Inhibiting and Supporting Factors in Reporting Patient Safety

Incidents Among Healthcare Workers: A Literature Review

Ika Novianna Wardani

, Betta Kurniawan

and Bayu Anggileo Pramesona

Master of Public Health Program, Faculty of Medicine, Universitas Lampung, Bandar Lampung, 35145, Indonesia

Keywords: Patient Safety Incidents, Inhibiting Factors, Supporting Factors, Literature Review.

Abstract: Reporting hospital incidents is still a matter of pros and cons in its implementation, both from the perspective

of patients and hospital staff. However, this is detrimental if it is not immediately corrected by building and

strengthening a safety culture. The present study aimed to determine the inhibiting and supporting factors in

reporting patient safety incidents among healthcare workers. This study used a literature review method by

collecting online literature data sources and obtained 5 (five) pieces of literature related to inhibiting and

supporting factors in reporting patient safety incidents among healthcare workers. Inhibiting factors consist

of individual aspects (feelings of fear of being blamed and threats of intimidation), psychological aspects

(worries about worsening the hospital's image), organizational aspects (lack of safety culture), and

government aspects (no laws to protect whistle-blowers). Meanwhile, supporting factors include supportive

organizational support, developing and strengthening a patient safety culture, hospitals regulating reporting

patient safety incidents, continuous evaluation in implementing patient safety training, and support for

government laws and regulations protecting staff. Efforts to support the reporting of patient safety incidents

by fostering and strengthening a culture of patient safety through a culture of learning, a culture of reporting,

a culture of fairness, and a culture of information openness in hospitals can support the realization of reporting

patient safety incidents safely and comfortably.

1 INTRODUCTION

Patient safety is crucial in implementing health

services as a benchmark for providing the best health

services and avoiding or reducing patient accidents

(Canadian Patient Safety Institute, 2020). It can act as

a reference or hospital procedure in providing health

services to patients by trying to avoid or at least

reduce the risk of accidents in the hope that patients

can feel safe and secure. Apart from that, patient

safety is also touched upon in the hospital

accreditation assessment provisions according to

Ministry of Health standards with a focus on patient

safety. Patient safety itself has 6 (six) target parts,

including accurate patient identification, increasing

effective communication, increasing the safety of

drugs that must be alert (high-alert), ensuring the right

location, proper procedure, suitable patient operation,

reducing the risk of service-related infections. Health

https://orcid.org/0009-0006-9859-8187

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https://orcid.org/0000-0002-9242-7129

and reducing the risk of patient falls (Ministry of

Health Republic Indonesia, 2022). The goals of

patient safety are realizing a culture of patient safety

in hospitals, increasing hospital accountability

towards patients and the community, reducing the

number of adverse events in hospitals, and

implementing prevention programs to prevent the

recurrence of adverse events (Ministry of Health

Republic Indonesia, 2008). However, the fact is that

the fear of being blamed, punished, and threatened

with intimidation is still a 'threat' for health workers,

as well as the fear of worsening the hospital's image

in reporting patient safety incidents. In fact, with open

and fair reporting of patient safety incidents, health

workers, hospitals, and patients can improve patient

safety efforts and obtain positive benefits. The

present study aimed to determine the inhibiting and

supporting factors in reporting patient safety

incidents.

Wardani, I. N., Kurniawan, B. and Pramesona, B. A.

Inhibiting and Supporting Factors in Reporting Patient Safety Incidents Among Healthcare Workers: A Literature Review.

DOI: 10.5220/0013667200003873

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 1st International Conference on Medical Science and Health (ICOMESH 2023), pages 151-155

ISBN: 978-989-758-740-5

151

2 METHODS

This research uses a literature review method by

specifically reviewing or summarizing literature from

online data sources in Google Scholar with a

publication period of 2020 – 2023 to provide a more

comprehensive understanding of the inhibiting and

supporting factors in reporting patient safety

incidents. The keywords in searching for this data

source are inhibiting factors in reporting patient

safety incidents and supporting factors in reporting

patient safety incidents. The inclusion criteria in

screening data sources are that the period of research

literature to be reviewed is limited to the last four

years (2020-2023), English and Indonesian language

journals, full-text journals, and journal research

objects are inhibiting and supporting factors in

reporting patient safety incidents. Meanwhile, the

exclusion criteria for this research are journals other

than English and Indonesian and paid journals. The

articles included are research articles conducted in

Indonesia and Japan. It can be seen from the year of

publication that there are two articles published in

2023, one published in 2022, one published in 2021,

and one published in 2020. Of these articles, three use

literature reviews, one use quantitative observational,

and one use descriptive quantitative.

3 RESULT AND DISCUSSION

3.1 Result

The literature reviewed in this research was published

from 2019 to 2023 in 5 (five) journals. Then, a study

was drawn up regarding inhibiting and supporting

factors in reporting patient safety incidents, and the

conclusions in each journal obtained several results,

including the following:

Table 1: Summary of research results based on research type

No Author and Year Title Methods Results

1 Nofita Tudang

Rombeallo, Takdir

Tahir and Ariyanti

Saleh (2022)

Faktor Penyebab

Rendahnya

Pelaporan Insiden

Keselamatan Pasien

di Rumah Sakit:

Literature Review

Literature Review Barriers for health workers in reporting

patient safety incidents in hospitals come

from the individuals themselves:

a. Feelings of fear of being punished,

blamed, judged incompe-tent, reputation

damage, and intimida-tion if reporting an

incident

b.Lack of knowledge, skills, and abilities in

reporting incidents

To support incident reporting, commitment

from policymakers is needed to improve

the patient safety incident reporting system

(Rombeallo, Tahir and Saleh, 2022)

2 Astari Ekaning-tyas

and Nasiatul Aisyah

Salim (2023)

Factors Associated

with Reporting

Patient Safety

Incidents by Nurses

at Panemba-han

Senopati Hospital

Bantul Yogya-karta

Observa-tional

Quantita-tive

Inhibiting factors: lack of non-punitive

response to errors, open communication,

feedback due to feelings of fear and guilt if

reporting incidents

However, there are supporting factors to

foster a non-punitive response, namely,

developing and strengthening a culture of

patient safety through a culture of learning,

justice, and reporting.

It also allows patients and their families to

report their experiences while in the

hospital. (Ekaningtyas and Salim 2023).

3 Tamaamah Habibah

and Inge Dhamanti

(2020)

Faktor yang

Mengham-bat

Pelaporan Insiden

Keselamat-an

Pasien di Rumah

Sakit: Literature

Review

Literature Review Barriers to incident reporting, namely:

a.Individual, namely feelings of fear of

intimidation or punishment

b.Organiza-tion, namely low feedback on

incident reporting and never investigating

the root cause of the problem

ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH

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c.Govern-ment, namely the absence of laws

that protect health workers who report

medical errors

To support incident reporting, further

evaluation of implementing patient safety

incident reporting in hospitals is needed.

(Habibah and Inge, 2020).

4 Salsabila Nurislami,

Bayu Anggileo

Pramesona, Risal

Wintoko and Rasmi

Zakiah Oktarlina

(2023)

Factors Influencing

Reporting of Patient

Safety Incidents:

Literature Review

Literature Review Factors that influence the reporting of

patient safety incidents generally come

from three factors, namely:

a.Individual, including knowledge, skills,

and abilities in carrying out reports and

awareness of patient safety

b.Psychology, including perceptions,

attitudes, and beliefs that patient safety is

beneficial, putting aside feelings of fear of

being blamed or punished because of

protecting colleagues and the reputation of

the workplace

c. As one of the supporting factors in

reporting incidents, the organization

includes a supportive environment and no-

blame work culture, availability of a patient

safety team, guidelines and report format,

anonymity of reports, and good feedback in

the form of further investigation and

corrective action. (Nurislami et al., 2023).

5 Masaru Kurihara,

Yoshimasa Nagao, and

Yasuharu Tokuda

(2021)

Incident reporting

among physicians-in-

training in Japan: A

national survey

Quantita-tive descript-

tive

Of the 6,164 doctors undergoing training, it

was found that although 78% had taken

patient safety training, 44% had not

submitted an incident report in the previous

year, and 40.6% did not know how to

submit an incident report. (Kurihara,

Nagao, and Tokuda, 2021).

3.2 Discussion

Based on the results of this research, several

inhibiting and supporting factors were obtained in

reporting patient safety incidents. These factors are

for various reasons but are generally related to patient

safety culture. Patient safety culture is the primary

and most important basis for reporting safety

incidents. This culture has a significant impact on

individuals and organizations. For example, one of

the inhibiting and dominating factors in reporting

patient safety incidents is that which originates from

individuals. Feelings of fear, worry about being

blamed, not knowing how to report, and threats of

intimidation if they report a patient safety incident

(Habibah and Inge, 2020; Rombeallo, Tahir and

Saleh, 2022; Nurislami et al., 2023). As a result,

individuals choose not to report it. Even though

reporting this incident has a positive impact and

benefit on patient safety and fosters a positive image

for the organization. Meanwhile, not all individuals

share this view because they are trapped in fear and

worry.

Apart from the feelings of fear that individuals

have, some organizations lack non-punitive responses

(Ekaningtyas and Salim 2023), Moreover, they are

not investigating the root causes of patient safety

problems (Habibah and Inge 2020). This particular

condition can occur due to the perception

(psychological aspect) that reporting patient safety

incidents gives the organization a bad image

(Habibah and Inge 2020; Nurislami et al. 2023). In

fact, on the contrary, an investigation into the root of

the problem can result in improvements for the

organization to protect its image and patient safety.

Moreover, hospitals are essential in supporting

patient safety efforts as a health organization. Then,

from a government perspective, it was found that

there was no law to protect health workers who

reported medical errors (Habibah and Inge 2020).

This effort also prevents an atmosphere of non-

punitive attitudes from being realized. There is a

blaming culture and feelings of discomfort with

fellow health workers to maintain conducive working

Inhibiting and Supporting Factors in Reporting Patient Safety Incidents Among Healthcare Workers: A Literature Review

153

relationships. So, it would be better to have policies

or laws that protect health workers who report

medical errors or patient safety incidents, hoping to

encourage and strengthen a patient safety culture.

Regarding individual knowledge, it was found

that the cause of delays in reporting patient safety

incidents was a lack of knowledge, abilities, and skills

(Rombeallo, Tahir and Saleh, 2022; Nurislami et al.,

2023). This condition is also related to patient safety

culture, which means there are obstacles to its

implementation. This aspect of knowledge can be

improved by strengthening the patient safety culture

through a learning culture. Health workers can

acquire this learning culture through training

programs in hospitals. However, it is not just about

carrying out training; monitoring must be done by

evaluating patient safety training and alternative

methods through a reporting culture. The aim is to

strengthen the patient safety culture. As one example,

the first national survey on incident reporting in Japan

found that half of junior residents had not submitted

patient safety incident reports due to residents' lack of

experience in making patient safety incident reports,

even though 96% of residents had taken patient safety

training, so alternative methods through

strengthening were needed patient safety reporting

culture (Kurihara, Nagao, and Tokuda 2021).

Some of these inhibiting factors can be overcome

with supporting factors for reporting patient safety

incidents, including supportive organizational

support. Hospitals can play their role in establishing

regulations and fostering and strengthening a patient

safety culture so that health workers have the

confidence or courage to be open because they do not

have fear or are threatened with intimidation in

reporting patient safety incidents. Hospitals also

participate in creating patient safety training

programs, such as learning culture, reporting culture,

fair culture, and patient safety culture. In this way, an

atmosphere of openness will be created and benefit

patients and hospitals.

Second, develop and strengthen a patient safety

culture. This effort can be achieved by the strength of

hospital regulations regarding patient safety culture,

providing patient safety training programs, and

monitoring and evaluating the implementation of

patient safety culture when providing health services

to patients. Third, hospitals regulate regulations

regarding reporting patient safety incidents

(including format, reporting system, and patient

safety team) to avoid a culture of blaming each other,

which leads to feelings of fear and the threat of

intimidation—fourth, continuous and ongoing

evaluation in implementing patient safety training.

Without monitoring (evaluation), hospitals cannot

make continuous improvements to improve patient

safety culture so that the hospital's image will have a

positive value. Fifth, government support in

protecting health workers when reporting medical

errors or patient safety through legislation. The

existence of legal protection for medical personnel in

reporting medical errors or patient safety incidents

not only gives officers a sense of confidence but also

provides a deterrent effect on parties who are

negligent in providing services that are not oriented

toward patient safety.

4 CONCLUSIONS

Based on the results and discussion above, it can be

concluded that inhibiting and supporting factors in

reporting patient safety incidents have their role.

Inhibiting factors (individual, psychological,

organizational, and governmental aspects) can create

negative value for the hospital, in contrast to

supporting factors (supportive organizational

support; developing and strengthening a patient

safety culture; the hospital regulates regulations

related to reporting patient safety incidents; ongoing

evaluation- continuous and continuous

implementation of patient safety training; and support

for government laws and regulations in protecting

health workers) provide positive value for hospitals.

This supporting factor should be adopted or used in

health service activities not only in hospitals but all

health facilities can also apply it. Implementing

patient safety incident reporting means that patient

safety culture can be fulfilled so patients feel safe,

comfortable, and safe.

ACKNOWLEDGEMENTS

The author would like to thank all parties who

contributed to this research, both supervisors and

other research colleagues, for the reference material

that can be used in this research.

REFERENCES

Canadian Patient Safety Institute. 2020. Patient Safety

Incident. Institut Canadien Pour La Securite Des

Patients.

Ekaningtyas, Astari, and Nasiatul Aisyah Salim. 2023.

‘Factors Associated with Reporting Patient Safety

Incidents by Nurses at Panembahan Senopati Hospital

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Bantul Yogyakarta’. Jurnal Surya Muda 5(1): 90–103.

Habibah, Tamaamah, and Dhamanti Inge. 2020. ‘Factors

Inhibiting Reporting of Patient Safety Incidents in

Hospitals: Literature Review’. Jurnal Kesehatan

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Kurihara, Masaru, Yoshimasa Nagao, and Yasuharu

Tokuda. 2021. ‘Incident Reporting among Physicians-

in-Training in Japan: A National Survey’. Journal of

General and Family Medicine 22(6): 356–58.

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