Nurses' willingness to report medication administration errors in Saudi Arabia

Factors influencing the reporting of medication errors and near misses among nurses: A systematic mixed methods review

AIM

This study aimed to systematically review empirical evidence on factors influencing nurses to report medication errors and near misses.

BACKGROUND

There is underreporting of medication errors among nurses, in particular among novice and beginner nurses. To improve quality of care, factors influencing the reporting of medication errors and near misses should be documented.

METHOD

A systematic mixed methods review was conducted. CINAHL, Cochrane Collaboration, Embase, Medline, PsycINFO and Web of Science databases were explored and analysed from December 1990 to December 2023. Two reviewers independently selected and extracted data using a standardized data extraction grid. Data were analysed using thematic analysis based on the adapted theory of planned behaviour.

RESULTS

Forty-two studies met the eligibility criteria. Principal factors influencing the reporting of medication errors and near misses among nurses were associated with perceived behavioural control, subjective norm and attitude. Few studies examined factors influencing reporting medication errors and near misses among novice and beginner nurses, and sociodemographic and professional factors.

CONCLUSION

To understand factors influencing reporting of medication errors and near misses, further studies should be conducted to investigate sociodemographic and professional factors.

Prevalence and factors associated with medication administration errors in the neonatal intensive care unit: A multicentre, nationwide direct observational study

AIM(S)

To determine the prevalence of medication administration errors and identify factors associated with medication administration errors among neonates in the neonatal intensive care units.

DESIGN

Prospective direct observational study.

METHODS

The study was conducted in the neonatal intensive care units of five public hospitals in Malaysia from April 2022 to March 2023. The preparation and administration of medications were observed using a standardized data collection form followed by chart review. After data collection, error identification was independently performed by two clinical pharmacists. Multivariable logistic regression was used to identify factors associated with medication administration errors.

RESULTS

A total of 743 out of 1093 observed doses had at least one error, affecting 92.4% (157/170) neonates. The rate of medication administration errors was 68.0%. The top three most frequently occurring types of medication administration errors were wrong rate of administration (21.2%), wrong drug preparation (17.9%) and wrong dose (17.0%). Factors significantly associated with medication administration errors were medications administered intravenously, unavailability of a protocol, the number of prescribed medications, nursing experience, non-ventilated neonates and gestational age in weeks.

CONCLUSION

Medication administration errors among neonates in the neonatal intensive care units are still common. The intravenous route of administration, absence of a protocol, younger gestational age, non-ventilated neonates, higher number of medications prescribed and increased years of nursing experience were significantly associated with medication administration errors.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The findings of this study will enable the implementation of effective and sustainable interventions to target the factors identified in reducing medication administration errors among neonates in the neonatal intensive care unit.

REPORTING METHOD

We adhered to the STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

An expert panel consisting of healthcare professionals was involved in the identification of independent variables.

Medication administration errors: Causes and reporting behaviours from nurses perspectives

Evaluation of nurses' perceptions towards medication administration errors (MAEs) reporting is a key aspect for improving patient safety, and prevention of errors repetition. Thus, this study has evaluated nurses' behaviour towards MAEs reporting practice, and factors contributing to their under-reporting of errors. This is a cross-sectional survey-based study that was conducted during February 2021. During the study period, a convenience sample of nurses working at Jordan university hospital was invited to voluntarily participate in the study and to fill an online questionnaire uploaded on an electronic data collection platform. The questionnaire assessed nurses MAEs reporting practice, their perception towards factors contributing to MAEs, factors associated with under-reporting of MAEs, and their perception towards MAEs preventive measures. A total of 150 nurses responded to the electronic questionnaire, with 54.0% of them (n = 81) were males and the majority had a bachelor's degree in nursing (n = 138, 92.0%). Regarding MAE reporting's practice, 78% of them (n = 117) indicated that they are always/often report MAEs even if it is not possible to improve the patient's health status. With regard to factors contributing to MAEs, results showed that "insufficient staffing" was the most common reason contributing to MAEs occurrence reported by nurses (n = 114, 94.0%). Personal fear from nursing administration was the primary cause of MAEs under-reporting (n = 98, 65.3%), while 94.0% of nurses (n = 141) agreed/strongly agreed that following the six rights is a way to prevent MAEs occurrence. This study indicates a positive reporting attitude towards MAEs. Nursing administration concerns were considered the main reason associated with the under-reporting of MAEs. This study shed the light on the deep need for continuous education programmes about the importance of the right MAEs reporting. As well, the need for effective and restricted rules in a non-punitive environment to prevent MAEs incidences.

Preventing dispensing errors through the utilization of lean six sigma and failure model and effect analysis: A prospective exploratory study in China

AIMS

To utilize lean six sigma (LSS) and failure model and effect analysis (FMEA) to prevent dispensing errors in a Chinese teaching hospital.

METHODS

Medication errors (MEs) reported to the China Core Group of the international network for the rational use of drugs (INRUD) by pharmacists at the hospital were collected. Following LSS methodology, the data analysis was structured according to define, measure, analyse, improve, and control (DMAIC) phases, and typical LSS tools (Pareto diagrams, brainstorming sessions) were used to determine the risk factors leading to dispensing errors. FMEA was applied to generate the risk priority numbers (RPNs) of MEs events, and key medications targeted for error prevention strategies were identified through quantitative analysis of the impacts of failure. Finally, corrective measures to prevent MEs were implemented and monitored for efficacy.

RESULTS

Before the implementation of this programme, a total of 603 cases of dispensing errors were reported from the Year 1 to Year 6, reaching an average rate of incidence of 0.33 cases per 10 000 medication orders delivered, and no difference was found between these years (P = .9424). There was also no difference as location, error type, contributing factors, cause classification were considered. We then determined the real cause behind dispensing errors, and a total of 67 medications were targeted for specific error prevention strategies. One year after intervention, progress had been achieved in the following aspects: the incidence rate of dispensing errors was significantly decreased compared with the previous years (0.19, P = .007). Simultaneously, the incidence rate of dispensing errors occurred in outpatient pharmacy (0.04, P = .0008), with junior pharmacists (0.15, P = .0258), with LASA medications (0.06, P = .0319), as well as with memory-based errors were significantly decreased (0.03, P = .0191).

CONCLUSION

The combination of LSS and the FMEA tool can be an efficient approach for helping reduce MEs in pharmacy dispensing.

Barriers to Incident Reporting among Nurses: A Qualitative Systematic Review

Incident reporting in health care prevents error recurrence, ultimately improving patient safety. A qualitative systematic review was conducted, aiming to identify barriers to incident reporting among nurses. Joanna Briggs Institute methodology for qualitative systematic reviews was followed, with data extracted using JBI QARI tools, and selected studies assessed for methodological quality using Critical Appraisal Skills Program (CASP). A meta-aggregation synthesis was carried out, and confidence in findings was assessed using GRADE ConQual. A total of 921 records were identified, but only five studies were included. The overall methodological quality of these studies was good and GRADE ConQual assessment score was "moderate." Fear of negative consequences was the most cited barrier to nursing incident reporting. Barriers also included inadequate incident reporting systems and lack of interdisciplinary and interdepartmental cooperation. Lack of nurses' necessary training made it more difficult to understand the importance of incident reporting and the definition of error. Lack of effective feedback and motivation and a pervasive blame culture were also identified.

Top four types of sentinel events in Saudi Arabia during the period 2016-19

BACKGROUND

This study discusses the summary, investigation and root causes of the top four sentinel events (SEs) in Saudi Arabia (SA) that occurred between January 2016 and December 2019, as reported by the Ministry of Health (MOH) and private hospitals through the MOH SE reporting system (SERS). It is intended for use by legislators, health-care facilities and the public to shed light on areas that still need improvement to preserve patient safety.

OBJECTIVES

The purpose of this study is to review the most common SEs reported by the MOH and private hospitals between the years 2016 and 2019 to assess the patterns and identify risk areas and the common root causes of these events in order to promote country-wide learning and support services that can improve patient safety.

METHODS

In this retrospective descriptive study, the data were retrieved from the SERS, which routinely collects records from both MOH and private hospitals in SA. SEs were analyzed by type of event, location, time, patient demographics, outcome and root causes.

RESULTS

There were 727 SEs during this period, 38.4% of which were under the category of unexpected patient death, 19.4% under maternal death, 11.7% under unexpected loss of limb or function and 9.9% under retained instruments or sponge. Common root causes were related to policies and procedures, guidelines, miscommunication between health-care facilities, shortage of staff and lack of competencies.

CONCLUSION

Given these results, efforts should focus on improving the care of deteriorating patients in general wards, ICU (Intensive Care Units) admission/discharge criteria and maternal, child and surgical safety. The results also highlighted the problem of underreporting of SEs, which needs to be addressed and improved. Linking data sources such as claims and patient complaints databases and electronic medical records to the national reporting system must also be considered to ensure an optimal estimation of the number of events.

Knowledge, perceived barriers and facilitators of medication error reporting: a quantitative survey in Malaysian primary care clinics

Background Medication errors are the most common types of medical errors that occur in health care organisations; however, these errors are largely underreported. Objective This study assessed knowledge on medication error reporting, perceived barriers to reporting medication errors, motivations for reporting medication errors and medication error reporting practices among various health care practitioners working at primary care clinics. Setting This study was conducted in 27 primary care clinics in Malaysia. Methods A self-administered survey was distributed to family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. Main outcome measures Health care practitioners' knowledge, perceived barriers and motivations for reporting medication errors. Results Of all respondents (N = 376), nurses represented 31.9% (n = 120), followed by doctors (n = 87, 23.1%), pharmacists (n = 63, 16.8%), assistant medical officers (n = 53, 14.1%), pharmacist assistants (n = 46, 12.2%) and family medicine specialists (n = 7, 1.9%). Of the survey respondents who had experience reporting medication errors, 56% (n = 62) had submitted medication error reports in the preceding 12 months. Results showed that 41.2% (n = 155) of respondents were classified as having good knowledge on medication error and medication error reporting. The mean score of knowledge was significantly higher among prescribers and pharmacists than nurses, pharmacist assistants and assistant medical officers (p < 0.05). A heavy workload was the key barrier for both nurses and assistant medical officers, while time constraints prevented pharmacists from reporting medication errors. Family medicine specialists were mainly unsure about the reporting process. On the other hand, doctors and pharmacist assistants did not report primarily because they were unaware medication errors had occurred. Both family medicine specialists and pharmacist assistants identified patient harm as a motivation to report an error. Doctors and nurses indicated that they would report if they thought reporting could improve the current practices. Assistant medical officers reported that anonymous reporting would encourage them to submit a report. Pharmacists would report if they have enough time to do so. Conclusion Policy makers should consider using the information on identified barriers and facilitators to reporting medication errors in this study to improve the reporting system to reduce under-reported medication errors in primary care.

The mediating role of power distance and face-saving on nurses' fear of medication error reporting: A cross-sectional survey

BACKGROUND

The fear of social and professional consequences is a significant barrier to medication error reporting among nurses. Although some studies have identified cultural factors as playing a significant role in medication error reporting, little is known about the mechanisms by which these cultural characteristics influence the relationship between patient safety emphasis and the fear of medication error reporting.

OBJECTIVES

(1) Identify nurses' perceptions of patient safety emphasis, face-saving, power distance, and fear of medication error reporting; and (2) explore face-saving and power distance as the underlying mechanisms for cultural factors in the relationship between nurses' perceptions of safety emphasis and the fear of medication error reporting.

DESIGN

A cross-sectional, descriptive, and correlational design.

SETTINGS

Three tertiary teaching hospitals located in China, including one children's hospital and two adult hospitals.

PARTICIPANTS

We recruited a total of 569 female registered nurses with at least one year of work experience. Most of the participants (73.8%) were junior nurses with mid-associate or associate degrees (55.4%).

METHODS

Participants completed four questionnaires, including Safety Emphasis subscales from the Safety Climate Scale, Face-Saving Scale, the Index of Hierarchy of Authority, and the Nurses' Fear of Medication Error Reporting.

RESULTS

The average scores of safety emphasis, face-saving, power distance, and the fear of medication error reporting were 20.27 (SD=2.36), 14.63 (SD=3.57), 17.36 (SD=3.49), and 18.92 (SD=4.20), respectively. There were no demographic characteristics associated with these variables, except education (B=-0.16, p = 0.013) and work experience (B=-0.14, p = 0.019), which were related to power distance. Face-saving and power distance were significant mediators that explained the effect of safety emphasis on nurses' fear of medication error reporting. The overall indirect effect for both mediators was statistically significant (β=-0.27, p<0.05). When we compared the specific mediators' indirect effects, face-saving was a more powerful mediator than power distance (β=-0.24 vs. β=-0.04). These mediation effects remained after we adjusted for the effects of education and work experience on power distance.

CONCLUSIONS

When nurses have a common cultural background, they tend to perceive similar barriers to medication error reporting. For this study, face-saving and power distance are the two most important cultural factors because they significantly influence the relationship between safety emphasis and the fear of medication error reporting among Chinese nurses. It may not be possible to develop a work culture that minimizes fears of medication error reporting without first addressing face-saving needs and power differences.

Reducing Missed Medication Doses in Intensive Care Units: A Pharmacist-Led Intervention

Objective:

The objectives of this study were to investigate the frequency and reasons for missing doses and impact of a pharmacist-led intervention to reduce the missed doses in intensive care units.

Methods:

This study was completed in two phases. In the first phase, a retrospective quality assurance audit was conducted to quantify the problem of missed doses from the pharmacist/nurse communication slip record. The frequency and potential reasons for missing dose occurrences were identified and listed, and respective solutions were finalized by a joint health-care team. In the second phase of the study, post-intervention analysis was done for a period of 1 month to check the impact of intervention. The data were recorded from pharmacy/nursing communication forms for medication, dosage form, route of administration (ROA), frequency of missed doses, and underlying reasons for missing doses.

Findings:

There was a substantial reduction in the number of incidences of missed doses in post-intervention phase. The number of events decreased from 190 (pre-intervention; 2 months) to 11 (post-intervention; 1 month), 389 to 87, and 133 to 12 for automatic stop order, unknown reason, and late mix medication, respectively. No missed dose event was recorded secondary to order overseen and inactive patient status in post-intervention phase. Moreover, identified reasons, ROA, frequency, and the system status were the significant predictors of missing doses.

Conclusion:

The findings of this study emphasized the need to introduce better documentation procedures and continuous surveillance system to decrease the number of missing doses and further improve already established drug distribution service.

Interventions to improve reporting of medication errors in hospitals: A systematic review and narrative synthesis

BACKGROUND

In 2017, the World Health Organisation pledged to halve medication errors by 2022. In order to learn from medication errors and prevent their recurrence, it is essential that medication errors are reported when they occur.

OBJECTIVES

The aim of this systematic review was to identify studies in which interventions were carried out in hospitals to improve medication error reporting, to summarise the findings of these studies, and to make recommendations for future investigations.

METHODS

A comprehensive search of five electronic databases (PubMed, Medline (OVID), Embase (OVID), Web of Science, and CINAHL) was conducted from inception up to and including December 2018. Studies were included if they described an intervention aiming to increase the reporting of medication errors by healthcare providers in hospitals and excluded if there was no full-text English language version available, or if the reporting rate in the hospital prior to the intervention was not available. Data extracted from included studies were described using narrative synthesis.

RESULTS

Of 12,025 identified studies, seventeen were included in this review - fifteen uncontrolled before versus after studies, one survey and one non-equivalent group controlled trial. Five studies carried out a single intervention and twelve studies conducted multifaceted interventions. The most common intervention types were critical incident reporting, implemented in fifteen studies, and audit and feedback, implemented in seven studies. Other intervention types included educational materials, educational meetings, and role expansion and task shifting. As only one study compared a control and intervention group, the effectiveness of the different intervention types could not be evaluated.

CONCLUSION

This is the first review to address the evidence on medication error reporting in hospitals on a global scale. The review has identified interventions to improve medication error reporting that were implemented without evidence of their effectiveness. Due to the essential role played by incident reporting in learning from and preventing the recurrence of medication errors more research needs to be done in this area.

Addressing medication errors in an adult oncology department in Saudi Arabia: A qualitative study

OBJECTIVE

There is a wide range of strategies that could help in minimizing medication errors during healthcare delivery. We undertook a qualitative study to identify recommended solutions to minimize medication errors in an adult oncology department in Saudi Arabia from the perspectives of healthcare professionals.

METHODS

This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining the required ethical approvals and written consents from the participants, seven focus group discussions were carried out for data collection. A stratified purposive sampling strategy was used to recruit medical doctors, pharmacists, and nurses. NVivo Pro version 11 was used for data analyses. Inductive content analysis was adopted in the coding of collected data.

RESULT

Our study showed that improving organizational support, staff education, and communication could help in minimizing medication errors in the adult oncology department.

CONCLUSION

The adoption of multiple strategies is required to improve the safety of the medication process in the adult oncology department. We argue that the availability of supportive leadership should be prioritized as it plays a crucial role in determining the effectiveness and efficiency of both staff education and communication.

Exploring healthcare professionals' perceptions of medication errors in an adult oncology department in Saudi Arabia: A qualitative study

Objective

Adverse events which result from medication errors are considered to be one of the most frequently encountered patient safety issues in clinical settings. We undertook a qualitative investigation to identify and explore factors relating to medication error in an adult oncology department in Saudi Arabia from the perspective of healthcare professionals.

Methods

This was a qualitative study conducted in an adult oncology department in Saudi Arabia. After obtaining required ethical approvals and written consents from the participants, semi-structured interviews and focus group discussions were carried out for data collection. A stratified purposive sampling strategy was used to recruit medical doctors, pharmacists, and nurses. NVivo Pro version 11 was used for data analyses. Inductive thematic analysis was adopted in the primary coding of data while secondary coding of data was carried out deductively applying the Hospital Survey of Patient Safety Culture (HSOPSC) framework.

Result

The total number of participants were 38. Majority of the participants were nurses (n = 24), females (n = 30), and not of Saudi nationality (n = 31) with an average age of 36 years old. Causes of medication errors were categorized into 6 themes. These causes were related teamwork across units, staffing, handover of medication related information, accepted behavioural norms, frequency of events reported, and non-punitive response to error.

Conclusion

There were numerous causes for medication errors in the adult oncology department. This means substantive improvement in medication safety is likely to require multiple, inter-relating, complex interventions. More research should be conducted to examine context-specific interventions that may have the potential to improve medication safety in this and similar departments.

Proportion of medication error reporting and associated factors among nurses: a cross sectional study

BACKGROUND

A medication error (ME) is any preventable event that may cause or lead to inappropriate medication use or patient harm. Voluntary reporting has a principal role in appreciating the extent and impact of medication errors. Thus, exploration of the proportion of medication error reporting and associated factors among nurses is important to inform service providers and program implementers so as to improve the quality of the healthcare services.

METHODS

Institution based quantitative cross-sectional study was conducted among 397 nurses from March 6 to May 10, 2015. Stratified sampling followed by simple random sampling technique was used to select the study participants. The data were collected using structured self-administered questionnaire which was adopted from studies conducted in Australia and Jordan. A pilot study was carried out to validate the questionnaire before data collection for this study. Bivariate and multivariate logistic regression models were fitted to identify factors associated with the proportion of medication error reporting among nurses. An adjusted odds ratio with 95% confidence interval was computed to determine the level of significance.

RESULT

The proportion of medication error reporting among nurses was found to be 57.4%. Regression analysis showed that sex, marital status, having made a medication error and medication error experience were significantly associated with medication error reporting.

CONCLUSION

The proportion of medication error reporting among nurses in this study was found to be higher than other studies.

Barriers to Medical Error Reporting for Physicians and Nurses

The purpose of the study was to determine what barriers to error reporting exist for physicians and nurses. The study, of descriptive qualitative design, was conducted with physicians and nurses working at a training and research hospital. In-depth interviews were held with eight physicians and 15 nurses, a total of 23 participants. Physicians and nurses do not choose to report medical errors that they experience or witness. When barriers to error reporting were examined, it was seen that there were four main themes involved: fear, the attitude of administration, barriers related to the system, and the employees’ perceptions of error. It is important in terms of preventing medical errors to identify the barriers that keep physicians and nurses from reporting errors.

Why are chemotherapy administration errors not reported? Perceptions of oncology nurses in a Nigerian tertiary health institution

OBJECTIVE

The administration of chemotherapy forms a major part of the clinical role of oncology nurses. When a mistake is made during chemotherapy administration, admitting and reporting the error timely could save the lives of cancer patients. The main objective of this study was to assess the perceptions of oncology nurses about why chemotherapy administration errors are not reported.

METHODS

This is a descriptive study that surveyed a convenient sample of 128 oncology nurses currently practicing in the Ogun State University Teaching Hospital, Nigeria. The tool for data collection was a structured questionnaire that consisted of two sections. The first section was for the demographic data of participants and the second section consisted of questions constructed based on the Medication Administration Error (MAE) reporting survey developed by Wakefield and his team.

RESULTS

Findings showed that majority of the nurses (89.8%) have made at least one MAE in the course of their professional practice. Fear (mean = 3.63) and managerial response (mean = 2.87) were the two major barriers to MAE reporting perceived among oncology nurses.

CONCLUSION

Critically analyzing why medication errors are not reported among oncology nurses is crucial to identifying strategic interventions that would promote reporting of all errors, especially those related to chemotherapy administration. It is therefore recommended that nurse managers and health care administrators should create a favorable atmosphere that does not only prevent medication errors but also supports nurses' voluntary reporting of MAEs. Education, information and communication strategies should also be put in place to train nurses on the need to report, if possible prevent, all medication errors.

Medicines management: an interview study of nurses at a secure psychiatric hospital

AIMS

To explore mental health nurses' knowledge, attitudes and clinical judgement concerning medicines management in an inpatient setting with a view to enhancing training.

BACKGROUND

Medicines management is a key role of mental health nurses, but little research has been conducted into their training needs.

DESIGN

An exploratory mixed-methods design was used involving individual interviews with participants to investigate their responses to hypothetical medicine administration scenarios.

METHODS

Interviews were held with a convenience sample of 50 Registered Nurses working in a specialist mental health hospital between November 2012-February 2013. Participants were presented with clinical vignettes describing eight scenarios they might encounter as part of their medicines management role and asked about how they would respond. Responses were assessed by two independent raters against ten quality standards underpinning the vignettes.

RESULTS

The median number of responses that were judged to demonstrate adequate awareness of associated quality standards was 4 (range 1-7), indicating that many participants did not appear to be aware of, or compliant with, current UK medicines management guidance and local policy. Many would not report a 'near miss' or medicines administration error. There was a lack of awareness of guidance on verbal prescribing, consent to treatment rules and the administration of off-label/unlicensed drugs. Past year attendance on a medicines management course, time since registration and self-reported knowledge of national standards for medicines administration did not discriminate between total score on the 10 quality standards.

CONCLUSION

The medicines management training needs of participants appeared not to be fully met by the existing learning sources. The use of vignettes to assess nurses' training needs requires evaluation in other settings.

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital

Medication administration errors and near misses are common including in mental health settings. Nurses should report all errors and near misses so that lessons can be learned and future mistakes avoided. We interviewed 50 nurses to find out if they would report an error that a colleague had made or if they would report a near-miss that they had. Less than half of nurses said they would report an error made by a colleague or a near-miss involving themselves. Nurses commonly said they would not report the errors or near misses because there was a good excuse for the error/near miss, because they lacked knowledge about whether it was an error/near miss or how to report it, because they feared the consequences of reporting it, or because reporting it was too much work. Mental health nurses mostly report similar reasons for not reporting errors and near misses as nurses working in general medical settings. We have not seen another study where nurses would not report an error or near miss because they thought there was a good excuse for it. Training programmes and policies should address all the reasons that prevent reporting of errors and near misses. Medication errors are a common and preventable cause of patient harm. Guidance for nurses indicates that all errors and near misses should be immediately reported in order to facilitate the development of a learning culture. However, medication errors and near misses have been under-researched in mental health settings. This study explored the reasons given by psychiatric nurses for not reporting a medication error made by a colleague, and the perceived barriers to near-miss reporting. We presented 50 nurses with clinical vignettes about error and near-miss reporting and interviewed them about their likely actions and about their views and perceptions. Less than half of participants would report an error made by a colleague (48%) or a near-miss involving themselves (40%). Thematic analysis revealed common themes for both not reporting an error or a near-miss were knowledge, fear, burden of work, and excusing the error. The first three themes are similar to results obtained from research in general medical settings, but the fourth appears to be novel. Many mental health nurses are not yet fully convinced of the need to report all errors and near misses, and that improvements could be made by increasing knowledge while reducing fear, burden of work, and excusing of errors.