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Underreporting of medical errors.

The Institute of Medicine (IOM) landmark report "To Err is Human" was released nearly 20 years ago. According to authors Kohn, Corrigan, and Donaldson (2000), up to 98,000 people die each year because of medical errors. After the IOM report, other sources suggested 98,000 deaths as an underestimation; the actual number of deaths from medical errors may be in the hundreds of thousands (James, 2013). However, because not all errors lead to patient death (Makary & Daniel, 2016), the total number of medical errors each year may be surprising. The true number of medical errors is unknown because many go unreported (Bayazidi, Zarezadeh, Zamanzadeh, & Parvan, 2012; Hajibabaee, Joolaee, Peyravi, Alijany-Renany, & Bahrani, 2014; Soydemir, Intepeler, & Mert, 2016). The reasons for underreporting are not simple but they warrant investigation so the incidence of errors can be reduced (Kim, Kang, Kim, & You, 2014).

Reasons for Underreporting

An error may not be reported because it may be considered to be no one's fault (Haw, Stubbs, & Dickens, 2014) or part of normal practice (Soydemir et al., 2016). For instance, the standard time for administration of a once-a-day medication may be 8:00 a.m. at a particular institution. A nurse administers a patient's morning medications at 2:00 p.m. because the patient was away from the unit for a procedure. No medical order indicated medications should be withheld until after the procedure. Having a seemingly valid excuse for late administration of the medication does not make this any less a medication error. If common practice on a unit is to hold morning medications without a medical order until a patient returns from off-unit procedures, this error may go unreported because it is seen as a normal part of care.

Another common perception is that an error does not need to be reported if it does not seem to cause harm. Nurses typically do not report near misses or errors if there are no serious consequences (Hashemi, Nasrabadi, & Asghari, 2012; Kim et al., 2014; Wagner, Damianakis, Pho, & Tourangeay, 2013). In the above example, the nurse may believe no harm was done because the patient did not develop any obvious complications and so may not report this late administration as an error.

Error underreporting also may be related to the lack of a reporting system at an institution or lack of staff awareness that a system for reporting exists (Lederman, Dreyfus, Matchan, Knott, & Milton, 2013; Soydemir et al., 2016). Fear of consequences if a medical error is reported is identified commonly as a contributing factor to error underreporting (Almutary, & Lewis, 2012; Haw et al., 2014; Kagan & Barnoy, 2013; Yung, Yu, Chu, Hou, & Tand, 2016). The IOM supported the concept of a culture of safety to encourage error reporting without fear of repercussion or blame so the root cause of errors could be identified and prevention measures instituted (Kohn et al., 2000). Poorolajal, Rezaie, and Aghigh, (2015) found clinical care providers remain concerned about being blamed as individuals. The negative feedback from administrators, managers, or others prompt bedside clinicians not to report errors (Bahadori et al., 2013; Hashemi et al., 2012). Also, when a trusting relationship between managers and staff does not exist, staff are less inclined to report errors (Kim et al., 2014).

Of note, underreporting is not limited to nurses. Soydemir and colleagues (2016) interviewed doctors and nurses, and found both professions did not report errors because of fear of blame and condemnation. These concerns suggest use of an anonymous reporting system may increase the number of reported errors. These and other researchers also noted staff underreported errors when they perceived reporting was of no consequence because they neither received feedback about their error reports nor saw any improvements due to the reporting (Hartnell, MacKinnon, Sketris, & Fleming, 2012; Soydemir et al., 2016).

Solutions to Address Underreporting

What can nurses do to support a culture of safety and facilitate the reporting of errors so trends and patterns can be identified and root causes discovered? Several initiatives should be instituted.

A Supportive Environment with Good Communication

A positive, supportive environment, with managers and administrators who focus on safety rather than on blame is key. Kagan and Barnoy (2013) surveyed 270 registered nurses (90% hospital-based) about their medical error reporting and found the rate at which they reported medical errors was related directly to the perception of a patient safety culture. A nonpunitive communication style for managers is important if errors are to be reported. Qin, Xie, Jiang, Zhen, and Ding (2015) performed a cross-sectional survey of 1,125 nurses in China and found errors were reported more often if staff perceived the environment was safe, stress by the staff was recognized, and job satisfaction was high. They also noted event reporting was influenced by the manager's attitude regarding safety reporting. Similar results were found in the study by Kim and colleagues (2014) of 547 Korean nurses. Wagner and co-authors (2013) surveyed 245 nurses in long-term care facilities in Canada and found similar results. Nurse leaders should share error report results with staff to highlight the value and positive impact of completing reports, especially when an improvement in the system leads to a safer environment. Communicating the benefits of error reporting might be done through forums, such as staff meetings, unit information boards, or unit newsletters, to highlight measures enacted precisely because the error was reported (Hartnell et al., 2012; McKaig, Collins, & Elsaid, 2014; Soydemir et al., 2016).

Easy-to-Use Reporting Systems

Implementation of a reporting system that is quick and simple to use may improve the rate of error reporting, as complicated reporting systems have been identified as a reason for not reporting errors (McKaig et al., 2014; Soydemir et al., 2016). Institutional leaders should seek input from clinical nurses to trial reporting systems before implementing them and identify systems that are easiest to use. Complicated reporting systems that collate data for easier review may seem to be a good idea, but errors will continue to go underreported if staff find reports difficult or time consuming to complete (Hartnell et al., 2012; Soydemir et al., 2016). Systems should be trialed by staff before purchase so easy-to-use claims made by vendors can be verified by staff who will be using them. If a system has been purchased and staff find it cumbersome, charge nurses or unit-based educators may be designated to assist with error data entry until the rest of the staff become more familiar with the process (McKaig et al., 2014; Soydemir et al., 2016).

Staff Education

Staff should be educated concerning what constitutes an error so errors can be recognized. Included in the education should be the irrelevance of if an error causes harm. This is particularly important because of the misperception there is no need to report an error if no harm occurred (Haw et al., 2014). Education also should include informing staff of the presence of a reporting system, how to use it, and what becomes of the information after reporting (Soydemir et al., 2016). To help ensure education about errors is sustained, hospital leaders should schedule it regularly and include simulation as a teaching method. Tawalbeh and Tubaishat (2014) examined knowledge retention of nursing students and found greater knowledge retention with simulation compared to only lecture and demonstration.

This same study identified decay of knowledge over time, supporting implementation of repeated sessions such as annual re-education programs.

Case study-based learning is an effective method (Bennal, Taklikar, & Pattar, 2016; Dutra, 2013). Included in the case studies should be examples of near misses that did not appear to cause harm but later resulted in an unforeseen consequence. A possible case study could identify a bedridden patient who is high risk for developing deep vein thrombosis (DVT) and has not received prophylaxis. The nurse calls the provider and the provider orders prophylaxis. The error is not reported because seemingly no harm has come to the patient. However, the nurse does not realize the patient has already developed DVT. The patient gets out of bed the following day and experiences shortness of breath due to a pulmonary embolus. Had the medication error been reported when it first occurred, the patient may not have developed this condition.

Nursing Implications

As around-the-clock care providers, medical-surgical nurses are able to identify and report errors (Harkanen, Turunen, Saano, & Vehvilainen-Julkunen, 2013). They have many opportunities for identifying errors as they administer medications, provide patient treatments, and report abnormal laboratory results to providers. Seasoned medical-surgical nurses who precept new graduate nurses function as role models for reporting errors as standard practice for patient safety (Kim et al., 2014). They can teach new nurses the importance of reporting errors, stressing accurate reporting as a key in error reduction (Bayazidi et al., 2012).

Medical-surgical nurses also play a key role in reducing errors through peer-to-peer support. Nurses have been hesitant to report their own errors for fear of what their peers would think, and have been hesitant to report errors made by colleagues because they do not want to report on their peers (Bayazidi et al., 2012; Qin et al., 2015). Recognizing the multifactorial nature of errors and participating in the process of identifying conditions that lead to errors help redirect the focus from blame to support by creating an environment in which nurses will report errors (Hashemi et al., 2012). While all errors do not result solely from systems problems, issues that may have contributed to the error can be identified and future errors prevented (Hashemi et al., 2012). When staff internalize the belief that reporting is key to improving patient safety rather than undermining a colleague, the approach toward errors may change.


Underreporting of medical errors is a widespread problem that must be addressed if medical errors are to be prevented (Kim et al., 2014). Medical-surgical nurses can be key to eliminating this phenomenon by promoting a culture of safety with a focus on what led to an error (Hashemi et al., 2012). The unique and valuable perspective of medical-surgical nurses makes them vital to identifying and reporting errors. By sharing the positive outcomes that occur as a result of reporting errors, managers can help staff realize the important role they play in error reduction and patient safety (Hartnell et al., 2012).


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Sue S. Scott, MSN, RN, is Instructor, Nursing Department, Westfield State University, Westfield, MA.

Elizabeth Henneman, PhD, RN, is Associate Professor, College of Nursing, University of Massachusetts, Amherst, MA.
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Title Annotation:Professional issues
Author:Scott, Sue S.; Henneman, Elizabeth
Publication:MedSurg Nursing
Geographic Code:1USA
Date:May 1, 2017
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