Document Type : Original Article


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


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.


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