Understanding nurses’ experiences with near‐miss error reporting omissions in large hospitals

Abstract Aim This qualitative study aimed to provide an in‐depth understanding of nurses’ experiences with near‐miss errors and report omissions known to be direct or indirect causes of medical accidents in hospitals and cited as precursors of serious medical accidents. Design This study collected experiences of research participants through an interview as a qualitative research method and confirmed the meaning through an inductive approach. Methods We selected nine nurses with various levels of experience from 27 May to 10 June 2019 for analysis. We adopted phenomenological research methods and procedures proposed by Colaizzi (Existential‐phenomenological alternative for psychology, 1978) and established the feasibility and integrity of our results based on narrative studies proposed by Lincoln and Guba (Naturalistic inquiry, 1985). Results This study demonstrated that near‐miss errors and report omissions experienced by professional nurses could be merged into the following themes: lack of cognitive susceptibility to near‐miss errors; confusion about the reporting system for near‐miss errors; lack of knowledge about near‐miss errors; disappointment with results of reporting near‐miss errors; and fear of reporting near‐miss errors. These results strongly suggest the need to improve recognition efforts based on a socio‐educational viewpoint involving the so‐called openness about failures.

| 2697 LEE from serious medical accidents, prevention before occurrence is of paramount importance. With this recognition, near-miss errors are attracting much attention as precursors of medical accidents.
Specifically, reducing cases of these errors is perceived as effective for preventing medical accidents (Lee, 2012). In fact, it is thought that near-miss errors occur approximately 7,700 times as often as serious medical accidents (Wagner et al., 2006). Considering that some eligible cases are not omitted in the recognition process of medical accidents, there might have been more near-miss errors than the number assumed (Kim et al., 2007). However, as most of existing studies have used quantitative approaches (Elder et al., 2007;Kim et al., 2007;Lee et al., 2013;Mayo & Duncan, 2004) in targeting sample groups as the mainstream research method, it is difficult to sense the seriousness of the situation intuitively. Moreover, the limited number of question items makes it impossible to develop an in-depth level of understanding. In particular, a limitation of existing studies is that they provide only a superficial understanding of experiences of medical accident victims. Thus, the purpose of this study was to provide detailed descriptions of experiences and perceptions of persons involved in near-miss error reporting omissions based on a qualitative approach in pursuit of a naturalistic paradigm. Given this, findings of this study are meaningful as basic data for various related future studies.

| CON CEP T OF NE AR-MISS ERROR S
Near-miss errors are errors that occur to a patient. However, the patient is never harmed because of fortuitous or appropriate intervention. Although damage has not occurred yet, such errors are highly likely to cause damage. Near-miss errors are also referred to as potential adverse events (Capucho, 2011). Near-miss errors are invisible.
However, medical accidents are clearly visible. If near-miss errors are never addressed internally or debated publicly, it is nearly impossible to discuss contexts related to near-miss errors objectively, which is a mainstream discussion method. Data of true contexts of near-miss errors as precursors to medical accidents are needed.

| S TUDY DE S I G N
This study collected experiences of research participants through an interview as a qualitative research method and confirmed their meanings through an inductive approach. Specific research methods are shown below.

| Participants
Participants of this study were nine nurses working in large hospitals in South Korea. Three of these nurses had 2 to 4 years of career experience, and six of them had 10 to 13 years of career experience. All nine nurses had either directly or indirectly experienced near-miss errors and reporting omissions at their hospitals. A study cooperation letter was sent to hospitals of these participants. Nine voluntary participants were selected based on gender, region, education level and career.

| Data collection
Original data for this study were collected using an individual indepth interview method as proposed by Colaizzi (1978). Interviews were recorded, and data were collected together with field notes. In the first round of individual interviews with study participants, we tried to build a mutual rapport through wide-ranging conversation concerning the purpose, intent and topic of this study. Beginning with the second round, snowball interviewing was conducted by developing stories based on the first round of interviews and creating additional questions (Heo et al., 2019;Kim, 2005). This study involved a total of 14 rounds of interviews, after which data reached theoretical saturation as no new information was revealed. Five of these 14 sessions were conducted in the form of group interviews, while nine were conducted through individual interviews. These interviews were conducted in researchers' laboratories for five months, from 10 January 2019 to 27 May 2019.

| Data analysis and research authenticity
Data analysis was conducted at the same time as data collection. Data were analysed based on the six-step analysis method suggested by Colaizzi (1978). First, after completing the transcription of collected data, the researcher repeatedly read all statements to identify and understand the phenomenon. Second, meaningful statements were derived by underlining phrases and sentences through line-by-line analysis. Third, a restatement with a general form was conducted What does this paper contribute to the wider global clinical community?
• This study suggests that sharing the process and results of near-miss errors in clinical field sites will provide an important foundation in securing the safety of patients.
• This study suggests that sharing the process and results of near-miss errors will contribute to the development of not only individual nurses but also the whole hospital community.
• This study suggests that sharing the process and results of near-miss errors by openly acknowledging those mistakes will provide the best learning opportunity and serve as a cornerstone for improving clinical practice. from a meaningful statement. Fourth, an attempt was made to identify similar statements at the stage of deriving the meaning formed from the meaningful statement and the restatement. Fifth, after integrating analysed contents, a final description was made through a collection of topics and categories that symbolized the essential structure of the research phenomenon. Sixth, an attempt was made to describe the phenomenon as accurately as possible with a complete description representing the essential structure. The most appropriate statement describing the topic as a quotation was then selected.
In this study, the entire information obtained from data collection and analysis process was shared with study participants. The researcher performed this to minimize errors arising from misunderstanding or misinterpreting participants' stories or statements.
This study did not rely only on interviews to collect data, but widely used related document records and journals written by study participants. The validity of all research processes, analysis of collected data, content analysis and subject development were verified by two professors in the nursing department, two doctoral researchers with extensive qualitative research experience and two nurses with more than 10 years of experience in large hospitals. In general, this series of methods to increase the veracity and validity of research results in qualitative studies is called triangulation which can increase the transferability of results (Lincoln & Guba, 1985).

| Ethical considerations
Before initiating this research, participants were fully informed about the intent and purpose of this study. They were also informed that whenever they wanted to know study contents, the information would be provided to them. Participants were informed that they could leave the study at any time and that all information acquired in the research processes would be used only for research purposes.
Approval was obtained from our Institutional Review Board before initiating the research. In addition, only participants who agreed to participate were included in this study. All participants were anonymous.

| Participant demographics
There were nine nurses as participants (seven females and two males). Six nurses worked at large hospitals in Seoul and three worked in Gyeonggi-do Province. In terms of their academic backgrounds, five nurses had graduated from nursing colleges and the remaining four held four-year degrees. Table 1 presents demographic characteristics of study participants. Themes identified from interview responses of these nine nurses through a data collection process are presented in the following sections.

| Theme 1. Lack of cognitive susceptibility to near-miss errors
Based on responses, it was found that study participants did not notice that they made near-miss errors. In other words, they did not have near-miss error sensitivity. They did not realize the seriousness of such errors or they did not report them. None of them had ever felt an urgent need to address such errors. Study participants perceived near-miss errors as part of a mechanical routine. They even considered such errors as natural mistakes. They said that they did not report near-miss errors by ignoring them, treating them as they had always been treated and justifying them as everyday errors. In terms of cognitive susceptibility, these nurses perceived near-miss errors not as malicious, but as part of their daily job routines (Table 2).
In the early days of my career, I did not know which mistake was a serious one or a minor one, and I just did what I was told to do. At that time, there was a preceptor who would take responsibility. However, when I became a senior nurse, these problems that I had overlooked or habitually done were not big things, and so I did not think it was necessary to report them. This was the way I worked.
(Nurse I, 12 years of career experience) For example, beginner nurses in this study were unaware of the term "near-miss errors" and its usage before they joined their hospitals. On the contrary, nurses with many years of career experience who were aware of near-miss errors and reasons for reporting still did not feel the need for such reporting. It can be hypothesized that all practices derive from the recognition of problems and unawareness of near-miss errors and their importance will decrease the probability of reporting. Nurses who do not perceive such errors will not think or know to report about them ( (Nurse G, 3 years of career experience)?

| Theme 5. Fear of near-miss error reporting
A near-miss error is an obvious mistake, whether it is officially reported or not. Therefore, individuals have a psychological and emotional repulsion of mistakes made during the performance of their work. Nurses often avoid reporting near-miss errors because they are responsible for their own mistakes. In interviews of this study, nurses confessed that they deliberately ignored and avoided these responsibilities and explained that this was due to disadvantages of reporting near misses (

| D ISCUSS I ON
Results of this study are as follows. Study participants' experiences These participants' ignorance of near-miss acts was manifested as a distrust of near-miss reporting effects, leading to further distrust of the importance of thorough reporting, information sharing, and the effect of reporting. That is why these nurses do not feel the need to report minor near misses, leading to the fear that near-miss reporting will result in actual and implied disadvantages. In this study, the experience of omitting near-miss reporting was not limited to one factor, but was caused by multiple factors. The experience of a near miss and "the omission of near-miss reporting" stated by nurses who participated in the study reflected results of a previous study that reported that 76.5% of hospital nurses did not report near-miss errors .
According to previous studies, causes of reporting omissions can be summed up as follows: nurses perceive near-miss errors as simple mistakes that are harmless to patients Kim, 2006), there is a lack of knowledge about accurate criteria for error detection (Kagan & Barnoy, 2008), there is a fear of possible penalties and blame (Elder et al., 2007;Mayo & Duncan, 2004), there is a lack of confidence about improvement effects and there is concern that the information will be used to evaluate job performance (Ahn et al., 2007). Other reasons for the low rate of reporting near-miss errors include a lack of confidentiality, a lack of time, no feedback on reported cases (Kaplan & Barach, 2002), a fear of peer or boss reactions (Mayo & Duncan, 2004) and a negative attitude towards near-miss error reporting .
With these justifications and explanations, it is possible that the potential danger of near-miss errors is being downplayed because nurses cannot establish a negative impact of these near misses on their patients (Cohen, 2000). Thus, it is natural that most of related previous studies on this topic are discussions about methods for improving the phenomenon of not identifying and reporting near-miss errors in hospitals. to avoid the experience of failing (Bartels & Ryan, 2013;Mullet et al., 2014).

The proverbs and adages about mistakes in Western and
From the viewpoint of a supervisor, it is inevitable to control errors and failures which can be considered antagonistic to success. However, for the performer, the only two choices are failure and success. In that context, mistakes that do happen can be concealed. Accumulated hidden mistakes can eliminate opportunities for improvement. Such failure to improve is highly likely to lead to learned unconcern which is related to learned helplessness (Nanda et al., 2012). After all, the perception of the learning process (Bauer & Mulder, 2007;Cha & Cho, 2016) or the perspective of constructivism (Son, 2005) that leads to professional improvement and progress derives from disclosing errors and mistakes for better understanding between related parties.
In this regard, disclosure of academic failure (Cannon & Edmondson, 2005;Kim, 2017;Lee, 2018) is based on the belief that failure is not necessarily negative because it can ultimately lead to a positive practice. This belief strongly emphasizes the mutual benefit of disclosing failure and offering assistance in turn. People who are open-minded about failure can easily obtain information they need and share their experiences with peers and colleagues. Disclosing errors also facilitates adaptive emotional responses, motivates active learning and ultimately provides a foundation for positive achievement (Kim, 2017;Lee, 2018). With the above as our guide and in the context of the topic of reporting near-miss errors in hospitals, we strongly recommend disclosing information about these errors to relevant people to increase awareness and prevention before such errors cause damage to patients.

| CON CLUS ION
Up to date, discussions on near-miss errors have mainly focused on identifying their causes and substantially reducing them.
Researchers have also discussed near-miss errors from a more macroscopic viewpoint (Lee et al.,2008(Lee et al., , 2013Jeong et al., 2006;Park et al., 2006) and presented methods to establish and utilize hospital systems to prevent medical accidents by promoting near-miss error reporting. However, the presentation of near-miss errors as failures to be avoided is consistent across studies.
On the contrary, we propose sharing the process and results of near-miss errors. Also, it is inferred that disclosing failure is the best learning opportunity for improving practices as a cornerstone for further progress. If near-miss errors become perceived as opportunities for individual and institutional development rather than as failures, they can prompt active and lively discussions on previously hidden near-miss error cases. Such changes represent a foundation for mutual development of nurses and hospital communities and for patient safety.

| LIMITATI ON S OF RE S E ARCH
This study has the following limitations. First, because this was a qualitative study and the main purpose of the study was to interpret subjective experiences of participants and discuss their meaning, it was difficult to generalize results of this study. Second, it was difficult to collect various cases because participants' geographical areas in this study were limited to easily accessible areas.

| RELE VAN CE TO CLINI C AL PR AC TI CE
To reduce near-miss errors, clinical nurses must make efforts in the following three dimensions. First, negative impressions of near-miss errors must be reframed and viewed as opportunities or cases to enhance nursing practice. Especially from the viewpoint of lifelong essentials for professionals like nurses, near-miss errors are important issues that must be shared and learned. More concrete and practical efforts must be made for hospital cultures to perceive near-miss errors as opportunities to learn lessons.
Second, supplementary training should be provided to currently practising nurses to raise their awareness about the nature and importance of near-miss errors and to systematically manage and distribute lessons learned from them. Lastly, a more systematic and effective transfer of knowledge about near-miss errors is needed for the education of prospective nurses. In this study, nurses with relatively shorter career experience said that they had not heard the term "near-miss error" until they started working for hospitals. This shows that education on near-miss errors is rarely included in the curriculum for prospective nurses. Thus, an in-depth discussion has to be undertaken regarding the reestablishment of empirical and theoretical systems for near-miss errors and incorporation of them into nursing curriculum.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the finding of this study are available from the corresponding author upon reasonable request.