Document Type : Original Article
Authors
1 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
2 Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
3 Department of Health Information Management, School of Health Management and Information Science, Iran University of Medical Sciences, Tehran, Iran
Abstract
INTRODUCTION: Reporting medical errors is a major challenge in patient safety and improving
service quality. The purpose of the present study is to investigate the status of error reporting and
the challenges of developing an error‑reporting system in Iran.
METHODS: This study was designed with qualitative approach and grounded theory method in
teaching hospitals affiliated to Iran University of Medical Sciences. The views of safety authorities
at various levels of management, including those responsible for safety at the Ministry of Health,
Vice Chancellor and Hospitals affiliated to Iran University of Medical Sciences, were investigated in
2019 regarding adverse events.
RESULTS: Four major themes were identified included iceberg reporting and disclosure, weak
reporting, underreporting, and non‑error disclosure. The most common problems in reporting
medical error were non‑involvement of physicians in the error‑reporting process, structural (human
and information) bugs in root cause analysis sessions, and defective error prevention approaches
designed based on the failure mode and effects analysis.
DISCUSSION: Despite a large number of medical errors occurred in health‑care settings, error
reporting is still very low, with only a limited number of errors being reported routinely in hospitals
and the rest are minor and occasional reports.
CONCLUSION: Creating a mandatory error‑reporting system and requiring physicians to report and
participate in error analysis sessions can create a safety culture and increase the error‑reporting rate.
Keywords
- Leape LL, Woods DD, Hatlie MJ, Kizer KW, Schroeder SA,
Lundberg GD. Promoting patient safety by preventing medical
error. JAMA 1998;280:1444‑7.
2. Toufighy S, Maleki MR, Khoushgam M, Atar JN. Applying
the proactive Failure Mode and Effects Analysis (FMEA)
methodology for improving the triage process in an emergency
department. Iran J Forensic Med 2009;15:161‑70.
3. Carlton G, Blegen MA. Medication‑related errors: A literature
review of incidence and antecedents. Annu Rev Nurs Res
2006;24:19‑38.
4. Makary MA, Daniel M. Medical error‑the third leading cause of
death in the US. BMJ 2016;353:i2139.
5. Slawomirski L, Auraaen A, Klazinga NS. The Economics of Patient
Safety; 2017.
6. Jackson T. One Dollar in Seven: Scoping the Economics of Patient
Safety. The Canadian Safety Institute; 2009.
7. Weingart SN, WilsonRM, GibberdRW, Harrison B. Epidemiology
of medical error. BMJ 2000;320:774‑7.
8. Chaudhry SI, Olofinboba KA, Krumholz HM. Detection of errors
by attending physicians on a general medicine service. J Gen
Intern Med 2003;18:595‑600.
9. Braithwaite RS, DeVita MA, Mahidhara R, Simmons RL, Stuart S,
Foraida M,. Use of medical emergency team (MET) responses to
detect medical errors. Qual Saf Health Care 2004;13:255‑9.
10. Joolaee S, Hajibabaee F, Peyrovi H, Haghani H, Bahrani N. The
relationship between incidence and report of medication errors
and working conditions. Int Nurs Rev 2011;58:37‑44.
11. Khammarnia M, Setoodehzadeh F. Medical error as a challenge
in Iran’s health system. Health Scope 2017;6:1‑2.
12. Alsulami Z, Conroy S, Choonara I. Medication errors in the
Middle East countries: A systematic review of the literature. Eur
J Clin Pharmacol 2013;69:995‑1008.
13. Hirose M, Regenbogen SE, Lipsitz S, Imanaka Y, Ishizaki T,
Sekimoto M,. Lag time in an incident reporting system at a
university hospital in Japan. Qual Saf Health Care 2007;16:101‑4.
14. Lipczak H, Schiøler T. Reporting of incidents. Experiences with
medical registration systems. Ugeskr Laeger 2001;163:5350‑5.
15. Wolf ZR, Hughes RG. Error reporting and disclosure.
In: Hughes RG, editor. Patient Safety and Quality: An
Evidence‑Based Handbook for Nurses. AHRQ Pub: Rockville
Agency for Healthcare Research and Quality (US); 2008. p. 48.
16. Dehghani M, Hayavie Haghighi M, Salimi J, Khorami F.
Culture of patient safety from nurses’ perspective. Iran J Nurs
2015;28:42‑54.
17. Dabagh A, Esmaeil AM, Fathi M. Medical errors in the health
system. Ann Military Health Sci Res 2006;4:957.
18. Shwikhi AA, Taghaddosinejad F, Mesri M, Aziz AFM. The
assessment of physicians’attitude regarding disclousure of
medical errors in imam Khomeini hospital, Tehran. Sci J Forensic
Med 2010;16:8.
19. Sheikhtaheri A, Sadeqi‑Jabali M, Hashemi‑Dehaghi Z. Physicians’
perspectives on causes of health care errors and preventive
strategies: A study in a developing country. Iran J Public Health
2018;47:720‑8.
20. Jolaee S, Hajibabaee F, Peyravi H, Haghani H. Nursing medication
errors and its relationship with work condition in Iran University
of Medical Sciences. J Med Ethics History Med 2009;3:65‑76.
21. Fahimi F, Ariapanah P, Faizi M, Shafaghi B, Namdar R,
Ardakani MT. Errors in preparation and administration of
intravenous medications in the intensive care unit of a teaching
hospital: An observational study. Aust Crit Care 2008;21:110‑6.
22. Vaziri S, Fakouri F, Mirzaei M, Afsharian M, Azizi M,
Arab‑Zozani M. Prevalence of medical errors in Iran: A systematic
review and meta‑analysis. BMC Health Serv Res 2019;19:622.
23. Matin BK, Hajizadeh M, Nouri B, Rezaeian S, Mohammadi M,
Rezaei S. Period prevalence and reporting rate of medication
errors among nurses in Iran: A systematic review and
meta‑analysis. J Nurs Manag 2018;26:498‑508.
24. Noble DJ, Pronovost PJ. Underreporting of patient safety
incidents reduces health care’s ability to quantify and accurately
measure harm reduction. J Patient Saf 2010;6:247‑50.
25. Kohan AD, Mahfoozpour S, Palesh M, Ouchhesar FF. Assessing
barriers to medical errors reporting among clinical staff members
of teaching hospitals affiliated with Shahid Beheshti University
of Medical Sciences in Tehran‑2016. J Health Field 2018;5:8‑16.
26. Sharbaafchi Zadeh N, Souri S, Rostami Z, Aghili Dehkordi G.
Occurrence and reporting of nurses’ medication errors in a
teaching hospital in Isfahan. J Health Adm 2019;21:11. - 27. Shirkesh S, Behkar M. Reporting of Medical Errors in Amirkola
Children’s Hospital in 2015. Academic Conference on Research
in Administrative and Financial Areas of Health System; Babol
University of Medical Sciences; 2015.
28. Zaboli R, Abbaszade A, Shahabinejad M. Assessing the barriers
of error reporting from perspective of nurses in Kerman hospitals.
Med Ethics 2016;10:31‑53.
29. Manjoghi N, NooriA, Arizi H, Fasihizadeh N. Errors, misconducts,
improper hospital conditions, and whistle‑blowing by nurses of
Isfahan hospitals. Iran J Med Ethics History Med 2012;5:51‑64.
30. Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH. Rates
and types of events reported to established incident reporting
systems in two US hospitals. Qual Saf Health Care 2007;16:164‑8.
31. Cousins DH, Gerrett D, Warner B. A review of medication
incidents reported to the National Reporting and Learning
System in England and Wales over 6 years (2005‑2010). Br J Clin
Pharmacol 2012;74:597‑604.
32. Howell AM, Burns EM, Bouras G, Donaldson LJ, Athanasiou T,
Darzi A. Can patient safety incident reports be used to compare
hospital safety? Results from a quantitative analysis of the
english national reporting and learning system data. PLoS One
2015;10:e0144107.
33. Hutchinson A, Young TA, Cooper KL, McIntosh A, Karnon JD,
Scobie S,. Trends in healthcare incident reporting and relationship
to safety and quality data in acute hospitals: Results from the
National Reporting and Learning System. Qual Saf Health Care
2009;18:5‑10.
34. Souzani A, Bagheri H, Pourheydari M. Survey nurse’s view about
factors affects medication errors in different care units of imam
hossein hospital in Shahroud. Knowled Health 2007;2:8‑13.
35. Kabirzadeh A, Bozorgi F, Motamed N, Mohseni Sarav B,
Gholipour Baradari A, Dehbandi M. Survey on attitude of chief
managers of hospitals towards voluntary incident reporting
system, 2010‑2011. J Mazandaran Univ Med Sci 2011;21:131‑7.
36. Saadati M, Oghli SE, Vahidi R, Kazemi L. Medical errors
and reporting barriers from the perspective of nurses and
managers‑Tabriz Shahid Madani heart hospital. Depiction Health
2015;6:33‑8.
37. Weingart SN, Callanan LD, Ship AN, Aronson MD.
A physician‑based voluntary reporting system for adverse events
and medical errors. J Gen Intern Med 2001;16:809‑14.
38. Weingart SN, Ship AN, Aronson MD. Confidential
clinician‑reported surveillance of adverse events among medical
inpatients. J Gen Intern Med 2000;15:470‑7.
39. Kingston MJ, Evans SM, Smith BJ, Berry JG. Attitudes of doctors
and nurses towards incident reporting: A qualitative analysis.
Med J Aust 2004;181:36‑9.
40. Kaldjian LC, Jones EW, Wu BJ, Forman‑Hoffman VL, Levi BH,
Rosenthal GE. Reporting medical errors to improve patient safety:
A survey of physicians in teaching hospitals. Arch Intern Med
2008;168:40‑6.
41. Shaw R, Drever F, Hughes H, Osborn S, Williams S. Adverse
events and near miss reporting in the NHS. Qual Saf Health Care
2005;14:279‑83.
42. Evans SM, Berry JG, Smith BJ, Esterman A, Selim P,
O’Shaughnessy J,. Attitudes and barriers to incident reporting:
A collaborative hospital study. Qual Saf Health Care 2006;15:39‑43.
43. Howell AM, Burns EM, Bouras G, Donaldson LJ, Athanasiou T,
Darzi A. Can Patient Safety Incident Reports Be Used to Compare
Hospital Safety? Results from a Quantitative Analysis of the
English National Reporting and Learning System Data. PLoS One
2015;10:e0144107.
44. Harrison R, Birks Y, Hall J, Bosanquet K, Harden M, Iedema R.
The contribution of nurses to incident disclosure: A narrative
review. Int J Nurs Stud 2014;51:334‑45.
45. Azarabad S, Zaman S, Nouri B, Valiee S. Frequency, causes
and reporting barriers of nursing errors in the operating room
students. Res Med Educ 2018;10:18‑27.
46. Movahednia S, Partovishayan Z, Bastanitehrani M, Moradi F.
Nurse Managers’ perspectives about Reasons for not reporting
medical errors in Firoozgar Hospital: 2012. Razi J Med Sci
2014;21:110‑8.
47. Koohestani HR, Baghcheghi N. Barriers to the reporting of
medication administration errors among nursing students.
Australian J Adv Nurs 2009;27:66.
48. Seidi M, Zardosht R. Survey of nurses\’viewpoints on causes
of medicinal errors and barriers to reporting in pediatric units
in Hospitals of Mashhad University of Medical Sciences. J Fasa
Univ Med Sci 2012;2:142‑7.
)