The World Health Organization (WHO) (2019) warns that patient harm is among the leading causes of the global disease burden, comparable with diseases such as malaria and tuberculosis. Globally, it is estimated that every year, around 42.7 million patients endure adverse events when in hospital. These incidents are related to documentation, missed or wrong diagnosis, medication errors, drug prescription and administration errors, surgical complications and wrong decision-making (Institute of Medicine, 2009). There remains a large gap in the understanding of the particular chain of events, and the weaknesses and faults that lead to safety incidents, as well as their cost to patients, healthcare staff and the organisation as a whole. In order to develop the learning culture, the incident reporting system should be non-punitive and needs to provide timely, constructive and non-judgemental feedback to motivate staff to keep participating in the learning process (Benn et al, 2009; Woo and Avery, 2021).
This article provides an insight into Maltese nurses' use of incident reporting and the barriers that can contribute to under reporting. Although change takes time, improvements in the incident reporting system and patient safety are worth the collective effort. It would not be possible to eliminate all errors, but it is important to enable learning from them. In this way, health professionals can improve the quality and safety of the care they provide.
Local context – Maltese healthcare system
The healthcare system in Malta is based on the UK's NHS, being mainly free at the point of delivery. However, as Scerri (2014) states, there are dual systems of private and public health services. The primary hospital in Malta is the Mater Dei Hospital, which opened in 2007 and is one of the largest medical buildings in Europe (Ministry for Energy and Health, 2014). Public healthcare in Malta is funded from taxation and covers almost any treatment, from hospitalisation, prescriptions for chronic illness, childbirth, surgeries to rehabilitation. Despite the generally good healthcare provision in Malta (Ministry for Health, 20222) there remain some challenges related to the growing, diverse, and ageing population of Malta. Azzopardi-Muscat et al (2017) explained that the health system needs to reorganise its resources and services from hospitals to primary care, ensure access to new medicines, and to continuing improving all while being financially sustainable. The latest National Health Systems Strategy for Malta 2023–2030 document states that these demographic changes necessitate the health services to anticipate the changing population needs in the coming years and to change and renovate accordingly (Ministry for Health, 2022).
Incident reporting system
In 2009, the hospital incident report form was introduced to report dangerous occurrences, near misses and incidents involving equipment had to be reported within 24 hours of the incident occurring. However, the form was not anonymous.
In autumn 2014 in Mater Dei Hospital, a patient safety and quality improvement team (PASQIT) was established to investigate incidents and promote patient safety. Since its inception, the committee has conducted numerous cases of root cause analysis and havs published four standard operating procedure (SOP) documents:
- Generating safety alerts
- Collection, archiving and classification
- Investigation
- Implementation and dissemination of learning.
In April 2015, PASQIT launched the Safety Alert (SA) Learn System. In order to encourage incident reporting, PASQIT made the online SA form voluntary, confidential and anonymous. PASQIT receives both SA forms and the hospital incident report form which report clinical occurrences that deal with patient safety. In 2016, PASQIT received 143 reports, 149 reports in 2017, 109 reports in 2018 and 56 reports in 2019. In all these reports, 69% were submitted by nurses whereas only 17% were reported by doctors (Azzopardi, 2020). Although PASQIT had introduced a well-thought out incident reporting system, there was still lack of visibility and awareness. This motivated the authors to explore this topic further. Assessing the nurses' attitudes and practices of incident reporting, could help address the gap in local literature and shed further awareness of the need to strengthen the existing incident reporting system.
Methodology
This study aimed to assess nurses' attitudes and barriers towards incident reporting; therefore, a non-experimental, descriptive, cross-sectional quantitative design was chosen. An online questionnaire was designed to define behaviours, attributes and activities of the study population (Parahoo, 2014). Such descriptive studies provide an overview of the state of a phenomenon (Polit and Beck, 2017).
Ethical approval
The researcher obtained approval from the Chief Executive Officer and the Director of Nursing Administration at the Mater Dei Hospital. Permission to proceed with the study was then granted by the University of Malta's Faculty of Health Science Research Ethics Committee.
Data collection
The data for this study were collected from nursing staff at the Mater Dei general teaching hospital in Malta, which has around 1000 hospital beds. Data were collected using an online questionnaire, permitting a large sample size without great cost and allowing the quantitative data to be investigated by statistical computer programmes (Parahoo, 2014). An invitation to all nursing staff was sent by e-mail through an intermediary person. This e-mail included an information letter and a direct link to the online survey using the Google Forms platform. Reminders were sent in the same way to try to improve participation rates. In addition, a hard copy of the information letter was sent to each participating ward/unit to be placed on the notice boards. The raw data were exported automatically onto Statistical Package for Social Sciences (SPSS) by Google Forms. The chosen research tool was adapted from the study by Evans et al (2006), known as the Incident Reporting Questionnaire. Permission to use and adapt the tool was sought from the original authors and approved by Dr Berry. A few modifications on the questionnaire had to be carried out, adapting it for use it at Mater Dei Hospital. The modifications were mainly related to the nomenclature used, such as ‘patient safety report’ or ‘incident report’ and also in the demographic categories, which had to be adapted for the local setting to depict the different levels of nursing (ie, charge nurse, staff nurse etc).
Results
A total of 1383 nurses including deputy charge nurses and charge nurses working on a full time-basis were invited to participate in this study. Only 23% (n=323) of those invited responded and although the response rate was low, the sample size acquired still gave a 4.78 confidence interval with a 95% confidence level.
It is notable that most of the participants were female (75%; n=241) and a third had more than 20 years of experience working as a nurse (33%; n=107) (Table 1). Additionally, nurses working in specialised areas had a higher response rate than in the other clinical areas (37%; n=119). In view of the very small number of enrolled nurses (1%; n=4) who had answered the questionnaire, enrolled nurses were clustered together as one group with staff nurses when analysing data through statistical tests.
Table 1. Demographic characteristics of the participants
| Demographic clustered group | Category | Frequency and Percentage |
|---|---|---|
| Gender | Male | 82 (25%) |
| Female | 241 (75%) | |
| Age (years) | 19–35 | 160 (50%) |
| 36–50 | 85 (26%) | |
| Over 50 | 78 (24%) | |
| Nursing grade | Charge nurse/deputy charge nurse | 81 (25%) |
| Staff nurse | 238 (74%) | |
| Enrolled nurse | 4 (1%) | |
| Nursing level of education | Traditional nursing education | 30 (9%) |
| Conversion nurse | 17 (5%) | |
| Diploma | 49 (15%) | |
| Degree | 145 (45%) | |
| Postgraduate | 82 (25%) | |
| Years of experience working as a nurse | Less than 1 year | 21 (6%) |
| 1–5 years | 79 (25%) | |
| 6–10 years | 45 (14%) | |
| 11–20 | 71 (22%) | |
| More than 20 years | 107 (33%) | |
| Nursing clinical setting | Medical ward | 47 (15%) |
| Surgical ward | 83 (26%) | |
| Paediatric ward | 36 (11%) | |
| Specialised units | 119 (37%) | |
| Relieving pool* | 38 (12%) |
As shown in Table 2, the majority of the participants (82.7%; n=267) had filled in an incident report form at least once. Moreover, Table 2 shows that a larger percentage of charge nurses/deputy charge nurses (98.8%) than staff nurses (77.3%) had filled an incident report form at least once throughout their nursing career. The difference between these two percentages is significant (P<0.001). Furthermore, the study shows that almost half of the participants (48.3%; n=156) had filled an incident report form during the last year.
Table 2. Incident reporting by nursing grade
| Nursing grade | |||||
|---|---|---|---|---|---|
| Charge nurses/deputy charge nurses | Staff nurses | Total | |||
| Have you ever filled in an incident form? | Yes | Number | 80 | 187 | 267 |
| Percentage | 98.8% | 77.3% | 82.7% | ||
| No | Number | 1 | 55 | 56 | |
| Percentage | 1.2% | 22.7% | 17.3% | ||
| Total | Number | 81 | 242 | 323 | |
| Percentage | 100% | 100% | 100% | ||
Note: X2(1) = 19.561, P< 0.001
Staff views on barriers to incident reporting
The third section of the questionnaire presented 20 potential reasons for not reporting incidents and asked the participants to rate their response on a 5-point Likert scale (Table 3). The statement, ‘if I report something, I never get any feedback on what action is taken’ received the highest score (mean=3.67; SD=1.192) indicating it was the most perceived barrier towards incident reporting. This was followed by the statement, ‘when the incident does not eventuate or a correction was made then I don't see any point in reporting it’ (mean=3.16; SD=1.241), and ‘adverse incident reporting is unlikely to lead to system changes that will improve the quality of care’ (mean=3.12; SD=1.264). The mean rating score provided to statement ‘I don't want the case discussed in meetings’ (mean=2.41; SD=1.092) was the lowest indicating the lowest perceived barrier towards incident reporting. In the open-ended question, when asked whether the participant can identify other potential barriers or comments related to not reporting clinical incidents, 80 participants mentioned other reasons. Table 4 shows the most common perceived barriers and reasons for not reporting grouped into themes with a few direct quotes from the participants. Other reasons not included in Table 4 were lack of awareness of such system, which gets often overlooked, the feeling of stress if people turn against you and forms not always being applicable to their reason for reporting.
Table 3. Barriers towards incident reporting
| Barriers towards incident reporting | Mean | SD |
|---|---|---|
| I am worried about disciplinary action | 2.62 | 1.254 |
| When the ward is busy, I forget to make a report | 2.63 | 1.235 |
| I am worried about litigation | 2.86 | 1.248 |
| The incident form takes too long to fill out and I just don't have the time | 2.55 | 1.161 |
| My co-workers may be unsupportive | 2.88 | 1.269 |
| My managers may be unsupportive | 2.72 | 1.265 |
| I don't know whose responsibility it is to make a report | 2.52 | 1.175 |
| I don't want the case discussed in meetings | 2.41 | 1.092 |
| I don't feel confident that the form is kept anonymous | 2.87 | 1.342 |
| Adverse incident reporting is unlikely to lead to system changes that will improve the quality of care | 3.12 | 1.264 |
| I don't want to get into trouble | 2.77 | 1.247 |
| Junior staff are often blamed unfairly for adverse incidents | 2.98 | 1.238 |
| When the incident doesn't eventuate or a correction was made then I don't see any point in reporting it | 3.16 | 1.241 |
| If I report something, I never get any feedback on what action is taken | 3.67 | 1.192 |
| The report form is too complicated and requires too much detail | 2.66 | 1.082 |
| I feel that if I discuss the case with the person involved nothing else needs to be done | 2.66 | 1.092 |
| I worry about who else is privy to the information that I disclose | 3.05 | 1.132 |
| The incident was too trivial | 2.96 | 1.073 |
| It's not my responsibility to report somebody else's mistake | 2.71 | 1.196 |
| Even if I don't give my details, I'm sure they'll track me down | 3.02 | 1.175 |
Note: X2(19) = 503.132; P<0.001
Table 4. Common barriers to reporting (open-ended questions)
| Barrier or reason for not reporting | Number of participants | Direct quotes |
|---|---|---|
| Disappointment due to lack of feedback | 21 | ‘I file too many incident reports, yet I never ever had any type of feedback or follow up on them, so they are becoming pretty useless.’‘Reports have always fallen onto deaf ears in our department.’ |
| Blame culture and labelling | 18 | ‘Incident reporting culture in Malta is more related to the blame game and gossip rather than trying to learn from each other's mistakes and actually improve things …’‘… a lot of time I always end up being the one to write a report, being labelled as difficult character and as a know-it-all.’‘When I reported what was going on, my superiors bullied me. One of my superiors on another incident used verbal abuse in front of my work mates by saying, “who are you to report people?”. Nowadays whatever I see I have to shut up or else I am the one to pay dearly for somebody else's mistake‘I used to report incidents regularly in the UK – I was strongly dissuaded from doing so here as, you are labelled a trouble-maker, and it is the opposite of a blame-free culture.’ |
| Worry when higher management is involved | 11 | ‘Some problems may arise when report involves higher management.’ |
The participants were assessed on their awareness of how to access the hospital incident report form and also, if they knew what to do after the incident form was completed (Table 5). The majority of the participants knew how to locate or access the incident report form (n=232; 71.8%), similarly, the majority were aware of what to do with the form once it was complete (n=228; 70.6%). However, 20.4% of participants were not sure of where and how to access the incident form. Likewise 23.8% answered that they were not sure of what to do with the completed form.
Table 5. Nurses' knowledge of the local incident report system
| Do you know how to locate or access the incident form? | Do you know what to do with the completed incident form? | |||
|---|---|---|---|---|
| Number | Percentage | Number | Percentage | |
| Yes | 232 | 71.8% | 228 | 70.6% |
| No | 25 | 7.7% | 18 | 5.6% |
| Not sure | 66 | 20.4% | 77 | 23.8% |
| Total | 323 | 100% | 323 | 100% |
The participants were also asked about their preferred form (Table 6); most of the participants (n=185; 57.3%) used only the hospital incident report form, whereas only 7 (2.2%) of the nurses claimed that they used the SA form only.
Table 6. Nurses' preferred reporting method
| For each incident that you report, what method do you use? | Number | Percentage |
|---|---|---|
| Use only the hospital incident form | 185 | 57.3% |
| Use only the SA form | 7 | 2.2% |
| Use both the hospital incident form and SA form | 18 | 5.6% |
| Use one or the other, whichever I feel is more appropriate | 61 | 18.9% |
| Never know which form to use | 52 | 16.1% |
| Total | 323 | 100% |
Discussion
When this survey was conducted in 2020, the hospital incident reporting form had been used in the hospital for at least 12 years and the anonymous SA Learn system had been used for at least 6 years. It is a matter of concern that there are nurses who are still unaware of these systems. It is surprising that only 11.5% of the participants had used one of the forms and that most who had were charge nurses. This might be due to lack of awareness of such a system and lack of encouragement from management and unions. A safety campaign reminding the staff of the hospital incident reporting system and its importance should be a yearly occurrence, especially on World Patient Safety Day.
This study also shows that the SA form is not the nurses' preferred method of incident reporting. This might be because the SA form is anonymous, and the nurses would like to be able to obtain some direct feedback or some type of follow-up and closure.
Staff views on barriers to reporting
In this study, the major barriers to reporting were associated with lack of trust in terms of organisational barriers. In fact, the top three perceived barriers in this study were related to lack of feedback, viewing near misses as pointless to report and the belief that reporting would not lead to system changes. Similar findings were reported in the study conducted by Lee et al (2016) where nurses perceived the worth of making incident reports as the driving force to engage with reporting. If nurses' efforts are not justified in reporting incidents, they will not report and encourage others to do so. In the same study, Lee et al (2016) asserted that before individuals report, they consider the potential risks and benefits. Lack of belief and confidence in an incident reporting system is a very worrying issue. Incident reporting systems function on the principle that reporting specific events and their investigations can produce beneficial information to address weaknesses in a hospital system (Woo and Avery, 2021). Eventually, root causes of failures and information concerning near misses will provide preventive and remedial actions in order to improve safety. In addition, this type of information should be widely disseminated with the front-liners in order to increase awareness of existing operational risks and their remedial actions (Benn et al, 2009).
Lack of feedback hinders future reporting
Feedback is an important, yet overlooked, area of incident reporting systems. In this study, a lack of feedback seemed to be the greatest deterrent to reporting (mean=3.67) where 63.4% of the participants agreed with such statement. This study's findings also agreed with Evans et al (2006) who reported that 61.8% of their participants perceived that lack of feedback was the major barrier for not reporting incidents. Similar findings were obtained by Fitzgerald et al (2011), who demonstrated how a lack of feedback or action impedes future reporting. In the end, nurses become apathetic and reluctant to report incidents due to the perception that their management is not taking action on what was reported and a lack of resulting changes. Feedback needs to be given in a timely manner in order to be effective in an incident reporting system. In a study conducted in NHS trusts in England and Wales, Wallace et al (2009) gave 15 different recommendations regarding feedback in an incident reporting system. These included that the feedback is visible, credible, preserving confidentiality, involve immediate comprehension of risks and offer support to front-line staff. Feedback guarantees that the reports are being acted on and will not end up in an organisational ‘black hole’.
In this study's open-ended question, nurses continued to express their disappointment in the system with some stating that they never received any feedback. This delayed, or non-existent, feedback at Malta's acute general hospital might be due to the fact that there are no full-time members of staff who can dedicate all their effort towards the safety committee and incident reporting.
A culture that encourages reporting should involve feedback mechanisms that promotes a systematic view on the causes of failure, rather than focus on individuals' faults. Petrova et al, (2010) found that the main reason for not reporting medical errors in Malta's local acute general hospital was because the nursing administration focused on the individual rather than looking at the system as a potential cause of error. Feedback should never be solely based on publicising incident rates, but should go beyond that (Benn et al, 2009). Macrae (2016: 74) described the problem with incident reporting as, ‘we collect too much and do too little’. Nurses need to be presented with timely, visible and repeatable corrective action that ultimately improves their own safety and that of their colleagues and their patients.
Fear factor and the importance of having supportive management
Barriers related to fear of reporting, although present, were not the top barriers of reporting in nurses working at the acute general hospital. Such barriers would be concerns about disciplinary action and litigation, unsupportive co-workers and managers, and not wanting to get into trouble. These barriers were given as main reasons for under-reporting of incidents in various studies and were the result of a blame culture (Chiang and Pepper, 2006; Alrabadi et al, 2020). However, nurses in this present study did not appear concerned by disciplinary action. Lin and Ma (2009) recounted how when an incident happens, initially the nurses blame themselves and then they get blamed by their managers and department. Further exploration through the open-ended question revealed that individuals who tend to report are labelled as difficult to work with and in some instances, end up being bullied by their colleagues and charge nurses. Instead of portraying the reporter as the ‘bad person’, Chiang et al (2019) suggested that nursing managers should openly recognise and reward nurses who contributed to patient safety improvement through incident reporting. As a result, this recognition would greatly strengthen the nurses' confidence in future instances of incident reporting. Researchers conclude how a positive reporting culture can pursue an incident reporting system, which is based on a system driven, learning-based and blame-free framework (Hewitt et al, 2017).
Limitations
The results of this study cannot be generalised to all health institutions in Malta. Moreover, this study was only focused on nurses. Therefore, future local researchers should design their studies to enable comparison of attitudes and perceptions toward incident reporting among different health professionals and institutions to assess if incident reporting is being addressed and made aware to all health professionals in Malta.
The questionnaire was previously validated for reliability and validity in various studies (Evans et al, 2006; AbuAlRub et al, 2015; Jember et al, 2018; Kaya et al, 2020) and reached a very large number of potential respondents (n=1383) in a limited time duration, with several reminders sent. However, one main attributable reason for the low response rate could have been due to the COVID-19 pandemic that saw the nurses' workload increase affecting their mental health and decreasing their work motivation (Xuereb, 2020). In addition, in trying to keep the questionnaire short to reduce response burden, results and barriers might not have been included, thus limiting the results obtained. Finally, potential non-responder bias cannot be excluded as the researcher was unable to gather information on non-respondents due to the anonymous questionnaire design that could have led to mistakes in estimating population characteristics grounded on the under representation of these phenomena.
Conclusion
The main findings revealed that the majority of nurses in this acute general Maltese hospital were not familiar with the methods of incident reporting, they did not trust the system and felt discouraged due to a lack of feedback. Therefore, there needs to be a strong organisational pledge to establish and manage human and system failures in a timely manner to drive the safety agenda and initiate a positive shift in the nursing culture. The safety alert system in place needs more visibility and systems to ensure it is trustworthy and having a shared strategy to support nurse's learning and emotional wellbeing after reporting would be a priority. Investment is also needed in a team of health professionals to provide the regular update and awareness campaigns needed to promote the organisation's commitment to the safety alert system to learning. Finally, the hospital should work to improve nurses' attitude to incident reporting by certifying that practice enhancements resulting from reports are circulated to health professionals, because only then will incident reporting be understood as valuable and relevant.
KEY POINTS
- A positive reporting culture on incident reporting should be based on a system driven, learning-based and blame-free framework
- More visibility on this positive reporting culture is needed to further create a safety culture within the hospital, these could include leadership walk rounds and multi-faceted unit programs and taking part in World HEalth Organization patient safety campaigns
- Feedback and communication on the outcomes of an incident report is vital to the process of patient safety
- Nursing managers should openly recognise and reward nurses who contributed to patient safety improvements through incident reporting
CPD reflective questions
- Are you informed and confident in reporting patient safety concerns? If not, do you know who to ask?
- Do you feel safe in reporting an incident or near-miss event in your place of work? If not, consider why.
- How can you become more involved in patient safety issues?