International Journal for Quality in Health Care, 2016, 28(4), 508–514

doi: 10.1093/intqhc/mzw058
Advance Access Publication Date: 9 June 2016
Article

Article

Safety climate and attitude toward medication

error reporting after hospital accreditation

Downloaded from https://academic.oup.com/intqhc/article/28/4/508/2594940 by Research 4 Life user on 26 September 2022

in South Korea
EUNJOO LEE
College of Nursing, Research Institute of Nursing Science, Kyungpook National University, 101 Dong-in Dong
Jung-gu, Daegu 700-422, South Korea

Address reprint requests to: Eunjoo Lee, College of Nursing, Research Institute of Nursing Science, Kyungpook National
University, 101 Dong-in Dong Jung-gu, Daegu 700-422, South Korea. Tel: +82-53-420-4934; Fax: +82-53-425-1258; E-mail:
jewelee@knu.ac.kr
Accepted 11 May 2016

Abstract
Objective: This study compared registered nurses’ perceptions of safety climate and attitude
toward medication error reporting before and after completing a hospital accreditation program.
Medication errors are the most prevalent adverse events threatening patient safety; reducing
underreporting of medication errors significantly improves patient safety. Safety climate in hospi-
tals may affect medication error reporting.
Design: This study employed a longitudinal, descriptive design. Data were collected using
questionnaires.
Setting: A tertiary acute hospital in South Korea undergoing a hospital accreditation program.
Participants: Nurses, pre- and post-accreditation (217 and 373); response rate: 58% and 87%,
respectively.
Interventions: Hospital accreditation program.
Main outcome measures: Perceived safety climate and attitude toward medication error reporting.
Results: The level of safety climate and attitude toward medication error reporting increased sig-
nificantly following accreditation; however, measures of institutional leadership and management
did not improve significantly. Participants’ perception of safety climate was positively correlated
with their attitude toward medication error reporting; this correlation strengthened following com-
pletion of the program.
Conclusions: Improving hospitals’ safety climate increased nurses’ medication error reporting;
interventions that help hospital administration and managers to provide more supportive leader-
ship may facilitate safety climate improvement. Hospitals and their units should develop more
friendly and intimate working environments that remove nurses’ fear of penalties. Administration
and managers should support nurses who report their own errors.

Key words: medication errors, nurses, Korea, patient safety, incident reporting

Introduction changed, as the KOIHA’s accreditation program prioritizes patient

The Korea Institute for Healthcare Accreditation (KOIHA) was safety issues [1, 2]. Following KOIHA’s establishment, hospitals
established in 2010; patient safety awareness has subsequently have implemented numerous initiatives to improve patient safety by

© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com 508
Safety climate and attitude toward medication error reporting • Safety Indicators
eliminating unsafe hospital practices; however, the rate of medical
errors has remained stable and little research has examined hos-
pital accreditation programs’ effects on patient safety in South
Korea [1–4].
Lee estimated that medical errors affect 9.2% of all inpatients,
and nearly 40 000 patients have died due to medical errors in Korea
[5]. Additionally, the World Health Organization nominated the
lack of a system for monitoring patient safety as the Korean health
system’s most serious problem [6]. Korean administrators therefore
urgently need to monitor patient safety and manage the prevalence
of medical errors.
Medication errors are among the most prevalent medical errors
in Korea and worldwide [7–10]. In a survey, 98.7% of Korean
nurses reported committing medication errors within the previous
3 months, with an average of 13.57 errors [11]. Identifying medica-
tion error types, frequency and consequences using data stored in
the reporting system enables identification of unsafe practices and
the reasons for medication errors, thus preventing future medication
errors and increasing patient safety [12, 13]. Failure to identify
errors leads to repetition of mistakes and deteriorating patient safety
in healthcare organizations. Although the error reporting system is
the most commonly used method for identifying medication errors,
there is significant underreporting [12, 14–16] and the reporting
rate has been very low in Korea [9, 17, 18].
Organizations’ safety climates and cultures affect error reporting
rates [15, 19] and are associated with employees’ safety performance
[20–22]. Safety culture and climate are not synonymous: safety
climate is more measureable and superficial than safety culture,
the values and norms shared among an organization’s members
[23, 24]; nonetheless, few studies have examined safety climate’s
relationship with nurses’ medication error reporting [17, 18, 25].
In addition, few studies have examined changes in nurses’ percep-
tion of safety climate and attitudes toward medication error
reporting following completion of a hospital accreditation pro-
gram (regarded as critical to patient safety movement in South
Korean hospitals).
Implementing hospital accreditation systems may change health-
care professionals’ behavior and increase patient safety in Korean
hospitals. This study’s aims were therefore as follows: (1) to identify
differences in RNs’ perceived safety climate and attitudes toward
medication error reporting before and after hospital accreditation;
(2) to identify the relationship between perceived safety climate and
attitude toward medication error reporting among RNs in Korea.
The healthcare delivery system and hospital
accreditation program in South Korea
Korea’s healthcare system changed dramatically following the coun-
try’s modernization and the introduction of Western medicine in the
early 20th century [26]. The Korean demand for healthcare
increased suddenly following dramatic economic growth in the
1970 s and implementation of the national health insurance system
in 1989, which provided universal coverage [27, 28]. Total health-
care spending increased from 2.8% to 4.0% of GDP between 1975
and 1989, rising to 7.6% of GDP in 2012 [29]; this growth rate
exceeded that of GDP. Particularly in the 1990 s and in urban areas,
the dramatic increase in demand for healthcare brought an asso-
ciated increase in hospitals’ numbers and sizes [26, 28].
Following this explosion of healthcare demand, Korea came to
possess more hospitals equipped with cutting-edge medical technol-
ogy than most other Organisation for Economic Co-operation and
509
Development (OECD) countries. Healthcare spending per capita has
increased nearly 8% annually since 2002, more than double the
OECD average (3.6%) [28]. Nonetheless, increasing hospitals and
healthcare spending may not lead to increased care quality and
patient safety. Malpractice-related legal disputes are currently esti-
mated at 1% of all healthcare expenditure, increasing 15% per year
[6]. Consistent with efforts to enhance the quality of healthcare ser-
vices, KOIHA was established in 2010 and a new hospital accredit-
ation program focused on patient safety was implemented in 2011
[1, 2].
These accreditation programs’ first component was installed in
Downloaded from https://academic.oup.com/intqhc/article/28/4/508/2594940 by Research 4 Life user on 26 September 2022
2004: hospitals were ranked mainly by structural factors such as
facilities, equipment and resources [1, 2]. This was criticized for
focusing attention on formal factors, such as hospital size and avail-
able facilities, and for promoting provider-oriented evaluation rather
than patient-centered care [1]. The new hospital accreditation pro-
gram was therefore developed to identify the root causes of health-
care professionals’ behavior and prioritize quality improvement
efforts and patient safety, rather than examining facilities and equip-
ment [1, 2].
Under the new hospital accreditation program, general hospitals
must fulfill requirements pertaining to 537 measurable elements,
divided into 4 domains, 13 chapters, 48 categories and 91 stan-
dards. Hospitals’ accreditation status is either ‘accreditation’, ‘condi-
tional accreditation’ or ‘fail’. Accreditation is valid for 4 years;
conditional accreditation is valid for 1 year [29]. By the end of
2011, 44 tertiary hospitals (100%), 33 general hospitals (12%) and
8 small hospitals (0.6%) had received the new accreditation [2].
This may indirectly reflect low prioritization of patient safety in
Korea; healthcare facilities throughout Korea need to adopt the new
hospital accreditation program. In addition, research urgently needs
to examine the new accreditation program’s effect on healthcare
professionals’ behavior and attitudes toward patient safety, and to
monitor healthcare professionals, to continuously improve hospitals’
care quality.
Methods
Design
This study used a comparative longitudinal design to compare RNs’
perceptions of safety climate level and attitudes toward medication
error reporting before and after completing a hospital accreditation
program in South Korea.
Setting and participants
Participants were RNs at a non-profit tertiary hospital affiliated
with a university. The hospital had 850 beds, was located in a
metropolitan city in South Korea, and received hospital accredit-
ation in August 2011. All RNs who cared directly for patients were
eligible to participate. A total of 217 and 373 RNs participated in
this study in 2010 (before accreditation) and 2013 (after accredit-
ation), respectively.
The G-power program was used to calculate appropriate sample
size. Power analysis indicated that 201 participants were needed to
achieve power (1-β) of 0.85 in two independent sample t-tests with
an α of 0.05 and medium effect size (0.30), calculated by mean dif-
ferences between groups. This study therefore examined a sufficient
number of participants to identify differences between groups over
the investigation period.
510
Data collection
Convenience sampling was used for participant recruitment. The
researcher directly visited the hospital and explained the study’s pur-
poses and data collection processes to the director of the hospital’s
nursing department before and following accreditation. After
obtaining permission, nursing department personnel distributed
questionnaires to RNs in the clinical unit.
Each prospective participant received a letter explaining the
study’s purpose and the questionnaire; the consent form clearly sta-
ted that participation was voluntary. Participants were informed of
their right to withdraw from the research at any time. RNs who
agreed to participate and completed the questionnaires comprised
the final sample.
Participants were asked to return the completed questionnaire to
a locked box placed in the nursing lounges within 2 weeks of
receipt. After 2 weeks, a research assistant visited each ward in
order to retrieve the locked box. A total of 400 and 450 question-
naires were distributed pre- and post-accreditation; 233 and 393
were returned (response rates: 58% and 87%), respectively. Sixteen
and twenty responses were excluded due to insufficient information.
The final sample sizes were therefore 217 and 373. All data were
stored in a locked cabinet to ensure confidentiality and anonymity.
Questionnaire
The questionnaire was composed of items examining the following
topics: (a) safety climate, (b) participants’ attitude toward medica-
tion error reporting and (c) demographic information, including
education and years of nursing experience.
Safety climate survey
A measure developed by Sexton et al. and endorsed by the Institute
for Healthcare Improvement was used to examine hospital safety cli-
mate. This measure has been tested in many hospitals in the USA
and Europe [23].
This measure was suitable for this study’s purposes, as it exam-
ines frontline clinical staff’s perceptions of safety in their clinical
area and management’s commitment to safety. This study used the
Korean version with minor revisions to increase item understanding.
Nineteen items measured hospital safety climate with a 5-point
Likert scale (1 = ‘strongly disagree’; 5 = ‘strongly agree’). Higher
total scores indicated a more positive safety climate. Reliability was
not reported in the scale’s original paper; however, Kho et al.
obtained a Cronbach’s α of 0.86 [30]. In our study, values were
0.79 and 0.86 for Times 1 and 2, respectively.
Nurses’ attitudes toward medication error reporting
A measure based on the Modified Ulanimo survey [31] was adapted
with a related literature search and input from five experts with over
10 years’ clinical experience in tertiary hospitals each; this was used
to identify nurses’ attitudes toward medication error reporting. The
measure contained 14 items on a 5-point Likert scale (1 = ‘strongly
disagree’; 5 = ‘strongly agree’).
Test-retest reliability was assessed using a sample of registered
nurses working in the same hospital. Approximately 3 weeks after
initial examination, these nurses completed a second survey. They
received approximately US$5 for their participation and for com-
pleting each survey. Twenty-five participants completed surveys at
both times. The obtained value of Pearson’s correlation coefficient
was 0.803; Cronbach’s alpha was 0.70 and 0.65 pre- and post-
Lee
accreditation, respectively. This measure’s reliability was thus rela-
tively low; however, Nunnally et al. suggest that measures may have
reliability values as low as 0.60 and remain useable; they further
suggested that newly developed measures are useable with reliability
of ≥0.60 [32]. This measure was therefore used.
Analysis
Data were analyzed using SPSS v.20.0 (IBM, Armonk: NY).
Descriptive statistics were calculated regarding participants’ general
characteristics. Chi-square tests were used to examine nurses’ demo-
Downloaded from https://academic.oup.com/intqhc/article/28/4/508/2594940 by Research 4 Life user on 26 September 2022
graphic homogeneity pre- and post-accreditation. Independent
t-tests were used to compare nurses’ perceptions of safety climate
and attitudes toward medication error reporting pre- and post-
accreditation. Pearson’s correlation coefficients were calculated
between safety climate perception and attitude toward medication
error reporting; negative items were reverse coded in examination of
RNs’ safety climate perception and attitude toward medication error
reporting. Statistical significance was set at P < 0.05.
Results
Participant demographics
Table 1 summarizes participants’ demographic characteristics pre-
and post-accreditation (paired percentages in this paragraph are
respective of pre- and post-accreditation). Most participants were
female (99.1% and 97.8%); the most common age was 26–30 years
(36.0% and 32.1%). Around one-third of participants had a regis-
tered nurse to bachelor of science in nursing (RN-BSN) degree
(31.6% and 33.3%), and had >10 years of clinical experience
(32.1% and 36.7%); 92% of nurses were working in rotating shifts
pre- and post-accreditation.
Safety climate
Table 2 presents RNs’ scores on perceived safety climate level pre-
and post-accreditation; the mean score improved significantly fol-
lowing accreditation. Scores on seven items examining safety climate
did not improve significantly; scores on the remaining 12 items
improved significantly.
Attitude toward medication error reporting
Table 3 presents RNs’ scores on attitude toward medication error
reporting pre- and post-accreditation; the mean score improved sig-
nificantly following accreditation. Scores on several items (e.g.
‘I know what constitutes a medication error’, ‘I know all medication
errors should be reported’) did not improve significantly following
accreditation; however, negative attitudes toward medication error
reporting decreased significantly following hospital accreditation.
These items included ‘I am afraid of the manager’s reaction’, ‘I am
afraid of coworkers’ reactions’, ‘I am afraid that patients or family
members may develop negative attitudes toward nurses’, ‘I do not
report errors that are not serious enough’ and ‘the head nurse would
manage an error within the unit rather than reporting it to a higher
level’.
The highest-scoring items examining medication error reporting
were ‘medication error reporting always improves patient safety’
and ‘I know all medication errors should be reported’. The lowest-
ranked item was ‘I am afraid of penalties if I report errors’
(Table 3).
Safety climate and attitude toward medication error reporting • Safety Indicators 511

Table 1 Participant demographics before and after accreditation (N = 587)

Before (n = 214) After (n = 373) χ2 (P)

n (%) n (%)

Sex Female 215 (99.1) 356 (97.8)

Male 2 (0.9) 8 (2.2) 1.24 (0.22)
Age ≥25 44 (20.6) 73 (19.7)
26–30 77 (36.0) 119 (321.1)
31–35 40 (18.7) 68 (18.3) 1.97 (0.58)
≥36 53 (24.8) 111 (29.9)
Education Diploma 56 (26.0) 97 (26.1)
RN-BSN 68 (31.6) 124 (33.3) 0.224 (0.97)

Downloaded from https://academic.oup.com/intqhc/article/28/4/508/2594940 by Research 4 Life user on 26 September 2022

BSN 60 (27.9) 99 (26.6)
Master’s degree 31 (14.4) 52 (14.0)
Years of clinical experience <1 year 6 (2.8) 26 (7.0)
1–4 years 62 (28.8) 84 (22.5) 7.70 (0.10)
4–7 years 47 (21.9) 74 (19.8)
7–10 years 31 (14.4) 52 (13.9)
>10 years 69 (32.1) 137 (36.7)
Years of hospital experience <1 year 13 (6.0) 27 (7.3) 4.77 (0.31)
1–4 years 61 (28.4) 96 (25.8)
4–7 years 41 (19.1) 76 (20.4)
7–10 years 33 (15.3) 38 (10.2)
>10 years 67 (31.2) 135 (36.8)
Present department work experience <1 year 38 (17.6) 78 (21.2) 2.02 (0.57)
≥1 and <4 years 120 (55.6) 183 (49.7)
4–7 years 48 (22.2) 89 (24.2)
>7 years 10 (4.6) 18 (4.9)

Perception of safety climate’s relationship with attitude
toward medication error reporting
Table 4 presents values of correlations between pre- and post-
accreditation scores on perception of safety climate and attitude
toward medication error reporting. Correlations between percep-
tions of safety climate and attitude toward medication error
reporting were 0.167 and 0.288 before and after accreditation,
respectively. Scores on perceptions of safety climate were thus
positively correlated with scores on attitude toward medication
error reporting; further, this relationship grew stronger following
accreditation.
Discussion
Reporting medication errors is important for improving patient
safety, and safety climate change in healthcare organizations is
necessary in order to increase error recognition and enhance patient
safety. This study compared South Korean RNs’ perceptions of
safety climate and attitudes toward medication error reporting prior
to and following their hospital’s accreditation.
RNs’ perceived safety climate and attitudes toward medication
error reporting improved following completion of the accredit-
ation program. Specifically, negative attitudes toward medication
error reporting (e.g. fear of managers, coworkers, patients, or
families’ reactions, fear of penalties) decreased significantly after
accreditation; this suggests that RNs considered error reporting
more important, and feared negative consequences less, following
accreditation.
Nonetheless, mean scores did not improve significantly among
items examining positive feedback, the necessity of reporting all
medication errors and reporting effects on patient safety. RNs thus
appeared to consider minor medication errors unnecessary to report;
this implies that some medication errors remain unreported. If so,
opportunities for meaningful changes in safe medication administra-
tion practice would be missed. Administrators should aim to
improve these attitudes through organizational support. In addition,
scores did not improve significantly on items examining the necessity
of disclosing medication errors to patients or family members, sug-
gesting that RNs may fear losing professional credibility and
patients or family members’ trust by reporting medication errors.
In this study, scores reflecting nurses’ knowledge of medication
errors did not increase significantly from pre- to post-accreditation.
Nurses’ understanding of what constitutes a medication error may
be the most important factor affecting reporting. Osborne et al.
found that 15.8% of nurses were unsure of what constituted a medi-
cation error and 14% were unsure when to report [33]. Mayo and
Duncan identified inconsistencies in US nurses’ definitions of medi-
cation errors, suggesting inadequate understanding of what constitu-
tes a medication error [34] and inadequate knowledge of
pharmacology as the top causes of medication errors among nurses
[35]. Nurses should therefore undergo continuing education and
training to improve their knowledge of and competence in medica-
tion administration. Additionally, hospitals should provide support
and materials permitting nurses to maintain and update their knowl-
edge and skills in their workplaces.
Importantly, regarding perceived safety climate, scores did not
significantly improve on items examining managers’ attitudes and
ability to learn from mistakes (e.g. ‘managers listen to and care
about RNs’ concerns’, ‘managers do not knowingly compromise
safety’, ‘I am satisfied with the managers’ and ‘managers view
undesirable events as multiple systems failures rather than individual
actions’). Previous research has consistently found that nurses fear
negative managerial feedback and that fear mainly prevents the
reporting of medication errors [31, 34, 36, 37]. Additionally, error
reporting may be related to organizations’ power hierarchies [36].
512 Lee

Table 2 Safety climate before and after accreditation

Items Before (n = 214) After (n = 373) t P

Mean (SD) Mean (SD)

The culture in this clinical area makes it easy to learn from the mistakes 2.88 (0.86) 2.86 (0.87) 0.30 0.76
of others.
Medical errors are handled appropriately in this clinical area. 3.10 (0.74) 3.24 (0.66) −2.34 0.02
The senior leaders in my hospital listen to me and care about my 3.15 (0.86) 3.47(0.73) −4.66 0.00
concerns.
Physicians and nurse leaders in my area listen to me and care about 3.23 (0.79) 3.36 (0.75) −1.70 0.09
my concerns.
Leadership is driving us to be a safety-centered institution. 2.59 (0.86) 2.82 (0.78) −3.32 0.00

Downloaded from https://academic.oup.com/intqhc/article/28/4/508/2594940 by Research 4 Life user on 26 September 2022

My suggestions about safety would be acted upon if I expressed them 2.84 (0.72) 3.07 (0.70) −3.80 0.00
to management.
Management/leadership does not knowingly compromise safety concerns 3.00 (0.89) 3.06 (0.86) −0.59 0.55
for productivity.
I am encouraged by my colleagues to report any patient safety concerns 2.89 (0.75) 3.11 (0.75) −3.44 0.00
I may have.
I know the proper channels to direct questions regarding patient safety. 2.84 (0.76) 3.02 (0.85) −2.49 0.01
I receive appropriate feedback about my performance. 2.96 (0.70) 3.13 (0.77) −2.73 0.01
I would feel safe being treated here as a patient. 2.88 (0.70) 3.04 (0.82) −2.35 0.02
Briefing personnel before the start of a shift (i.e. to plan for possible 3.71 (0.71) 3.71 (0.75) −0.02 0.99
contingencies) is important for patient safety.
Briefings are common where I work. 3.46 (0.89) 3.54 (0.87) −1.06 0.29
I am satisfied with the availability of clinical leadership physicians and 3.20 (0.71) 3.21 (0.78) −0.03 0.98
nurses in this clinical area.
This institution is doing more for patient safety now than it did 1 year 3.22 (0.70) 3.43 (0.78) −3.23 0.00
ago.
I believe that most adverse events occur as multiple systems failures and 3.25 (0.88) 3.28 (0.78) −0.50 0.62
are not attributable to one individual’s actions.
The personnel in this clinical area take responsibility for patient safety. 3.38 (0.64) 3.56 (0.80) −3.39 0.00
Personnel frequently disregard rules or guidelines (e.g. handwashing, 2.66 (0.79) 2.50 (0.55) 2.24 0.03
treatment protocols/clinical pathways, sterile field, etc.) that are
established for this clinical area.a
Patient safety is consistently reinforced as the priority in this clinical area. 3.43 (0.72) 3.57 (0.64) −2.47 0.01
Total mean 3.13 (0.38) 3.27 (0.41) −4.20 <0.001

a
Reverse coded.

Table 3 Attitudes toward medication error reporting before and after accreditation

Items Before (n = 214) After (n = 373) t P

Mean (SD) Mean (SD)

I am afraid of the manager’s reaction.a 3.26 (0.91) 3.05 (0.90) 2.709 0.007
I am afraid of reactions from coworkers.a 3.14 (0.90) 2.76 (0.87) 5.016 <0.001
I am afraid that patients or family may develop negative attitudes toward nurses.a 3.22 (0.87) 2.91 (0.90) 4.157 <0.001
I would not report errors that are not serious enough.a 3.15 (0.94) 2.89 (0.94) 3.231 0.001
I am afraid of penalties if I report errors.a 2.61 (0.89) 2.28 (0.79) 4.590 <0.001
I would not report medication errors committed by coworkers.a 2.91 (0.69) 2.71 (0.75) 3.241 0.001
I know all medication errors should be reported. 3.36 (0.81) 3.36 (0.85) −0.015 0.99
Medication error reporting always improves patient safety. 3.49 (0.80) 3.58 (0.77) −1.307 0.19
I would receive positive feedback on medication error reporting. 3.08 (0.83) 3.18 (0.88) −1.339 0.17
I know what constitutes a medication error. 3.35 (0.72) 3.32 (0.67) 0.403 0.69
If medication errors occur, I would report medication errors to patient or family members. 2.99 (0.67) 3.01 (0.72) −0.456 0.65
The head nurse would deal with it within the unit rather than reporting it to a higher level.a 2.97 (0.75) 2.79 (0.83) 2.622 0.009
I have seen medication errors.a 3.52 (0.79) 3.38 (0.82) 1.981 0.048
I would not receive feedback from administration.a 2.68 (0.80) 2.56 (0.76) 1.875 0.061
Total mean 3.06 (0.39) 3.21 (0.41) −4.53 <0.001

a
Reverse coded.

Negative perceptions of managers and coworkers regarding errors Positive feedback and support from administrators and man-
made by nurses thus remain barriers to reporting medication errors, agers regarding medication error reporting are critical to building
although researchers have consistently highlighted the importance of organizations’ safety climates. Increasing medical error reporting
creating non-blame workplace cultures. requires hospitals and units to create climates that increase nurses’
Safety climate and attitude toward medication error reporting • Safety Indicators
Table 4 Safety climate and attitude toward medication error
reporting
Medication error reporting
Before r (P) After r (P) Total r (P)
Safety climate 0.167 (0.016) 0.288 (<0.001) 0.271 (<0.001)
comfort with discussing concerns and issues encountered during
patient care or requesting explanations of matters they do not
understand [17].
In the USA, voluntary reporting and other safety detection meth-
ods missed 90% of adverse events [16]; however, error reporting is
considered essential to patient safety, as nurse managers and admin-
istrators require data stored in medication error reporting systems in
order to identify personal, environmental or organizational factors
affecting patient safety and to prevent error recurrence. Error report-
ing is thus directly related to both safety culture and patient safety.
Reporting culture affects administrators and managers’ ability to
gather information regarding factors affecting safety throughout the
hospital.
Some research has examined error reporting’s relationship with
organization safety culture [17, 38]. The present study found a sig-
nificant positive correlation between perceived safety climate and
attitudes toward medication error reporting. Previous research has
found that patient safety culture is significantly positively correlated
with error reporting rate [17]. Safety climate enables nurses to docu-
ment errors; feedback and rewards importantly motivate error
reporting [38].
Error reporting rate predicts behavioral commitment to patient
safety. Blegen et al. found higher rates of medication error reporting
in units using quality management processes [39]. Managerial sup-
port and staff education regarding error reporting through building
safety climate are critical to promoting patient safety practices in
hospitals. Improved medication error reporting may only occur in
an environment that encourages and supports reporting errors [40].
Creating an environment conducive to reporting errors requires a
non-blaming and fair organizational approach. Administrators
should organize regular measurement of their organization’s safety
culture and their staff’s perception of organizational management
and leadership [17], as organizational climate and culture critically
affect staff error reporting.
This study has the following limitations. This study used a con-
venience sample recruited within one hospital, limiting the results’
generalizability. Future research should examine nurses within a
variety of healthcare settings and regions in order to deliver more
generalizable results on safety climate and medication error report-
ing in Korea. Additionally, this study did not examine healthcare
professionals such as physicians and pharmacists, who may also
relevantly contribute to medication errors and their reporting; future
research should examine these personnel’s relationship with medica-
tion errors and their reporting.
Conclusions
In general, total mean score of safety climate and attitude toward
medication error reporting improved significantly following
accreditation. However, some items, particularly regarding percep-
tion of leadership and management, were not significantly improved.
Leadership and managerial support are critical to promoting a safety
513
climate in hospitals; promoting such a climate may increase the rate
of medication error reporting. Increased medication error reporting
helps to prevent error recurrence; analysis of errors recorded in med-
ical error reporting systems may reduce the rate of medical errors
that will occur in the future. Hospital administrators and nurse
managers should therefore give positive feedback to nurses who
report medication errors. All frontline nurses should be involved in
improving care quality and understand that error reporting is closely
related to quality improvement.
Downloaded from https://academic.oup.com/intqhc/article/28/4/508/2594940 by Research 4 Life user on 26 September 2022
Funding
This work was supported by the Ministry of Education of the Republic
of Korea and the National Research Foundation of Korea (NRF-
2015S1A5A2A01009760).
References
1. Park JH. Understanding of the new Korea healthcare accreditation sys-
tem. J Korean Med Assoc 2011;54:142–5.
2. Seok SH. Improvement plans of accreditation program for healthcare
organizations in Korea. Health Welf Policy Forum 2013;202:39–47.
3. Park S. Effects of psychiatric nurse’s awareness of healthcare accreditation
system on patient safety management activities and nursing performance.
Master’s Thesis. Seoul: Hanyang University, 2012.
4. Shin M. The effects of hospital accreditation program to the organiza-
tional culture, job satisfaction, financial performances, and patient safety
at geriatric hospital: about Busan Metrocity. J Digit Converg 2014;12:
455–66.
5. Lee S. Development of Institutional Mechanism for Improving Patient
Safety in Korea. Korea Centers for Disease Control and Prevention,
2013. http://www.cdc.go.kr/CwjDC/notice/CdcKrInfo0201.jsp?menuIds=
HOME001-MNU1154-MNU0004-MNU1889&cid=21512 (24 June 2015,
date last accessed).
6. World Health Organization. OECD Health Care Quality Review: Korea.
Assessment and recommendations, 2012. http://www.oecd.org/els/health-
systems/49818570.pdf (20 July 2015, date last accessed).
7. Härkänen M, Turunen H, Saano S et al. Detecting medication errors:
analysis based on a hospital’s incident reports. Int J Nurs Pract 2015;21:
141–6.
8. Milch CE, Salem DN, Pauker TG et al. Voluntary electronic reporting of
medical errors and adverse events. An analysis of 92,547 reports from
26 acute care hospitals. J Gen Intern Med 2006;21:165–70.
9. Kim CH, Kim M. Defining reported errors on web-based reporting system
using ICPS from nine units in a Korean university hospital. Asian Nurs
Res 2009;3:167–76.
10. Thomsen LA, Winterstein AG, Sondergaard B et al. Systematic review of the
incidence and characteristics of preventable adverse drug events in ambula-
tory care. Ann Pharmacother 2007;41:1411–26. doi:aph.1H658 [pii].
11. Kim E, Lee S, Eom MR. DICS behavior pattern and medication errors by
nurses. J Korean Acad Nurs Admin 2013;19:28–38.
12. Stratton KM, Blegen MA, Pepper G et al. Reporting of medication errors
by pediatric nurses. J Ped Nurs 2004;19:385–92.
13. Richter JP, McAlearney AS, Pennell ML. Evaluating the effect of safety
culture on error reporting: a comparison of managerial and staff perspec-
tives. Am J Med Qual 2015;30:550–8. doi:1062860614544469 [pii].
14. Classen DC, Resar R, Griffin F et al. ‘Global trigger tool’ shows that
adverse events in hospitals may be ten times greater than previously mea-
sured. Health Aff 2011;30:581–9.
15. Kagan I, Barnoy S. Factors associated with reporting of medication errors
by Israeli nurses. J Nurs Care Qual 2008;23:353–61.
16. Hogan H, Olsen S, Scobie S et al. What can we learn about patient
safety from information sources within an acute hospital: a step on the
ladder of integrated risk management? Qual Saf Health Care 2008;17:
209–15.
514
17. Kim KS, Kwon S, Kim J et al. Nurses’ perceptions of medication errors and
their contributing factors in South Korea. J Nurs Manage 2011;19:346–53.
18. Kim M. Role of transformational leadership in the relationship between
medication error management climate and error reporting intention of
nurse. Korean J Adult Nurs 2013;25:633–43.
19. Morello RT, Lowthian JA, Barker AL et al. Strategies for improving
patient safety culture in hospitals: a systematic review. BMJ Qual Saf
2013;22:11–8. doi:10.1136/bmjqs-2011-000582.
20. Hutchinson A, Young TA, Cooper KL et al. Trends in healthcare incident
reporting and relationship to safety and quality data in acute hospitals:
results from the national reporting and learning system. Qual Saf Health
Care 2009;18:5–10. doi:10.1136/qshc.2007.022400.
21. Mardon RE, Khanna K, Sorra J et al. Exploring relationships between
hospital patient safety culture and adverse events. J Pat Saf 2010;6:226–32.
doi:10.1097/PTS.0b013e3181fd1a00.
22. Singer S, Lin S, Falwell A et al. Relationship of safety climate and safety
performance in hospitals. Health Serv Res 2009;44:399–421.
23. Sexton J, Helmreich R, Neilands T et al. The safety attitudes question-
naire: psychometric properties, benchmarking data, and emerging
research. BMC Health Serv Res 2006;6:44.
24. Manojlovich M, Kerr M, Davies B et al. Achieving a climate for patient safety
by focusing on relationships. Int J Qual Health Care 2014;26:579–84.
25. Kim M, Kim MS. Canonical correlation between organizational charac-
teristics and barrier to medication error reporting of nurses. J Korean
Acad-Ind Coop Soc 2014;15:979–88.
26. Yang BM. Health Insurance and the Growth of the Private Health Sector
in the Republic of Korea. World Bank Institute, 2001.
27. Kwon S. Thirty years of national health insurance in South Korea: lessons
for achieving universal health care coverage. Health Policy Plan 2009;24:
63–71.
Lee
28. Jeong HS. Korea’s National Health Insurance—lessons from the past
three decades. Health Aff 2011;30:136–44.
29. Korean Institute for Healthcare Accreditation. Standards to Become
Accreditation, 2016. Retrieved January from http://www.koiha.kr/
member/kr/board/establish/establish_BoardView.do (in Korean).
30. Kho ME, Carbone JM, Lucas J et al. Safety Climate Survey: reliability of
results from a multicenter ICU survey. Qual Saf Health Care 2005;14:
273–8.
31. Ulanimo VM, O’Leary-Kelley C, Connolly PM. Nurses’ perceptions of
causes of medication errors and barriers to reporting. J Nurs Care Qual
2007;22:28–33.
32. Nunnally JC. Psychometric Theory. New York, NY: McGrawHill, 1978.
Downloaded from https://academic.oup.com/intqhc/article/28/4/508/2594940 by Research 4 Life user on 26 September 2022
33. Osborne J, Blais K, Hayes JS. Nurses’ perceptions: when is it a medication
error? J Nurs Admin 1999;29:33–8.
34. Mayo AM, Duncan D. Nurse perceptions of medication errors: what we
need to know for patient safety. J Nurs Care Qual 2004;19:209–17.
35. Lan Y, Wang, KK, Yu S et al. Medication errors in pediatric nursing:
assessment of nurses’ knowledge and analysis of the consequences of
errors. Nurs Educ Today 2014;34:821–8.
36. Chiang H, Pepper GA. Barriers to nurses’ reporting of medication admin-
istration errors in Taiwan. J Nurs Sch 2006;38:392–9.
37. Potylycki MJ, Kimmel SR, Ritter M et al. Nonpunitive medication error
reporting: 3-year findings from one hospital’s Primum Non Nocere initia-
tive. J Nurs Admin 2006;36:370–6.
38. Güneş ÜY, Gürlek Ö, Sönmez M. Factors contributing to medication
errors in Turkey: nurses’ perspectives. J Nurs Manage 2014;22:295–303.
39. Blegen MA, Vaughn T, Pepper G et al. Patient and staff safety: voluntary
reporting. Am J Med Qual 2004;19:67–74.
40. Homsma GJ, Van Dyck C, De Gilder D et al. Learning from error: the
influence of error incident characteristics. J Bus Res 2009;62:115–22.