Influence of perceptions of reporting nurses’ medical errors and patient safety culture on patient safety nursing practices in Korea: a cross-sectional study

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J Korean Biol Nurs Sci. 2025;27(1):104-114

Publication date (electronic) : 2025 February 25

doi : https://doi.org/10.7586/jkbns.24.028

Young Hee Kim¹, Mi Young Kim^,2

¹Graduate School of Clinical Nursing, Hanyang University, National Police Hospital, Depart of Deputy of Nursing, Seoul, Korea

²College of Nursing, Hanyang University, Seoul, Korea

Corresponding author: Mi Young Kim College of Nursing, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea Tel: +82-2-2220-0704 E-mail: miyoung0@hanyang.ac.kr

Received 2024 October 9; Revised 2025 February 1; Accepted 2025 February 1.

Abstract

INTRODUCTION

Patient safety is at the heart of public healthcare and an essential challenge in the relevant fields [1]. As a key determinant of the quality of healthcare services, patient safety is defined as the prevention of errors in providing healthcare services and the elimination or amelioration of patient injuries that can be caused by such errors [2]. Recently, awareness of the importance of patient safety has steadily increased. In particular, nurses at medical institutions take part in maintaining and increasing the level of patient safety at hospitals via nursing [3]. As a group of experts expected to sensitively perceive any problems of patient safety related to the prevention of falls, drug administration, and infection, nurses make a critical contribution to the improvement of patient safety [4,5].

A patient safety incident is an unforeseen event or accident that can cause patient harm [6]. The World Health Organization estimates that unsafe care affects millions of patients each year, with approximately 1 in 10 patients experiencing harm from adverse events while receiving healthcare [7]. To address this issue, member countries of the Organisation for Economic Co-operation and Development spend 15% of their total national hospital expenditure and activity on patient safety incidents [8]. The categories of patient safety incidents are near miss, adverse event, and sentinel event. Near miss is a case of an error that does not cause patient harm; adverse event is a case where an injury caused by a medical procedure demands treatment or intervention. Further, sentinel event is a case that causes unexpected death or loss of a major function in a patient [9]. According to a study analyzing the data of reports on patient safety for three years between 2018 and 2020, adverse events as a patient safety accident are influenced by the patient’s age, hospital bed number, level of medical institution, accident location, and accident type. Sentinel events are influenced by the patient’s sex and age, accident location, accident type, and nurses’ work hours [10]. For the type of patient safety accidents, the percentage of fall accidents is the highest in all three categories of near miss, adverse event, and sentinel event. Compared with infection and contamination accidents, fall accidents increase the risk of sentinel event by 2.7 times [10]. According to the Korea Patient Safety Reporting & Learning System, the number of reported incidents was 11,935 in 2019, 13,919 in 2020, 13,416 in 2021, 14,820 in 2022, and 1,779 as of January 2023, with ≥ 1,000 cases per month since April 2022 [11]. The data are from voluntary reports by medical institutions; as such, the actual number of incidents may be higher [12].

Relevant measures are essential to reduce patient safety incidents and improve overall patient safety. To advance healthcare quality and patient safety, South Korea has operated a medical institution accreditation system since 2004 [13]. This system, through regular preparation and education on assessment items conducted every four years, has significantly contributed to enhancing the quality of clinical nursing services. Notably, it has improved the perception of patient examination as a key measure to prevent safety incidents [14]. However, despite these efforts to bolster patient safety and elevate the quality of clinical nursing services, the extent of improvement in nurses' perceptions achieved through this system has not been thoroughly investigated.

Meanwhile, patient safety incidents are associated with medical errors managed after their reporting. The reporting of nurses’ medical errors is the reporting of all potential errors, mistakes, and accidents in the healthcare delivery system regardless of patient harm [15]. Perception of medical error reporting refers to the attitudes, beliefs, concerns, and level of knowledge related to reporting such medical errors among healthcare professionals [16]. Through such reports, staff nurses can share information about the incident with the senior nurse and medical institution. Healthcare professionals must empathize with the need to report nurses’ medical errors toward enhanced patient safety [17,18]. Furthermore, to reduce the rate of medical errors, medical institutions must emphasize the improvement of the patient safety culture and the establishment of a non-punitive system for reporting nurses’ medical errors [17]. Nonetheless, as cases of non-reporting of medical errors remain owing to the organizational culture [19], studies should be conducted on the change in the level of perception in nurses regarding the reporting of errors.

The perception of patient safety culture reflects the structure of beliefs, values, and behaviors shared at the individual, department, and organization levels to minimize and prevent medical errors that can arise in a healthcare setting [16]. Perception of patient safety culture refers to the shared awareness among organizational members regarding the importance of patient safety [15]. The patient safety practices by a team of healthcare professionals at a medical institution could vary according to how patient safety culture is perceived—the perception of patient safety culture reflects system-related factors, including the measures taken in the event of a patient safety incident. For a patient safety incident, the patient’s guardian would question what caused the incident, whereas the healthcare staff would experience the fear of a potential lawsuit, deteriorated relationship with the patient, and a damaged reputation as a professional [1]. Indeed, the perception of patient safety culture has been shown to affect patient safety nursing practices by nurses at general hospitals [20]. With recent changes focusing on patient safety across medical institutions, scholars must investigate the perception of nurses, who are in the closest contact with patients, regarding patient safety and how their perception affects patient safety nursing practices.

The increased specialization in and division of nursing tasks have increased nurses’ workload [21]. To further emphasize nurses’ role in patient safety nursing practices, in-depth analyses and investigations on patient safety culture and patient safety nursing practices are necessary. Moreover, with the emphasis on the perceptions of reporting nurses’ medical errors and patient safety culture, their respective levels should be determined. Thus, this study aimed to investigate the effects of the perceptions of reporting nurses’ medical errors and patient safety culture on patient safety nursing practices.

This study aimed to determine the effects of the nurses’ perceptions of reporting nurses’ medical errors and patient safety culture on their patient safety nursing practices. The specific objectives are as follows:

1) Analyze the differences in nurses’ perceptions of reporting nurses’ medical errors and patient safety culture and nursing practices according to general characteristics;

2) Analyze the correlations across the perceptions of reporting nurses’ medical errors and patient safety culture and nursing practices;

3) Determine the influencing factors of patient safety nursing practices.

METHODS

RESULTS

1. Participants’ general characteristics

The general characteristics of the nurses are as shown in Table 1. There were 148 women (94.3%), with 61 individuals (38.9%) aged 31~40 years. A majority of 97 participants (61.8%) were single, and 91 participants (58.0%) reported having no religion. Regarding education, 106 participants (67.5%) held a bachelor's degree as their highest level of education, and 136 participants (86.6%) were staff nurses. 41 (26.1%) had 1~4.9 years of clinical experience, 90 (57.3%) worked in the ward, 116 (73.9%) worked in three shifts, 58 (36.9%) were in charge of five or fewer patients, 50 (31.8%) had experience in patient safety education once a quarter, and 92 (58.6%) worked an average of 40~49 hours per week.

Table 1.

Occupational and General Characteristics of Participants (N = 157)

2. The levels of the participants’ perception of reporting nurses’ medical errors, perception of perception of patient safety culture, and patient safety nursing practices

Table 2 presents the levels of the participants’ perception of reporting nurses’ medical errors, perception of patient safety culture, and patient safety nursing practices for each investigated item. The average score for patient safety culture was 3.38 ± 0.37 on a 5-point scale. Among the subdomains, the attitude of immediate supervisors and managers scored the highest at 3.77 ± 0.49, followed by the perception of the medical error reporting system (3.54 ± 0.53), the evaluation of patient safety within the department (3.38 ± 0.68), the perception of patient safety culture within the department (3.31 ± 0.40), the frequency of accident reporting (3.28 ± 0.70), and awareness of patient safety culture in the hospital (3.28 ± 0.54). The average score for nurses' safety nursing activities was 4.07 ± 0.52 on a 5-point scale. Among the subdomains, hand hygiene scored the highest at 4.31 ± 0.57, followed by high-risk medication management (4.14 ± 0.65), accurate patient identification (4.12 ± 0.54), surgical/procedural site marking (4.12 ± 0.59), fall prevention activities (4.12 ± 0.59), fire prevention and smoking cessation (4.09 ± 0.66), medical device inspection (3.97 ± 0.70), communication (3.91 ± 0.57), and facility/environment inspection (3.81 ± 0.84).

Table 2.

Levels of Perceptions of Reporting Nurses’ Medical Errors, Perceptions of Patient Safety Culture, and Patient Safety Nursing Practices (N = 157)

3. Differences in awareness of medical error reporting, patient safety culture awareness, and patient safe nursing activities according to general characteristics

Table 3 presents the variations in the perception of reporting nurses’ medical errors, perception of patient safety culture, and patient safety nursing practices according to general characteristics. Notably, we found no significant differences in patient safety nursing practices according to general characteristics. Significant differences were observed based on religion (t = –2.74, p = .007), position (t = –2.44, p = .017), the number of patients under care (F = 3.94, p = .005), and average weekly working hours (F = 10.42, p < .001). Participants with no religious affiliation and charge nurses, compared to staff nurses, showed significantly higher perceptions of patient safety culture, especially among those who had not experienced medical errors.

Table 3.

Differences in Awareness of Medical Error Reporting, Patient Safety Culture Awareness, and Patient Safe Nursing Activities According to General Characteristics (N = 157)

4. Correlation between medical error reporting awareness, patient safety culture awareness, and safe nursing activities

Table 4 presents the correlations among the perception of reporting nurses’ medical errors, perception of patient safety culture, and patient safety nursing practices. Patient safety nursing practices showed a positive (+) correlation with the perception of reporting nurses’ medical errors (r = .22, p = .005) and patient safety culture (r = .24, p = .002). The positive (+) correlation between the perception of reporting nurses’ medical errors and that of patient safety culture was statistically significant (r = .35, p < .001).

Table 4.

Correlations between Perceptions of Reporting Nurses’ Medical, Perceptions of Patient Safety Culture, and Patient Safety Nursing Practices (N = 157)

5. Influence on nurses’ safety nursing activities

Table 5 presents the results of the multiple regression analysis conducted to identify the influencing factors of patient safety nursing practices. For the regression analysis on perceptions of patient safety nursing practices, variables that could significantly impact the outcome variable were included. Even if no statistically significant differences were observed in the univariate analysis of this study, variables deemed meaningful based on prior research were incorporated. The dependent variable was the perception of patient safety nursing practices, while the independent variables in the stepwise regression included educational level, position, total years of practical nursing experience, number of patients, perception of reporting nurses’ medical errors, and perception of patient safety culture. Additionally, when including variables in the analysis, they were reclassified into dichotomous categories based on clinical significance, and categorical variables were processed as dummy variables for inclusion. In this study, the division based on six years of experience was referenced from prior research [26], which developed and validated a clinical career management system for nurses in Korea. According to this system, the categories of Novice, Advanced Beginner, and Competent correspond to nurses with less than 5~6 years of experience, while Proficient and Expert refer to those with six or more years of experience.We checked the tolerance and variance inflation factor (VIF) to test the multicollinearity of independent variables. The VIF was 1.09~1.56, well within the threshold of 10.0. The Durbin–Watson statistics (2.03) also confirmed the lack of auto-correlation, whereas the tolerance (0.64~0.92) was below the threshold of 1.0, indicating the lack of multicollinearity. The multiple regression analysis results revealed that the factors that influenced patient safety nursing practices were total practical experience as a nurse (β = .31, p = .027), perception of patient safety culture (β = .30, p = .030), and perception of reporting nurses’ medical errors (β = .30, p = .035). The overall explanatory power of these factors on patient safety nursing practices was 25.1%.

Table 5.

Factors that Influence Nurses’ Patient Safety Nursing Practices (N = 157)

DISCUSSION

We investigated the effects of the nurses’ perceptions of reporting nurses’ medical errors and patient safety culture on patient safety nursing practices to provide basic data for developing plans to improve patient safety nursing practices. The level of patient safety nursing practices was higher in nurses with total practical experience as a nurse of ≥ 6 years, more positive perception of reporting nurses’ medical errors, and more positive perception of patient safety culture; the explanatory power of these factors on patient safety nursing practices was 25.1%. Our finding that total clinical experience as a nurse influences patient safety nursing practices partially supports previous reports indicating that nurses in higher positions score higher on patient safety nursing practices [27]. However, since the influence of job position on patient safety nursing practices was not significant in this study, it is interpreted as being attributable to the accumulation of experience rather than the position itself. Nevertheless, caution is required in interpreting these results, and further research on this topic is needed. Regarding patient safety nursing practices, nursing departments should regularly review and implement corrective and preventive measures to address adverse injuries or potential safety issues in nursing practices [28]. Hence, nurses with a level of experience that allows higher competence in basic tasks are likely to monitor and improve any factors related to patient safety, compared with nurses with little experience, which could presumably explain our results. Moreover, experienced nurses and nurse managers are predicted to lead in creating changes in the safety-related organizational culture and adopt the respective roles in actual patient safety nursing practices.

Meanwhile, a more positive perception of reporting nurses’ medical errors was correlated with a higher level of patient safety nursing practices. This coincided with a previous finding that self- reporting in the reporting system for medical accidents that may lead to safety accidents increases as the knowledge and information on medical errors decrease, and the positive perception of reporting medical errors decreases with anxiety over punitive or judgmental repercussions [29]. In other words, the level of patient safety nursing practices would increase when the nurses perceive that patient safety could be improved through the reporting of medical errors rather than when negative aspects, such as punitive actions, are emphasized. Strategies to enhance patient safety culture may include fostering a transparent reporting culture, implementing standardized processes, improving teamwork and communication, and conducting continuous monitoring and evaluation.

Among our participants, the perception of reporting nurses’ medical errors scored 3.35 ± 0.37 (out of 5), indicating a moderate level. By subcategory, the intention to report the incident scored the highest at 3.98 ± 0.64 (out of 5), which lent support to a study on the reporting and disclosure of nurses’ medical errors at tertiary hospitals—nurses tended to perceive the need for reporting medical errors [30]. However, public healthcare organizations in South Korea are known to have a culture of silence and criticism and a tendency to cover up patient safety incidents [31]. Thus, although the nurses may have moderate levels of perception and knowledge on the need to report errors, emotional support should be provided for them to report medical errors. Additionally, a non-punitive culture must be established for the reporting of errors in practice.

Another influencing factor of patient safety nursing practices was the perception of patient safety culture. Similarly, Kwon [25] reported a correlation between the perception of patient safety culture and the patient safety nursing practices and where the increased perception of patient safety culture led to the increased patient safety nursing practice. Thus, nurses with a more positive perception of the patient safety culture would more actively comply with patient safety nursing practices. In a study on self-reporting in the reporting system for medical incidents that could lead to safety accidents, Moon and Yun [29] found that reporting rates were lower than the actual occurrence of events. This was attributed to insufficient knowledge and information about medical errors, concerns about punitive or judgmental repercussions, and a lack of awareness about the importance of reporting. This, in line with our study, suggests that the perception of patient safety culture affects patient safety nursing practices.

Our analysis of the differences in the perception of reporting nurses’ medical errors showed that the perception was higher in women nurses than in men and charge nurses than staff nurses. Considering that the attitudes on the reporting of patient safety accidents in previous studies are of higher levels in women nurses and chief nurses [30], the level of perception may be higher in nurses in charge and chief nurses who view patient safety from a systemwide perspective rather than as individual cases. We also found that nurses with 6–10 patients under their care reported a more positive perception of the patient safety culture compared with nurses caring for a greater number of patients. This finding aligned with a previous finding of nurses with a higher workload having lower levels of perception on patient safety culture and performance of nursing tasks [24]. Thus, patient safety may be jeopardized by challenges in patient safety nursing practices unless the problems of insufficient personnel and nurse allocation are improved. However, since nurses caring for fewer than five patients did not exhibit higher perceptions of patient safety culture, it is challenging to interpret this solely based on the number of nurses or workload. Therefore, caution is needed in interpreting these findings, and further research is required.

Additionally, there have been cases where medical errors are not reported owing to the lack of efforts to improve the punitive and judgmental culture at medical institutions regarding the reporting of nurses’ medical errors [18]. Thus, hospitals’ organizational culture should be improved to move away from punitive and judgmental actions against the reporting of nurses’ medical errors. The departments and organizations must endeavor to prevent the recurrence of errors by collecting feedback on medical errors, thereby enhancing patient safety nursing practices.

CONCLUSION

This study explored the effects of nurses’ perceptions of reporting nurses’ medical errors and perception of the patient safety culture on patient safety nursing practices. The results showed that nurses’ total practical experience as a nurse, perception of patient safety culture, and perception of reporting nurses’ medical errors were the influencing factors of patient safety nursing practices. The results will serve as basic data for implementing safety education and monitoring nurses with a low level of total practical nursing experience, which may help improve patient safety nursing practices. Moreover, our findings can benefit the development of various safety education programs aimed at patient safety nursing practices that incorporate the perceptions of reporting nurses’ medical errors and patient safety culture as key variables.

Furthermore, the significance of this study lies in providing a foundation for utilizing indicators commonly used in basic nursing, such as patient safety adverse events and medication errors, when addressing patient safety issues in the future. The study's findings have limitations in terms of generalizability due to the restricted sample and setting. Additionally, the researchers selected a medium effect size while considering the specific context of the study and the practical significance of the effect size, which is another limitation that should be taken into account when interpreting the results. However, this study provides valuable insights, suggesting the inclusion of basic nursing indicators as part of the factors influencing patient safety nursing in future research.

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