References

Akbari N, Malek M, Ebrahimi P, Haghani H, Aazami S Safety culture in the maternity unit of hospitals in Ilam province, Iran: a census survey using HSOPSC tool. Pan Afr Med J. 2017; 27

Albaalharith T, A'aqoulah A Level of patient safety culture awareness among healthcare workers. J Multidiscip Healthc. 2023; 16:321-332 https://doi.org/10.2147/JMDH.S376623

Almansour H Barriers preventing the reporting of incidents and near misses among healthcare professionals. J Health Manag. 2023; https://doi.org/10.1177/09720634231167031

Alonazi WB Building learning organizational culture during COVID-19 outbreak: a national study. BMC Health Serv Res. 2021; 21:(1) https://doi.org/10.1186/s12913-021-06454-9

Alshyyab MA, FitzGerald PG, Ababneh EY, Zghool AW, Albsoul RA Nurses' perceptions regarding the impact of teamwork on patient safety culture in the operating room: a qualitative study. Perioper Care Oper Room Manag. 2023; 33 https://doi.org/10.1016/j.pcorm.2023.100345

Alves MdFT, de Carvalho DS, de Albuquerque GSC Barriers to patient safety incident reporting by Brazilian health professionals: an integrative review. Ciência & Saúde Coletiva. 2019; 24:(8)2895-2908 https://doi.org/10.1590/1413-81232018248.23912017

Amiri A Role of nurses and midwives in improving patient safety during childbirth: evidence from obstetric trauma in OECD countries. Appl Nurs Res. 2020; 56 https://doi.org/10.1016/j.apnr.2020.151343

Anderson JE, Kodate N, Walters R, Dodds A Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting. Int J Qual Health Care. 2013; 25:(2)141-150

Anderson JE, Kodate N Learning from patient safety incidents in incident review meetings: organisational factors and indicators of analytic process effectiveness. Safety Science. 2015; 80:105-114

Argote L Organizational learning research: past, present and future. Manag Learn. 2011; 42:(4)439-446

Ayisa A, Getahun Y, Yesuf N Patient safety culture and associated factors among health-care providers in the University of Gondar Comprehensive Specialized Hospital, northwest Ethiopia. Drug Healthc Patient Saf. 2021; 13:141-150 https://doi.org/10.2147/DHPS.S291012

Banakhar M, Tambosi A, Asiri S, Banjar Y, Essa Y Barriers of reporting errors among nurses in a tertiary hospital. Int J Nurs Clin Pract. 2017; 4:(1)

Barach P, Small SD Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000; 320:(7237)759-763

Beigi M, Khorasani F, Kohan S Improving service delivery using the self-reporting of errors by midwives and midwifery student. J Educ Health Prom. 2020; 9:(1) https://doi.org/10.4103/jehp.jehp_393_20

Bovis JL, Edwin JP, Bano CP, Tyraskis A, Baskaran D, Karuppaiah K Barriers to staff reporting adverse incidents in NHS hospitals. Future Healthc J. 2018; 5:(2)117-120

Brubacher J, Hunte G, Hamilton L, Taylor A Barriers to and incentives for safety event reporting in emergency departments. Healthc Q. 2011; 14:(3)57-65

Brás CPC, Figueiredo MCAB, Ferreira MMC Safety culture in maternity hospital: perception of nurse-midwives. J Adv Nurs. 2024; 80:(5)2091-2105 https://doi.org/10.1111/jan.15969

Cansever SM, Soğukpınar N Assessment of patient safety culture in midwives. Eximia. 2024; https://doi.org/10.47577/eximia.v13i1.422

Carmo JMA, Mendoza IYQ, Goveia VR, Souza KV, Manzo BF, Guimarães GL Culture of patient safety in hospital units of gynecology and obstetrics: a cross-sectional study. Rev Bras Enferm. 2020; 73:(5) https://doi.org/10.1590/0034-7167-2019-0576

Carson-Stevens A, Hibbert P, Williams H Characterising the nature of primary care patient safety incident reports in the England and Wales national reporting and learning system: a mixed-methods agenda-setting study for general practice. Health Serv Deliv Res. 2016; 4:(27)1-76

Çatal AT, Cebeci F, Uçak A Intern nursing students' perceptions of patient safety culture and their experiences with factors affecting the safety of care in hospital settings: a mixed method study. Nurse Educ Today. 2024; 135 https://doi.org/10.1016/j.nedt.2024.106120

Cheptum JJ, Mbuthia F, Celagat D Challenges experienced by midwifery trainers in midwifery training. J Midwifery Nurs. 2023; 5:(2)30-36 https://doi.org/10.35335/jmn.v5i2.3625

Cook-Richardson S, Addo A, Kim P, Turcotte J, Park A Show me the money, i'll show you my complications: impacts of incentivized incident self-reporting among surgeons. J Surg Res. 2022; 274:136-144 https://doi.org/10.1016/j.jss.2021.12.012

Dhamanti I, Leggat S, Barraclough S, Rachman T Factors contributing to under-reporting of patient safety incidents in Indonesia: leaders' perspectives. F1000 Res. 2021; 10 https://doi.org/10.12688/f1000research.51912.1

Dyab E, Elkalmi R, Bux S, Jamshed S Exploration of nurses' knowledge, attitudes, and perceived barriers towards medication error reporting in a tertiary health care facility: a qualitative approach. Pharmacy (Basel). 2018; 6:(4)

Ederer C, König-Bachmann M, Romano I, Knobloch R, Zenzmaier C Midwives' perception of patient safety culture-A qualitative study. Midwifery. 2019; 71:33-41 https://doi.org/10.1016/j.midw.2018.12.020

Endalamaw A, Khatri RB, Mengistu TS A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact. BMC Health Serv Res. 2024; 24:(1) https://doi.org/10.1186/s12913-024-10828-0

Feeser VR, Jackson AK, Savage NM When safety event reporting is seen as punitive. Ann Emerg Med. 2021; 77:(4)449-458 https://doi.org/10.1016/j.annemergmed.2020.06.048

Grissinger M Disrespectful behavior in health care: its impact, why it arises and persists, and how to address it-part 2. P T. 2017; 42:(2)74-77

Hamed MMM, Konstantinidis S Barriers to incident reporting among nurses: a qualitative systematic review. West J Nurs Res. 2022; 44:(5)506-523 https://doi.org/10.1177/0193945921999449

Hartnell N, MacKinnon N, Sketris I, Fleming M Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. BMJ Qual Saf. 2012; 21:(5)361-368

Hewitt T, Chreim S, Forster A Incident reporting systems: a comparative study of two hospital divisions. Arch Public Health. 2016; 74:(1)

Hüner B, Derksen C, Schmiedhofer M, Lippke S, Janni W, Scholz C Preventable adverse events in obstetrics-systemic assessment of their incidence and linked risk factors. Healthcare. 2022; 10:(1) https://doi.org/10.3390/healthcare10010097

Hüner B, Derksen C, Schmiedhofer M Reducing preventable adverse events in obstetrics by improving interprofessional communication skills – results of an intervention study. BMC Pregnancy Childbirth. 2023; 23:(1) https://doi.org/10.1186/s12884-022-05304-8

Ito A, Sato K, Yumoto Y, Sasaki M, Ogata Y A concept analysis of psychological safety: further understanding for application to health care. Nurs Open. 2022; 9:(1)467-489 https://doi.org/10.1002/nop2.1086

Jabarkhil AQ, Tabatabaee SS, Jamali J, Moghri J Assessment of patient safety culture among doctors, nurses, and midwives in a public hospital in Afghanistan. Risk Manag Healthc Policy. 2021; 14:1211-1217 https://doi.org/10.2147/RMHP.S292193

Kabanga MM, Mugimu CB, Oonyu J Exploring the pedagogical practices used in competence based education training of nurses and midwives in Uganda. Int J Learn Teach Educ Res. 2018; 17:(1)133-154

Kadivar M, Manookian A, Asghari F, Niknafs N, Okazi A, Zarvani A Ethical and legal aspects of patient's safety: a clinical case report. J Med Ethics Hist Med. 2017; 10

Kaya GK, Ustebay S, Nixon J, Pilbeam C, Sujan M Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data. Saf Sci. 2023; 166 https://doi.org/10.1016/j.ssci.2023.106260

Kertland H, Satchu S, Chant C, Garland J, Tom E Safety rounds: a patient safety initiative. Can J Hosp Pharm. 2018; 71:(6)385-388

Khoshakhlagh AH, Khatooni E, Akbarzadeh I, Yazdanirad S, Sheidaei A Analysis of affecting factors on patient safety culture in public and private hospitals in Iran. BMC Health Serv Res. 2019; 19:(1) https://doi.org/10.1186/s12913-019-4863-x

Kodate N, Taneda K, Yumoto A, Kawakami N How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative study. BMC Health Serv Res. 2022; 22:(1) https://doi.org/10.1186/s12913-022-07631-0

Krouss M, Alshaikh J, Croft L, Morgan DJ Improving incident reporting among physician trainees. J Patient Saf. 2019; 15:(4)308-310 https://doi.org/10.1097/PTS.0000000000000325

Lee W, Kim SY, Lee S, Lee SG, Kim HC, Kim I Barriers to reporting of patient safety incidents in tertiary hospitals: a qualitative study of nurses and resident physicians in South Korea. Int J Health Plann Manage. 2018; 33:(4)1178-1188

Lee SE, Dahinten VS, Seo JK, Park I, Lee MY, Han HS Patient safety culture and speaking up among health care workers. Asian Nurs Res (Korean Soc Nurs Sci). 2023; 17:(1)30-36 https://doi.org/10.1016/j.anr.2023.01.001

LeMaire SA, Trautner BW, Ramamurthy U An academic relative value unit system for incentivizing the academic productivity of surgery faculty members. Ann Surg. 2018; 268:(3)526-533 https://doi.org/10.1097/SLA.0000000000002921

Murray-Davis B, McDonald H, Cross-Sudworth F Learning from adverse events in obstetrics: is a standardized computer tool an effective strategy for root cause analysis?. J Obstet Gynaecol Can. 2015; 37:(8)728-735 https://doi.org/10.1016/S1701-2163(15)30178-X

Mustapha T, Ho Y, Andrews JS, Cullen MJ See no evil, hear no evil, stop no evil: institutional-level tracking to combat mistreatment of residents and fellows. J Grad Med Educ. 2019; 11:(5)601-605 https://doi.org/10.4300/JGME-D-19-00218.1

Nakamura N, Yamashita Y, Tanihara S, Maeda C Effectiveness and sustainability of education about incident reporting at a university hospital in Japan. Healthc Inform Res. 2014; 20:(3)209-215

O'Donovan R, De Brún A, McAuliffe E Healthcare professionals experience of psychological safety, voice, and silence. Front Psychol. 2021; 12 https://doi.org/10.3389/fpsyg.2021.626689

Oweidat I, Al-Mugheed K, Alsenany SA, Abdelaliem SMF, Alzoubi MM Awareness of reporting practices and barriers to incident reporting among nurses. BMC Nurs. 2023; 22:(1) https://doi.org/10.1186/s12912-023-01376-9

Pedroni VS, Gouveia HG, Vieira LB Patient safety culture in the maternal-child area of a university hospital. Revista Gaúcha de Enfermagem. 2020; 41:(spe) https://doi.org/10.1590/1983-1447.2020.20190171

Peyrovi H, Nikbakht Nasrabadi A, Valiee S Exploration of the barriers of reporting nursing errors in intensive care units: a qualitative study. J Intensive Care Soc. 2016; 17:(3)215-221 https://doi.org/10.1177/1751143716638370

Pramesona BA, Sukohar A, Taneepanichskul S, Rasyid MFA A qualitative study of the reasons for low patient safety incident reporting among Indonesian nurses. Rev Bras Enferm. 2023; 76:(4) https://doi.org/10.1590/0034-7167-2022-0583

Rashed A, Hamdan M Physicians' and nurses' perceptions of and attitudes toward incident reporting in Palestinian hospitals. J Patient Safety. 2019; 15:(3)212-217 https://doi.org/10.1097/PTS.0000000000000218

Ribeliene J, Blazeviciene A, Nadisauskiene RJ Patient safety culture in obstetrics and gynecology and neonatology units: the nurses' and the midwives' opinion. J Matern Fetal Neonatal Med. 2019; 32:(19)3244-3250 https://doi.org/10.1080/14767058.2018.1461831

Roberts ES How do risk management principles fit in with the reality of clinical midwifery?. Br J Midwifery. 2019; 27:(11)703-710 https://doi.org/10.12968/bjom.2019.27.11.703

Sanne JM Incident reporting or storytelling? Competing schemes in a safety-critical and hazardous work setting. Saf Sci. 2008; 46:(8)1205-1222

Sengane M Mothers' expectations of midwives' care during labour in a public hospital in Gauteng. Curationis. 2013; 36:(1)E1-E9

Shayan A, Golalizadeh Bibalan F, Shafaei M, Rahnavardi M, Masoumi SZ Challenges of clinical education in midwifery and strategies to improve it: a qualitative study. Educ Res Med Sci. 2019; 8:(1) https://doi.org/10.5812/erms.88228

Sorra J, Gray L, Streagle S, Famolaro T, Yount N, Behm J AHRQ hospital survey on patient safety culture: user's guide.Rockville, MD: Agency for Healthcare Research and Quality; 2018

Stavropoulou C, Doherty C, Tosey P How effective are incident-reporting systems for improving patient safety? A systematic literature review. Milbank Q. 2015; 93:(4)826-866 https://doi.org/10.1111/1468-0009.12166

Vetrugno G, Foti F, Grassi VM Malpractice claims and incident reporting: two faces of the same coin?. Int J Environ Res Public Health. 2022; 19:(23) https://doi.org/10.3390/ijerph192316253

Wagner C, Kristensen S, Sousa P, Panteli D Patient safety culture as a quality strategy. Improving healthcare quality in Europe: characteristics, effectiveness, and implementation of different strategies.Copenhagen, Denmark: European Observatory on Health Systems and Policies; 2019

Wang L, Wang X, Zou M, Jiang L, Ding H Assessing patient safety culture in obstetrics ward: a pilot study using a modified Manchester Patient Safety Framework in China. Nurs Open. 2023; 10:(2)658-664 https://doi.org/10.1002/nop2.1332

Waters NF, Hall WA, Brown H, Espezel H, Palmer L Perceptions of Canadian labour and delivery nurses about incident reporting: a qualitative descriptive focus group study. Int J Nurs Stud. 2012; 49:(7)811-821

Wieke Noviyanti L, Ahsan A, Sudartya TS Exploring the relationship between nurses' communication satisfaction and patient safety culture. J Public Health Res. 2021; 10:(2) https://doi.org/10.4081/jphr.2021.2225

World Health Organization. Global patient safety action plan 2021-2030 towards zero patient harm in health care. 2020. https//tinyurl.com/2p92ss56 (accessed 4 June 2024)

World Health Organization. Patient safety. 2023. https//tinyurl.com/mpsbua8s (accessed 10 February 2024)

Zhao X, Shi C, Zhao L Nurses' intentions, awareness and barriers in reporting adverse events: a cross-sectional survey in tertiary hospitals in China. Risk Manag Healthc Policy. 2022; 15:1987-1997 https://doi.org/10.2147/RMHP.S386458

Clinical incident

Cultivating patient safety culture in midwifery practices through incident reporting

02 July 2024
Professional
02 July 2024
Volume 32 · Issue 7

Abstract

This article explores the critical role of incident reporting in enhancing women's safety in midwifery care. Given the inherently dynamic, and often unpredictable, nature of pregnancy and childbirth, midwives are frequently tasked with navigating complex clinical and emotional scenarios. As women place high expectations on midwives for safe and quality care, incident reporting serves as a vital mechanism for ongoing improvement and learning. The discussion highlights the barriers inhibiting effective incident reporting, including fear of reprisal and blame, lack of understanding of incident reporting and perceived futility. By overcoming these barriers, incident reporting not only identifies and rectifies safety concerns but also acts as a catalyst for cultivating a positive safety culture in midwifery.

Incident reporting has gained significant importance in healthcare organisations, emerging as a pivotal policy measure (Lee et al, 2018). The incident report serves as a repository of unexpected events, near misses, clinical adverse events, instances of violence or aggression and safety issues. It relies on healthcare professionals to document and reflect on incidents, providing a narrative that captures the sequence of events and their insights into the causes, irrespective of whether they directly observed the incident (Sanne, 2008; Kodate et al, 2022). These reports are invaluable at the community level for developing strategies to reduce harm and, nationally, help identify systemic issues that may otherwise be overlooked (Carson-Stevens et al, 2016).

‘First, do no harm’ stands as the cornerstone principle of every healthcare service (World Health Organization, 2023). Patient safety is not a regional concern, but a worldwide priority that permeates all divisions of the healthcare system, with the goal to diminish patient harm in the delivery of healthcare services (Albaalharith and A'aqoulah, 2023). This conviction transforms patient safety from a theoretical idea into a practical necessity.

Register now to continue reading

Thank you for visiting British Journal of Midwifery and reading some of our peer-reviewed resources for midwives. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to our clinical or professional articles

  • New content and clinical newsletter updates each month

Register
Or continue by

Signing in with your registered email address

Clinical outcomes
Incident reporting
Midwifery
Patient safety
Risk management