Frequency of Medical Errors and Their Reporting Barriers in Operating Room Students of Birjand University of Medical Sciences in 2024

Patient safety is one of the important issues in improving the quality of health care (1); however, medical errors are one of the most significant challenges to patient safety (2). Healthcare organizations define medical error as: "Patient injury due to inappropriate and unethical behavior and inadequate and negligent action of the health service provider specialist in job activities" (3). All health and care team workers, regardless of how skilled, committed, and meticulous, may make mistakes when performing professional skills (4). These mistakes occur in different professions of the medical staff, such as doctors, nurses, and pharmacists (5). Medical science is based on the principle of "first do no harm"; however, despite technological advances, medical errors continue to threaten patient safety (6). Medical errors are the third most common cause of death in the United States (7). In Iran, the prevalence of errors in the health care system is not less than the prevalence of errors in other developing or developed countries, and between 50% and two-thirds of these errors occur in the operating rooms and emergency rooms of hospitals, with more than half being preventable (8).

The operating room is recognized as one of the most hazardous areas of the hospital due to its organizational, educational, environmental, and technological requirements (9), as pressure and stress within the operating room increase the likelihood of errors (10). Every year, about 234 million surgeries are performed worldwide, meaning, on average, one out of every 25 people undergoes surgery (8); therefore, since surgery plays a major and important role in medical centers globally, the focus has been directed to a high degree on the safety of the environment, personnel, and patient care in the operating room (11). On the other hand, it is believed that due to the ineffectiveness of the error reporting system and some structural weaknesses in the health system, the amount of errors is high, such that, according to the results of studies, 11.9% of medical errors occur in the operating room. Therefore, the prevention of injuries related to health care is considered a key and general principle in care (11).

Error reporting and analysis are important to improve patient safety (12). In the meantime, error reporting by changing the error culture helps to prevent punitive measures and encourage learning from mistakes to avoid repetition (13) and is necessary to facilitate the recognition of the causes of errors (14); therefore, the prevention of errors depends on its accurate reporting (15). Seidi also reported in his study that only 45% of nurses report their mistakes to the supervisor (16). Operating room students may also make mistakes more than nurses due to low experience and skill, as well as the lack of proper and safe educational environments during clinical practice (5, 17). According to the results of this study, the most common errors include foreign material remaining in the surgical site, incorrect counting of surgical sponges, and failure to diagnose the correct patient. On the other hand, due to reasons such as the perceived lack of importance of reporting nursing errors, forgetting to report errors, and not having a clear definition of error, error reporting has not been done. According to the results of Shiyasi and Norouzinia, considering error reporting to be useless and forgetting to report errors are important reasons for not reporting errors (18). According to other studies, the lack of a single and standard definition of error and when errors are eligible for reporting is one of the main barriers to reporting and disclosing reported errors (19, 20). According to studies, only 16.7% of students report their mistakes to the instructor (5).

Given the importance of errors in the operating room, this study, in response to the question of what errors are made by students in the operating room and what barriers exist to reporting them, evaluates the rate of medical errors and identifies barriers to reporting them among operating room students at Birjand University of Medical Sciences in 2024.

Out of 71 operating room students participating in the study, 42 (59.2%) were women and 29 (40.8%) were men. Among them, 65 students were single (91.5%) and 6 were married (8.5%). The average age of the students was 21.70 years, and they had a mean GPA of 16.79. Of the students participating in the study, 32 (45.1%) were in the 6th semester, 21 (29.6%) in the 8th semester, and 18 (25.4%) in the 4th semester. There was no significant relationship between the academic semester and the cases of error and its reporting (P > 0.05).

The results of the present study showed that the reasons for not reporting the error had no significant relationship with any of the demographic variables (age, gender, marital status, academic semester, academic grade point average) (P > 0.05). The most common error cases included, in order, remaining foreign material in the surgical site (3.00 ± 1.014), incorrect counting of surgical sponges (2.96 ± 0.992), and failure to diagnose the correct patient (2.94 ± 0.954). The least common error case was the use of inappropriate equipment (2.31 ± 0.994) (Table 1).

Additionally, from the students' perspective, the most common reasons for not reporting errors were related to the options of "no importance of reporting nursing errors" (3.37 ± 1.174), "forgetting to report errors" (3.31 ± 1.178), and "nursing error does not have a clear definition" (3.17 ± 1.207). The least common reasons for not reporting errors were "fear of finding out the doctor and being blamed by him" (2.27 ± 1.195), "fear of revealing the mistake and creating legal issues after it" (2.30 ± 1.151), and "fear of informing the instructor and being blamed by him" (2.56 ± 1.118) (Table 2).

The results of this study showed that from the perspective of operating room students, the highest average score among errors was related to the remaining foreign material in the surgical site and incorrect counting of surgical sponges, while the lowest average score was related to the use of inappropriate equipment. These findings align with Nnemati et al.'s study, where leaving a device in the patient's body was identified as one of the most significant errors (8). In contrast, Azarabad et al.'s study found that non-observance of sterile technique was the most common error (5). This discrepancy may be due to differences in the attitudes of the students in the two studies. However, Azarabad et al. also recognized the retention of foreign material in the surgical site as a significant error (5).

According to this study, the most common barriers to error reporting by students were "no importance of reporting nursing errors", "forgetting to report errors", and "nursing error does not have a clear definition". Similar findings were reported in other studies. Cramer's research indicated that nurses report an average of only 1.9% of their errors, with a third of them unsure about which errors to report (22). Zaboli et al. identified the lack of emphasis on the importance of recording and reporting errors and the lack of clarity in defining work errors as significant barriers to error reporting (23). Nasirpour's research on "Medical Error Threats" highlighted poor understanding of what should be reported and disbelief in reporting as factors discouraging error reporting (24). Heidari et al. also found that forgetting the error was a key reason for not reporting it (25).

The present study showed no significant relationship between the reasons for not reporting errors and demographic variables (age, gender, marital status, academic semester, academic grade point average). In contrast, Azarabad et al. found that fear of negative impacts on evaluation scores and educational consequences was significantly related to gender, with male students more likely to experience this fear (5). This difference may stem from variations in experiences, knowledge, and previous training between the populations studied. Hannani et al. also reported significant differences in error reporting barriers by gender and work experience (11), a contrast that may be due to the focus on students in our study, unlike Hannani's.

The average score for the total reasons for not reporting errors was 78.2 with a standard deviation of 0.68 (out of 5 points), indicating the relative importance of error reporting barriers in hospitals. In Abu Shaiqah's study, the average score for barriers to reporting errors was 2.99 out of 5, which was considered average (26). Identifying obstacles and facilitators of error reporting is crucial in designing and implementing an error learning system to enhance safety (27). According to Aristotle, honesty is a virtue in medical students, encouraging them to report clinical errors as a moral duty to maximize patient benefits (15). This positive approach to error reporting, along with modifying training methods, monitoring instructors, and employing non-punitive strategies, is necessary to reduce mistakes and ensure timely reporting (5).