A qualitative study of the reasons for low patient safety incident reporting among Indonesian nurses

Pramesona, Bayu Anggileo; Sukohar, Asep; Taneepanichskul, Surasak; Rasyid, M Fauzan Abdillah

doi:10.1590/0034-7167-2022-0583

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Revista Brasileira de Enfermagem

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Sumário

ORIGINAL ARTICLE • Rev. Bras. Enferm. 76 (4) • 2023 • https://doi.org/10.1590/0034-7167-2022-0583 copy

A qualitative study of the reasons for low patient safety incident reporting among Indonesian nurses

Um estudo qualitativo das razões para baixa notificação de incidentes de segurança do paciente entre enfermeiros indonésios

Un estudio cualitativo de las razones de la baja notificación de incidentes de seguridad del paciente entre las enfermeras de Indonesia

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to investigate the reasons for low patient safety incident reporting among Indonesian nurses.

Methods:

this qualitative case study was conducted among 15 clinical nurses selected purposively from a public hospital in Lampung, Indonesia. Interview guidelines were used for data collection through face-to-face in-depth interviews in July 2022. The thematic approach was used to analyze the data.

Results:

in this present study, seven themes emerged (1) Understanding incident reporting; (2) The culture; (3) Consequences of reporting; (4) Socialization and training; (5) Facilities; (6) Feedback; and (7) Rewards and punishments.

Final Considerations:

these findings should be considered challenges for the patient safety committee and hospital management to increase patient safety incident reporting, particularly among nurses in the hospital.

Descriptors:
Patient Safety; Incident Reporting; Nurses; Qualitative Study; Indonesia

Code	Age	Gender	Education	Work tenure	Work unit
P1	24	Female	Diploma	2 years	Outpatient department
P2	31	Female	Bachelor	7 years	Inpatient department
P3	36	Male	Bachelor	6 years	Outpatient department
P4	35	Female	Bachelor	11 years	Inpatient department
P5	37	Female	Bachelor	13 years	Emergency department
P6	47	Female	Diploma	22 years	Inpatient department
P7	27	Male	Bachelor	4 years	Operating room
P8	32	Female	Bachelor	7 years	Inpatient department
P9	51	Female	Diploma	28 years	Outpatient department
P10	33	Male	Diploma	6 years	Outpatient department
P11	28	Female	Diploma	6 years	Inpatient department
P12	26	Male	Bachelor	3 years	Inpatient department
P13	42	Female	Bachelor	15 years	Operating room
P14	39	Female	Diploma	15 years	Emergency department
P15	45	Female	Bachelor	18 years	Inpatient department

Themes	Participants’ responses	Quotes
Understanding incident reporting	Less understanding of the importance of incident reporting, its procedures, and contents	Q1: Nurses have a poor understanding of incident reporting, such as what should be filled out on forms, the types of incidents, and when we should report the incidents. (P2) Q2: I did not see any urgency in reporting the incidents, and I also did not know where to report it if it happened. (P4)
The culture	Afraid of being blamed by others The hospital reporting culture has not been implemented effectively	Q3: Mostly because we are afraid of being blamed by others. (R6) Q4: When we reported the incidents, the hospital management did not emphasize the no-blame culture. (P9) Q5: I knew I would be embarrassed if I reported the incidents caused by my omission, so I just kept quiet. (P4)
Consequences of reporting	Fear of legal action by patient or family Fear of being transferred to another hospital unit	Q6: Fear of lawsuits by patients or their families when they realize we made an error, the case will grow larger and worsen. (P1) Q7: I am just afraid of being transferred to another unit if I report the incident caused by my omission, so I just keep quiet. (P7)
Socialization and training	Inadequate socialization and training on incident reporting	Q8: I have been here for more than three years and have never heard or received training on reporting patient safety incidents. (P12) Q9: How can we learn about incident reporting procedures if hospital leaders and the patient safety committee never provide information like socialization or incident reporting training? (P8) Q10: I am not sure what incidents should be reported because the patient safety committee only distributed information to the PIC in each unit. The PIC did not provide any additional information to the other staff. (P11)
Facilities	There were insufficient resources to facilitate incident reporting.	Q11: In our unit, the forms were not always ready. (P13) Q12: I have never seen any forms for reporting incidents here. (P3) Q13: The forms should always be available; it would be preferable if the hospital administration or patient safety committee could provide an online reporting system. (P10)
Feedback	Feedback is predominantly slow or even non-existent	Q14: Sometimes we reported [the incidents], but there was no response from hospital management, prolonged response! (P3) Q15: We did it, we reported it, but there has been no response! (P14) Q16: The response was prolonged, even though we had reported [the incident]. (P15)
Rewards and punishments	There were no incentives or penalties	Q17: There was no money, no incentive of any kind. (P5) Q18: Demands good performance but does not recognize rewards. (P8) Q19: Even though it is our duty, there will be less motivation if there is no reward as a form of support. (P11) Q20: There are no rewards or punishments, so there is no motivation. (P4)

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[1] Corresponding author: Bayu Anggileo Pramesona, E-mail: bayu.pramesona@fk.unila.ac.id