The Impact of Patient Safety Culture
The Impact of Patient Safety Culture
The Impact of Patient Safety Culture
Abstract
Background: There is growing interest in examining the factors affecting the reporting of errors by nurses.
However, little research has been conducted into the effects of perceived patient safety culture and leader
coaching of nurses on the intention to report errors.
Methods: This cross-sectional study was conducted amongst 256 nurses in the emergency departments of 18
public and private hospitals in Tabriz, northwest Iran. Participants completed the Hospital Survey on Patient Safety
Culture (HSOPSC), Coaching Behavior Scale and Intention to Report Errors’ questionnaires and the data was
analyzed using multiple linear regression analysis.
Results: Overall, 43% of nurses had an intention to report errors; 50% of respondents reported that their nursing
managers demonstrated high levels of coaching. With regard to patient safety culture, areas of strength and
weakness were “teamwork within units” (PRR = 66.8%) and “non-punitive response errors” (PRR = 19.7%). Regression
analysis findings highlighted a significant association between an intention to report errors and patient safety
culture (B = 0.2, CI 95%: 0.1 to 0.3, P < 0.05), leader coaching behavior (B = 0.2, CI 95%: 0.1 to 0.3, P < 0.01) and
nurses’ educational status (B = 0.8, 95% CI: − 0.1 to 1.6, P < 0.05).
Conclusions: Further research is needed to assess how interventions addressing patient safety culture and leader
coaching behaviours might increase the intention to report errors.
Keywords: Coaching, Patient safety culture, Medical error, Cross-sectional studies, Iran
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Chegini et al. BMC Nursing (2020) 19:89 Page 2 of 9
Errors risk patients’ health and well-being as well as reports that are made [21]. In developing countries,
their lives and can increase the cost of medical treat- leaders frequently focus their activities on data collec-
ment, such that the quality of care is negatively affected tion, audit and reporting rather than on catalyzing learn-
[4]. James reported that, in US hospitals, a minimum of ing and supporting systems that lead to quality
210,000 deaths per annum were associated with medical improvement [22, 23]. However, a coaching program has
errors [5]. In Australia, each year, 18,000 preventable successfully promoted alternative perspectives and sup-
deaths are attributable to medical errors and at least 50, ported positive change [24], coaching having emerged as
000 patients are disabled [2], and in Germany 25,000 a major tool to continue the education process and en-
deaths result from 100,000 medical errors per year [6]. able a change to team-based care [25]. Up-to-date guid-
Fundamental to error prevention is the principle that er- ance and the support of educators and coaches mean
rors should be reported and, to this end, systems have that nurses participate in life-long learning and a culture
been established to promote error reporting: in Australia of safety is created and enhanced [24].
and the US in 2000, in the United Kingdom in 2003, and What research there is into leadership coaching for
in France in 2006 [3]. professionals in healthcare settings is anecdotal and a
In third world and developing countries, accurate esti- solid evidence-base is yet to be established [26]. How-
mates are difficult because with no effective recording ever, in Iran, the rate of medical errors in emergency de-
and reporting systems, there is a shortage of research in- partments is alarming [27]. A recent study in emergency
formation. However, it is thought that the medical errors departments has shown that medical errors occurred
rate is high [7]. In Iran, it is estimated that between 3 amongst 46.8% of nurses in emergency departments [28]
and 17% of in-patients experience unwanted side effects which are overcrowded, with shortages of staff and
as a result of medical errors with 30–70% of these being equipment, and patients admitted with life-threatening
preventable [8]. Despite such high rates of medical er- illnesses, all making it more likely that there will be a
rors, Iranian healthcare organizations have poor levels of higher incidence of medical errors [29]. According to a
reporting [9]. study conducted in the U. S, nearly 3% of all hospital ac-
Several factors influence medical error reporting cidents are related to the emergency department [30].
among nurses. One of these is the fear of creating a Given this, and the paucity of research exploring the
negative impression by ward staff towards the person association between PSC, nurses’ intentions to report er-
who reports an error [10]. Lack of adequate support rors and the coaching behaviour of leaders, [12] this
from colleagues is another factor. Therefore, it is im- study aims to investigate the relationship between these
perative to support health professionals in error-related variables amongst Iranian emergency nurses.
events [11]. Administrative factors, such as rigidity, cost-
cutting measures, lack of policy and standard operating Method
procedure and fault finding were other reasons for Study design
under-reporting the errors [12]. Most minor errors and A cross-sectional survey design was adopted for this
near misses often go unreported [13]. Near misses are study.
often discounted since they pose no harm to the patient.
Recognizing and reporting near misses is proactive pa- Sampling and data collection
tient safety and a quality improvement strategy that A survey was conducted in both public and private hos-
needs to be adopted in order to prevent similar and pitals (N = 18) in Tabriz, northwest Iran. The study
harmful events occurring in the future [14]. population included 350 nurses, working the morning
A review of existing literature found a relationship ex- and evening shifts in 18 emergency departments, with
ists between the number of medical errors reported and participants identified using census sampling. The inclu-
elements of PSC [15, 16]. It is evident that leadership is sion criteria for the sample selection included only staff
an important element of PSC and that patient safety can nurses (a) being a full-time nurse; (b) employment in the
be both facilitated and inhibited by perceptions of lead- emergency department for a minimum of 1 year, and (c)
ership amongst nurses [17, 18] with a leader’s attitude being available during the period of data collection.
being reported as a contextual factor in a health care Those on leave during the study period, nurse educators
professional’s decision to raise issues in relation to pa- and nurse managers were excluded from the study.
tient safety [19]. Institutional consent was obtained prior to data collec-
Adverse events are seen as providing “information- tion after explaining the purpose of the study to the
rich” data for learning and systems improvement by head of the nursing department of each participating
leaders who proactively strengthen PSC [20] and it has hospital. Individual consent was also obtained at the
been seen that PSC is significantly impacted through emergency departments from January to March 2019.
education and coaching when leaders follow up on The purpose of the study was explained to the nurses
Chegini et al. BMC Nursing (2020) 19:89 Page 3 of 9
and the consent forms were filled in by them. The ques- Coaching behaviors of the nurse leaders
tionnaires were given to those who volunteered to par- Leader coaching behaviour (LCB) was measured using
ticipate in the study. All ethical principles were strictly the Coaching Behavior Scale, a survey tool designed to
adhered to, as they were free to withdraw from partici- assess LCB amongst nurses developed by Stowell [36]
pating at any point in time, and their participation would and subsequently revised by Ko and Yu [12].
not affect their clinical practice. Anonymity was main- Two independent researchers, with a background in
tained throughout data collection. The completed sur- nursing, translated the LCB questionnaire into Persian.
veys were retrieved from participants by the designated The translation was double reviewed and checked by
research assistants in each hospital. two professors both with background in nursing, leader-
ship and in the English language. The LCB comprises 13
questions scored with a 5-point Likert scale measuring 4
Study instruments behavioural factors: direction (3 items), development (3
Tools for gathering data were Demographic and Hos- items), performance evaluation (3 items), and relation-
pital Survey on Patient Safety Culture (HSOPSC), ships (4 items). The total scores range from 13 to 65
Coaching Behavior Scale and Intention to Report Errors points. Higher scores indicate that the coaching behav-
Questionnaire. All questionnaires were administered in iour of a manager is perceived as positive.
Persian and instruments not already available in this lan- The validity and reliability of the tool has previously
guage were adapted to Persian using a standardized been established by Ko and Yu [12], with good internal
back-translation procedure [31] by a panel of experts. reliability at a Cronbach’s alpha coefficient ranging from
0.78 to 0.98. In this study, the Cronbach’s alpha of the
LCB was 0.92. The LCB of the nurses was divided into
Patient safety culture two groups: (high-performance coaching and low-
PSC was measured using the Hospital Survey on Patient performance coaching). The overall perception of LCB
Safety Culture (HSOPSC), developed by the Agency for for each respondent was calculated by taking the average
Healthcare Research and Quality [32] to determine scores of the 13 items in the LCB questionnaire. Using
nurses’ perceptions of PSC. The HSOPSC questionnaire this mean score, individuals with a score higher than 3.5
was translated into Persian in 2012 and has been vali- were placed in the high-performance coaching group,
dated in a previous study [33]. The HSOPSC comprises and the rest were placed in the low-performance coach-
12 PSC dimensions, encompassing a total of 42 items, ing group [12].
with 3 or 4 items per dimension. All items are measured
with a 5-point agreement scale (from 1 = strongly dis-
agree to 5 = strongly agree) or frequency (from 1 = never Intention to report errors
to 5 = always). To measure the nurses’ intentions to report their own
The mean score of each dimension was calculated. or others’ errors, we used an instrument developed by
Also, a Positive Response Rate (PRR) could be calculated Kim [37] which poses three questions: “If you com-
for each item from responses of “strongly agree/agree” mitted an error that had no adverse effect on patients
or “always/most of the time”. To calculate the PRR of in your current work situation, would you report the
each dimension, the first step was to compute the PRR error?” “If your colleague committed an error with no
for each item and then calculate the mean PRR across adverse effect on patients in your current work situ-
all items in the dimension. The mean PRRs of the overall ation, would you report the error?” and “Do you
HSOPSC can be similarly calculated: share information regarding errors or malpractice
with others?” The response options were ‘never’,
Scores of 75% and above are considered as ‘rarely’, ‘sometimes’, ‘usually’, and ‘always’. In Ko and
representing a good PSC/area of strength. Yu’s study [12] the Cronbach alpha was 0.83; and in
Scores between 50 and 75% are considered as a our study, it was 0.76. Previous research has estab-
neutral PSC. lished that appropriate performance of error reporting
Scores of less than 50% are considered as indicative is indicated by answers that the respondent “always”
of a poor/low PSC /need improvement [34]. or “usually” reported their clinical errors and “in-
appropriate” performance by the responses “some-
The HSOPSC was used previously in studies that times”, “rarely”, and “never” [38].
assessed the perception of staff on the PSC of several The demographic variables of the respondents, includ-
Iranian hospitals [33, 35]. In the study conducted by ing age, gender, marital status, education level, work ex-
Moghri et al., the Cronbach’s Alpha of the questionnaire perience (years), and work time (hours per week) were
was reported to be 0.82 [33] and in this study to be 0.83. collected at the end of the survey.
Chegini et al. BMC Nursing (2020) 19:89 Page 4 of 9
Data analysis the participants was 35.4 (SD = 8.6) years. The average
Data analyses were conducted using SPSS 22.0 (IBM experience in nursing was 10.9 (SD = 7.9) years and
Corp., Armonk, NY, USA). The demographic character- 42.2% had been working in nursing for more than 10
istics of the respondents were described using descrip- years. 53.9% of nurses worked less than 44 h per week
tive statistics including frequency, percentage and means and 58.6% were in permanent employment.
and standard deviations. A multiple linear regression The PRRs and mean (SD) scores of PSC, LCB and
model was developed with the intention to report errors intention to report errors are shown in Table 2. Mean
as the dependent variable, PSC and LCB as independent (SD) scores for PSC ranged from 2.5 (0.7) to 3.8 (0.7)
variables. The demographic variables were entered to and the PRRs ranged from 19.7% to 66.8%. The PRRs of
model as potential confounders. The level of significance PSC dimensions were all less than 75% and the overall
was set at 0.05. PRR was 44.8%. The PRR of “teamwork within units”
(PRR = 66.8%) was the highest followed by “manager ex-
Results pectations” (PRR = 65.8%). The PRR of “non-punitive re-
Some 279 responses were received over a three-month sponse errors” (PRR = 19.7%) was the lowest. This means
period. Of these 23 were excluded from the analysis as that hospital management did not provide a supportive
they were less than 50% complete or did not meet the working environment in the promotion of patient safety
inclusion criteria. With an overall response rate of as workers often preferred not to report errors for the
73.1%, a total of 256 questionnaires were analyzed. fear of stigmatization, blame and punishment.
Characteristics of the sample are summarized in Mean (SD) scores of LCB ranged from 3.2 (0.9) to 3.3
Table 1. The majority of the sample was female (68.4%) (1.1). The overall mean (SD) score of LCB was 3.3 (0.6)
and held a Bachelor’s degree in nursing (54.4%). 54.7% and of the four dimensions, the highest and lowest per-
of participants were married. The majority came within ceived coaching performance related to “performance
the age group 31–40 years (44.5%), and the mean age of evaluation” (55.5%) and “direction” (35.9%). The mean
(SD) score of intention to report errors among nurses in
Table 1 General Characteristics of sample (N = 256)
this study was found to be 3.4 (0.9). Of the total partici-
Variables N (%)
pants (n = 256), 43% reported that they had a high
Gender intention to report errors.
Male 81 (31.6) Table 3 shows the results of multiple linear regression
Female 175 (68.4) analysis which was used to predict nurses’ intention to
Marital status report error.
Single 116 (45.3)
A statistically significant difference was shown be-
tween the educational level of nurses and their intention
Married 140 (54.7)
to report errors. Nurses with associate degree education
Age (in years) were 80% times more likely to report errors than those
21–30 80 (31.3) with Bachelor, Masters or PhD degree (B = 0.8, 95% CI:
31–40 114 (44.5) − 0.1 to 1.6, P < 0.05). No significant relationship was
> 40 62 (24.2) found in relation to other demographic characteristics.
Work experience (in years)
An increase of 20% in the intention to report errors was
observed for a one unit increase in the score on PSC
≤5 81 (31.6)
(B = 0.2, CI 95%: 0.1 to 0.3, P < 0.05). Similarly, an in-
6–10 67 (26.2) crease of one unit in the score on LCB, the intention to
> 10 108 (42.2) report error was increased by 20% (B = 0.2, CI 95%: 0.1
Education level to 0.3, P < 0.01).
Associate degree 13 (5.1)
Bachelor’s degree 147 (54.4)
Discussion
This study examined the relationship between emer-
Master’s degree or PhD 96 (37.5)
gency nurses’ perception of PSC and LCB with their
Employment status intention to report errors. The results show that, based
Permanent 150 (58.6) on PRR scores, none of the 12 dimensions achieved
Contract 106 (41.4) scores of 75% and cannot, therefore, be considered to
Weekly work time (Hour) represent areas of patient safety strength. This result is
Normal (≤44) 138 (53.9)
in contrast to findings of other research [39]. It was also
lower than other studies conducted in countries includ-
Overtime (> 44) 118 (46.1)
ing Taiwan [40], Lebanon [16] and Saudi Arabia [41],
Chegini et al. BMC Nursing (2020) 19:89 Page 5 of 9
Table 2 Descriptive statistics of the PSC, LCB and Intention to Report Errors
Variables Mean (SD) PRR (%) Judgmenta
Teamwork within units 3.8 (0.7) 66.8 Neutral
Manager expectations 3.7 (0.9) 65.8 Neutral
Feedback communication about errors 3.7 (0.8) 57.2 Neutral
Staffing 3.4 (0.8) 54.2 Neutral
Events reported 3.3 (0.9) 52.2 Neutral
Management support for patient safety 3.3 (0.9) 48.2 Weakness
Perception of patient safety 3.2 (0.7) 43.8 Weakness
Organizational learning 3.2 (0.7) 42.9 Weakness
Communication openness 3.0 (0.7) 38.1 Weakness
Teamwork across units 2.7 (0.9) 26.6 Weakness
Handoffs and transitions 2.7 (0.6) 22.3 Weakness
Non-punitive response errors 2.5 (0.7) 19.7 Weakness
Overall PSC 2.9 (0.7) 44.8 Weakness
High-performance coaching (%)b Intention to report errors (%)
Performance evaluation 3.3 (1.0) 55.5 –
Development 3.3 (1.1) 43.8 –
Relationship 3.2 (1.0) 45.7 –
Direction 3.2 (0.9) 35.9 –
Overall LCB 3.3 (0.6) 50.0 –
Intention to report errors 3.4 (0.9) – 43.0
Note: PSC. Patient safety culture, LCB. Leader coaching behavior, PRR. Positive Response Rate
a
PRR > 75% was defined as patient safety strength, scores between 50 and 75% are considered as a neutral patient safety and scores of less than 50% are
considered as indicative of a poor patient safety
b
Score higher than 3.5 were placed in the high-performance coaching group
Table 3 Multiple linear regression analysis of factors associated with cultural and organizational differences relating to
with intention to report error (N = 256) patient safety thought to explain the differences.
Variables Beta (95% CI) Perhaps one of the most important factors to mention
Patient safety culture* 0.2 (0.1 to 0.3) in the same studies is the disparity in accreditation pol-
Leader coaching behavior **
0.2 (0.1 to 0.3) icies and procedures in three countries where the study
Age (reference: > 40) was conducted. For instance, there is a mandatory ac-
creditation system in the Iranian health system moni-
21–30 0.1 (− 0.3 to 0.5)
tored by the Ministry of Health which has not fully
31–40 0.2 (− 0.1 to 0.5)
taken shape, while Lebanon and Saudi Arabia were
Gender (reference: female) − 0.1 (− 0.3 to 0.2) among the countries in the Eastern Mediterranean re-
Marital status (reference: married) 0.1 (− 0.1 to 0.3) gion whose accreditation standards have been approved
Education level (reference: Masters or PhD degree) by the International Society for Quality in Health Care
Associate degree* 0.8 (− 0.1 to 1.6) (ISQUA) and are monitored by international organiza-
tions [42].
Bachelor 0.6 (− 0.1 to 1.3)
Another challenge of the Iranian healthcare system is
Employment status (reference: Contract) − 0.2 (− 0.5 to 0.1)
staff shortages, the financial pressures experienced by
Work experience (reference: > 10) hospitals, lack of senior management support for patient
≤5 −0.2 (− 0.5 to 0.1) safety culture and lack of systematic approach for
6–10 −0.3 (− 0.6 to 0.1) reporting errors [43, 44] which means patient safety is
Work hours (reference: overtime) 0.1 (− 0.1 to 0.3) seen as a low priority by managers. For patient safety to
be effective, there is a need for continuous educational
R = 4.7% F = 15.3 P < 0.001
2
advancement at every level of the organization. In
Dependent Variable: intention to report error
* indicates significant value (p < 0.05)
addition, provision of necessary infrastructure, resources
** indicates significant value (p < 0.01) (human, financial, technological and material) and
Chegini et al. BMC Nursing (2020) 19:89 Page 6 of 9
procedures necessary for the development of patient concluded that the perceived coaching behaviour in this
safety culture needs to be implemented [45]. study may impact negatively on nurse performance in
A previous Iranian study conducted in an academic in- respect of safety-related issues.
tensive care unit [46], like the results in this study, found This study found that, overall, 43% of nurses had a
that all dimensions needed to be improved. These find- high intention to report errors, a similar finding to those
ings contrast with those of Habibi et al. (2016) where a of earlier studies in other countries [56–58] in which it
higher PRR score was found in teaching hospitals in was demonstrated that the proportion of error reporting
Tehran [47]. A recent Iranian systematic review illus- amongst nurses was less than 50%. These findings are
trates that, compared to the results of studies conducted significant as there is evidence which suggests that whilst
in other countries, the mean of the responses in Iran for nurses intercept 86% of potential errors [59],between 34
the different dimensions of PSC is low, a finding which and 50% don’t report medical incidents [60].
underlines the fact that, for many people working in In looking to explain the low rates found in these
Iranian hospitals (including the managers), the concepts studies, it is possible that an intention to report is linked
of PSC are unknown [48]. This is possibly because, ra- to an attitude towards reporting and an awareness of
ther than the issue being neglected, PSC is a relatively reporting, as well as the existence of support [4]. There
new concept in Iranian hospitals and has not been fully are also a multitude of reasons, including fear, humili-
recognized [49]. ation, a punitive reporting culture and limited follow up,
The dimension with the highest PRR was “teamwork following error reporting, that may lead to under-
within units”. Whilst this reflects the findings of other reporting [10]. Having said this it was found, in an Ethi-
studies [10, 50], in our study it was an area of patient opian study, that the proportion of error reporting
safety weakness. “Non-punitive response to error” had amongst nurses was 57.4% [61], a difference that may be
the lowest PRR, a finding which follows an earlier study related to differences in error reporting systems and to
conducted in a public hospital in Tabriz and which ex- differences in the time frame in which the studies were
amined the same issues [51]. These findings are consist- conducted.
ent with other local findings [47] and those from Human behaviour is influenced by motivators which are
international studies [10, 16, 52], and would suggest that borne out of their intentions, which show peoples’ willing-
a major barrier to error reporting is the risk of a punitive ness and commitment to their actions and behaviour [62].
response. When non-punitive measures are taken, errors Ajzen (1991) explained this in the Theory of Planned Be-
will be detected and reported early and further occur- havior (TPB) that intention can predict an individual’s
rences will be prevented [53]. needs and it has been confirmed in many studies [63]. Ac-
Punishing staff for their mistakes has been a strong cording to the TPB, intention mediates between attitude
measure taken by administrators and senior colleagues and actual behaviour or performance [62].
in many Iranian hospitals, without considering the rea- This study found a significant association between
sons for such errors. This policy has affected continuous nurses’ intention to report errors and the level of their
education and the work environment at large [48]. For education. Those nurses with an associate degree educa-
example, nurses in this study, like those in other similar tion were 78% more likely to report errors than nurses
studies, felt that if they reported their errors, a record of at a different educational level. This may be because pro-
their mistakes would be held in their personal file and fessional nurses have a fear of legal consequences or of
may be used against them at some point in the future losing their occupational position [10]. In contrast, a
and, for this reason they preferred silence over-reporting study conducted by Poorolajal et al. (2015) found that
errors. managers and staff who had attained higher educational
It is of interest that 50% of nurses in this study tended levels had a greater willingness to report errors [9]. An-
to rate their managers’ coaching behaviour as high. In other study also revealed that reporting medical errors
line with the study conducted by Ko and Yu [12] the depends on individual’s marital status [64]., while this is
highest and lowest perceived LCB in this study was at- not confirmed in our study.
tached to “performance evaluation” and “direction”. It is Nurses who experienced a high level of PSC were
important to note that, in respect of “performance evalu- found to be more likely to report errors in this study, a
ation”, only half of the participants described their finding which reflects that of Kagan et al. (2013) whose
leaders as being high-performing coaches and that in re- Israeli study confirmed that a readiness to report errors
spect of “direction” the percentage was 35.9%. Given the was influenced by an organization’s safety culture [58].
evidence that a lack of performance appraisal can impact Furthermore, a flexible culture can promote patient
negatively on nurse performance [54] and that coaching safety and error reporting within an organization by de-
on the part of team leaders supports learning from prob- veloping trust and improving the problem-solving cap-
lems and errors amongst members [55], it can be abilities of nurses [12].
Chegini et al. BMC Nursing (2020) 19:89 Page 7 of 9
This study also found that nurses who saw their man- response errors” and the fact that a fear of punishment
agers’ coaching as being at a high level of performance has consistently been found to reduce the frequency of
reported a stronger intention to report errors, a finding error reporting, it is incumbent on health decision-
which follows that of Ko and Yu [12]. In nursing, a man- makers to adopt programs that create an atmosphere in
ager develops capabilities by exposing nurses to appro- which individuals can openly discuss medical errors and
priate coaching strategies which together with regular potential hazards.
feedback encourages them to work independently [65]. Further, a culture which sees errors as an opportunity
As has been pointed out by Reid Ponte et al. [66] nurses to improve a system should replace a blame culture, in
who have experienced coaching describe it as helping which errors are seen as personal failures. Indeed the
them to recognize and modify behaviours that have usefulness of education and of efforts towards develop-
hampered their performance, and in doing so, improve ing a culture which encourages the reporting of patient
their effectiveness and that of the organization. safety issues is evident. Neither should it be forgotten
that nurses who perceived the manager’s coaching as be-
Strengths and limitations ing of a high level of performance reported a stronger
This study has several strengths. Notably, it is the first intention to report errors. Medical errors cause patients
study to have investigated the LCB of Iranian nurses, across the world to suffer disabling injuries and leader-
using validated tools to measure variables with a homo- ship coaching could be a significant means by which
geneous study population. However, the study also has error reporting is facilitated, thereby benefiting not only
limitations. Participants in the study were emergency patients and their families, and those that work in the
nurses working in hospitals in Tabriz, Iran and, as such, health service, but also the wider community.
the results may not be generalized to other hospitals or
Abbreviations
different clinical settings. Given such limitations, further PSC: Patient safety culture; HSOPSC: Hospital Survey on Patient Safety
studies in settings other than an emergency department Culture; PRR: Positive Response Rate; LCB: Leader coaching behaviour;
may be required if the findings of this study are to be SPSS: Statistical Package for Social Sciences; TPB: Theory of Planned Behavior
fully justified. Furthermore, as nurses were the focus of
Acknowledgements
this study a more complete picture might be obtained if Many thanks are offered to those nurses who participated in the study and
other studies focusing on other staff were conducted. the efforts of Dr. Lizzie Abderrahim of the Universitat Rovira i Virgili,
Besides, as this study adopted a cross-sectional ap- Tarragona, Spain in editing this manuscript are much appreciated.
proach and did not seek to establish cause and effect, it Ethical statement and consent to participate
is recommended that further studies adopt a longitu- The study was reviewed and approved by the Ethics Committee of Tabriz
dinal evaluation. It is also the case that potential University of Medical Science (IR.TBZMED.REC.1397.272). Attached to each
questionnaire was a cover letter explaining what was expected of the
organizational factors and a blame culture that were respondents who had to sign, indicating their informed consent before they
both identified in this study would benefit from a further provided answers. In this way, the full understanding and the voluntary
in-depth study in which a qualitative approach was participation of the respondents was established. Throughout the research,
confidentiality was respected and ensured. The third author obtained
adopted. Finally, the near misses are counted as insignifi- permission to use the questionnaires from the copyright holders via e-mail.
cant since there is no harm to the patient and because
of poor research evidence, due to ineffective recording Authors’ contributions
and reporting systems in developing countries such as ZCH designed and conducted the study, performed the analysis and drafted
the manuscript. EK advised on the study design, facilitated data collection
Iran, this study has measured the intention to report er- and revised the manuscript. AJ helped coordinate the study and assisted in
rors, instead of the actual number of errors reported. data collection. MAJ assisted in data collection and data analysis. ZCH and EK
Therefore, it is suggested to measure numbers of errors validated the analysis findings and revised the manuscript. All authors read
and approved the final manuscript.
reported in future studies.
Funding
Conclusion This work was supported by the Tabriz University of Medical Science, Tabriz
health services management research centre (NO Grant: 59002). The funders
In this study the intention to report errors among nurse had no role in study design, data collection and analysis, decision to publish,
respondents was low. Given that a high perception of or preparation of the manuscript.
PSC and LCB increases nurse intention to report error,
it seems that hospital managers and nursing administra- Availability of data and materials
The datasets analyzed during the current study are available from the
tors have an important role to play. They have the power corresponding author on reasonable request.
to shape the working environment, in terms of removing
barriers to error reporting and providing a supportive Consent for publication
Not applicable.
environment so that nurses feel they can report errors
without fearing reprisals. Given that the greatest con- Competing interests
tributor to low levels of PSC relates to “non-punitive The authors declare that they have no competing interests.
Chegini et al. BMC Nursing (2020) 19:89 Page 8 of 9
Author details 20. Parand A, Dopson S, Vincent C. The role of chief executive officers in a quality
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