International Journal of Nursing Studies 63 (2016) 162–178

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Review

Barriers to reporting medication errors and near misses among nurses:

A systematic review
Dominika Vrbnjaka,* , Suzanne Denieffeb , Claire O’Gormanb , Majda Pajnkiharc
a
University of Maribor Faculty of Health Sciences, Žitna ulica 15, 2000 Maribor, Slovenia
b
Waterford Institute of Technology, Department of Nursing & Health Care Co. Waterford, Ireland
c
University of Maribor Faculty of Health Sciences, University of Maribor Faculty of Medicine, Maribor, Slovenia

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To explore barriers to nurses’ reporting of medication errors and near misses in hospital
Received 11 April 2016 settings.
Received in revised form 6 August 2016 Design: Systematic review.
Accepted 31 August 2016
Data sources: Medline, CINAHL, PubMed and Cochrane Library in addition to Google and Google Scholar
and reference lists of relevant studies published in English between January 1981 and April 2015 were
Keywords: searched for relevant qualitative, quantitative or mixed methods empirical studies or unpublished PhD
Medication errors
theses. Papers with a primary focus on barriers to reporting medication errors and near misses in nursing
Near miss
Nurses
were included.
Patient safety Review methods: The titles and abstracts of the search results were assessed for eligibility and relevance
Barrier by one of the authors. After retrieval of the full texts, two of the authors independently made decisions
Systematic review concerning the final inclusion and these were validated by the third reviewer. Three authors
independently assessed methodological quality of studies. Relevant data were extracted and findings
were synthesised using thematic synthesis.
Results: From 4038 identified records, 38 studies were included in the synthesis. Findings suggest that
organizational barriers such as culture, the reporting system and management behaviour in addition to
personal and professional barriers such as fear, accountability and characteristics of nurses are barriers to
reporting medication errors.
Conclusions: To overcome reported barriers it is necessary to develop a non-blaming, non-punitive and
non-fearful learning culture at unit and organizational level. Anonymous, effective, uncomplicated and
efficient reporting systems and supportive management behaviour that provides open feedback to
nurses is needed. Nurses are accountable for patients’ safety, so they need to be educated and skilled in
error management. Lack of research into barriers to reporting of near misses’ and low awareness of
reporting suggests the need for further research and development of educational and management
approaches to overcome these barriers.
ã 2016 Elsevier Ltd. All rights reserved.

What is already known about the topic?
 Open and honest disclosure of medication errors and near misses
is critical to patient safety and optimisation of quality nursing
care.
 Medication errors and near misses are underreported.
 Knowledge of the barriers to medication error and near miss
reporting is important to improve medication safety.
* Corresponding author.
E-mail addresses: dominika.vrbnjak@um.si (D. Vrbnjak), sdenieffe@wit.ie
(S. Denieffe), cogorman@wit.ie (C. O’Gorman), majda.pajnkihar@um.si
(M. Pajnkihar).
What this paper adds
 Culture, the reporting system and management behaviour are
organizational barriers that inhibit the reporting of medication
errors.
 Fear, accountability and characteristics of nurses have been
identified as personal and professional barriers that influence
reporting of medication errors.
 There are a lack of studies specifically exploring the barriers to
reporting near misses in relation to medication management in
nursing.

http://dx.doi.org/10.1016/j.ijnurstu.2016.08.019
0020-7489/ã 2016 Elsevier Ltd. All rights reserved.
 D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178
1. Introduction
Nurses have an important role in the medication management
process as they are primarily involved in the preparation and
administration of medications (Hughes and Blegen, 2008; Parry
et al., 2015). All nurses receive training to ensure the safe
administration of medications but as acknowledged by the
Institute of Medicine (1999), to err is human, and this is certainly
applicable to the area of medication management. A medication
error is defined as an “act of commission (doing something wrong)
or omission (failing to do the right thing) that leads to an
undesirable outcome or significant potential for such an outcome”,
whereas a near miss can be defined as “an event or situation that
did not produce patient injury, but only because of chance”
(Agency for Healthcare Research and Quality, AHRQ PSNet, 2014). A
near miss is a medication error that does not cause any harm to the
patient because it is intercepted and corrected before reaching the
patient (Hughes and Blegen, 2008). Medication errors are a
significant cause of morbidity and mortality in hospitalized
patients and can result in prolonged hospital stay, thereby
indicating the major risk posed to patient safety on a local,
national and international level, with this issue attracting global
attention (Berdot et al., 2016; Brady et al., 2009; Parry et al., 2015).
Medication management guidance for nurses indicates that all
medication errors and near misses should be reported in order to
improve this process and optimise the quality of patient care
(Brady et al., 2009; Harrison et al., 2014; Haw et al., 2014). However,
reporting of medication errors by nurses occurs in only 37.4%–67%
of cases, which is challenging, as underreporting makes it
impossible to analyse the process behind all medication errors
and near misses (Hajibabaee et al., 2014; Haw et al., 2014; Maiden,
2008; Mayo and Duncan 2004; Mrayyan and Al-Atiyyat, 2011;
Stratton et al., 2004; Wakefield et al., 1999). This indicates that the
current body of knowledge in this area is not fully informed and
there is insufficient evidence that the health care team will be able
to learn from errors (Brady et al., 2009; Levinson, 2009).
Numerous authors have investigated the reasons for medica-
tion errors and found that they are the result of multiple system
factors and also individual factors (Brady et al., 2009; Keers et al.,
2013; Parry et al., 2015). Knowing and understanding the causes
has resulted in numerous interventions that have been developed
to prevent or reduce medication errors, such as nurse training and
education, automated delivery systems and barcode assisted
medication administration systems. However, there is still a lack
of evidence that they effectively decrease medication errors
(Berdot et al., 2016). Medication errors still occur, particularly in
hospital settings (Institute of Medicine, 1999). Blegen and Hughes
(2008) reported errors in hospitals occurring in at least one and
possibly three doses out of ten. Failure to report or under-reporting
errors is a major limitation to patient safety.
Table 1
Inclusion and exclusion criteria.
Inclusion criteria
Topic Primary focus on barriers to reporting medication errors or near misses in nursing
Population Nurses working in hospital settings
Type of Qualitative, quantitative or mixed methods empirical studies, unpublished PhDs
study
Language English
Time frame Studies published between January 1981 and April 2015
Exclusion criteria
Studies not on the topic and not meeting inclusion criteria (primary focus on other medical and nursing errors, other professional working in hospital
setting), reviews, editorials, notes, commentary pieces, conference papers, books, news
Duplicates
163
The initial step to address this is the identification of barriers to
reporting medication errors and near misses by nurses. Although
numerous single studies have investigated this, they have not yet
been systematically examined and synopsised to gain a more
comprehensive understanding of issues that have been studied.
1.1. Aim
The aim of this systematic review was to identify and examine
the barriers hindering nurses’ disclosure of medication errors and
near misses in hospital settings.
2. Method
The eight-stage QESISAES framework: Question, Eligibility,
Source, Identification, Selection, Appraisal, Extract, Synthesis was
used in the present review (Pluye et al., 2013).
2.1. Research question
The research question of this review was:
What are the barriers to nurses’ reporting medication errors or
near misses in hospital settings?
2.2. Eligibility criteria
Predefined inclusion and exclusion criteria were utilised as
outlined in Table 1.
2.3. Search strategy
A systematic mixed method review was conducted to identify
relevant literature. Initially, a limited search in CINAHL was
undertaken in collaboration with librarians to identify key words
and key studies. Following this, a systematic search was conducted
using Medline, CINAHL, PubMed and Cochrane Library. Key word
combinations used included medication error; medicine error;
medicament error; drug error; near miss; nurse attitudes; truth
disclosure; whistle blowing; incident report; voluntary reporting;
report (See Supplementary data 1 for an example of a search
strategy used in CINAHL). In addition Google and Google Scholar
were searched for relevant studies and unpublished PhD theses.
Reference lists of identified studies were considered for inclusion
in this review and were manually searched.
2.4. Study identification and selection
Studies published in English and unpublished PhD theses in
English between January 1981 and April 2015 were considered for
inclusion in the review, as no studies prior to 1981 were identified
164 D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178

in the initial limited search in CINAHL. Identified references were
imported into the reference manager software EndNote and
duplicates were removed. The titles and abstracts of the search
results were then assessed for eligibility and relevance by one of
the authors (DV) and papers that did not meet the selection criteria
(see Table 1) were removed. After retrieval of the full text, two of
the authors (DV, CO) independently made decisions concerning
final inclusion of the studies. This was then validated by the third
reviewer (SD). Disagreements between reviewers were discussed
until consensus was reached.
2.5. Quality appraisal
Each published study or unpublished PhD thesis was indepen-
dently assessed for methodological quality by three authors (DV,
CO, SD). Disagreements between reviewers were discussed until
consensus was reached. Study quality was explored using the
Mixed Methods Appraisal Tool (MMAT). MMAT contains 19
methodological quality criteria for appraising quantitative, quali-
tative and mixed methods studies. These criteria are scored on a
nominal scale (Yes/No/Can't tell) and allow for the assessment of
five main types of studies which include qualitative studies,
randomized controlled trials, non-randomized quantitative stud-
ies, quantitative descriptive studies and mixed methods research
(Pluye et al., 2011). Methodological quality criteria for three
different types of studies that were included in the systematic
review are presented in Table 2. For qualitative and quantitative
studies, scores are based on the number of criteria met divided by
four (scores varying from one criterion met – 25% to all criteria met
– 100%). A very low score (score = 0%) indicates that the research
question was not clearly stated or none of the criteria were met. For
mixed methods research, the overall quality of a combination of
scores cannot exceed the quality of its weakest component and is
the lowest score of the study components. For example, the score is
25%, when one criterion is met in qualitative or quantitative
component and none of the criteria are met in mixed methods. The
score is 100%, when all criteria are met in qualitative, quantitative
and mixed methods sections (Pluye et al., 2011). MMAT classifica-
tion generates five methodological quality categories – very low
(score = 0%,), low (score = 25%), moderate (score = 50%), high
(score = 75%), very high (score = 100%). Studies with an MMAT
score of less than 25% were excluded (Leblanc et al., 2015).
2.6. Data extraction and synthesis
Data were extracted by one reviewer and checked by two other
reviewers using predefined data extraction criteria, which includ-
ed source, country, objectives, design and data collection methods,
sample and setting and main findings related to identified barriers.
Disagreements were resolved by discussion and consensus.
A convergent qualitative synthesis design was used, where
results from studies that included qualitative, quantitative and
mixed methodologies were transformed into qualitative findings
(Pluye and Hong, 2014). To combine the nurses’ views and identify
key themes and conclusions a thematic approach was adopted to
synthesise the data emerging from the literature. This involved line
by line coding of each study to enable the identification of free
codes. These codes were then organised into descriptive primary
level subthemes, which were analysed and compared to develop
secondary level themes from which a thematic framework
emerged (Thomas and Harden, 2008).
3. Results
3.1. Study selection
The search yielded 4035 records from electronic databases
and 3 records from other sources. After removal of duplicates,
3125 studies were screened by title and abstract for relevance
by applying inclusion and exclusion criteria, leading to the
exclusion of 3028 studies. Full-texts (n = 97) were then assessed
for eligibility. After reading the full texts, 59 studies were
discarded (See Supplementary data 2 for the reasons for
exclusion). One additional record, identified through a hand
search yielded an additional paper. Therefore, a total of 39
studies were included in the critical appraisal. One study was
excluded (Karadeniz and Cakmakçi, 2002) after quality
appraisal, because it received 0% MMAT score. Finally, 38
studies were retained for qualitative synthesis. Fig. 1 illustrates
the flow diagram of study selection.
3.2. Methodological quality
The results of MMAT scoring are presented in Table 3. Four
studies were evaluated with a low quality score (score = 25%),

Table 2
MMAT criteria (Pluye et al., 2011).

Type of study Methodological quality criteria

Screening questions (for all Are there clear qualitative and quantitative research questions (or objectivesa ), or a clear mixed methods question (or objectivea )?
types Do the collected data allow address the research question (objective)?

Further appraisal may be not feasible or appropriate when the answer is ‘No’ or ‘Can’t tell’ to one or both screening questions
Qualitative Are the sources of qualitative data relevant to address the research question (objective)?
Is the process for analysing qualitative data relevant to address the research question (objective)?
Is appropriate consideration given to how findings relate to the context, e.g., the setting, in which the data were collected?
Is appropriate consideration given to how findings relate to researchers’ influence, e.g., through their interactions with participants?
Quantitative descriptive Is the sampling strategy relevant to address the quantitative research question (quantitative aspect of the mixed methods question)?
Is the sample representative of the population understudy?
Are measurements appropriate (clear origin, or validity known, or standard instrument)?
Is there an acceptable response rate (60% or above)?
Mixed methods Is the mixed methods research design relevant to address the qualitative and quantitative research questions (or objectives), or the
qualitative and quantitative aspects of the mixed methods question (or objective)?
Is the integration of qualitative and quantitative data (or resultsa ) relevant to address the research question (objective)?
Is appropriate consideration given to the limitations associated with this integration, e.g., the divergence of qualitative and quantitative
data (or resultsa ) in a triangulation design?
Criteria for the qualitative component and criteria for the quantitative component must be also applied.
a
These two items are not considered as double-barrelled items since in mixed methods research, there may be research questions (quantitative research) or research
objectives (qualitative research), and data may be integrated, and/or qualitative findings and quantitative results can be integrated.
 D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178 165

Records identified through database Additional records identified

searching through other sources
(n = 4035) (n = 3)

Records after duplicates removed

(n = 3125)

Records screened Records excluded

(n = 3125) (n = 3028)

Full-text studies assessed Full-text studies excluded,

for eligibility with reasons
(n = 97) (n = 59)
Additional records identified
through hand search
(n = 1)
Studies retained for critical Studies excluded due to
appraisal very low quality
(n = 39) (n = 1)

Studies included in
synthesis
(n = 38)

Fig. 1. Flow chart of study selection.

fourteen as moderate quality (score = 50%), thirteen as high quality
(score = 75%) and seven as very high quality (score = 100%).
3.3. Study characteristics
Thirty identified papers used a quantitative design, five utilised
a qualitative design and three used a mixed methods design. In all
quantitative designs, questionnaires were used for data collection.
In the qualitative studies two used individual interviews, two used
focus groups and one study used both interviews and focus groups.
In mixed methods designs, one study used a questionnaire and
interview, one study used a questionnaire and focus groups and
one study used a questionnaire, interview and review of incident
forms.
Five studies stated they had utilised a theoretical or conceptual
framework. Reason’s Accident Causation Model was utilised by
Shanty (2011), Sanghera et al. (2007) and Kingston (2011).
Kingston also utilised a Theory of Cognitive Dissonance, Theory
of Self-Reconciliation and a conceptual framework proposing that
organizational, individual, and work related barriers contribute to
reporting. Shanty (2011) also proposed a conceptual model of
medication safety. Hartnell et al. (2012) utilised Safety Culture
theory. Wakefield et al. (2001) utilised a conceptual framework;
their research was based on the belief that the reasons nurses do
not report medication errors are, in part, a function of the
organizational culture and the extent of implementation of
continuous quality improvement philosophy and principles.
Thirty-eight studies focused on researching barriers for not
reporting medication errors with only one of these primarily
focusing on reasons for not reporting near misses. Studies were
conducted in the United States (12), Iran (5), Taiwan (3), United
Kingdom (3), Jordan (3), Saudi Arabia (2), Canada (2), Australia (2),
Egypt (1), Israel (1), South Korea (1), Nigeria (1) and Malta (1).
Detailed descriptions of individual studies can be seen from
Table 3.
3.4. Barriers to reporting medication errors and near misses
To identify the barriers to reporting medication errors and near
misses, line by line coding for all studies enabled identification of
free codes (n = 261) leading to the development of 30 descriptive
primary level subthemes and when analysed and compared led to
6 secondary level themes. All themes were synthesised to develop
a thematic framework from which the two main themes were
identified (see Table 4).
3.4.1. Organisational barriers
Within organisational barriers, three secondary level sub-
themes were identified as barriers to reporting medication errors:
culture, reporting system and management behaviour.
3.4.1.1. Culture. The subtheme of culture included four elements:
unit type, work environment, hospital and multi-cultural staff.
Researchers found differences in reporting medication errors
were dependent on the type of unit. Blegen et al. (2004), for
example, found greater underreporting in Intensive Care Units
(ICU’s) compared to medical-surgical units. Similarly, Mrayyan
(2012) demonstrated differences between ICU nurses and ward
Table 3

166
Characteristics of studies included in critical appraisal (sorted by source).

Source and country Objectives Design, data- Sample, setting Main findings related to identified barriers MMAT
collection methods score
Aboshaiqah (2013) To assess why medication administration errors are not reported as Quantitative 307 nurses in large  Administrative response such as blaming the nurses if something 100%
Saudi Arabia perceived by nurses in a large government-owned tertiary hospital Questionnaire government-owned happens to the patient as a result of medication administration error
tertiary hospital) and focusing on the individual rather than looking at the system

Almutary and Lewis To determine how frequently RNs report medication Quantitative 62 nurses in a  Personal factors such as concern about repercussions (p  0.05) and 25%
(2012) administration errors when practicing in Saudi Arabia and to Questionnaire tertiary referral concern about legal action (p  0.05)
Saudi Arabia identify potential factors that may contribute to the non-reporting hospital  Administration factors such as nurse would receive negative feedback
of medication administration error from administration if report a medication administration error
(p  0.05), administration would focus on individual nurse as primary
cause of error (p  0.05) and would believe this to be a measure of the
quality of care (p  0.05)
 Response toward staff would not consider measure severity of
medication administration error (p  0.05)

D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178

 Increase in education level associated with greater reporting of
medication administration error (p  0.05)

Bahadori et al. (2013) To study the factors influencing not reporting on medication errors Quantitative 83 nurses from  Managerial factors such as focusing on the individual 50%
Iran from the nurses’ viewpoints in Abbasi Hospital of Miandoab Questionnaire different inpatient  Fear of the consequences such as judicial issues
units of one hospital  Factors related to the process of reporting
affiliated to  A relationship between employment status and fear of the con-
university sequences of reporting on medication errors (p  0.05)

Bakr Manal and Atalla To examine the perception of medication errors, perceived causes, Quantitative 186 nurses (115 from  Fear of managerial reaction in 76.5% in wards and 67.7% in ICUs 25%
(2012) and reporting behaviours among nurses Questionnaire ICU and 71 from
Egypt other wards) in
teaching hospital,
university hospital
and national
institute
Bayazidi et al. (2012) To explore medication error reporting rate and its barriers and Quantitative 733 nurses in  Blaming individuals instead of the system 100%
Iran facilitators among nurses in teaching hospitals of Urmia University Questionnaire teaching hospital  Consequences of reporting errors
of Medical Sciences  Fear of reprimand and punishment

Blegen et al. (2004) To explore reporting rates of medication administration errors,
United States patient falls and worker injuries and to describe nurses’
perceptions of medication administration errors that should be
reported, reasons for not reporting medication administration
errors, reporting of nurses’ exposure to blood-borne pathogens and
back injuries, work environment and nurse factors associated with
reporting in a national sample of 25 hospitals
Quantitative 1105 nurses from  Personal fear, such as fear of being blamed, fear of peers thinking they 50%
Questionnaire 149 adult patient were incompetent, patient developing negative attitudes, physician’s
care units reprimands, losing their license or being exposed to the public through
media reports
 Administrative response such as over-reaction, focus on person rather
than system as cause, emphasis on errors as measure of care quality,
lack of recognition when things go well. The proportion of medication
administration errors reported was negatively related to both
administrative response (r = 0.214, p < 0.05) and personal fear
reasons (r = 0.184, p  0.05) for not reporting
 Quality management process in the unit was positively related to
reporting of medication administration errors (r = 0.216, p  0.05) and
negatively related to reasons for not reporting (r = 0.124, p  0.05 for
personal reasons, r = 0.387, p  0.05 for administrative response
reasons; meaning that perceptions of a strong quality management
process were related to lower agreement with administrative and
personal reasons for not reporting)

Chiang and Pepper To describe nurses’ perceptions of reporting barriers to reporting Quantitative 597 nurses in one  Fear such as being blamed for medication administration error results 100%
(2006) medication administration errors and to examine the relationship Questionnaire medical centre and fear of adverse consequences
Taiwan between the barriers to medication administration errors reporting  Administrative barriers such as no positive feedback and excessive
and cultural relevant factors, nursing work environment and emphasis on medication administration error as nursing quality
demographic characteristics including personal experiences of
 Reporting process such as too much time required for filling reports,
medication administration errors among hospital nurses
too much time for contacting physicians
  Barriers to medication administration error reporting were positively
correlated with power hierarchy (r = 0.55, p  0.05) and face-saving
concern (r = 0.64, p  0.05). Power hierarchy and face-saving concern
had different strengths of correlation among the barriers factors,
power hierarchy had a greater influence on the reporting process
(r = 0.48, p  0.05) and face-saving concern more on the fear (r = 0.64,
p  0.05)

Chiang et al. (2010) To examine the predictive association between the failure in Quantitative 838 nurses in five  Experience of making medication administration errors 100%
Taiwan reporting medication administration errors and the related factors Questionnaire teaching tertiary  Attitude toward reporting self- and co-worker medication adminis-
including reporting barriers, nursing work environment, and hospitals tration errors
demographic variables among Taiwanese hospital nurses  Medication administration error reporting rate
 Nursing professional development
 Nursing quality
 Fear

Covell and Ritchie To determine the type of medication errors nurses report, why they Mixed methods 50 nurses in  Fear such as fear of adverse consequences identified in both the 50%
(2009) decide to report errors or not, and the strategies they believe will Questionnaire and quantitative and 10 questionnaires and interview

D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178

Canada improve reporting open-ended nurses in qualitative
interview questions in a 1000-bed
university health
centre
Evans et al. (2006) To assess awareness and use of the current incident reporting Quantitative 482 nurses in one  Lack of feedback (61.8%) 75%
Australia system and to identify factors inhibiting reporting of incidents in Questionnaire major referral  Senior nurses (nurse managers and clinical nurses) were more likely
hospitals hospital than junior nurses to know how to access a form (100.0% v 88.0%; RR
And 105 nurses in 1.14, 95% CI 1.09–1.18), to know what to do with it (100.0% v 80.9%; RR
two major rural base
1.24, 95% CI 1.13–1.35), and to have ever filled one out (100.0% v 89.0%;
hospitals
RR 1.12, 95% CI 1.10–1.15)
 Permanently employed nurses were significantly more likely than
contract nurses to know how to locate/access an incident form (89.1% v
57.1%; RR 1.56, 95% CI 1.25–1.95), to know what to do with it once
completed (82.7% v 50.0%; RR 1.65, 95% CI 1.12–2.45), and to have ever
filled one out (90.0% v 57.1%; RR 1.57, 95% CI 1.21–2.06)
 Nurses with more than 5 years post entry level experience were more
likely to know how to locate a form (91.5% v 83.8%; RR 1.09, 95% CI
1.04–1.14), to know what to do with it once completed (85.5% v 76.7%;
RR 1.12, 95% CI 1.06–1.17), and to have ever filled out an incident form
(94.0% v 82.5%; RR 1.14, 95% CI 1.06–1.23) than those with less
experience

Gladstone (1995) To identify the most common risk factors for nurses in the process Mixed methods 81 trained nurses, 12  Nurses' fear of management reaction (74%) 50%
United Kingdom of drug administration, to enable nurse managers and teachers to Questionnaire, semi- nurse managers and
understand the scenarios in which drug errors are most likely to structured interview 14 nurses who made
occur, to provide research-based information to be used in the and review of an error in three
evaluation and planning of continuing education and risk incident forms principal referral
management programmes hospitals
Hartnell et al. (2012) To identify incentives, barriers and facilitators to encourage Qualitative 9 physicians, 7  Reporter burden such as extra time required to report, extra work 100%
Canada medication error reporting as perceived by front-line hospital staff, In-depth interview pharmacists and 14 required to report, cumbersome incident report forms
to understand why certain factors serve as barriers, to explore how and focus groups nurses in focus  Professional identity such as hesitancy about “telling on” someone
some hospitals have successfully removed barriers with predetermined group in four else, fear of loss of reputation/perceived incompetence, anticipated
question guide community
negative attitudes from patients
hospitals
 Information gap such as perceived severity of error (less severe, less
likely to report), inability to recognize or identify medication errors,
lack of definitions or standards for reporting, ineffective reporting
systems
 Organisational factors such as ineffective reporting system, lack of
trust about how error reports will be used, reporting is the
responsibility of someone else
 Fear such as fear of reprisal from management/administration and fear
of exposure to malpractice suits

167
 168
Table 3 (Continued)
Source and country Objectives Design, data- Sample, setting Main findings related to identified barriers MMAT
collection methods score
Hashemi et al. (2012) To explore the factors associated with reporting the nursing errors Qualitative 115 nurses in  Factors associated with nurses such as fear of legal action and job 100%
Iran Focus groups with a university hospitals threats, fear of economic losses, fear of honour and dignity, weakness
scenario of targeted of knowledge, weakness of nursing skills in error management, and
questions unwillingness to accept the responsibility of the errors
 Nurses’ perception of the incidence and consequences of the errors
such as the impact degree as well as the severity of the error, not
having adverse events, and ambiguity in the notion of the error
 Organisational factors such as unpleasant behaviours and previous
inadequate reactions of the organization, including the managers,
physicians, and colleagues, and also the inappropriate reaction of the
manager regarding the impact and intensity of the error lead to under-
reporting the errors and covering them up, shortcomings in the safety
culture, nonexistence of team response, shame culture.

D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178

 Work pressure such as the personnel’s lack of time and the reporting
process’ being time-consuming

Haw et al. (2014) To explore the reported reasons given by inpatient psychiatric Qualitative 50 nurses (34 staff or  Reasons not reporting a near miss were identified as excusing (no 75%
United Kingdom nurses for not reporting a medication error made by a colleague Semi-structured senior staff nurses, harm, won’t happen again, forgetfulness), fear (loss of status, stigma
and to determine the perceived barriers to near miss reporting interview remainder ward or and/or trust with peers, disciplinary action including dismissal,
deputy ward litigation), knowledge (definition, unaware of medication error
managers) in acute
reporting system), burden (work pressure, too much effort, not a
psychiatric setting
worthwhile activity)
 Reasons not report a medication error made by colleague were
identified as passing the buck, it was just a one off and won’t happen
again, a good reason, not worthwhile reporting, empathy and wanting
to support and not punish a colleague, fear, knowledge, burden

Kagan and Barnoy To examine medication self-error reporting, estimate the perceived Quantitative 201 nurses  Reported frequency of discovering medication errors in negative 50%
(2008) incidence of medication errors and error reporting, and gather Questionnaire correlation with self-reporting of errors (r = 0.32, p  0.05)
Israel Israeli nurses’ personal views on error reporting and the factors  Positive correlations between self-reporting medication errors and the
that influence it respondent’s personal views on how the ward and hospital dealt with
errors (r = 0.43, p  0.05), and the perception of the way error reporting
was handled (r = 0.41, p  0.05)
 Negative correlation between medication error incidence and the way
the ward handled error reporting (r = 0.24; p  0.05)
 Negative correlations between error self-reporting and the practice of
nurse managers (r = 0.26, p  0.05) and staff nurses’ tendency to
correct errors without reporting them to a higher authority (r = 0.33,
p  0.05)

Kim et al. (2011) To identify the types of medication errors that occur in nursing Quantitative 220 nurses from  Fear of being troublemaker (46.7%) 50%
South Korea practice, the contributing factors for medication errors and the Questionnaire seven hospitals  Lack of awareness of the importance of reporting even minor errors
nurses’ perceptions of medication errors and reporting (25.0%)
 To cover up for the colleague involved (10.9%)

Kingston (2011) To describe participant nurses’ perceptions of medication error Qualitative 54 nurses in private  Contributing to the nurse’s likelihood to report a medication error such 75%
United States reporting, describe participant explanations of the emotional, Focus groups with paediatric hospital as the nurse’s response to a culture of blame (fear of disciplinary action
cognitive, and physical reactions to making a medication error, open ended and punitive action against the nurse), the desire to do no harm, a focus
identify pre-reporting conditions that make it less likely for a nurse questions on self-preservation, the reaction to the process of reporting an error
to report a medication error; and to identify pre-reporting
conditions that make it more likely for a nurse to report a
medication error
Lin and Ma (2009) To explore the prevalence of medication administration errors and Quantitative 605 nurses in 14  Concerns related to taking medical responsibility (74.3%) 75%
Taiwan the willingness of nurses to report them Questionnaire hospitals  Receiving punishment (73.1%).
 Medical disputes (70.6%)
 Distrust from patients (70.3%)

 Lack of ill effects of medication administration errors on the patient’s
condition (69.9%)
 The nurses’ willingness to report medication administration errors
differed by job position (x2 = 8.11, p  0.05), nursing grade (x2 = 9.56,
p  0.05), type of hospital (x2 = 6.44, p  0.05), hospital funding
(x2 = 18.30, p  0.05)
 Nurses working in private (91.8%) and non-profit hospitals (91.4%) had
higher medication administration error reporting rate than nurses
working in public hospitals (77.4%)
 Nurses who worked in a medical centre had a higher medication
administration error reporting rate (91.5%) than nurses working in
local hospitals (87.5%) and district hospitals (84.7%)

Mayo and Duncan To describe nurse perceptions about medication errors and Quantitative 983 nurses in 16  Fear of manager (76.9%) 75%
(2004) reporting Questionnaire acute care hospitals  Fear of peer reactions (61.4%)
United States  Medication error not serious to warrant reporting (52.9%)
 Weak relationship between type of unit and percentage of perceived

D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178

reported errors (r = 0.21, p  0.05) and between percentages of errors
perceived reported and years of RN practice (r = 0.15, p  0.05)

Mostafaei et al. (2014) To determine formal and informal medication errors of nurses and Quantitative 100 nurses in one  Lack of recording system for medication errors 50%
Iran the level of importance of factors in refusal to medication errors Questionnaire hospital  Non significance of reports of medication errors to hospital authorities
among nurses  Lack of a clear definition for medication errors
 Not knowing or diagnosing whether an error has occurred
 No significant relationship between demographic variables and the
level and the causes of reporting medication errors

Mrayyan (2012) To assess the reported incidence, causes and reporting of Quantitative 212 nurses in 4  Afraid of the reactions from nurse managers (78.0%) 75%
Jordan medication errors in intensive care units (ICUs) and wards of Questionnaire teaching hospitals  Afraid of reactions from their co-workers (78.0%)
Jordanian teaching hospitals  Ward nurses were more afraid than ICU nurses to report medication
errors because they might be subjected to disciplinary actions or even
losing their jobs (x2 = 3.18, p  0.05)

Mrayyan and Al-Atiyyat To compare medication errors between university-affiliated Quantitative 171 nurses from two  Afraid of the reactions from nurse manager (66.2%) 75%
(2011) teaching hospitals and non-university-affiliated teaching hospitals Questionnaire university-affiliated  Afraid of reactions from their co-workers (62.7%)
Jordan teaching hospitals,  Afraid of disciplinary actions or losing their jobs (52.4%)
and 98 nurses from  Significance difference between university-affiliated teaching hospi-
two non-university-
tals and non-university-affiliated teaching hospitals in all demo-
affiliated teaching
graphics (p  0.05) except in terms of nurses’ time commitment to
hospitals
work
 Significant difference between the two types of hospitals in regard to
the overall percentage of medication errors reported to nurse
managers by incident reports (x2 = 84.9, p  0.05)

Mrayyan et al. (2007) To describe Jordanian nurses’ perceptions about various issues Quantitative 799 nurses in 24  Afraid of the reactions from nurse manager (65.4%) 50%
Jordan related to medication errors Questionnaire hospitals  Afraid of reactions from their co-workers (59.6%)
 Female nurses reporting a higher number of medication errors than
the male nurses (p  0.05)

Osborne et al. (1999) To describe nurses' perceptions about what qualifies as a Quantitative 57 nurses in  Nurses are afraid of reporting medication error (86%) 75%
United States medication errors and to identify the main causes of medication Questionnaire community hospital  Medication administration error was not serious (57.9%)
errors  Fear of repercussions (25%)

Oshikoya et al. (2013) To investigate the self-reported experience of medication Quantitative 50 nurses in  Fear of intimidation, retribution or punitive action (22%) 50%
Nigeria administration errors among nurses working in paediatric units of Questionnaire paediatric units in  Lack of policies for reporting medication administration error (26%)
the public hospitals in Lagos, Nigeria public hospitals
Patrician and Brosch To assess civilian and military nurses’ perceptions of the reasons for Quantitative 43 nurses in survey  Fear the most common reason for not reporting 50%
(2009) medication administration error’s, reasons for not reporting errors, Questionnaire and 462 nurses in  Administrative response
United States and extent of underreporting, to assess the differences between (cross-sectional and longitudinal survey  Disagreement over error
anonymous reports of medication administration error’s and the longitudinal survey) in a large military  Reporting effort
reports generated via the current formal incident reporting system, Formal incidence medical centre
 Higher fear scores associated with less formal reporting (p  0.05)

169

 170
Table 3 (Continued)
Source and country Objectives Design, data- Sample, setting Main findings related to identified barriers MMAT
collection methods score
to examine the relationship of the nursing work environment and report Good physician/nurse relationship associated with higher perception
medication administration reporting Staffing info of reporting (p  0.05)

Petrova (2010) To determine nurses’ perceptions of factors that may contribute to
Malta medication administration error’s, to examine nurses’ views of
barriers to reporting medication administration error’s and to
identify possible measures to prevent errors
Quantitative 38 nurses in medical  Fear such as blamed if something happens to the patient, fear of 75%
Questionnaire wards adverse consequences, patient or family may develop a negative
attitude towards nurses, nurses believe that other nurses will think
they are incompetent
 Administrative response such as focus on the individual rather than
looking at the system as a potential cause of error and no positive
feedback for administering medication correctly
 Disagreements over error as error not important enough to be reported
and not recognizing that an error has occurred
 Relationship between nurses’ medical experience and their opinions

D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178

on medication errors (no p value reported)

Sanghera et al. (2007) To identify both reported and non-reported medication errors to Qualitative 13 members of staff  Not being aware that an error had occurred 100%
United Kingdom explore their causes, and to investigate the motivational factors and Semi-structured involved in 12 errors  Process of reporting (detailed paperwork, time constraints, not
barriers towards reporting of such incidents interview in 12-bed understanding incident reporting process)
anaesthetist-led ICU  No benefit (perception that nothing is done with the data)
in a 1000-bed UK
 Motivational factors (no encouragement by management, fear of loss
NHS Trust
of professional registration, fear of being in trouble or looking
incompetent, feeling upset, fear that will be blamed, not wanting to
report colleagues’ errors)
 Cultural differences

Shanty (2011) To compare differences in perceptions of the influence of Quantitative 447 nurses working  Fear as reason for not reporting 75%
United States organizational safety, to compare nurses’ practice environment on Questionnaire in Magnet, Magnet-  Safety culture variables (non-punitive response and hospital man-
med occurrence and barriers to reporting among nurses working in aspiring and non- agement) and years as a nurse
Magnet, Magnet- aspiring, and non-Magnet hospitals using an Magnet designated  Work environment variables (nursing foundation for quality of care,
Internet survey method hospitals
staffing and resources, and nurse manager ability)

Stratton et al. (2004) To estimate the proportion of medication errors that are actually Quantitative 57 paediatric and  Management-related reasons as paediatric nurses tended to have the 50%
United States reported by nurses in paediatric in-patient units, to examine the Questionnaire 227 adult hospital highest level of agreement with “nurse administration focuses on the
documented medication error rates in light of the proportion of nurses from 33 acute person rather than looking at the system”
medication errors nurses say are reported, to obtain nurses’ reasons care units in 11  Individual/personal reasons as paediatric nurses tended to have the
as to why medication errors occur, and reasons for not reporting, to hospitals
highest level of agreement with “nurses fear adverse consequences
specifically compare the paediatric nurse findings with previously
from reporting” and “nurses believe other nurses will think they are
reported adult and paediatric nurse findings related to reporting of
incompetent”
medication errors
Tabatabaee et al. (2014) To explore barriers to medication error reporting from a nurse’ s Quantitative 97 nurses in private  Fear of legal involvements 50%
Iran perspective in private hospital Questionnaire hospital  Fear of losing job
 Fear of the consequences of medication error
 Correlations between the nurses’ age and the mean scores of fear

Toruner and Uysal To review the causes of errors from the point of view of paediatric Quantitative 119 nurses in  Potential blaming of nurses in case of adverse outcome for the patient 25%
(2012) nurses, the factors affecting error notification, and their Questionnaire inpatient paediatric (52.95%)
Turkey suggestions as to how to avoid such error wards in 4 hospitals  Loss of trust (50.45%)
 Fear of disciplinary proceedings (42%)
 Rate of notification was significantly higher among intensive care
nurses than among service nurses (t = 5.98, p  0.05), and among
nurses looking after 1–5 patients (t = 4.78, p  0.05) than for nurses
caring for an average of 6–10 patients
 No statistically significant differences in notification rates according to
age, years of work experience, or working hours (p > 0.05)

Ulanimo et al. (2007) To describe nurses' perceptions about medication errors and the Quantitative 27 nurses in  Fear of peers’ reaction (64%) 50%
United States effects of physician order entry and barcode medication Questionnaire medical-surgical  Fear of nurse managers’ reaction (60%)
administration on medication errors wards in Veterans
 Affairs Medical  Lack of knowledge about policies, procedures, and unit routines
Center  Busy units and not enough time to report a medication error
 The nurse's negligence to report
 The nurse's attitude, personality, and compliance as barriers to
reporting medication errors

Wakefield et al. (1996) To assess and analyse nurses' perceptions regarding why Quantitative 1384 nurses in 24  No positive feedback for passing medications correctly” 50%
United States medication errors may go unreported Questionnaire hospitals  “Could be blamed if something happens to the patient”
 “When medication errors occur the focus is on the individual rather
than the system”
 “Nurses may not think the error is important enough to be reported”
 “Nurses believe that other nurses will think they are incompetent”
 “Nurses fear adverse consequences from reporting medication errors”

Wakefield et al. (2001) To explore the relationships among measures of nurses’ Quantitative 292 nurses in 6  Higher barriers to reporting scores were associated with decreased 75%
United States perceptions of organizational culture, continuous quality Questionnaire Midwest hospitals reporting at the individual level analysis
improvement implementation and medication administration  Correlations at individual, unit and hospital level between medication
error reporting administration error reporting barriers and estimated medication

D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178

administration error reporting rates were significant at individual level
for all barriers: fear (r = 0.24, p  0.05), disagreement over definition
of medication administration error (r = 0.23, p  0.05), administra-
tion response (r = 0.25, p  0.05), reporting effort (r = 0.22, p  0,05)
 Significant differences among the hospitals for 3 or 4 culture types
(group F = 13.9, p  0.05; developmental F = 1.62, p > 0.05; hierarchical
F = 3.9, p  0.05; rational F = 5.8, p  0.05), perceived extent of
continuous quality improvement implementation (F = 7.58, p  0.05),
and perceived percentage of medication administration errors
reported (F = 4.9, p  0.05)

Wakefield et al. (1999) To conduct a confirmatory analysis of a hypothesised 4-factor Quantitative 1428 nurses in 29  Fear 50%
United States solution describing reasons that medication administration errors Questionnaire hospitals  Administrative response
may not be reported and to analyse the resulting subscale variation
at nursing unit level
Walker and Lowe (1998) To identify nurses’ beliefs about medication incident reporting Mixed methods 43 nurses in six  Fear of reprimand from those in authority 25%
Australia Questionnaire, focus clinical units  Self-preservation
groups with  It depends on clinical situation
predetermined  Concerns about time taken to fill the incident report
question guide
 Inadequate understanding of what constitutes an error
 Lack of feedback on the number of medication errors
 Inaction on reported errors
 To report a medication incident when nurses believed that patient
safety is compromised, not reporting wrong time, drugs given but not
signed for, additive label on IV fluids incomplete, patient medication
found at bedside

Walters (1992) To describe nurses’ perceptions of the causes and types of Quantitative 284 nurses who  Significantly fewer medication errors were reported by RNs registered 75%
United States reportable medication errors and to examine the influence of Questionnaire attended an in- over 1 year (p  0.05) and RNs employed at the organization over 1 year
nurses’ age, years of practice, years of employment on the service on  Significantly fewer medication errors were reported by RNs in nursing
occurrence and reporting of medication errors medication over 1 year and 35 years of age and older (p  0.05)
administration in
large Midwestern
tertiary hospital

171
 172
Table 4
Overview of data synthesis associated with barriers to reporting medication errors or near misses.

Main Themes Secondary level Descriptive primary level Free codes

subthemes subthemes
Organisational Culture Unit type  type of unit, unit culture, quality management processes
Barriers Work environment  staffing, resources, nursing foundation for quality of care, nurse/physician relationship
Hospital  type of hospital, hospital culture, quality improvements implementations, power hierarchy, lack of trust
Multi-cultural staff  staff from other countries

Reporting system Policy and processes  ineffective reporting system, lack of policies, lack of recording system
Standards and definitions  lack of standards, lack of clear definitions
Burden  time consuming, detailed paperwork, work pressure, too much time for contacting physicians

Management Focusing on the individual  management focuses on the individual rather than looking at the systems as a potential cause of the error
behaviour Blaming and overreaction  focusing only on finding the culprits, blaming for medication errors results, overreacting, response not matching the severity of the error
Lack of feedback  negative feedback, no positive feedback

D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178

No benefit  nothing is done with data, handling the error
Emphasis on medication error as  medication error is a measure of the quality of nursing care provided
a quality measure

Personal and Fear Personal  being blamed, being a troublemaker, losing honour and dignity, losing status, being stigmatized
Professional Manager  fear of manager’s reaction on medication error, fear of feeling incompetent in front of manager
Barriers Co-worker  fear of co-workers or peers’ reaction, fear of feeling incompetent in front of co-workers
Physician  physician reprimands
Patient and family response  patient or family may develop negative attitude towards nurses, distrust of healthcare
Disciplinary actions  intimidation, retribution or punitive action, punishment, repercussions, disciplinary proceedings, legal actions, judicial issues, malpractice suits,
medical disputes, being exposed to the public trough media, losing the licence, losing professional registration, losing job, losing economic stability

Accountability Recognition  inability to recognize or identify medication error, not want to admit that medication error occurs
Responsibility  negligence, attitude, personality, compliance, unwillingness to accept responsibility, lack of awareness of the reporting
Severity of medication error  some medication errors are not serious enough to warrant reporting, depending on the nurses’ assessment of the clinical situation, no harm resulting or
Disagreement attributing to an error, less severe less likely to report
Self-preservation  disagreement with the error occurrence, inadequate understanding of what constituted an error
 previous experience of making medication errors, previous experiences of getting into trouble, not want to ‘tell on’ or punish colleagues a colleague
(especially if more experienced) or a friend

Characteristics of Education  higher frequency of reporting among nurses with higher levels of education, shortcomings in educational system
nurses Training  type of training, inclusion in continuing education programmes
Knowledge and skills  lack of knowledge of reporting process, lack of skills in error management, uncertainty about definitions
Working experiences  years of experiences in reporting and fear as a reason for not reporting
Age  young versus older nurses
Job position  senior versus junior nurses, nurses with higher job positions versus nurses with lower job position
Employment status  permanently employed nurses versus contract nurses
 D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178
nurses, with the latter more afraid to report due to fear of
disciplinary actions or losing their job. Toruner and Uysal (2012)
also found the reporting rate to be higher among ICU nurses than
among service nurses. Mayo and Duncan (2004) indicated that
maternal child health nurses perceived a greater percentage of
medication error reporting compared with nurses working in
medical and surgical units. In support of this, Stratton et al. (2004)
also found differences between paediatric and adult units, where
higher levels of estimated reporting occurred on paediatric units.
Such differences between units were regarded as being possibly
due to varying unit cultures or, different quality management
processes on the unit (Blegen et al., 2004).
Differences between units could also be due to work environ-
ment elements, such as nurse staffing, resources and understand-
ing of quality of care (Shanty, 2011). For example, Toruner and
Uysal (2012) indicated better reporting rates with nurses looking
after 1–5 patients as opposed to 6–10 patients. Chiang et al. (2010)
found that nurses demonstrating greater disagreement on nursing
quality were more likely to underreport. A good physician/nurse
relationship was also found to be associated with higher
perceptions of reporting (Patrician and Brosch, 2009).
Differences in reporting depending on the type of hospital were
also found (Lin and Ma, 2009; Mrayyan and Al-Atiyyat, 2011;
Shanty, 2011; Wakefield et al., 2001). This was attributed to
differing organizational culture and quality improvement imple-
mentation. Quality improvements were seen as a means of culture
change (Blegen et al., 2004). Other culturally relevant barriers,
such as power hierarchy (Chiang and Pepper, 2006) and lack of
trust in the organisation about how error reports would be used
(Hartnell et al., 2012) were also found to be perceived barriers to
medication error reporting.
Organizational culture was found to be an important barrier,
with cultural differences in terms of staff from other countries also
being identified as a barrier to the reporting of medication errors
(Sanghera et al., 2007).
3.4.1.2. Reporting system. The subtheme of the reporting system
included three elements: policy and processes, standards and
definitions, burden.
Reporting policy and processes were seen as an important
barrier affecting the reporting of medication errors (Chiang and
Pepper, 2006; Sanghera et al., 2007). The problem occurs when
there is an ineffective reporting system, especially if nurses do not
understand incident reporting processes (Hartnell et al., 2012),
when there is a lack of policies (Oshikoya et al., 2013) and lack of a
recording system (Mostafaei et al., 2014).
Lack of standards for reporting (Hartnell et al., 2012) and lack of
clear definitions of what constitutes medication errors (Bahadori
et al., 2013; Mostafaei et al., 2014) were also found to influence the
reporting of medication errors and near misses.
A reporting system that is perceived as a burden also affects
rates of reporting (Hartnell et al., 2012; Haw et al., 2014; Patrician
and Brosch, 2009). Nurses perceived reporting processes as a
burden (Hartnell et al., 2012; Hashemi et al., 2012; Walker and
Lowe, 1998), because of the detailed paperwork (Sanghera et al.,
2007) and long or cumbersome forms (Evans et al., 2006; Hartnell
et al., 2012). Due to work pressure (Hashemi et al., 2012; Ulanimo
et al., 2007) nurses did not perceive that they had enough time to
report (Evans et al., 2006) or even forgot to report some medication
errors (Bahadori et al., 2013). If excessive time was required to
contact physicians this also influenced willingness to report
(Chiang and Pepper, 2006).
3.4.1.3. Management behaviour. The subtheme of management
behaviour included five elements: focusing on the individual,
173
blaming and overreacting, lack of feedback, no benefit and
emphasis on medication error as a quality measure.
Focusing on the individual rather than looking at the system as
a potential cause of error was identified as one of the most
important aspects of management behaviour that affected the
nurses’ disclosure of medication errors (Aboshaiqah, 2013;
Almutary and Lewis, 2012; Bahadori et al., 2013; Patrician and
Brosch, 2009; Petrova, 2010; Stratton et al., 2004; Wakefield et al.,
1996).
Poor management behaviour affecting medication error and
near miss reporting also included focusing only on finding the
culprits rather than taking other factors into consideration
(Bahadori et al., 2013), blaming nurses for medication error
results, especially if something happens to the patients (Chiang
and Pepper, 2006; Patrician and Brosch, 2009; Petrova, 2010;
Wakefield et al., 1996) and overreacting (Almutary and Lewis,
2012; Blegen et al., 2004; Hashemi et al., 2012). Some nurses
believed that managers’ responses to medication errors failed to
match the severity of the error (Chiang and Pepper, 2006).
A lack of feedback (Evans et al., 2006; Sanghera et al., 2007;
Walker and Lowe, 1998), negative feedback (Almutary and Lewis,
2012) or no positive feedback (Blegen et al., 2004; Chiang and
Pepper, 2006; Petrova, 2010; Wakefield et al., 1996) were also seen
as deterrents towards reporting. It was perceived by nurses that
managers should provide full feedback openly to all staff (Sanghera
et al., 2007), which also includes providing positive feedback on
correct medication administration (Blegen et al., 2004; Chiang and
Pepper, 2006; Petrova, 2010; Wakefield et al., 1996), rather than
focusing solely on the negatives.
A perception that nothing was done with the data and that
there was no benefit in reporting, decreased reporting likelihood
(Gladstone, 1995; Walker and Lowe, 1998). The more positively
nurses saw the response and handling of the medication error, the
higher the rate of medication error self-reporting, whereas when
managers tended to cover up the error, without reporting to a
higher authority, errors were reported less frequently (Kagan and
Barnoy, 2008).
Medication error reporting was also affected where nurses
perceived that nurse managers put too much emphasis on
medication error as a quality indicator of nursing care (Almutary
and Lewis, 2012; Blegen et al., 2004; Chiang and Pepper, 2006).
3.4.2. Personal and professional barriers
Within personal and professional barriers, three secondary
level subthemes were identified as barriers to reporting medica-
tion errors and near misses in nursing: fear, accountability,
characteristics of nurses.
3.4.2.1. Fear. The subtheme of fear included six elements:
personal, manager, co-worker, physician, patient and family
response and disciplinary actions.
Nurses are afraid of reporting medication errors (Wakefield
et al., 1999) due to personal fears, such as fear of being blamed
(Blegen et al., 2004; Petrova, 2010; Sanghera et al., 2007; Toruner
and Uysal, 2012) or being perceived as a troublemaker (Kim et al.,
2011; Sanghera et al., 2007). They were also afraid of losing their
honour and dignity (Hashemi et al., 2012), status or being
stigmatized (Haw et al., 2014).
They were particularly afraid of managers (Bakr Manal and
Atalla, 2012; Gladstone, 1995; Hartnell et al., 2012; Mayo and
Duncan, 2004; Mrayyan, 2012; Mrayyan and Al-Atiyyat, 2011;
Mrayyan et al., 2007; Ulanimo et al., 2007).
Fear of co-workers or peers was another barrier (Blegen et al.,
2004; Mayo and Duncan, 2004; Mrayyan, 2012; Mrayyan and Al-
Atiyyat, 2011; Mrayyan et al., 2007; Petrova, 2010; Ulanimo et al.,
2007). Nurses were afraid that managers and co-workers would
174 D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178
consider them as incompetent (Blegen et al., 2004; Hartnell et al.,
2012; Petrova, 2010; Sanghera et al., 2007; Stratton et al., 2004;
Wakefield et al., 1996). Fear of physicians or their reprimands
(Blegen et al., 2004) was found less frequently as a barrier.
Nurses were also concerned about patient and family responses
(Blegen et al., 2004; Hartnell et al., 2012; Petrova, 2010) and their
distrust of healthcare received if a medication error was reported
(Lin and Ma, 2009).
However, nurses mostly had a fear of adverse consequences
(Bahadori et al., 2013; Bayazidi et al., 2012; Chiang and Pepper,
2006; Chiang et al., 2010; Covell and Ritchie, 2009; Kim et al., 2011;
Patrician and Brosch, 2009; Petrova, 2010; Sanghera et al., 2007;
Wakefield et al., 1996), especially in terms of disciplinary actions,
such as intimidation, retribution or punitive action (Oshikoya et al.,
2013), reprimand and punishment (Bayazidi et al., 2012),
repercussions (Almutary and Lewis, 2012; Osborne et al., 1999)
and disciplinary proceedings (Haw et al., 2014; Kim et al., 2011;
Mrayyan and Al-Atiyyat, 2011; Toruner and Uysal, 2012), legal
actions (Almutary and Lewis, 2012; Hashemi et al., 2012;
Tabatabaee et al., 2014), judicial issues (Bahadori et al., 2013),
malpractice suits (Hartnell et al., 2012), medical disputes (Lin and
Ma, 2009) and being exposed to the public through media (Blegen
et al., 2004). They were afraid of losing their license to practice
(Blegen et al., 2004), professional registration (Sanghera et al.,
2007), losing their job (Hashemi et al., 2012; Mrayyan and Al-
Atiyyat, 2011; Tabatabaee et al., 2014) and economic instability
(Hashemi et al., 2012).
3.4.2.2. Accountability. The subtheme of accountability included
five elements: recognition, responsibility, severity of medication
error, disagreement and self-preservation.
Nurses may not have realised that a medication error had
occurred (Hartnell et al., 2012; Mostafaei et al., 2014; Petrova,
2010; Sanghera et al., 2007; Walker and Lowe, 1998) or did not
want to admit that the medication error had occurred (Walker and
Lowe, 1998).
Barriers to reporting included negligence, attitude, personality,
and compliance (Ulanimo et al., 2007), concerns related to taking
medical responsibility (Lin and Ma, 2009) or unwillingness to
accept the responsibility of the error (Hashemi et al., 2012). A lack
of awareness of the importance of reporting even minor errors was
also identified (Kim et al., 2011).
The perceived severity of the medication error was important
when nurses were deciding to report (Hartnell et al., 2012;
Hashemi et al., 2012; Lin and Ma, 2009; Mayo and Duncan, 2004;
Petrova, 2010; Walker and Lowe, 1998). Nurses perceived that
some medication errors are not serious enough to warrant
reporting (Hashemi et al., 2012; Mayo and Duncan, 2004; Petrova,
2010), particularly if there is a lack of ill effects of medication errors
on the patient’s condition (Hashemi et al., 2012; Lin and Ma, 2009;
Walker and Lowe, 1998). Reporting sometimes depended on the
nurses’ assessment of the clinical situation (Walker and Lowe,
1998), with less severe medication errors, being less likely to be
reported (Hartnell et al., 2012; Walker and Lowe, 1998).
Errors were less likely to be reported where nurses disagreed
with the error occurrence (Patrician and Brosch, 2009; Wakefield
et al., 2001) or had inadequate understanding of what constituted
an error (Walker and Lowe, 1998). Using excuses such as no
harmful effects attributing to an error to mere forgetfulness were
also found to be barriers to reporting near misses (Haw et al., 2014).
Previous experience of making medication errors (Chiang et al.,
2010; Walker and Lowe, 1998) and getting into trouble (Walker and
Lowe, 1998) were found as self-preservation barriers towards non-
reporting. Nurses also did not want to ‘tell on’ colleagues (Hartnell
et al., 2012; Kim et al., 2011; Sanghera et al., 2007; Walker and
Lowe, 1998), had empathy with the colleague and wanted to
support and not punish a colleague (Haw et al., 2014).
3.4.2.3. Characteristics of nurses. The subtheme characteristics of
nurses included seven elements: education, training, knowledge
and skills, working experiences, age, job position and employment
status.
Reporting of medication errors could be associated with
nurses’ education level and their training. Almutary and Lewis
(2012) found that the frequency of reporting was higher among
nurses who had higher levels of education. Lin and Ma (2009)
found that nurses with higher nursing grades, job training, such
as nurses with holistic care training and clinical teaching reported
errors more frequently than nurses with different job training,
such as nurses with new nurse orientation training, basic nursing,
critical care training and specialized training. On the other hand,
Chiang et al. (2010) found that nurses who rated their
professional development as greater were more likely to
underreport. Nurses’ inclusion in continuing education pro-
grammes, clinical ladder projects and advanced nursing training
in workplaces was linked to increased likelihood to underreport.
Some also emphasised that the educational system had short-
comings (Haw et al., 2014).
Knowledge in managing the error influenced nurses’ medica-
tion error reporting, especially if they had a lack of knowledge of
the process, were unaware of the medication error reporting
system (not knowing how to report an error) or had a lack of skills
in error management (Hashemi et al., 2012). Uncertainty about
definitions was another knowledge deficit (Hashemi et al., 2012;
Haw et al., 2014). The most commonly reported knowledge deficit
was about the definition of a near miss, while knowledge deficits
about the reporting process and systems were less commonly
reported.
A relationship between nurses’ working experience and their
opinions on medication errors was identified (Petrova, 2010).
Years of experience as a nurse was seen to be important. Those
with longer post entry level experience were more competent in
completing incident forms (Evans et al., 2006), although despite
this finding, Mayo and Duncan (2004) indicated that inexperi-
enced nurses reported medication errors as frequently as more
experienced nurses, with a very low correlation demonstrated
between years of experience and perceived reporting rates
(r = 0.15, p  0.05). However, some studies have indicated older
nurses with more years of practice experience had a greater fear
of consequences regarding medication error reporting, thus
indicating this to be a significant barrier to effective reporting
(Tabatabaee et al., 2014; Walters 1992). Conversely, Shanty (2011)
demonstrated that nurses with more years of experience believed
that fear was less likely to be a barrier to reporting medication
errors.
Job position and employment status were also other influential
elements. Evans et al. (2006) reported that senior nurses (nurse
managers and clinical nurses) and those in permanent positions
were more likely than junior nurses to know how to access a form,
what to do with it and to have ever filled one out. A similar finding
also emerged in Lin and Ma's (2009) study where nurses with
higher job positions were more willing to report medication errors.
This is probably the result of the relationship between employ-
ment status and fear of the consequences of reporting medication
errors (Bahadori et al., 2013). However, Mostafaei et al. (2014) did
not find a significant relationship between demographic variables
and reporting medication errors and likewise, Toruner and Uysal
(2012) did not find any statistically significant differences in
reporting rates, according to age, years of work experience, or
working hours.
 D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178
4. Discussion
This review provides an overview of the literature on the
barriers to reporting medication errors and near misses by nurses.
The results identify these as organizational, personal and
professional barriers.
Several studies confirmed that organisational barriers, such as
culture, the reporting system and management behaviour influ-
ence reporting. Hospital, organizational and unit cultures that are
perceived as blaming (Aboshaiqah, 2013; Bahadori et al., 2013) and
a lack of trust in managers are counterproductive to reporting. A
culture that is supportive of error reporting rather than looking to
blame individuals is required (Shanty, 2011; Stratton et al., 2004).
“People follow the culture of the floor”, meaning that unit culture
could have an even stronger influence than the culture of the
organization (Covell and Ritchie, 2009). Creating an open,
trustworthy, safe environment in hospital and units that will be
conducive to reporting requires a systems approach to patients’
safety (Stetina et al., 2005). Culture change is not an easy or
expedient process and requires the patience and persistence of all
leaders in an organization (Patrician and Brosch, 2009).
Management behaviour seems to be one of the most important
barriers that influence nurses’ reporting. Managers should not
focus on the individual but rather on the system, reinforcing the
importance of complete reporting, providing feedback, rewarding
good performance and implementing quality improvement
initiatives (Wakefield et al., 2001, 1999). Reporting systems should
be anonymous and without negative consequences (Lin and Ma,
2009). The reporting process should be simple and not require too
much extra work or time (Hartnell et al., 2012), as otherwise nurses
will perceive it as a burden. The organization must maintain
accountability while promoting voluntary, anonymous and confi-
dential reporting (Uribe et al., 2002).
Clear definitions of medication errors and near misses should
be identified by organizations and nurses should agree with them
and be informed about them. If there is a disagreement over what
constitutes a medication error, or if managers lack understanding
of their staff perceptions, then interventions to enhance medica-
tion error reporting may not be successful (Wakefield et al., 1999).
However, when there is an agreed clear definition, nurses should
report medication errors and not redefine them based on clinical
situations or perceive them as unimportant if there is no harm to
patients.
In order to promote reporting nurses should not be afraid of
consequences. Fear of disciplinary action and punitive action
against the nurse is a result of a culture of blame (Kingston, 2011).
Nurses put themselves under pressure, as they think they should
be perfect (Covell and Ritchie, 2009) and not make errors. When a
medication error occurs, nurses first blame themselves and then
they are blamed or punished by the manager and department (Lin
and Ma, 2009). Nurses are also afraid of patients’ and their families’
responses. When an error occurs, there needs to be communication
between the team members and patients (Levinson, 2009). Nurses
may be concerned that an apology will make litigation more likely,
but the evidence suggests that patients are less likely to start legal
processes if they feel they have been listened to and have been
offered a proper, sincere apology (Armstrong, 2009; Levinson,
2009).
Provision of support and training is essential to overcome the
reported barriers faced by nurses (Harrison et al., 2014) and
should be provided by organizations. Nurses need to be educated,
skilled in error management and patient safety and have a clear
definition of a medication error and a near miss and how to report
this. Surprisingly, the literature review showed, that continuing
education and nurses’ professional development could be linked
to increased likelihood to underreport medication errors (Chiang
175
et al., 2010). There is little literature related to researching
professional development and medication error reporting and
one possible explanation is that experienced nurses are more
confident and autonomous and might think that not all
medication errors are severe enough to be reported (Antonow
et al., 2000; Smith and Silver, 2000; Chiang et al., 2010). Nurses
with more years of nursing experience are more prone to
reformulate or reclassify (Chiang et al., 2010; Walters, 1992).
Therefore, a strong emphasis on the importance of reporting
should be placed during continuing professional development.
Where studies demonstrate conflicting results in terms of the
influence of years of nursing experience and fear of reporting, this
could perhaps be attributed to the system or culture of the
organisation taking precedence over personal or professional
nursing characteristics.
This systematic exploration of the literature revealed that there
are a lack of studies that have specifically explored the barriers to
reporting near misses. There is also a low awareness of reporting
them. Blegen et al. (2004) found that only 36% of nurses indicated
that near misses should be reported. Evans et al. (2006) found that
41.9% of nurses perceive reporting near misses as the least
important incident that should be always reported and they did
not see any point in reporting them. Educators, managers and
practitioners need to develop teaching, policy and practice to
minimise this behaviour and persuade nurses to develop a true
learning culture where near miss reporting is viewed as an
opportunity and not a burden (Haw et al., 2014).
Although this was not the aim of our study, it seems that health
care providers other than nurses also perceive similar barriers
when it comes to reporting errors. Holmström et al. (2012)
researched barriers to reporting at an international level. Medica-
tion safety experts, identified through the International Pharma-
ceutical Federation and other professional organizations from
different countries, perceived that blame culture, a lack of time,
training and coordination are major barriers to reporting. Wolf and
Hughes (2008) identified fear, understanding, burden of effort and
administrative/management/organisational barriers as reasons
why clinicians do not report and disclose errors and near misses.
Some suggest that there are different attitudes to reporting, such as
Sarvadikar et al. (2010), who found that nurses and pharmacists
are more likely to believe they will be blamed and criticized for an
error compared to physicians, with nurses also expressing a higher
expectation for disciplinary action compared to other health care
professionals.
Overcoming barriers can contribute to a cultural shift and
creation of an environment that will promote and enhance
reporting (Uribe et al., 2002). Identified barriers can also be seen
as strategies, motivational factors, empowerments or facilitators to
increase reporting. Nurses are motivated to report if they have
knowledge, skills (Bayazidi et al., 2012; Hartnell et al., 2012;
Hashemi et al., 2012), professional commitment and professional
accountability. The organization must have an anonymous
reporting system (Bayazidi et al., 2012; Hashemi et al., 2012) that
reduces reporter burden (Hartnell et al., 2012) and a clear
medication error definition. Nurses must perceive a dominant
supportive atmosphere, profit from reporting (Bayazidi et al., 2012;
Hashemi et al., 2012) and see that physicians are not shirking from
their responsibility (Hashemi et al., 2012). Managers and
physicians should be understanding and supportive. Nurses must
be actively involved in determining medication errors and
promptly report them to the nurse manager. Nurse managers
should consistently follow an action plan to correct errors if made
frequently (Ulanimo et al., 2007). Other suggested strategies to
increase reporting are the implementation of continuous quality
improvement initiatives (Wakefield et al., 2001).
176 D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178
4.1. Methodological limitations of the included studies
Conclusions should be drawn with caution, because of some
methodological limitations of the included studies, particularly as
the studies were heterogeneous. They were conducted in different
types of hospitals and units. Almost half of the quantitative studies
were conducted in developed countries and the other half in
developing, eastern countries. Interestingly, when it comes to
Europe, with one exception (Malta), all included studies were
conducted in the UK. The majority of qualitative and mixed
methods studies were conducted in western countries. Thus, more
than half of included studies concerned barriers to reporting in
developed countries.
Quality of included studies varied. Studies from Almutary and
Lewis 2012; Bakr Manal and Atalla, 2012; Touruner and Uysal,
2012; Walker and Lowe, 1998 were assessed with a low quality
score (score = 25%). Sampling strategy, representativeness of the
sample and appropriateness of measurement (validity and
reliability) were lacking in these studies. The quality of most
selected studies with a quantitative design was evaluated as
moderate. Studies with quantitative designs that were assessed as
moderate were lacking in terms of sampling strategy, sample
representativeness or appropriateness of measurement. The
quality of most included studies with a qualitative design was
evaluated as very high and high. The quality of most included
selected studies with a mixed methods design was moderate. The
major criteria lacking in studies with a mixed methods design were
considerations given to the limitations associated with integration
of qualitative and quantitative data. It should also be noted that five
included studies, (Blegen et al., 2004; Mayo and Duncan, 2004;
Mrayyan et al., 2007; Wakefield et al., 1996, 1999) received a lower
MMAT score due to acceptable response rate criteria (60% or above)
despite large sample sizes (1105, 983, 799, 1384, and 1428,
respectively). Most of the included quantitative studies used
convenience sampling which limits the generalizability of the
findings. The majority of studies were cross sectional, therefore, it
was not possible to determine causational relationships between
variables.
Researchers explored different barriers and used different
survey instruments. However, survey instruments may not capture
all of the reasons for failure to report with findings identified based
on the researchers’ interpretation of which barriers may be
important.
Only one study primarily focused on researching barriers to
reporting near misses, suggesting that further research is needed
and thus any conclusion based on this one study is not
representative.
4.2. Limitations of the review
Although a broad range of material was accessed, some relevant
work may have been omitted due to the inclusion of material only
in the English language. Quality assessment was done by MMAT, an
efficient tool, although its’ reliability could be further improved as
it appraises the methodological quality of included studies and not
the quality of their reporting (Souto et al., 2015). The methodolog-
ical quality of included studies also varied.
4.3. Implications for education, practice, policy and research
Our findings have useful implications for improving medication
errors and near miss reporting. Nurses should become more aware
and comfortable with reporting the medication errors and
especially near misses. The first step is the evaluation of
educational programmes to ensure that they effectively prepare
a novice nurse for maintaining patient safety. Education and
training about safe medication management should not be focused
only on new employees, but should become a part of nurses’
lifelong education and training. Emphasis should be placed on the
importance of reporting, especially for near misses. In addition to
patient safety management, ethical and professional responsibility
should be promoted.
Organizations should embrace reporting as part of an everyday
patient safety issue. Open reporting culture and an effective
reporting system should be developed in each organization.
Therefore, managers should promote and encourage reporting by
implementing effective strategies to improve patient safety and
provide support to their staff. In addition, open and honest
communication is needed between managers and nurses so that
trust can be built within the organization.
Managers should develop policies that support open commu-
nication and non-punitive, fearless learning cultures in order to
improve the reporting of medication errors and near misses. Clear
standards and definitions are needed in addition to burdenless
reporting processes. Managers should inform nurses about policies
and include them in their preparation so that policy adherence will
be an everyday practice.
There is a paucity of research on the reporting of near misses
and therefore, more studies are needed. As organizations differ,
each should research their own reporting situation. Mixed
methods studies could be used, as quantitative study designs
may not capture all of the barriers to medication error and near
miss reporting. To fully understand the nature of relationships
between different barriers, high quality longitudinal studies are
required.
5. Conclusion
“To err is human, to share is divine”. Reporting and sharing
information about medication errors and near misses is needed to
enhance patient safety and to prevent their recurrences (Koczmara
et al., 2006). A systems approach is required to manage reporting
medication errors and near misses. It cannot be expected that
nurses will report medication errors and near misses in blaming,
punitive, fearful cultures. Nurses need to trust their superiors in
order to minimize their fear of reporting consequences. Effective,
uncomplicated and non-time consuming anonymous reporting
systems are needed in order to minimize nurses’ burden. Managers
should not focus on individuals, blame them for medication errors
and overreact, but rather encourage nurses to report medication
errors and near misses in order to develop a non-punitive, fearless,
learning culture. Managers should acknowledge that the majority
of medication errors are the result of the system rather than a
single nurse. However, as there are also individuals’ barriers
affecting medication error and near miss reporting, nurses'
individual responsibility cannot be ignored. Open feedback on
reporting and commending or rewarding safe medication admin-
istration and reporting is very important for nurses and could
increase rates of reporting. Nurses, policy makers and managers
should also agree on what constitutes a medication error and near
miss. Nurses should become more aware that reporting of all
medication errors and also near misses is needed. This should be
emphasised through education and lifelong training. As nurses are
accountable for their work, they should be competent in safe
medication management. Nurses and managers should be aware of
the importance of reporting medication errors and near misses to
ensure competency in safe medication management.
Conflicts of interest
None declared.
 D. Vrbnjak et al. / International Journal of Nursing Studies 63 (2016) 162–178
Funding
None declared.
Ethical approval
None declared.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.
ijnurstu.2016.08.019.
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