Incident reporting has gained significant importance in healthcare organisations, emerging as a pivotal policy measure (Lee et al, 2018). The incident report serves as a repository of unexpected events, near misses, clinical adverse events, instances of violence or aggression and safety issues. It relies on healthcare professionals to document and reflect on incidents, providing a narrative that captures the sequence of events and their insights into the causes, irrespective of whether they directly observed the incident (Sanne, 2008; Kodate et al, 2022). These reports are invaluable at the community level for developing strategies to reduce harm and, nationally, help identify systemic issues that may otherwise be overlooked (Carson-Stevens et al, 2016).
‘First, do no harm’ stands as the cornerstone principle of every healthcare service (World Health Organization, 2023). Patient safety is not a regional concern, but a worldwide priority that permeates all divisions of the healthcare system, with the goal to diminish patient harm in the delivery of healthcare services (Albaalharith and A'aqoulah, 2023). This conviction transforms patient safety from a theoretical idea into a practical necessity.
The obstetric environment is uniquely characterised by inherent vulnerabilities and risks, where providing care involves more than following standard medical procedures; it requires quick, critical decision making that can have lasting effects on women and their families (Murray-Davis et al, 2015; Roberts, 2019). A significant number of pregnant women encounter preventable adverse events. Hüner et al (2022) reported that 13% of obstetric cases presented adverse events and 3% of all reviewed records were preventable (resulting from peripartum therapeutic delay, diagnostic error, inadequate birth position, organisational error, inadequate fetal monitoring and medication error).
These preventable events not only compromise women's access to high-quality and safe healthcare but also potentially impact their wellbeing and that of their infants. Research has highlighted the necessity of standardised risk management to identify and mitigate these events, further emphasising the importance of vigilant incident reporting as a cornerstone of ensuring women safety (Hüner et al, 2023).
In such complex and high-stake environments, establishing a culture of robust women safety is an absolute priority. In general, patient safety culture refers to the aggregation of values, attitudes, perceptions, competencies and patterns of behaviour in an organisation that determine the commitment, style and proficiency of the organisation's health and safety management (Ayisa et al, 2021; Çatal et al, 2024). Safety culture can enhance the quality of care through the creation of an environment that encourages safe practices and attitudes, which in turn affects the systems, procedures and, eventually, the outcome of medical care (Wagner et al, 2019). There has been increasing acknowledgment that a positive midwifery safety culture includes elements such as the acquisition of knowledge in an organisation, teamwork, open communication, constructive feedback, a non-punitive approach towards mistakes and mutual cultural perspectives rooted in the value of women's safety (Khoshakhlagh et al, 2019).
Strengthening continuous quality improvements fosters a culture of continuous learning and innovation, promoting proactive problem-solving. This approach encourages staff involvement and confidence, ultimately leading to better quality of care (Endalamaw et al, 2024). Incident reporting is an appropriate tool for this strategy as it allows data to be gathered and compiled for the identification of patterns that may need corrective action (Hewitt et al, 2016). In addition, it offers insights into the prevalence of a safety-first mindset among clinicians and the wider adoption of a non-punitive culture in healthcare settings (Vetrugno et al, 2022).
Incident reporting in healthcare
Incident reporting is more than a historical account of an incident; it is a proactive step toward identifying solutions and fostering an environment of learning (Hamed and Konstantinidis, 2022). Incident reporting involves a multi-stage process that includes detection, analysis, learning and feedback, with each stage being critical to enhancing safety and care quality (Hewitt et al, 2016). Anderson et al (2013) emphasised the importance of systematic identification of problems, followed by a thorough evaluation of implemented changes to determine their effectiveness. The authors stressed the importance of providing feedback to staff members to reinforce a culture of safety awareness and continuous learning in the healthcare environment.
Barriers to incident reporting
Higher rates of incident reporting are intricately linked with a more positive patient safety culture (Kaya et al, 2023). However, the potential for incident reporting systems to facilitate learning and enhance patient safety is significantly compromised by non- or under-reporting (Dhamanti et al, 2021). This hinders the effectiveness of incident monitoring and initiatives aimed at reducing safety concerns (Hamed and Konstantinidis, 2022).
Fear of reprisal and blame
Despite the richness of incident report data, incident reporting may not always be designed to facilitate learning and can instead contribute to a culture of shame and blame (Anderson and Kodate, 2015; Stavropoulou et al, 2015). Nurses and midwives may be reluctant to share experiences of incidents that compromised women's safety. The fear of being perceived as at fault, held accountable and facing punitive measures may make healthcare professionals hesitant to report incidents (Hamed and Konstantinidis, 2022; Almansour, 2023; Oweidat et al, 2023).
The reluctance to report incidents is underscored by apprehension of legal consequences when reporting incidents that compromised women's safety. The fear of potential lawsuits and legal problems serve as a significant deterrent for healthcare professionals who may otherwise contribute crucial insights through incident reporting (Peyrovi et al, 2016; Dyab et al, 2018). Healthcare professionals across various disciplines are subjected to an excessive number of hostile behaviours (Kaya et al, 2023), which runs counter to the fundamental principle of psychological safety (Ito et al, 2022). Individuals who perceive low psychological safety are hesitant to take interpersonal risks, resorting to avoidance and silence (O'Donovan et al, 2021). Kaya et al (2023) suggested that such hostility negatively impacts reporting habits, which subsequently affects patient safety outcomes (Mustapha et al, 2019).
In addressing this issue, it is crucial to recognise that coercive measures, such as the threat of legal action, can be counterproductive. Enforcing incident reporting through fear of legal consequences is more likely to intensify defensive behaviours among healthcare professionals than foster the desired culture of openness and transparency (Stavropoulou et al, 2015). It is imperative for healthcare organisations to perceive mistakes as opportunities for constructive learning to enhance patient safety, rather than viewing them solely as personal failures (Zhao et al, 2022). Although anonymous reporting may limit subsequent follow up and investigation, Oweidat et al (2023) proposed that implementing an optional anonymous reporting system, instead of exposing and blaming operators, could significantly mitigate this barrier and foster a culture of open communication and improvement.
Insufficient understanding of incident reporting
An integrative review conducted by Alves et al (2019) highlighted a barrier in the incident reporting process stemming from a lack of understanding regarding adverse events and reporting protocols. Such confusion often arises from the ambiguous definition of an incident and the perception that reporting necessity hinges on the outcome of the incident (Hamed and Konstantinidis, 2022), as well as uncertainty on how to locate or access the relevant form (Oweidat et al, 2023). However, there is the potential for heightened awareness of incident reporting to positively influence the attitudes of healthcare professionals, including midwives, potentially leading to behavioural changes (Beigi et al, 2020). Consequently, leaders can play a crucial role in enhancing incident reporting goals. By implementing educational interventions that actively transfer knowledge and establishing a specific management and education system in a supportive working environment, they can effectively increase staff members' intent to report incidents and ultimately improve patient safety (Pramesona et al, 2023).
Futility
Despite its importance, incident reporting can be viewed as inconvenient and ineffective. Studies have consistently identified factors such as a lack of time, heavy workload and forgetfulness as significant contributors to under-reporting (Banakhar et al, 2017; Dyab et al, 2018). In labour and birth settings, midwives often encounter a demanding work environment, characterised by high-stress situations that require quick, critical decision making and effective medical interventions for the safety of both mother and child. These intense circumstances are compounded by substantial workloads, potentially impeding midwives' ability to consistently complete incident reports as a result of time constraints.
Furthermore, studies have shown that a considerable number of incident reporting systems do not offer feedback to nurses and midwives (Bovis et al, 2018; Oweidat et al, 2023; Pramesona et al, 2023). Waters et al (2012) highlighted that this lack of feedback leads to doubts among nurses and midwives regarding the purpose of incident reporting; they are discouraged from reporting incidents, as they feel their concerns are ignored. This detrimental trend can have severe implications, as it undermines nurses and midwives' sense of accountability and moral obligation over time (Oweidat et al, 2023). Building on these challenges, Alves et al (2019) highlighted the need to streamline the reporting process. The authors advocated for reducing bureaucracy and hierarchical barriers to make it easier to report incidents, thereby ensuring important information is not overlooked because of procedural complexities.
Addressing the barriers
It is fundamental for midwives to prioritise women's safety and minimise adverse events, thus reducing maternal morbidity and mortality (Amiri, 2020). Women and their families expect midwives to provide a service that ensures a safe and caring environment (Sengane, 2013).
To address the barriers associated with incident reporting, healthcare organisations should consider implementing incentives to motivate staff. Cook-Richardson et al (2022) demonstrated that introducing financial incentives for reporting incidents correlates with increased rates of incident reporting. Such incentives not only motivate staff to report incidents, but also enhance staff accountability, self-awareness and self-reflection (LeMaire et al, 2018; Rashed and Hamdan, 2019). Additionally, education and training in incident reporting can equip midwives with a deeper understanding of safety and their role in fostering a safer healthcare environment (Brubacher et al, 2011; Hartnell et al, 2012).
As the process of incident reporting can be perceived as punitive (Feeser et al, 2021), it is important to cultivate a culture of openness and ongoing improvement. Accordingly, reporting systems should be designed with protective measures in place, offering a safeguard against legal action and professional censure (Barach and Small, 2000), fostering voluntary incident reporting (Kadivar et al, 2017). Such safeguards, although not absolute, aim to shield professionals from undue repercussions, encouraging midwives to report incidents without fear of unwarranted consequences. Such protections are crucial for fostering an environment where honest reporting is standard practice.
Educational interventions
When an individual holds an unfavourable view towards something, they are less likely to participate in that activity. While this negativity bias can create reluctance to engage in incident reporting, it also presents an opportunity for change through interventions that challenge and modify negative impressions over time. While studies have explored the impact of educational interventions on incident reporting (Nakamura et al, 2014; Krouss et al, 2019), there is a paucity of research addressing specific educational programmes or training initiatives enhancing incident reporting knowledge and practices among midwives. Research on incident reporting in healthcare has largely centred on resident physicians and other medical professionals, with the specific training needs of midwives often overlooked.
Krouss et al (2019) implemented an educational initiative for internal medicine residents to enhance competency in filing incident reports. This initiative began with a survey assessing residents' baseline understanding of incident reporting and patient safety issues. The education they received included clear definitions, guidelines on when and how to file reports, demonstrations of electronic filing systems and strategies to overcome common barriers to reporting. This was complemented by weekly patient safety rounds that provided an opportunity for in-depth discussions of specific incidents, reinforcing the education received and monitoring the progress of filed reports. These rounds also facilitated direct communication between leadership and care providers about incident prevention strategies. A follow-up survey measured any shifts in knowledge, reporting frequency and persistent obstacles to reporting. The intervention led to significant enhancements in residents' understanding and execution of incident reporting. This was evidenced by a marked increase in the frequency of reports logged by the trainees, with the median number of incident reports rising from one per month prior to the intervention to 10 per month following it.
Nakamura et al (2014) reported that an educational initiative led to a significant increase in incident reporting for 6 months post-intervention, indicating its immediate effectiveness. The intervention highlighted the value of reporting, underlined the non-punitive nature of disclosing medical errors and provided training on using computerised reporting systems. However, the study acknowledged that the positive effects of such educational measures often diminish over time. To maintain heightened reporting rates, ongoing reinforcement and periodic re-education were recommended.
Kertland et al (2018) further highlighted the effectiveness of safety rounds, where pharmacists regularly convened to critically discuss and learn from medication safety incidents. Though focused on pharmacists, this strategy facilitates proactive identification and resolution of safety concerns, emphasising the importance of creating a supportive environment where frontline staff can engage in open, interdisciplinary dialogue to enhance patient safety.
The demonstrated success of these educational interventions underscores the role of consistent and focused training in enhancing patient safety. Equipping healthcare professionals with the necessary knowledge and tools can not only improve incident reporting practices but also create a healthcare environment where patient safety is continually advanced through learning and adaptation.
Despite recognition of the need for studies that design and assess training programmes aimed at boosting incident reporting competencies in midwifery, there are barriers to implementing such specialised training, including limited availability of qualified instructors, financial and resource constraints, technological challenges and varying levels of engagement from both trainers and midwives (Kabanga et al, 2018; Shayan et al, 2019; Cheptum et al, 2023). Addressing these challenges is critical for developing effective incident reporting education for midwives.
Patient safety culture in midwifery
Midwives play an important role in promoting women's safety, ultimately reducing the incidence of adverse events, safety lapses and maternal morbidity and mortality. Assessing current safety culture in midwifery is crucial to maximise the impact on clinical outcomes. This evaluation is essential to determine whether the current culture supports or inhibits midwives' proactive efforts in safeguarding patient safety. However, research into the patient safety culture specific to midwifery remains markedly scarce.
Teamwork
Research indicates that teamwork is the most positively rated aspect of safety culture in maternity units (Akbari et al, 2017; Cansever and Soğukpınar, 2024). In an environment where healthcare professionals collaborate effectively, there tends to be a strong sense of solidarity and mutual respect (Sorra et al, 2016). However, Carmo et al (2020) reported variations in the perceived importance of teamwork across three maternity hospitals. This suggests a disparity in the emphasis placed on teamwork in different institutional cultures. This finding was echoed by Brás et al (2024), who observed similar variations in team cohesion in different maternity hospitals, especially where team instability was noted. Collaborative teamwork among healthcare professionals has been shown to foster better safety culture, leading to fewer adverse events and incidents for patients, as well as improved job satisfaction and reduced turnover among healthcare workers (Alshyyab et al, 2023).
Communication
In an organisational context, communication plays an important role in facilitating coordination of activities and promoting a culture of mutual understanding among staff members and trusting relationships among staff members, thereby contributing to safe and reliable patient care (Wieke Noviyanti et al, 2021). A study investigating patient safety culture in obstetrics, gynaecology and neonatology units reported that midwives' assessments of ‘feedback and communication about error’ were overwhelmingly positive (Ribeliene et al, 2019). In contrast, Ederer et al (2019) found that some midwives perceived a lack of certain communication forms, including verbal discussions with management regarding errors, addressing errors during team meetings or case discussions, participating in quality circles, written documentation of errors or incident reporting. Patient safety culture thrives on communication characterised by tolerance and respect. Specifically, open communication means staff feel at ease approaching management or colleagues to report incidents or make constructive suggestions and voice their concerns to improve service in their unit or hospital, as well as patient safety (Lee et al, 2023).
Organisational learning
Organisational learning involves a continuous process where knowledge is developed through work experiences in a specific context, subsequently influencing future learning through effective changes in the organisation's environment (Argote, 2011). Multiple studies have shown that organisational learning is among the most positively perceived dimensions of safety culture in maternity and neonatal units (Akbari et al, 2017; Ribeliene et al, 2019; Pedroni et al, 2020; Jabarkhil et al, 2021). However, Wang et al (2023) highlighted that while midwives recognised the importance of organisational learning for women's safety, they reported minimal tangible benefits. This was attributed to the perceived irrelevance of such learning to daily clinical responsibilities and the inflexible nature of educational content. Effective organisational learning is key to improving efficiency and effectiveness through knowledge sharing. However, for it to be impactful, healthcare institutions must adapt to the dynamic nature of their environment and embrace flexible learning models that resonate with clinical practice (Alonazi, 2021).
Conclusions
Incident reporting is pivotal in shaping a safety-conscious culture in midwifery, moving beyond mere documentation to become a catalyst for shared responsibility in women's care. It paves the way for learning from incidents, fostering improvements and ensuring transparent communication. To realise its full potential, healthcare organisations must dismantle barriers to reporting, championing a system that encourages rather than penalises incident reporting. Continuous reinforcement of these practices is crucial to keeping reporting rates robust and maintaining an enduring commitment to women safety. There is a pressing need for ongoing research to tailor these systems to the unique environment of midwifery and ensure that interventions remain relevant and effective.
Key points
- Incident reporting is a vital tool for enhancing safety in maternity settings.
- Systematic collection of data allows identification of recurrent patterns that need corrective action.
- Barriers to effective incident reporting include fear of punitive action, insufficient understanding of reporting protocols and the perception that incident reporting is futile.
- Positive patient safety culture in midwifery is characterised by knowledge acquisition, teamwork, open communication, constructive feedback and a non-punitive approach to mistakes.
- Continuous educational interventions and training in incident reporting are crucial.
CPD reflective questions
- How does the practice of incident reporting in your work setting enhance patient safety, and what strategies might improve its effectiveness?
- Reflect on the current patient safety culture in your midwifery practice. What elements are well established and where is there room for improvement?
- How does open communication in the healthcare team contribute to patient safety, and what role does feedback play in this dynamic?
- Consider the role of feedback in incident reporting. How does feedback, or the lack of it, affect your willingness to report incidents, and how can this process be optimised?
- In light of the research gaps identified in the article, what specific aspects of incident reporting in midwifery do you believe should be prioritised for future study to enhance clinical practice?