultures while 

larger institutions tended to be more hierarchal (which was negatively associated with error 

reporting). They also found that the extent of CQI implementation increased with bed size of the 

hospital, and perceived rate of medication administration error reporting decreased. Considered 

together, the presence of a group-oriented culture and higher levels of CQI implementation were 

positively but not significantly associated with reporting errors. 

One study surveyed physicians and nurses about barriers that could be modified to enable 

error reporting. The modifiable barriers they identified were the structure and processes for 

reporting errors and the lack of education about errors. The least modifiable barriers they 

reported were fear of lawsuits, fear of being blamed, and motivational issues.149 

Error-Reporting Strategies 

Thirteen studies investigated the effects of new and revised error-reporting systems on error 

reporting. Investigators examined a clinical pharmacist on units;119 education, a revised reporting 

system, and a call center;120 a voluntary reporting system;121, 122 a voluntary system for near 

misses;154 a voluntary, paper-based reporting system;133, 136, 137 a confidential, electronic-based 

reporting system;135 education enhanced by error report summaries;115 education of nurse case 

managers;126 a Web-based anonymous reporting system;112 and confidential peer interviews.36

Only one study assessed the impact of mandatory error reporting.144 

Three of the studies introduced an “expert” to assist providers in detecting errors. In one, a 

clinical pharmacist was introduced on units to improve medication safety and increase 

medication error reporting as well as error reporting generally. Error reports remained relatively 

constant, yet error reports from physicians decreased. The severity of errors decreased over time, 

and the reporting of near misses increased from 9 percent to 51 percent.119 Another study 

introduced an “expert peer” to prompt assessment of patients, using confidential peer interviews 

during morning rounds or via e-mail. Verbal reports of errors were confirmed with the patient 

medical records, but only one incident report was submitted by a house officer for a patient fall. 

Nurses submitted the majority of incident reports for errors involving patient slips and falls, 

medication errors, and other events.36 In the third study, a hospital introduced nurse case 

managers to review patient medications, detect adverse drug events (ADEs), and report detected 

ADEs. Once the nurse case managers began reviewing medications and submitting ADE reports, 

the majority of which were for serious ADEs and possible ADEs, the reports of ADEs nearly 

doubled.126

19 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Researchers in one study provided error reporting education to staff, revised their current 

reporting system, and introduced a call center. As a result, reporting increased throughout the 

hospital—more physicians in the emergency department and more nurses in medical units 

submitted error reports—and there were more anonymous reports compared to the hospital used 

as a control. More reports were submitted using the one-page form than through the call center. 

Nurses continued to submit the majority of reports.120

One study aimed to improve error reporting through educational initiatives in 10 critical 

access hospitals. The investigators conducted several education workshops about the nature of 

errors, the design of safety systems, and best practices in medication safety. Then they collected 

error reports from all the hospitals and provided quarterly reports from the error reports to each 

of the hospitals, including the results and averages from the group of hospitals. The investigators 

found that most of the errors were not harmful and were associated with medication 

administration, mostly for dose omissions. The reports helped hospitals identify and address 

systems factors that were conducive to errors.116

Five studies tested the effects of new, voluntary error-reporting systems. One study assessed 

the impact of introducing an error-reporting system in community, primary care research 

networks. Investigators found that the number of reports increased, but the confidential reports 

were more complete than the anonymous ones.121 Another study also found that error reports 

increased after the introduction of a voluntary reporting system, that nurses submitted the 

majority of the errors reports, followed by pharmacists, and physicians submitted an error report 

only if the error was detected and prevented by the nurse.122 A teaching hospital in New York 

implemented a new confidential, electronic-based error-reporting system along with an 

educational program. Investigators found that error reporting increased, but reporting remained 

low among physicians.135 Another study assessed the effects of introducing a new Web-based 

anonymous reporting system. Investigators found that error reports, including those for 

intercepted errors, increased, and errors attributed to physicians increased while those attributed 

to nurses and pharmacists decreased.112 The last of these five studies assessed the impact of using 

a voluntary reporting that called near misses, “close calls” and frequent feedback reports. The 

investigators found that after six months, the number of error reports increased by 1,468 

percent.154

The association between voluntary error reporting and the number of error reports submitted 

was tested in two prospective, interrelated studies, using paper-based SAFE (Safety, Actions, 

Focus, Everyone) cards. One tested these cards in the medical ICU,137 the other in the surgical 

ICU.136 The SAFE report card was used over a period of 6 months to document types of events, 

including errors in tests, treatments, and procedures; medication; equipment; blood products; 

intravenous complications; behavioral/psychiatric; laboratory; surgery; and falls. This new 

reporting system resulted in more reported events (232 events) than what was captured by the 

existing hospitalwide database used to register errors and high-risk events (29 events before and 

26 events during the intervention). The investigators believed that the system fostered reporting 

by unit team members and could reduce events proactively through improved practice.136 The 

second study used similar methodology and added an additional step: the cards were withdrawn 

then reintroduced. The cards were reintroduced once the investigators assessed the significant 

drop in error reporting. The initial use of the cards increased nurse and physician reporting. After 

the cards were withdrawn, there was a decrease in reports by both nurses and physicians; instead, 

there were an increased number of reports submitted to the hospital electronic reporting system 

by nurses. The investigators found that a higher proportion of events reported by physicians were 

20
Error Reporting & Disclosure

for events that resulted in patient harm, whereas the higher proportion for nurses was for events 

that did not result in patient harm.136 In both studies, nurses submitted the majority of reports and 

physician reporting increased. 

Disclosure Preferences 

Five studies investigated factors associated with disclosure preferences of nurses. Two 

studies investigated disclosure preferences of patients and clinicians. In one of these studies, 

which used surveys with error scenarios, patients reported wanting full disclose of errors, yet 

physicians and nurses wanted to disclose only what happened.81 In the other study, which used 

focus groups, patients and clinicians agreed that errors should be disclosed when the patient was 

harmed. The degree of harm caused by errors and whether patients and others were aware of 

errors were related to disclosure preferences. Institutional culture (perceived tolerance for error 

and supportive infrastructure) was important to the disclosure decision. Relevant 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.91

Three studies used surveys to investigate disclosure preferences of EMTs, physicians, and 

nurses. In one study that specifically asked only nurses, nurses reported that they were less likely 

than physicians to want to disclose errors.81 Another survey found that 74 percent of physicians, 

23 percent of nurses, and 19 percent of EMTs had disclosed errors.95 Physicians were also more 

likely to disclose (71 percent) an error than were nurses (59 percent), but nurses (68 percent) 

were more likely to report an error than were physicians (54 percent).92

Another survey found that 29 percent of physicians and 64 percent of nurses reported feeling 

comfortable discussing mistakes. Also, 42 percent of physicians and 44 percent of nurses 

reported feeling uncomfortable discussing errors with patients.143 

Evidence-Based Practice Implications 

Given the history of error reporting and the role nurses have in patient care, it is important to 

emphasize that nurses are pivotal in improving patient safety via error reporting. Patient safety 

will improve when systems effectively assure and improve safety, predicated on a culture in 

which the reporting of errors or near misses is considered valuable, and positive actions lead to 

study and change for improvement, not blame.155 To avert underreporting of errors and to 

effectively learn from errors, administrators in health care agencies need to develop policies that 

support the routine reporting of errors, so that increased numbers of reports of actual errors and 

near misses are rewarded on an individual or unit basis. By easing the transition of an institution 

to a culture of safety, eliminating blame and the pressure of a punitive environment, error 

reporting will most likely increase. Additionally, it is evident that caregivers and patients profit 

from detailed accounts and increased reports, specifically in hospitals that act on unsafe practices 

identified through analysis of error reports. Systems improvements need to be communicated 

with all stakeholders so that they benefit from seeing the feedback loop in action. 

Ethical principles—including beneficence, fiduciary responsibility, respect for autonomy, 

justice, and honesty—guide clinical practice and mandate reporting and disclosure.156 These 

principles guide safety efforts and must be espoused by administrators and providers. Improved 

21 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

safety practices begin with policy and procedure development and continue with the allocation of 

resources for developing reporting systems and databases as well as educating caregivers. 

New systems of reporting errors are generally developed in-house or purchased by health 

care agencies. Electronic systems that are Web-based—that include easy reporting and standard 

definitions of errors, near misses, and potential root causes as well as personnel responsible for 

analyzing and sharing safety hazards—provide opportunities for data management and pattern 

identification of unsafe practices. They also save time for providers as reports are entered into 

databases and help to shorten the time from incident to report. Developing new systems of 

reporting requires administrators to budget accordingly so that additional personnel and 

electronic reporting systems as well as complementary software are financed. Periodic training 

of personnel and upgrading reporting databases are necessary, as are systems improvements that 

depend on error-report analysis. 

Patients and families desire disclosure of health care errors by health care providers. 

Providers have an ethical responsibility to disclose. Generally, organizations use verbal reports, 

followed by written reports offered by patient safety officers, in consultation with agency 

attorneys, in accord with institutional reporting and disclosure policies. Refusing to disclose 

suggests fear and a need for provider control rather than patients’ and families’ need for honesty 

about their care. Disclosure policies must be created with honesty and respect for patient 

autonomy in mind; apologies must be required. 

The emotional responses and perceptions of caregivers about errors are important barriers to 

reporting. Providers consider themselves at risk when they report errors because many providers 

carry the residue from previous experiences with mistakes. Anger from coworkers, shame, lack 

of confidence, and the like combine with guilt about the suffering of patients and fear of 

potential litigation to hinder reporting and disclosure. Nurses respond similarly to errors as 

physicians. They feel vulnerable to disciplinary action and legal repercussions; thus errors go 

underreported. Providers must experience changes in institutional culture, where systems 

improvements are targeted rather than individual blame. 

Teamwork training improves error reporting and reduces clinical errors. Teamwork 

principles include increased communication among health care providers. One element of a 

teamwork training program, cross-monitoring, might result in decreased errors as providers 

observe each other, identify unsafe behaviors, and act to correct each others’ mistakes. Status 

barriers must be penetrated. Cross-monitoring involves interdisciplinary/caregiver observations, 

identifying unsafe behaviors, and acting to correct unsafe behaviors. The challenge is how this 

team training element might be successfully initiated and consistently reinforced in acute care 

hospitals, critical access hospitals, nursing homes, long-term care facilities, and other agencies. 

Along these lines, nurse educators are challenged to include teamwork strategies and exercises 

aimed at increasing safety practices in health care agencies in undergraduate and graduate 

nursing courses, taking into account content on existing status issues among health care 

providers. 

Research Implications 

The majority of the research on error reporting has occurred within the past 10 years. While 

the studies included in this analysis provide important insight into what is being reported, they 

were primarily descriptive and none were nonrandomized or randomized controlled trials. Thus, 

additional well-designed studies are called for. Teamwork training holds promise as an 

22
Error Reporting & Disclosure

intervention that might affect frequency and severity of reported errors. Emphasizing crossmonitoring and increased communication as team training strategies might also affect outcomes. 

Teamwork training could include scenarios that challenge clinicians to determine how and what 

to report. Multisite team training programs should be investigated. The benefit of team training is 

in the development of expertise in reporting and disclosure among front-line providers. However, 

additional research is needed on the effect of team training on error frequency and reporting and 

disclosure skills, especially among nurses. Examples of research questions might be, Are there 

differences in patient and family member satisfaction when disclosure of errors is provided by 

team-trained versus usual-approach health care providers? Does team training affect error and 

near-miss reporting rates? 

Additional studies could be conducted in which disclosure of errors to patients and families is 

linked to differences in outcomes, for example, claims reports and monetary awards. More 

research is needed on the impact of Web-based reporting systems on time used for reporting via 

data entry, time from incident to report, time to systems improvement, as well as a classification 

of systems improvement strategies and the effect of strategies on error outcomes. Examples of 

research questions might be, Are there differences in severity scores following errors when Webbased versus incident-report methods of reporting are used by health care providers? Are there 

differences in frequency of error reports when Web-based versus incident reporting systems are 

used? Comparisons also might be made between physician and administrator methods of 

disclosure to patients and families in which simplicity or complexity of disclosure events are 

examined. Examples of research questions might be, Are there differences in patient and family 

satisfaction when physician/administrator disclosers are trained using standard, simple script 

versus unscripted (usual) disclosure communication approaches? Are there differences in the 

number of liability claims and monetary awards when mandatory versus voluntary disclosure 

policies are used? 

Notable in the reviewed literature was the dearth of studies on reporting and disclosure 

regarding the variety of adverse events, for example, blood transfusion errors, device 

malfunctions, health care acquired infections, and others. Most addressed were medication 

errors. Data are needed across all settings; most research on reporting is hospital-based. 

Community settings, nursing homes, free-standing short-procedure units, and primary care 

offices also require additional study regarding error reporting and disclosure. Consequently, 

there are many research opportunities for nurse investigators. Research is needed describing 

initial patterns of errors across various settings and focusing on other events, including blood 

transfusions, surgical incidents, device malfunctions, etc. Comparisons might also be made in 

liability lawsuit statistics between institutions that have disseminated and acted on the no-blame 

cultural approach versus those that have initially instituted this approach. 

Conclusions 

Sustained and collaborative efforts to reduce the occurrence and severity of health care errors 

are required so that safer, higher quality care results. To improve safety, error-reporting 

strategies should include identifying errors, admitting mistakes, correcting unsafe conditions, and 

reporting systems improvements to stakeholders. The greater the number of actual errors and 

near misses reported, the more reliable a health care organization or system could be, from a 

safety viewpoint, when systems improvements are consistent with error patterns. 

23 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Clinicians appreciate seeing the results of the reports they submitted transformed into 

systems improvements. Understanding and communicating the root causes of errors and near 

misses can decrease the risk of future errors, and support the concept that health care errors are 

often systemic and multifactorial. Reporting errors and near misses may increase through 

voluntary reporting systems, because voluntary systems provide additional evidence that the 

blame/shame patterns are being eliminated in health care organizations and systems. 

Electronic error-reporting systems can possibly make the time required to report shorter, 

shorten the time for correcting unsafe conditions, and alert providers to emerging unsafe 

patterns. Some systems can also facilitate quality improvement initiatives through enhanced 

error-reporting systems. The benefits of Web-based health care reporting systems that clinicians 

find easy to use and see the effects of their reporting in changes to systems might ultimately 

reduce the incidence of serious errors, and significantly improve the safety and quality of health 

care afforded patients. 

Search Strategy 

Various databases were searched to locate studies and related literature on reporting and 

disclosing health care errors, including CINAHL®, PubMed®, and Psycharticles. Search terms 

included “medical errors” and “medical error reports.” Published results in a non-English 

language, expert opinions, case reports, and letters were excluded. Studies specifically assessing 

rates, types, and causes of reported medication administration errors were excluded as well. To 

be included in the analysis, each article had to involve nursing and report findings specific to 

nurses. Most of the articles identified in the literature search were primarily descriptive. 

Author Affiliations 

Zane Robinson Wolf, Ph.D., R.N., F.A.A.N., dean and professor, La Salle University School 

of Nursing and Health Sciences. E-mail: wolf@lasalle.edu. 

Ronda G. Hughes, Ph.D., M.H.S., R.N., senior health scientist administrator, Agency for 

Healthcare Research and Quality. E-mail: Ronda.Hughes@ahrq.hhs.gov. 

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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 e

misses were med73 nurses reportereported making bduring the study p

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 va

reported overall; inrate overall. Repobeing blamed, peebecoming negativphysicians, losing reporting. Reporting of MAEquality managemeErrors resulting in were underreporte

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 

MAEs, significantlorganizational powsaving concerns. 

32 
33 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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, emailed 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 th

did not punish erroStaff have learned continue to learn fMost agreed that trecognized that m(64%) and that errby all employees (Majority felt comfocomfortable (32%errors. Attempts to maintbelief about lackinnurses from questPharmacists were ability to recognize Nurses reported munclear or confusiNonphysicians attnursing practices. 96% of nurses anphysicians, adminassigned patient snurses. 22% of reclinicians and admresponsibility for pNurses reported thfor reporting errors themselves (98%)in procedures (88reviewing reported participating in inv(72%). However feparticipated in invanalyzing errors. 
34 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 rbut reports from nconstant and the rdecreased. The pharmacist direporting 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 nu

reporting experien27% more. 34% of ICU staff rPhysicians reportewhile nurses reponurses had a morPhysicians and numisses. 47% reported time punitive actions as 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 reportin

time, forgetfulnesswhat to and who sMost common reperrors was a perce

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 

physicians and nuwhat happened. Nurses (the only cless likely to want patients. 
35 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

Espin 2007130 Error reporting Cross-sectional 

study 

Administered 4 error scenarios to nurses 

13 perioperative nurses at 1 hospital in Canada 

None 58% of theoretica

errors, only 26.7% been reported by Nurses perceived profession-specifishould report erroThe presence of a appeared to be a for nurse error repNurses had a greaerrors informally wnurse 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 physicia

of the incident repNurses were more submit an error recompleted an erroknow where to su(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 increashospitals. More rephysicians in EDs Nurses generated 
36 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 err

when patients are caused by error aothers were aware characteristics relaInstitutional culturerror and supportiimportant to disclofactors were healtdesire for informatprovider. Provider malpractice, reputchange in rapport perceived professmedical training, ladisclosure skills, a

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 ediagnostic tests, 3and 13.6% with bodiagnostic test; 70associated with coConfidential reporthan anonymous rReporting differennot vary between confidential report

France 2003122 Reporting system Quality improvement Assessed utilization of a voluntary reporting 

system and providerinitiated improvements (Level 4) 

1 hospital in Tennessee 

Implemented a voluntary reporting system 

Nurse reporting siimplementation, wsignificantly increa

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 7

of 2.2 reports per The majority of ernurses and pharmminor. Physicians were fowhen detected anpharmacists. 
37 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 

knowledge of the system, but less th20% of physicians system. Physicians and nuabout the effectivereporting system. Physicians reporteresponsible for rep40% of physicians concerned about tyet 86% of nurses favored feedback in response to the 40% of physicians concerned that the 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, cardbased reporting program to encourage anonymous reporting of errors 

Nurses submitted followed by 23.1% by other reportersOf the reports whepatient, 31.1% wefrom other staff, aOf the reports wer33.9% were from nurses, and 13% f

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% 

which were categoPhysicians submitreporting rate of 0nurses submitted reporting rate of 3errors. Lag time was 18% than minor, and 75
38 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 patie

provider type (19% 74% physicians). 59% of physicians another provider d

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 m

disclose an error tbut nurses were mthe error than wer

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 h

problematic behavsafeguarding agaisubcutaneous injeError rates that webut not all, were mendoscopy preparadministration of pand blood transfusError rates were hpatients, those witbehavior, and the Incidence of errors violations, managnonstandardized n
39 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 m

providers’ concern considered in systreporting and policimprove error repoinformation about considering perceand including fronperspectives on creport, education anonymous reportpersonnel, and roreports for educatNurses were more how to report erroAll mentioned barlack of confidentiaafter an error—are Both physicians areporting was inteand policy to prom

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 availability of pharreporting greater perrors (circumstancause error) and Coccurred, but the patient). Nurses submitted 
40 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 hospit

technology (HIT); medication adminradiology. 

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 rep

errors resulting in About half were ube reported. 32% worried that tfiles. 52% reported havand informed abo48% reported spesomething negativopinions that diffe66% felt that their patient safety wer83% felt that more happened than didunits had serious 56% reported probphysicians. Frequency of repoamong nurses witexperience. Head more frequently th

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 

intentional wrongdquestionable behaThe perception of whether the error Unintentional erro

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 manaADEs, compared and 75% of seriou
41 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 mo

outcome. Physicians were lethan were nurses Health care profesreport errors of sePhysicians were uof clinical protocolmidwives were mo

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 wa

majority would repphysician, but few incident report for compared to abouNurses working in units perceived hi(52.5%) than did tmedical/surgical uThe mean perceiverrors was 45.6%92.6% reported knerror was, and 91when to use an inReporting barriers reactions (76.9%)reactions (61.4%)was not serious e(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 increase (from 175 afterwards) in the Reports facilitated interventions to im
42 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 re

involving medicatiprocedures. 89% of incident re48% of incidents o21% in ICUs, and Nurses were involpotentially prevenphysicians were in

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 medicalsurgical units in a 700-bed community hospital in South Florida 

None 43.9% of respond

25% of medication 84.2% of respondknew what defined medication errors because of fear. 57.9% reported thmedication error wit serious. There was no diffeassociated with aglevel 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 per 100 ICU patieNurses reported th(59.1%), followed (27.2%) and ICU a(2.6%). Most reports invol(e.g., medicationsnecessary/plannemedication errors malfunctioning eq9.9% of events reqinterventions, and patient’s death. 60interventions were delays/omission ononmedication treplanned procedur
43 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 c

own errors in a pathan they are poinby others. 

Rudman 2005112 Error reporting systems Cross-sectional study Comparative description of baseline 

paper-based medication errors with postintervention Webbased 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 repactions taken. Error reports and increased. Intercepted nursepharmacist medicErrors attributed to nurses’ and pharmDetails of cause-o

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 reportin5.8 reports per 1,0nurses from 18 to patient days. When reporting caphysician reportinpatient days, then when the cards wA higher proportiophysicians were foharm, while the hireported by nursenot cause harm to 
44 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 e

medication errors nurses estimated patient-days were and 5.66 in adult uMedication errors pediatric and adulreported on pediaThe more strongly agreed with manaindividual/personaerrors, the lower treported. Pediatric nurses aconsequences fropeers will think of 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 

associated with inNurses providing more likely to repoNurses would repopatients and those 

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 7events; physicians Of the events repo

- 16% wer

near misevents wand 39% correctly

- 40% wer

events, 3events, a
45 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 e

and work involved not being able to rthinking that errors outcomes should legal actions; and someone else. Modifiable barriers structure and procand education. Least modifiable blawsuits, fear of bemotivational issuePhysicians identifito reporting than dtime and extra woan error. Nurses wabout anonymity, fear of lawsuits, areporting errors thharm. 

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 staf

error, occurrence with staff nurses, spersonal experienmedication admin

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, disagreeme

occurred, adminismedication errors, report MAE are rereport errors. Fear inhibits reporchange needed to complete error repemphasis placed measure of quality 
46 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 a

administrative resreporting, but the with individual chamanagement pracThe degree of agrtheir supervisors areported varied coSupervisors were administrative resreporting, whereaas 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 ty

institutions tended cultures, larger insmore hierarchal in The extent of CQI with bed size of thrate of MAE reporThe greater the nulower the reporting The presence of a and higher levels were positively buassociated with reHierarchical or ratnegatively associa

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 testretest 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 reas

reported were due definitions, the bufear (e.g., judgmeand their families, adverse consequefor patient harm), response (e.g., no individual blame, athe severity of the 
47 

Source 

Safety Issue Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) 

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 verb

officer and confirmrecord, only one whospitals’ incident Nurses recorded treports, whereas osubmitted by a ho

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 a

the hospital’s erroresidents and 72% use it. Residents were mculture as more thnonsupportive; 29nurses reported bdiscussing mistak44% of nurses wediscussing errors nurses were comfmistakes with sup54% of residents areported being moeither their own or 25% of residents amore likely to repolike the person wh

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 

similar when using checklists, nurse itests, and questioerrors. Falls were not alwon whether patienactivities of daily lstandardized care Restraint use was in patient record.