Learning or blaming? Understanding Nursing Students’ Barriers to Reporting Medication Errors: A Qualitative Study

Learning or blaming? Understanding Nursing Students’ Barriers to Reporting Medication Errors: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Learning or blaming? Understanding Nursing Students’ Barriers to Reporting Medication Errors: A Qualitative Study Yael Sela, Inbal Halevi Hochwald, Rachel Nissanholtz-Gannot, Keren Grinberg This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8892299/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: While the 'Just Culture' approach promotes reporting medical errors as a learning opportunity rather than punishment, studies indicate a gap between recognizing the importance of reporting and actual implementation. This study examined the barriers and facilitators to error reporting among nursing students. Methods: Using a descriptive-naturalistic approach nursing students who had reported experiencing a medication error or near-error during their clinical placements were interviewed and the data analysis was conducted using a thematic approach. Results: All participants experienced errors or near-errors, mostly during medication preparation and administration. Fears of negative impacts on grades or professional reputation, and concern about negative responses from instructors or peers, led some students to downplay events or avoid reporting. When instructors were empathetic, the atmosphere supportive, and dialogue encouraged, students were more likely to report incidents and view reporting as a means of professional growth and ethical responsibility. Conclusion: Nursing students report that errors are common. Avoiding reporting often reflects tension between formal expectations and informal norms, emotional discomfort, and organizational culture, rather than lack of responsibility. Future strategies should simplify reporting procedures, provide timely feedback, train instructors to foster empathy, and create safe spaces for discussing mistakes to strengthen a culture of reporting. Medication errors Error reporting Nursing students Patient safety culture psychological safety Introduction Quality assurance of medical care and patient safety have become central values ​​in health systems around the world (Mistri et al., 2023 ). Globally, one in 20 patients in health services is harmed by a preventable adverse event, and 12 percent of those incidents lead to serious illness or death. About half of these events are related to medication errors or procedural errors, which could be reduced through effective reporting and learning systems (Panagioti et al., 2019 ). Accordingly, the ‘Just Culture’ approach in nursing education emphasizes that open reporting of errors should be seen as part of a learning and systemic reflection process rather than as a means of assigning blame (Glarcher & Vaismoradi, 2025 ). According to this approach, the organizational emphasis shifts from the question “Who is to blame?” to the question “What caused the failure and how can it be prevented from happening again?”; this change allows organizations to become “learning organizations” and strengthen patient safety (Boysen, 2013 ; Robichaux & Vittone, 2023 ). However, staff members are expected to proactively report errors as part of a learning and improvement process, while also taking responsibility for their role in the incident (Alashram et al., 2024 ). Effective management plays a crucial role in fostering a culture of safety and collaboration, aiming to minimize harm to both patients (Hodkinson et al., 2020 ) and caregivers (Cohen et al., 2023 ). For nursing students, internalizing the principles of a 'Just Culture' is essential for shifting from a punitive to a constructive approach, where reporting errors leads to overall systemic improvement (Glarcher & Vaismoradi, 2025 ). Nursing students constitute a unique population at the crossroads of acquiring theoretical knowledge and applying it in the clinical sphere. This period is characterized by overload, pressure, and a high dependence on clinical instructors, factors that increase potential for errors (Kiernan, 2018 ). Studies show that approximately 28%–30% of students have experienced medication errors during training (Asensi-Vicente et al., 2018 ), and that the most common types of errors are dosage calculation mistakes, misidentifying a patient, administration of the wrong medication, or failure to administer a prescribed medication (Stolic et al., 2022 ; Secginli et al., 2021 ). There is a consistent gap between recognizing the importance of reporting and actually reporting the adverse event. In a recent study of nursing students, 97.5% of participants believed that errors should be reported, yet only 11.1% did so during clinical training (Alrasheeday et al., 2025 ). This gap may be explained by a combination of emotional and organizational barriers, primarily fear of unexpected negative consequences, such as punishment or damage to professional rating and reputation, as well as fear of harming the relationships with clinical supervisors and colleagues (Glarcher & Vaismoradi, 2025 ). Additionally, many students reported feeling useless due to the lack of feedback after reporting, a feeling documented in previous reviews of error reporting in clinical settings (Braiki et al., 2024 ). Beyond the emotional aspect, there is a cognitive barrier stemming from a lack of clarity about what constitutes an “error” and what requires reporting. Studies indicate that students have difficulty distinguishing between “significant” errors and “minor deviations” and sometimes perceive minor errors as opportunities for self-correction rather than as reasons for reporting (Jones et al., 2022 ; Stolic et al., 2022 ). This lack of standardization leads to subjective interpretation and increases avoidance of reporting. meanwhile, recent research highlights that adopting 'Just Culture' principles in training, which emphasize learning, reflection, and process improvement rather than blame, helps build confidence, reduces fears, and encourages students to report errors more often (Glarcher & Vaismoradi, 2025 ; Boysen, 2013 ). Most existing studies focus on measuring reporting rates or identifying general barriers, but do not delve deeply into the social and emotional factors that influence actual reporting behavior (Alrasheeday et al., 2025 ; Hodkinson et al., 2020 ). In recent years, efforts have been made to foster an educational and clinical environment based on the principles of a “non-punitive culture” and reporting for learning, following the 'Just Culture' model (Glarcher & Vaismoradi, 2025 ), but a gap still exists between the theoretical principles and their practical application in the clinical setting. It is also unclear how nursing students perceive these initiatives in terms of their significance and how they influence their sense of security and willingness to report. Therefore, this study aims to explore the factors that facilitate or hinder the reporting of treatment errors among nursing students in Israel nearing the end of their clinical training, based on their personal experiences. Methods This qualitative study applied the naturalistic descriptive approach (firsthand reported life experience) (Polit & Beck, 2020 ), using semi-structured interviews guided by a protocol. Participants Participants were recruited through a call for volunteers on social media platforms and agreed to participate in interviews. All respondents were in their final year of a Bachelor's in Nursing program at various academic institutions in Israel, and all had completed clinical rotations during that year. Procedure Data was collected from March to June 2025 through semi-structured in-depth interviews, conducted either face-to-face or online. Nursing students were recruited via social media channels where information about the study and eligibility criteria were disseminated. Interested students who had experienced medication errors or near-errors )”near miss”) during clinical practice contacted the research team to participate. After receiving an explanation and signing an informed consent form, a total of 22 nursing students were interviewed for this study. The interview guide was developed based on a preliminary literature review (Afaya et al., 2021 ; Glarcher & Vaismoradi, 2025 ) and consulting with experts in the field. The guide included sociodemographic questions (such as age, religious affiliation, gender, and religion) and open-ended questions related to the research topic. These included questions like: "Tell me about a case in which you experienced or saw a clinical error during your experience, what led you to report or not report the case? and How did you feel following the event and during the process of dealing with it?" The interviews lasted between 35 and 60 minutes, were recorded, and transcribed with the participants’ permission. Data Analysis Data collection continued until thematic saturation was reached, meaning no new categories or themes emerged (Hsieh & Shannon, 2005 ). The analysis of the interviews was based on Braun & Clarke ( 2006 ) thematic approach, which involved rereading the transcripts, initial coding by each researcher separately, grouping codes into categories and potential themes, checking these against the original data, defining and refining the themes, and finally writing up the results with selected quotes. To ensure the credibility of the findings, several methodological steps were taken: double coding some interviews by two researchers, team discussions to refine interpretations, incorporating direct quotes from participants (thick description), and systematically documenting the analysis process (DiCicco-Bloom & Crabtree, 2006 ). Results The study included 22 nursing students. The average age was 25 years (range: 21–31). Most of the participants were women, Jewish, with an internal diversity within the group, consisting of religious, traditional, and ultra-Orthodox. In addition, Arab, Muslim, and Christian students also participated (Table 1 ). Most of the errors described occurred during medication preparation and dispensing. These included incorrect dosages, confusion between similar names, late administration, documentation mistakes, skipping steps in the dispensing process, or omitting critical information when submitting a shift report. The range of errors varied from events that could potentially cause actual harm to the patient to incidents that appeared "minor" or unimportant to the students. However, an initial reaction of shock, embarrassment, and sometimes a feeling of stagnation was almost always described. Table 1 Select sociodemographic variables of participants (N = 22) Variable Value Average age 25 (21–31) Gender Men 7 Women 15 Ethnic affiliation Jewish 15 Muslim Arab 4 Christian Arab 3 Level of religiosity Secular 6 Religious 7 Traditional 7 Ultra-Orthodox (Jewish) 2 Course of study Bachelor's degree (BSN) 16 Second degree (career change) 6 Two main themes emerged from the interviews: 1) The cost of admitting a mistake: this theme captures the inner struggle of students who, when facing an error, experience a sense of shame and fear of exposure-an emotional “price” that often drives them to minimize or dismiss the incident; 2) Error as a learning opportunity: the student's perception that the mistake was an opportunity for development, especially when the clinical environment is supportive and non-punitive, and encourages the perception that taking responsibility for the mistake is part of a nurse's professional and ethical development (Table 2 ). Table 2 Overview of Themes and Subthemes Theme Category / Subtheme Description Illustrative Quote Theme 1: The cost of admitting a mistake Fear of academic and professional consequences Students feared that reporting would harm grades, evaluations, or future employment opportunities “At the end of the fourth year, every grade counts. If I open it, I’m digging a hole for myself.” (Participant 16) Shame and threat to professional identity Errors were experienced as personal failure and a stain on self-image “It felt like a stain that wouldn’t come off.” (Participant 11) Concealment and minimization Students tended to hide or downplay errors, especially when no harm occurred “If it was something small, I didn’t see the need [to report].” (Participant 5) Internal filtering of what counts as an ‘error’ Students distinguished between “serious” and “minor” errors and reported only the former “I do an internal review. Is it worth reporting or not?” (Participant 15) Normalization of ‘quiet correction’ Errors were often corrected informally without documentation, following staff norms “The nurses around me didn’t always report either; they corrected it on the spot.” (Participant 8) Lack of feedback and perceived futility Reporting was experienced as meaningless due to lack of response or learning “It just disappears from the system… like filling out a form for statistics.” Theme 2: Error reporting as a learning facilitator Supportive and empathetic instructor Instructor’s reaction shaped students’ willingness to report “She always asks ‘What did you learn?’ rather than ‘Why did you do it?’” (Participant 14) Psychological safety in the clinical environment Open, non-judgmental atmosphere enabled sharing and learning “When we talked about mistakes without blaming, I felt okay to talk about mine.” (Participant 6) Role modeling and team culture Observing respectful responses to others’ mistakes reduced fear “When I saw how she treated other students, I wasn’t afraid to tell.” Ethical responsibility to the patient Some students reported despite fear, driven by moral commitment “The patient comes first. That was stronger than any fear.” (Participant 18) Reframing error as part of professional growth Errors were seen as part of learning and professional development “Mistakes happen. What’s important is to learn from them.” (Participant 9) Theme 1: The Cost of Admitting a Mistake Almost all students described unpleasant feelings (fear, shame) surrounding a mistake or near-mistake, and fear of the price they would have to pay in dealing with the consequences. These feelings led to concealment or minimizing the mistake. Most participants described a conflict between the desire to report professionally and the fear of personal consequences. The main concerns raised were the risk of damaging their grade, harming evaluations by the instructor or staff, and potentially affecting their professional image before entering the workforce. This fear was especially heightened as they approached graduation and were candidates to join the departments. I knew I was wrong, but all I could think about was what would she say now? How would it look in my final evaluation? So I just kept quiet (Participant 7). I felt that if I told, it would be used against me, not for me (Participant 21). Students described the ability to hide a mistake when it had no clinical significance for the patient. They weighed the risks of disclosure against the benefits, often choosing concealment to avoid personal and professional repercussions. This hesitation was emotionally difficult: If I tell, it's as if I'm putting a label of 'incompetent/unprofessional student' on my forehead (Participant 19). At the end of the fourth year, every grade counts. If I open it [reporting the event], I'm digging a hole for myself (Participant 16). This hesitation was emotionally challenging. Several students emphasized that the experience of making a mistake “undermines confidence from within,” and that this feeling can last long after the event: It’s not just the instructor. I did not want to admit that I was wrong either, because I always saw myself as someone who had mastered the material (Participant 3). I always strive for excellence, so when it happened – it felt like a stain that wouldn’t come off (Participant 11). Even after weeks had passed, this thought returned, that maybe I wasn't suited for this profession (Participant 8). Shame also extended to interactions with staff. Some students described environments focused on blame rather than learning, where even minor mistakes were publicly exposed and used to label students as failures. After the incident, participants described feeling intense anxiety and scrutiny in their clinical work. One participant explained that, “ I was already afraid to touch a syringe. I felt that my every step was being examined and that every minor mistake would define me as a failure in front of the department." Others reflected on the consequences of reporting, noting, being exposed in front of the group or everyone in the department knowing about the incident. Collectively, these accounts illustrate a shared sense of intimidation and reluctance to report errors, reinforcing how the clinical environment amplified participants’ feelings of vulnerability and exposure. These experiences led students to avoid reporting, even when they recognized the potential value for learning and systemic improvement: In the end, you learn that it is better to remain silent. It feels safer, even if it is not professionally correct." (Participant 15) Students described an internal filtering process to assess the severity of errors. Those perceived as potentially harmful to patients were more likely to be reported, while minor deviations were often dismissed. Some participants noted that seemingly minor errors could have served as an important source of their learning or systemic improvement, but at the time of the event, they preferred not to share and disclose. If it was something that could harm the patient, I reported it. If it was something small, like a delay in administering medication, I did not see the need. (Participant 5) I do an internal review. Is it worth reporting or not? Not everything justifies a report form. (Participant 15) In the end, it is a matter of proportion; not every small mistake should become a big story. We also learn on the go. (Participant 12) Students commonly expressed that addressing minor errors immediately was preferable to engaging in formal reporting procedures. They described "correcting mistakes on the spot", often believing that this approach was sufficient to "avoid unnecessary hassle". Many felt that formally reporting every minor issue was burdensome and could escalate situations unnecessarily, leading them to prioritize immediate correction over official documentation. Some students observed that nurses around them also avoided reporting minor errors, reinforcing this behavior: The nurses around me didn’t always report either; they corrected it on the spot. So, I felt that I was okay, and not something unusual.” (Participant 8) Finally, some students felt that the professional environment did not take error reporting seriously. Lack of feedback and follow-up discouraged future reporting, expressing frustration that even when reported, "it [the event] just disappeared from the system", and it felt like "filling out a form so someone has statistics" and that it did "not really to change anything". Theme 2: Error Reporting as a Learning Facilitator Throughout the interviews, it also emerged that it is possible to learn and grow from mistakes. The interviewees noted that they had learned risk management and error-reporting theories and models over the years. The classroom approach emphasized learning and reflection rather than punishment. However, their clinical experience was described as significantly different from the classroom environment. The number of interview excerpts describing error reporting as a positive, supportive, educational, and developmental experience was very small (n = 3), compared with the majority of participants (n = 19) who described it as a difficult, embarrassing, and frightening experience that was both widespread and common. The analysis revealed that the presence of an empathetic, open, and non-judgmental clinical instructor was a key factor in students’ willingness to report mistakes. Support, reinforcement, and a positive message that encouraged acknowledging one's mistakes created an environment where errors were seen as a natural part of learning. This allowed students to feel more confident sharing, even in sensitive situations. Furthermore, participants emphasized that not only their personal experience but also the way the instructor treated other students' mistakes extensively influenced their perceptions. When students saw that the instructor responded to their classmates with respect and patience, without blame, this strengthened trust and reduced fear of future reporting. My instructor explicitly said: ‘Mistakes happen, what is important is to learn from them.’ This gave me the courage to come forward and tell. (Participant 9) She (the clinical instructor) always asks ‘What did you learn from this?’ rather than ‘Why did you do it?’ This difference changed my whole approach. (Participant 14) Students noted that in all clinical rotation sites (departments and clinics), there was a clear formal message that errors should be reported. However, they emphasized that the significant difference lay not in official statements but in the informal atmosphere and daily behavior of the staff. In places where open and informal conversations about errors occurred, a sense of psychological safety was created, enabling students to discuss personal cases. In such environments, errors were transformed from threatening events into opportunities for shared learning: When we would sit with the team and talk about all of our mistakes, without pointing fingers at anyone, I felt it was okay to talk about mine too. (Participant 6). The atmosphere in the department gave the feeling that we were all here to improve, not to find fault (Participant 13). Some participants emphasized that the primary motivation for reporting was ethical and moral, a sense of responsibility to maintain the patient’s safety. For these students, ethical obligation outweighed fear of reactions from instructors or peers. Their professional identity and led them to view reporting not only as a technical requirement but also as a moral act aimed at preventing future errors: I felt that if I did not report, I was leaving the patient at risk – and this was stronger than any fear. (Participant 18) I felt that I had to put my ego aside and understand that the patient comes first. (Participant 1) Overall, students’ experiences suggest that while formal policies mandated error reporting across all clinical sites, the real determinant of reporting behavior was the informal culture and daily interactions within each environment. Supportive teams that fostered open, nonjudgmental discussions created psychological safety, allowing students to learn from mistakes rather than fear them. Although ethical and moral considerations also played a central role, and students wanted to prioritize patient safety over personal apprehension, some participants were able to overcome the apprehension of possible negative consequences, while others were not. Together, these findings highlight that effective error reporting depends not only on official procedures but also on cultivating a culture of trust, shared learning, and ethical commitment. Discussion These results indicate a wide gap between nursing students' values ​​regarding the importance of reporting errors in healthcare and actual behavior. Although all participants had experienced an error or near-error during their clinical experience, only a minority had reported it openly. This gap, between "knowing that they should report" and "daring to report," is a classic expression of the tension between a culture of punishment, fear of punishment or harm to professional dignity, and a culture of learning (Just Culture) described in the international literature (Boysen, 2013 ; Glarcher & Vaismoradi, 2025 ). The study findings highlight that constitute a significant barrier to reporting. These findings of feeling fear, shame, and concern over adverse reactions from instructors or staff are consistent with previous studies that have shown that fear of academic or disciplinary consequences, as well as personal perceptions and stigmas, reduce the willingness to admit an error (Afaya et al., 2021 ). Shame has been described as a complex emotional experience that undermines students' sense of self-efficacy and impedes the transition from viewing an error as a personal failure to seeing it as an integral part of a professional learning process. In this sense, students are more inclined to see a medical error as a personal, rather than a system, failure, similar to findings among both nurses and physicians (Cohen et al., 2023 ). The experience of publicly exposing an error, sometimes in front of instructors and other students, evoked a sense of ongoing “failure.” This sense of stigma is also described in the literature as a factor leading to avoidance of participation in systemic learning processes (Bugalia et al., 2021 ). This perception leads to reduced reporting and hinders the development of a reporting culture, which should be promoted. Students are in a phase of professional socialization in which professional identity is in the process of formation (Vabo et al., 2021 ). During this period, students depend heavily on clinical instructors and are looking for validation and guidance (Honkavuo, 2020 ), which intensifies the fear of negative consequences for reporting errors. The fear of negative repercussions on the relationship with the instructor or on one's professional reputation was perceived as one of the main barriers to reporting both in this study and in the other research (Afaya et al., 2021 ; Alanazi et al., 2022 ). At the same time, the findings highlight a gap between the formal definitions of “error” taught in the classroom in contrast to the subjective practice in the clinical field. In practice, students used an internal filtering system: errors seen as potentially harmful were reported, while deviations perceived as “minor” stayed outside the reporting channels. This situation, which has also been documented in other studies (Jones et al., 2022 ; Woo & Avery, 2021 ), may lead to missed opportunities both for the students themselves, by not receiving feedback on their errors, and for the system, which cannot educate or identify repeated failures to implement control and correction measures. Several participants even admitted that errors they considered negligible in real time could have been a valuable source of organizational improvement. However, they preferred to take a passive, avoidant stance. Another finding that emerged was the decision to “quietly correct,” without causing a stir, rather than report. This was due to the student's desire to avoid dealing with the results, as well as to informal behavioral norms among clinical teams. Some teams preferred to keep quiet about an error and make a correction without reporting, as long as no visible damage was caused. These norms permeated students' behavior and shaped their patterns. This phenomenon reinforces the understanding that the informal culture in the department, and not only the formal procedures, influences and shapes reporting patterns (Dionisi et al., 2020 ; Stolic et al., 2022 ). Accordingly, formal statements about the importance of reporting are insufficient, and senior staff's modeling behavior must influence field teams' practical behavior (Bugalia et al., 2021 ). In addition to practical considerations, the emotional dimension was found to be a significant barrier. Feelings of shame and damage to self-image accompanied the experience of the error, which was perceived not only as proof of professional failure but also as a threat to personal identity and a sense of competence. These feelings, documented in other studies (Heydarikhayat et al., 2024 ; Hoffmann et al., 2022 ), deepened the desire to avoid reporting and led to actual avoidance. At the organizational level, two key barriers stood out: lack of feedback and a culture of blame. Students reported that, even when they chose to report, they did not receive a response or guidance, which created a sense of purposelessness and reduced their motivation to report in the future. This finding is consistent with previous studies that indicated that a lack of feedback is a significant factor in weakening the willingness to report (Afaya et al., 2021 ; Munn et al., 2023 ). At the same time, some students described a culture of blame in which mistakes were publicly exposed, the subject of gossip, or harshly criticized by instructors. These experiences created a discouraging climate in which reporting was perceived as a personal risk rather than an opportunity for professional improvement, consistent with the literature highlighting the negative impact of a punitive culture on willingness to report (Rusdi et al., 2024 ; Woo & Avery, 2021 ; Yang et al., 2025 ). However, the findings also revealed conditions that promote reporting. Empathetic, nonjudgmental instructors provided students with a sense of security, allowing them to share even in sensitive situations. These experiences align with the literature on psychological safety (Edmondson, 2018 ) and with studies showing that instructors who serve as positive role models for reporting increase students’ willingness to report (Chegini et al., 2020 ; Glarcher & Vaismoradi, 2025 ; Silvestre & Spector, 2023 ). Additionally, the informal atmosphere in the departments, where open discussions about errors took place, contributed to making reporting a tool for shared learning rather than a focus on blame (Yang et al., 2025 ). Furthermore, a sense of ethical responsibility towards the patient was found to be a strong motivator that sometimes outweighed personal concerns, indicating the internalization of a professional ethos that aligns with theoretical frameworks of planned behavior (Secginli et al., 2021 ). Some students described deep internal motivation as a driving force for reporting, despite fears. This approach is consistent with models of professional ethics in nursing that prioritize the patient's well-being over personal comfort (Barkhordari-Sharifabad & Mirjalili, 2020 ). Strengthening this value perception may serve as an important lever for promoting a non-punitive reporting culture, but systemic support is required to ensure that reporting indeed translates into learning and not punishment. Limitations This study may be subject to selection bias due to voluntary participation, potentially leading to underrepresentation of specific student populations. Efforts were made to include students from diverse sociodemographic backgrounds to enhance representativeness. Although participants came from various cultural and ethnic groups, the analysis did not systematically examine how these variables intersect with reporting behaviors. Additionally, all data were self-reported, which may have introduced social desirability bias- some participants might have withheld difficult experiences or portrayed themselves more favorably despite assurances of anonymity. Interviews were conducted near the end of clinical training, a period marked by stress and heightened evaluation, which could have influenced participants’ reflections and framing of their experiences. Finally, the study reflects only students’ perspectives, without input from clinical instructors or nursing staff, thereby limiting understanding of the broader dynamics surrounding error reporting. Conclusions and future recommendations The study demonstrates that nursing students’ reluctance to report errors does not stem from irresponsibility or lack of awareness, but from navigating tensions between formal expectations and informal norms, professional responsibility and personal emotions, and academic standards versus clinical culture. Students’ professional identities are still forming, and their dependence on instructors and visibility in clinical settings heightens sensitivity to errors. Informal norms such as 'quiet correction' and blame culture significantly shape reporting behaviors, often more than formal guidelines. Conversely, a supportive environment characterized by empathy, constructive feedback, and ethical encouragement may facilitate meaningful reporting and transforms errors into opportunities for learning. To foster a culture of safe and constructive error reporting, it is essential to create informal spaces for open dialogue, simplify reporting procedures, promote ethical responsibility towards patients, and model positive reporting behaviors among staff and instructors. These measures can help reframe error reporting as a professional and educational tool rather than a personal failure, ultimately enhancing patient safety and systemic learning. Declarations Funding This research did not receive funding. Human Ethics and Consent to Participate declarations This study was reviewed and approved by the Institutional Review Board (IRB) for Non-Clinical Research Involving Human Participants at Ariel University (Approval No: AU-HEA-RNG-0122). All procedures were conducted in accordance with institutional ethical standards and the principles of the Declaration of Helsinki. Given the sensitive nature of reporting clinical errors, particular attention was paid to protecting participants’ confidentiality and anonymity. Eligible participants received detailed written and verbal information regarding the study aims and procedures, and written informed consent was obtained prior to participation, including consent for audio recording of the interviews. All identifying details were removed from transcripts, and any potentially identifiable information was omitted without compromising the integrity of the research. Confidentiality was maintained throughout all stages of data collection, analysis, and reporting, in line with established qualitative research guidelines for sensitive topics (Assarroudi et al., 2018; Kaiser, 2009). Consent to Publish declaration not applicable Competing interests The authors declare no competing interests. Authors’ Contribution All authors contributed to the conception and design of the study. Y.S. and R.N.G. developed the methodology and conducted the formal analysis. Y.S. and K.G. drafted the initial manuscript. K.G. led project administration and contributed to participant coordination. I.H.H. assisted with conducting the interviews and coordinating with participants, transcribed the interview data, contributed to methodology and formal analysis, and prepared the tables. All authors reviewed and approved the final manuscript Data availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. References Afaya A, Essandoh AF, Yakong VN, Afaya RA, Amankwaa I. Barriers to reporting medication errors among nursing students: An integrative review. J Nurs Adm Manag. 2021;29(5):1243–53. https://doi.org/10.1111/jonm.13282 . Alanazi FK, Sim J, Lapkin S. Systematic review: Nurses' safety attitudes and their impact on patient outcomes in acute-care hospitals. Nurs Open. 2022;9(1):30–43. https://doi:10.1002/nop2.1063 . Alashram WM, Elseesy NAM, Gheith NADS, Ghonaim HM, Sindi NA, Elwan HM, Hazazi RA, AlFaidi WA, AlHawsawi ED. The unreported truth: Unveiling barriers to medication error reporting among nurses in Saudi Arabia. Rev Diabet Stud. 2024;276–87. https://doi.org/10.70082/94n21406 . Alrasheeday AM, Alkubati SA, Alqalah TAH, Alrubaiee GG, Alshammari B, Almazan JU, Abdullah SO, Loutfy A. Nursing students' perceptions of patient safety culture and barriers to reporting medication errors: A cross-sectional study. Nurse Educ Today. 2025;146:106539. https://doi.org/10.1016/j.nedt.2024.106539 . Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno MF. (2018). Medication errors involving nursing students: A systematic review. Nurse Educator ; 43 : E1-E5. https://doi.org/10.1097/NNE.0000000000000481 Assarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: The description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42–55. https://doi.org/10.1177/1744987117741667 . Barkhordari-Sharifabad M, Mirjalili NS. Ethical leadership, nursing error and error reporting from the nurses’ perspective. Nurs Ethics. 2020;27(2):609–20. https://doi.org/10.1177/096973301985870 . Boysen PG. Just culture: a foundation for balanced accountability and patient safety. Ochsner J. 2013;13(3):400–6. Braiki R, Douville F, Gagnon MP. Factors influencing the reporting of medication errors and near misses among nurses: A systematic mixed methods review. Int J Nurs Pract. 2024;30(6):e13299. https://doi.org/10.1111/ijn.13299 . Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa . Bugalia N, Maemura Y, Ozawa K. A system dynamics model for near-miss reporting in complex systems. Saf Sci. 2021;142:105368. https://doi.org/10.1016/j.ssci.2021.105368 . Chegini Z, Kakemam E, Asghari Jafarabadi M, Janati A. The impact of patient safety culture and the leader coaching behaviour of nurses on the intention to report errors: a cross-sectional survey. BMC Nurs. 2020;19(1):89. https://doi.org/10.1186/s12912-020-00472-4 . Cohen R, Sela Y, Nissanholtz-Gannot R. Addressing the second victim phenomenon in Israeli health care institutions. Isr J Health Policy Res. 2023;12(1):30. https://doi.org/10.1186/s13584-023-00578-5 . DiCicco-Bloom B, Crabtree BF. Making sense of qualitative research. Med Educ. 2006;40(4):314–21. Dionisi S, Di Simone E, Franzoso V, Caldarola E, Cappadona R, Di Muzio F, Giannetta N, Di Muzio M. The application of the Theory of Planned Behaviour to prevent medication errors: a scoping review. Acta Bio Medica: Atenei Parmensis. 2020;91(Suppl 6):28. https://doi/10.23750/abm.v91i6-S.9290 . Edmondson A. The Fearless Organization: Creating Psychological Safety in the Workplace. Wiley & Sons; 2018. Glarcher M, Vaismoradi M. Promoting just culture in nursing education: A systematic integrative review on enhancing patient safety. Nurse Educ Today. 2025;106776. https://doi.org/10.1016/j.nedt.2025.106776 . Heydarikhayat N, Ghanbarzehi N, Sabagh K. (2024). Strategies to prevent medical errors by nursing interns: A mixed-methods study. BMC Nursing , 23 (48), 2024. https://doi.org/10.1186/s12912-024-01726-1 Hodkinson A, Tyler N, Ashcroft DM, Keers RN, Khan K, Phipps D, Abuzour A, Bower P, Avery A, Campbell S, Panagioti M. Preventable medication harm across health care settings: A systematic review and meta-analysis. BMC Med. 2020;18(1):313. https://doi.org/10.1186/s12916-020-01774-9 . Hoffmann M, Schwarz CM, Schwappach D, Banfi C, Palli C, Sendlhofer G. Speaking up about patient safety concerns: View of nursing students. BMC Health Serv Res. 2022;22(1):1547. Honkavuo L. Nursing students’ perspective on a caring relationship in clinical supervision. Nurs Ethics. 2020;27(5):1225–37. 10.1177/0969733019871695 . Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88. Jones JR, Boltz M, Allen R, Van Haitsma K, Leslie D. Nursing students’ risk perceptions related to medication administration error: A qualitative study. Nurse Educ Pract. 2022;58:103274. https://doi.org/10.1016/j.nepr.2021.103274 . Kaiser K. Protecting respondent confidentiality in qualitative research. Qual Health Res. 2009;19(11):1632–41. https://doi.org/10.1177/1049732309350879 . Kiernan LC. Evaluating competence and confidence using simulation technology. Nursing. 2018;48(10):45–52. https://doi/10.1097/01.NURSE.0000545022.36908.f3 . Mistri IU, Badge A, Shahu S. Enhancing patient safety culture in hospitals. Cureus. 2023;15(12). https://doi.org/10.7759/cureus.51159 . Munn LT, Lynn MR, Knafl GJ, Willis TS, Jones CB. A study of error reporting by nurses: the significant impact of nursing team dynamics. J Res nursing: JRN. 2023;28(5):354–64. https://doi.org/10.1177/17449871231194180 . Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, Bower P, Campbell S, Haneef R, Avery AJ, Ashcroft DM. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019;366:l4185. https://doi.org/10.1136/bmj.l4185 . Polit D, Beck C. Essentials of nursing research: Appraising evidence for nursing practice. 9th ed. Lippincott Williams & Wilkins; 2020. Robichaux C, Vittone S. Ethics: Addressing error: Partnership in a Just Culture. OJIN: Online J Issues Nurs. 2023;28(2). https://doi.org/10.3912/OJIN.Vol28No02EthCol01 . Rusdi R, Said FM, Umar NS. The effect of empowerment to improve patient safety culture among hospital nurses. Int J Public Health. 2024;13(4):1903–11. https://doi.org/10.11591/ijphs.v13i4.24418 . Secginli S, Nahcivan NO, Bahar Z, Fernandez R, Lapkin S. Nursing students' intention to report medication errors: Application of theory of planned behavior. Nurse Educ. 2021;46(6):E169–72. https://doi.org/10.1097/NNE.0000000000001105 . Silvestre J, Spector N. Nursing student errors and near misses: Three years of data. J Nurs Educ. 2023;62(1):12–9. Stolic S, Ng L, Southern J, Sheridan G. Medication errors by nursing students on clinical practice: An integrative review. Nurse Educ Today. 2022;112:105325. https://doi.org/10.1016/j.nedt.2022.105325 . Vabo G, Slettebø Å, Fossum M. Nursing students’ professional identity development: An integrative review. Nordic J Nurs Res. 2021;42(2):62–75. https://doi:10.1177/20571585211029857 . Woo MW, Avery MJ. Nurses’ experiences in voluntary error reporting: An integrative literature review. Int J Nurs Sci. 2021;8(4):453–69. https://doi:10.1016/j.ijnss.2021.07.004 . Yang L, Peng X, Song W, Su H, Wang C, Yang S, Wu D. The barriers to medication error reporting by nurses and factors associated with it: a cross-sectional study in a tertiary hospital of south-west China. BMJ open. 2025;15(4):e091058. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8892299","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603100972,"identity":"611a4c9f-9c8e-4429-843b-3198dccfae4b","order_by":0,"name":"Yael Sela","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYHACxgMMFWC6AcxlYydCzwGGM8hamInRwtiGzCWkxeD44QMHf867l7hdurntAUONHQMfQS1n0hIO824rTtw552C7AcOxZMIOMziQY3CYcVtC4oYbiW0SDGwHiNBy/v2Hgz/nwLT8I0bLjRyGA7wNUC2MbURokbzxzOAwz7EEY6Bf2iQS+5J5CGrhO5/88OGPmgTZ7dLtzyQ+fLOTk29vwK9F4QDMhRJAIoGBgYeAHQwM8jAjwVpGwSgYBaNgFGADACTyRQohY7m9AAAAAElFTkSuQmCC","orcid":"","institution":"Ruppin Academic Center","correspondingAuthor":true,"prefix":"","firstName":"Yael","middleName":"","lastName":"Sela","suffix":""},{"id":603100973,"identity":"d5fbe3c4-59a5-4950-938e-e4d079158ddb","order_by":1,"name":"Inbal Halevi Hochwald","email":"","orcid":"","institution":"Max Stern Academic College of Emek Yezreel","correspondingAuthor":false,"prefix":"","firstName":"Inbal","middleName":"Halevi","lastName":"Hochwald","suffix":""},{"id":603100975,"identity":"6bec1cab-a158-4720-a70e-f7bdd1989aff","order_by":2,"name":"Rachel Nissanholtz-Gannot","email":"","orcid":"","institution":"Ariel University","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Nissanholtz-Gannot","suffix":""},{"id":603100976,"identity":"9b4adc5f-8387-4a77-aae0-aaffdafc8559","order_by":3,"name":"Keren Grinberg","email":"","orcid":"","institution":"Ruppin Academic Center","correspondingAuthor":false,"prefix":"","firstName":"Keren","middleName":"","lastName":"Grinberg","suffix":""}],"badges":[],"createdAt":"2026-02-16 10:38:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8892299/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8892299/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105292199,"identity":"d0f3f920-b49d-4a3e-850e-37fcd2f8d5ea","added_by":"auto","created_at":"2026-03-24 12:28:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":601700,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8892299/v1/79fc3b81-f404-4e3c-92b8-3707699d4fa2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Learning or blaming? Understanding Nursing Students’ Barriers to Reporting Medication Errors: A Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eQuality assurance of medical care and patient safety have become central values ​​in health systems around the world (Mistri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Globally, one in 20 patients in health services is harmed by a preventable adverse event, and 12 percent of those incidents lead to serious illness or death. About half of these events are related to medication errors or procedural errors, which could be reduced through effective reporting and learning systems (Panagioti et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccordingly, the \u0026lsquo;Just Culture\u0026rsquo; approach in nursing education emphasizes that open reporting of errors should be seen as part of a learning and systemic reflection process rather than as a means of assigning blame (Glarcher \u0026amp; Vaismoradi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). According to this approach, the organizational emphasis shifts from the question \u0026ldquo;Who is to blame?\u0026rdquo; to the question \u0026ldquo;What caused the failure and how can it be prevented from happening again?\u0026rdquo;; this change allows organizations to become \u0026ldquo;learning organizations\u0026rdquo; and strengthen patient safety (Boysen, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Robichaux \u0026amp; Vittone, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, staff members are expected to proactively report errors as part of a learning and improvement process, while also taking responsibility for their role in the incident (Alashram et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Effective management plays a crucial role in fostering a culture of safety and collaboration, aiming to minimize harm to both patients (Hodkinson et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and caregivers (Cohen et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor nursing students, internalizing the principles of a 'Just Culture' is essential for shifting from a punitive to a constructive approach, where reporting errors leads to overall systemic improvement (Glarcher \u0026amp; Vaismoradi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Nursing students constitute a unique population at the crossroads of acquiring theoretical knowledge and applying it in the clinical sphere. This period is characterized by overload, pressure, and a high dependence on clinical instructors, factors that increase potential for errors (Kiernan, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Studies show that approximately 28%\u0026ndash;30% of students have experienced medication errors during training (Asensi-Vicente et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), and that the most common types of errors are dosage calculation mistakes, misidentifying a patient, administration of the wrong medication, or failure to administer a prescribed medication (Stolic et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Secginli et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is a consistent gap between recognizing the importance of reporting and actually reporting the adverse event. In a recent study of nursing students, 97.5% of participants believed that errors should be reported, yet only 11.1% did so during clinical training (Alrasheeday et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). This gap may be explained by a combination of emotional and organizational barriers, primarily fear of unexpected negative consequences, such as punishment or damage to professional rating and reputation, as well as fear of harming the relationships with clinical supervisors and colleagues (Glarcher \u0026amp; Vaismoradi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Additionally, many students reported feeling useless due to the lack of feedback after reporting, a feeling documented in previous reviews of error reporting in clinical settings (Braiki et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBeyond the emotional aspect, there is a cognitive barrier stemming from a lack of clarity about what constitutes an \u0026ldquo;error\u0026rdquo; and what requires reporting. Studies indicate that students have difficulty distinguishing between \u0026ldquo;significant\u0026rdquo; errors and \u0026ldquo;minor deviations\u0026rdquo; and sometimes perceive minor errors as opportunities for self-correction rather than as reasons for reporting (Jones et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Stolic et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This lack of standardization leads to subjective interpretation and increases avoidance of reporting. meanwhile, recent research highlights that adopting 'Just Culture' principles in training, which emphasize learning, reflection, and process improvement rather than blame, helps build confidence, reduces fears, and encourages students to report errors more often (Glarcher \u0026amp; Vaismoradi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Boysen, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost existing studies focus on measuring reporting rates or identifying general barriers, but do not delve deeply into the social and emotional factors that influence actual reporting behavior (Alrasheeday et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Hodkinson et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In recent years, efforts have been made to foster an educational and clinical environment based on the principles of a \u0026ldquo;non-punitive culture\u0026rdquo; and reporting for learning, following the 'Just Culture' model (Glarcher \u0026amp; Vaismoradi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), but a gap still exists between the theoretical principles and their practical application in the clinical setting. It is also unclear how nursing students perceive these initiatives in terms of their significance and how they influence their sense of security and willingness to report. Therefore, this study aims to explore the factors that facilitate or hinder the reporting of treatment errors among nursing students in Israel nearing the end of their clinical training, based on their personal experiences.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis qualitative study applied the naturalistic descriptive approach (firsthand reported life experience) (Polit \u0026amp; Beck, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), using semi-structured interviews guided by a protocol.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e Participants were recruited through a call for volunteers on social media platforms and agreed to participate in interviews. All respondents were in their final year of a Bachelor's in Nursing program at various academic institutions in Israel, and all had completed clinical rotations during that year.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eData was collected from March to June 2025 through semi-structured in-depth interviews, conducted either face-to-face or online. Nursing students were recruited via social media channels where information about the study and eligibility criteria were disseminated. Interested students who had experienced medication errors or near-errors )\u0026rdquo;near miss\u0026rdquo;) during clinical practice contacted the research team to participate. After receiving an explanation and signing an informed consent form, a total of 22 nursing students were interviewed for this study. The interview guide was developed based on a preliminary literature review (Afaya et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Glarcher \u0026amp; Vaismoradi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and consulting with experts in the field. The guide included sociodemographic questions (such as age, religious affiliation, gender, and religion) and open-ended questions related to the research topic. These included questions like: \"Tell me about a case in which you experienced or saw a clinical error during your experience, what led you to report or not report the case? and How did you feel following the event and during the process of dealing with it?\" The interviews lasted between 35 and 60 minutes, were recorded, and transcribed with the participants\u0026rsquo; permission.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData collection continued until thematic saturation was reached, meaning no new categories or themes emerged (Hsieh \u0026amp; Shannon, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). The analysis of the interviews was based on Braun \u0026amp; Clarke (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) thematic approach, which involved rereading the transcripts, initial coding by each researcher separately, grouping codes into categories and potential themes, checking these against the original data, defining and refining the themes, and finally writing up the results with selected quotes. To ensure the credibility of the findings, several methodological steps were taken: double coding some interviews by two researchers, team discussions to refine interpretations, incorporating direct quotes from participants (thick description), and systematically documenting the analysis process (DiCicco-Bloom \u0026amp; Crabtree, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 22 nursing students. The average age was 25 years (range: 21\u0026ndash;31). Most of the participants were women, Jewish, with an internal diversity within the group, consisting of religious, traditional, and ultra-Orthodox. In addition, Arab, Muslim, and Christian students also participated (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Most of the errors described occurred during medication preparation and dispensing. These included incorrect dosages, confusion between similar names, late administration, documentation mistakes, skipping steps in the dispensing process, or omitting critical information when submitting a shift report. The range of errors varied from events that could potentially cause actual harm to the patient to incidents that appeared \"minor\" or unimportant to the students. However, an initial reaction of shock, embarrassment, and sometimes a feeling of stagnation was almost always described.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelect sociodemographic variables of participants (N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(21\u0026ndash;31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEthnic affiliation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJewish\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim Arab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChristian Arab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eLevel of religiosity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReligious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltra-Orthodox (Jewish)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCourse of study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBachelor's degree (BSN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecond degree (career change)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTwo main themes emerged from the interviews: 1) The cost of admitting a mistake: this theme captures the inner struggle of students who, when facing an error, experience a sense of shame and fear of exposure-an emotional \u0026ldquo;price\u0026rdquo; that often drives them to minimize or dismiss the incident; 2) Error as a learning opportunity: the student's perception that the mistake was an opportunity for development, especially when the clinical environment is supportive and non-punitive, and encourages the perception that taking responsibility for the mistake is part of a nurse's professional and ethical development (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of Themes and Subthemes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory / Subtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIllustrative Quote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 1: The cost of admitting a mistake\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFear of academic and professional consequences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudents feared that reporting would harm grades, evaluations, or future employment opportunities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;At the end of the fourth year, every grade counts. If I open it, I\u0026rsquo;m digging a hole for myself.\u0026rdquo; (Participant 16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShame and threat to professional identity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eErrors were experienced as personal failure and a stain on self-image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;It felt like a stain that wouldn\u0026rsquo;t come off.\u0026rdquo; (Participant 11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConcealment and minimization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudents tended to hide or downplay errors, especially when no harm occurred\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;If it was something small, I didn\u0026rsquo;t see the need [to report].\u0026rdquo; (Participant 5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternal filtering of what counts as an \u0026lsquo;error\u0026rsquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudents distinguished between \u0026ldquo;serious\u0026rdquo; and \u0026ldquo;minor\u0026rdquo; errors and reported only the former\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;I do an internal review. Is it worth reporting or not?\u0026rdquo; (Participant 15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormalization of \u0026lsquo;quiet correction\u0026rsquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eErrors were often corrected informally without documentation, following staff norms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;The nurses around me didn\u0026rsquo;t always report either; they corrected it on the spot.\u0026rdquo; (Participant 8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of feedback and perceived futility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReporting was experienced as meaningless due to lack of response or learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;It just disappears from the system\u0026hellip; like filling out a form for statistics.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTheme 2: Error reporting as a learning facilitator\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupportive and empathetic instructor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInstructor\u0026rsquo;s reaction shaped students\u0026rsquo; willingness to report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;She always asks \u0026lsquo;What did you learn?\u0026rsquo; rather than \u0026lsquo;Why did you do it?\u0026rsquo;\u0026rdquo; (Participant 14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychological safety in the clinical environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpen, non-judgmental atmosphere enabled sharing and learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;When we talked about mistakes without blaming, I felt okay to talk about mine.\u0026rdquo; (Participant 6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRole modeling and team culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObserving respectful responses to others\u0026rsquo; mistakes reduced fear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;When I saw how she treated other students, I wasn\u0026rsquo;t afraid to tell.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthical responsibility to the patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSome students reported despite fear, driven by moral commitment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;The patient comes first. That was stronger than any fear.\u0026rdquo; (Participant 18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReframing error as part of professional growth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eErrors were seen as part of learning and professional development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ldquo;Mistakes happen. What\u0026rsquo;s important is to learn from them.\u0026rdquo; (Participant 9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eTheme 1: The Cost of Admitting a Mistake\u003c/h3\u003e\n\u003cp\u003eAlmost all students described unpleasant feelings (fear, shame) surrounding a mistake or near-mistake, and fear of the price they would have to pay in dealing with the consequences. These feelings led to concealment or minimizing the mistake. Most participants described a conflict between the desire to report professionally and the fear of personal consequences. The main concerns raised were the risk of damaging their grade, harming evaluations by the instructor or staff, and potentially affecting their professional image before entering the workforce. This fear was especially heightened as they approached graduation and were candidates to join the departments.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI knew I was wrong, but all I could think about was what would she say now? How would it look in my final evaluation? So I just kept quiet (Participant 7).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eI felt that if I told, it would be used against me, not for me (Participant 21).\u003c/p\u003e \u003cp\u003eStudents described the ability to hide a mistake when it had no clinical significance for the patient. They weighed the risks of disclosure against the benefits, often choosing concealment to avoid personal and professional repercussions. This hesitation was emotionally difficult:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf I tell, it's as if I'm putting a label of 'incompetent/unprofessional student' on my forehead (Participant 19).\u003c/p\u003e\u003cp\u003eAt the end of the fourth year, every grade counts. If I open it [reporting the event], I'm digging a hole for myself (Participant 16).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis hesitation was emotionally challenging. Several students emphasized that the experience of making a mistake \u0026ldquo;undermines confidence from within,\u0026rdquo; and that this feeling can last long after the event:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt\u0026rsquo;s not just the instructor. I did not want to admit that I was wrong either, because I always saw myself as someone who had mastered the material (Participant 3).\u003c/p\u003e\u003cp\u003eI always strive for excellence, so when it happened \u0026ndash; it felt like a stain that wouldn\u0026rsquo;t come off (Participant 11).\u003c/p\u003e\u003cp\u003eEven after weeks had passed, this thought returned, that maybe I wasn't suited for this profession (Participant 8).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eShame also extended to interactions with staff. Some students described environments focused on blame rather than learning, where even minor mistakes were publicly exposed and used to label students as failures. After the incident, participants described feeling intense anxiety and scrutiny in their clinical work. One participant explained that, \u003cem\u003e\u0026ldquo;\u003c/em\u003eI was already afraid to touch a syringe. I felt that my every step was being examined and that every minor mistake would define me as a failure in front of the department.\" Others reflected on the consequences of reporting, noting, being exposed in front of the group or everyone in the department knowing about the incident. Collectively, these accounts illustrate a shared sense of intimidation and reluctance to report errors, reinforcing how the clinical environment amplified participants\u0026rsquo; feelings of vulnerability and exposure. These experiences led students to avoid reporting, even when they recognized the potential value for learning and systemic improvement:\u003c/p\u003e \u003cp\u003eIn the end, you learn that it is better to remain silent. It feels safer, even if it is not professionally correct.\" (Participant 15)\u003c/p\u003e \u003cp\u003eStudents described an internal filtering process to assess the severity of errors. Those perceived as potentially harmful to patients were more likely to be reported, while minor deviations were often dismissed. Some participants noted that seemingly minor errors could have served as an important source of their learning or systemic improvement, but at the time of the event, they preferred not to share and disclose.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf it was something that could harm the patient, I reported it. If it was something small, like a delay in administering medication, I did not see the need. (Participant 5)\u003c/p\u003e\u003cp\u003eI do an internal review. Is it worth reporting or not? Not everything justifies a report form. (Participant 15)\u003c/p\u003e\u003cp\u003eIn the end, it is a matter of proportion; not every small mistake should become a big story. We also learn on the go. (Participant 12)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStudents commonly expressed that addressing minor errors immediately was preferable to engaging in formal reporting procedures. They described \"correcting mistakes on the spot\", often believing that this approach was sufficient to \"avoid unnecessary hassle\". Many felt that formally reporting every minor issue was burdensome and could escalate situations unnecessarily, leading them to prioritize immediate correction over official documentation. Some students observed that nurses around them also avoided reporting minor errors, reinforcing this behavior:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe nurses around me didn\u0026rsquo;t always report either; they corrected it on the spot. So, I felt that I was okay, and not something unusual.\u0026rdquo; (Participant 8)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFinally, some students felt that the professional environment did not take error reporting seriously. Lack of feedback and follow-up discouraged future reporting, expressing frustration that even when reported, \"it [the event] just disappeared from the system\", and it felt like \"filling out a form so someone has statistics\" and that it did \"not really to change anything\".\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Error Reporting as a Learning Facilitator\u003c/h2\u003e \u003cp\u003eThroughout the interviews, it also emerged that it is possible to learn and grow from mistakes. The interviewees noted that they had learned risk management and error-reporting theories and models over the years. The classroom approach emphasized learning and reflection rather than punishment. However, their clinical experience was described as significantly different from the classroom environment.\u003c/p\u003e \u003cp\u003eThe number of interview excerpts describing error reporting as a positive, supportive, educational, and developmental experience was very small (n\u0026thinsp;=\u0026thinsp;3), compared with the majority of participants (n\u0026thinsp;=\u0026thinsp;19) who described it as a difficult, embarrassing, and frightening experience that was both widespread and common.\u003c/p\u003e \u003cp\u003eThe analysis revealed that the presence of an empathetic, open, and non-judgmental clinical instructor was a key factor in students\u0026rsquo; willingness to report mistakes. Support, reinforcement, and a positive message that encouraged acknowledging one's mistakes created an environment where errors were seen as a natural part of learning. This allowed students to feel more confident sharing, even in sensitive situations.\u003c/p\u003e \u003cp\u003eFurthermore, participants emphasized that not only their personal experience but also the way the instructor treated other students' mistakes extensively influenced their perceptions. When students saw that the instructor responded to their classmates with respect and patience, without blame, this strengthened trust and reduced fear of future reporting.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMy instructor explicitly said: \u0026lsquo;Mistakes happen, what is important is to learn from them.\u0026rsquo; This gave me the courage to come forward and tell. (Participant 9)\u003c/p\u003e\u003cp\u003eShe (the clinical instructor) always asks \u0026lsquo;What did you learn from this?\u0026rsquo; rather than \u0026lsquo;Why did you do it?\u0026rsquo; This difference changed my whole approach. (Participant 14)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStudents noted that in all clinical rotation sites (departments and clinics), there was a clear formal message that errors should be reported. However, they emphasized that the significant difference lay not in official statements but in the informal atmosphere and daily behavior of the staff. In places where open and informal conversations about errors occurred, a sense of psychological safety was created, enabling students to discuss personal cases. In such environments, errors were transformed from threatening events into opportunities for shared learning:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen we would sit with the team and talk about all of our mistakes, without pointing fingers at anyone, I felt it was okay to talk about mine too. (Participant 6).\u003c/p\u003e\u003cp\u003eThe atmosphere in the department gave the feeling that we were all here to improve, not to find fault (Participant 13).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants emphasized that the primary motivation for reporting was ethical and moral, a sense of responsibility to maintain the patient\u0026rsquo;s safety. For these students, ethical obligation outweighed fear of reactions from instructors or peers. Their professional identity and led them to view reporting not only as a technical requirement but also as a moral act aimed at preventing future errors:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI felt that if I did not report, I was leaving the patient at risk \u0026ndash; and this was stronger than any fear. (Participant 18)\u003c/p\u003e\u003cp\u003eI felt that I had to put my ego aside and understand that the patient comes first. (Participant 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOverall, students\u0026rsquo; experiences suggest that while formal policies mandated error reporting across all clinical sites, the real determinant of reporting behavior was the informal culture and daily interactions within each environment. Supportive teams that fostered open, nonjudgmental discussions created psychological safety, allowing students to learn from mistakes rather than fear them. Although ethical and moral considerations also played a central role, and students wanted to prioritize patient safety over personal apprehension, some participants were able to overcome the apprehension of possible negative consequences, while others were not. Together, these findings highlight that effective error reporting depends not only on official procedures but also on cultivating a culture of trust, shared learning, and ethical commitment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThese results indicate a wide gap between nursing students' values ​​regarding the importance of reporting errors in healthcare and actual behavior. Although all participants had experienced an error or near-error during their clinical experience, only a minority had reported it openly. This gap, between \"knowing that they should report\" and \"daring to report,\" is a classic expression of the tension between a culture of punishment, fear of punishment or harm to professional dignity, and a culture of learning (Just Culture) described in the international literature (Boysen, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Glarcher \u0026amp; Vaismoradi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study findings highlight that constitute a significant barrier to reporting. These findings of feeling fear, shame, and concern over adverse reactions from instructors or staff are consistent with previous studies that have shown that fear of academic or disciplinary consequences, as well as personal perceptions and stigmas, reduce the willingness to admit an error (Afaya et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Shame has been described as a complex emotional experience that undermines students' sense of self-efficacy and impedes the transition from viewing an error as a personal failure to seeing it as an integral part of a professional learning process. In this sense, students are more inclined to see a medical error as a personal, rather than a system, failure, similar to findings among both nurses and physicians (Cohen et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The experience of publicly exposing an error, sometimes in front of instructors and other students, evoked a sense of ongoing \u0026ldquo;failure.\u0026rdquo; This sense of stigma is also described in the literature as a factor leading to avoidance of participation in systemic learning processes (Bugalia et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This perception leads to reduced reporting and hinders the development of a reporting culture, which should be promoted.\u003c/p\u003e \u003cp\u003eStudents are in a phase of professional socialization in which professional identity is in the process of formation (Vabo et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). During this period, students depend heavily on clinical instructors and are looking for validation and guidance (Honkavuo, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), which intensifies the fear of negative consequences for reporting errors. The fear of negative repercussions on the relationship with the instructor or on one's professional reputation was perceived as one of the main barriers to reporting both in this study and in the other research (Afaya et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Alanazi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAt the same time, the findings highlight a gap between the formal definitions of \u0026ldquo;error\u0026rdquo; taught in the classroom in contrast to the subjective practice in the clinical field. In practice, students used an internal filtering system: errors seen as potentially harmful were reported, while deviations perceived as \u0026ldquo;minor\u0026rdquo; stayed outside the reporting channels. This situation, which has also been documented in other studies (Jones et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Woo \u0026amp; Avery, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), may lead to missed opportunities both for the students themselves, by not receiving feedback on their errors, and for the system, which cannot educate or identify repeated failures to implement control and correction measures. Several participants even admitted that errors they considered negligible in real time could have been a valuable source of organizational improvement. However, they preferred to take a passive, avoidant stance.\u003c/p\u003e \u003cp\u003eAnother finding that emerged was the decision to \u0026ldquo;quietly correct,\u0026rdquo; without causing a stir, rather than report. This was due to the student's desire to avoid dealing with the results, as well as to informal behavioral norms among clinical teams. Some teams preferred to keep quiet about an error and make a correction without reporting, as long as no visible damage was caused. These norms permeated students' behavior and shaped their patterns. This phenomenon reinforces the understanding that the informal culture in the department, and not only the formal procedures, influences and shapes reporting patterns (Dionisi et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Stolic et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Accordingly, formal statements about the importance of reporting are insufficient, and senior staff's modeling behavior must influence field teams' practical behavior (Bugalia et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to practical considerations, the emotional dimension was found to be a significant barrier. Feelings of shame and damage to self-image accompanied the experience of the error, which was perceived not only as proof of professional failure but also as a threat to personal identity and a sense of competence. These feelings, documented in other studies (Heydarikhayat et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Hoffmann et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), deepened the desire to avoid reporting and led to actual avoidance.\u003c/p\u003e \u003cp\u003eAt the organizational level, two key barriers stood out: lack of feedback and a culture of blame. Students reported that, even when they chose to report, they did not receive a response or guidance, which created a sense of purposelessness and reduced their motivation to report in the future. This finding is consistent with previous studies that indicated that a lack of feedback is a significant factor in weakening the willingness to report (Afaya et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Munn et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). At the same time, some students described a culture of blame in which mistakes were publicly exposed, the subject of gossip, or harshly criticized by instructors. These experiences created a discouraging climate in which reporting was perceived as a personal risk rather than an opportunity for professional improvement, consistent with the literature highlighting the negative impact of a punitive culture on willingness to report (Rusdi et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Woo \u0026amp; Avery, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yang et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, the findings also revealed conditions that promote reporting. Empathetic, nonjudgmental instructors provided students with a sense of security, allowing them to share even in sensitive situations. These experiences align with the literature on psychological safety (Edmondson, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) and with studies showing that instructors who serve as positive role models for reporting increase students\u0026rsquo; willingness to report (Chegini et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Glarcher \u0026amp; Vaismoradi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Silvestre \u0026amp; Spector, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, the informal atmosphere in the departments, where open discussions about errors took place, contributed to making reporting a tool for shared learning rather than a focus on blame (Yang et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Furthermore, a sense of ethical responsibility towards the patient was found to be a strong motivator that sometimes outweighed personal concerns, indicating the internalization of a professional ethos that aligns with theoretical frameworks of planned behavior (Secginli et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSome students described deep internal motivation as a driving force for reporting, despite fears. This approach is consistent with models of professional ethics in nursing that prioritize the patient's well-being over personal comfort (Barkhordari-Sharifabad \u0026amp; Mirjalili, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Strengthening this value perception may serve as an important lever for promoting a non-punitive reporting culture, but systemic support is required to ensure that reporting indeed translates into learning and not punishment.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study may be subject to selection bias due to voluntary participation, potentially leading to underrepresentation of specific student populations. Efforts were made to include students from diverse sociodemographic backgrounds to enhance representativeness. Although participants came from various cultural and ethnic groups, the analysis did not systematically examine how these variables intersect with reporting behaviors. Additionally, all data were self-reported, which may have introduced social desirability bias- some participants might have withheld difficult experiences or portrayed themselves more favorably despite assurances of anonymity. Interviews were conducted near the end of clinical training, a period marked by stress and heightened evaluation, which could have influenced participants’ reflections and framing of their experiences. Finally, the study reflects only students’ perspectives, without input from clinical instructors or nursing staff, thereby limiting understanding of the broader dynamics surrounding error reporting.\u003c/p\u003e "},{"header":"Conclusions and future recommendations","content":"\u003cp\u003eThe study demonstrates that nursing students’ reluctance to report errors does not stem from irresponsibility or lack of awareness, but from navigating tensions between formal expectations and informal norms, professional responsibility and personal emotions, and academic standards versus clinical culture. Students’ professional identities are still forming, and their dependence on instructors and visibility in clinical settings heightens sensitivity to errors. Informal norms such as 'quiet correction' and blame culture significantly shape reporting behaviors, often more than formal guidelines. Conversely, a supportive environment characterized by empathy, constructive feedback, and ethical encouragement may facilitate meaningful reporting and transforms errors into opportunities for learning. To foster a culture of safe and constructive error reporting, it is essential to create informal spaces for open dialogue, simplify reporting procedures, promote ethical responsibility towards patients, and model positive reporting behaviors among staff and instructors. These measures can help reframe error reporting as a professional and educational tool rather than a personal failure, ultimately enhancing patient safety and systemic learning.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Institutional Review Board (IRB) for Non-Clinical Research Involving Human Participants at Ariel University (Approval No: AU-HEA-RNG-0122). All procedures were conducted in accordance with institutional ethical standards and the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eGiven the sensitive nature of reporting clinical errors, particular attention was paid to protecting participants\u0026rsquo; confidentiality and anonymity. Eligible participants received detailed written and verbal information regarding the study aims and procedures, and written informed consent was obtained prior to participation, including consent for audio recording of the interviews.\u003c/p\u003e\n\u003cp\u003eAll identifying details were removed from transcripts, and any potentially identifiable information was omitted without compromising the integrity of the research. Confidentiality was maintained throughout all stages of data collection, analysis, and reporting, in line with established qualitative research guidelines for sensitive topics (Assarroudi et al., 2018; Kaiser, 2009).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception and design of the study. Y.S. and R.N.G. developed the methodology and conducted the formal analysis. Y.S. and K.G. drafted the initial manuscript. K.G. led project administration and contributed to participant coordination. I.H.H. assisted with conducting the interviews and coordinating with participants, transcribed the interview data, contributed to methodology and formal analysis, and prepared the tables. All authors reviewed and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAfaya A, Essandoh AF, Yakong VN, Afaya RA, Amankwaa I. Barriers to reporting medication errors among nursing students: An integrative review. J Nurs Adm Manag. 2021;29(5):1243\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jonm.13282\u003c/span\u003e\u003cspan address=\"10.1111/jonm.13282\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlanazi FK, Sim J, Lapkin S. Systematic review: Nurses' safety attitudes and their impact on patient outcomes in acute-care hospitals. Nurs Open. 2022;9(1):30\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1002/nop2.1063\u003c/span\u003e\u003cspan address=\"https://doi:10.1002/nop2.1063\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlashram WM, Elseesy NAM, Gheith NADS, Ghonaim HM, Sindi NA, Elwan HM, Hazazi RA, AlFaidi WA, AlHawsawi ED. The unreported truth: Unveiling barriers to medication error reporting among nurses in Saudi Arabia. Rev Diabet Stud. 2024;276\u0026ndash;87. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.70082/94n21406\u003c/span\u003e\u003cspan address=\"10.70082/94n21406\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlrasheeday AM, Alkubati SA, Alqalah TAH, Alrubaiee GG, Alshammari B, Almazan JU, Abdullah SO, Loutfy A. Nursing students' perceptions of patient safety culture and barriers to reporting medication errors: A cross-sectional study. Nurse Educ Today. 2025;146:106539. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nedt.2024.106539\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2024.106539\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsensi-Vicente J, Jim\u0026eacute;nez-Ruiz I, Vizcaya-Moreno MF. (2018). Medication errors involving nursing students: A systematic review. \u003cem\u003eNurse Educator\u003c/em\u003e;\u003cem\u003e43\u003c/em\u003e: E1-E5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NNE.0000000000000481\u003c/span\u003e\u003cspan address=\"10.1097/NNE.0000000000000481\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssarroudi A, Heshmati Nabavi F, Armat MR, Ebadi A, Vaismoradi M. Directed qualitative content analysis: The description and elaboration of its underpinning methods and data analysis process. J Res Nurs. 2018;23(1):42\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1744987117741667\u003c/span\u003e\u003cspan address=\"10.1177/1744987117741667\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarkhordari-Sharifabad M, Mirjalili NS. Ethical leadership, nursing error and error reporting from the nurses\u0026rsquo; perspective. Nurs Ethics. 2020;27(2):609\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/096973301985870\u003c/span\u003e\u003cspan address=\"10.1177/096973301985870\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoysen PG. Just culture: a foundation for balanced accountability and patient safety. Ochsner J. 2013;13(3):400\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraiki R, Douville F, Gagnon MP. Factors influencing the reporting of medication errors and near misses among nurses: A systematic mixed methods review. Int J Nurs Pract. 2024;30(6):e13299. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ijn.13299\u003c/span\u003e\u003cspan address=\"10.1111/ijn.13299\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1191/1478088706qp063oa\u003c/span\u003e\u003cspan address=\"10.1191/1478088706qp063oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBugalia N, Maemura Y, Ozawa K. A system dynamics model for near-miss reporting in complex systems. Saf Sci. 2021;142:105368. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ssci.2021.105368\u003c/span\u003e\u003cspan address=\"10.1016/j.ssci.2021.105368\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChegini Z, Kakemam E, Asghari Jafarabadi M, Janati A. The impact of patient safety culture and the leader coaching behaviour of nurses on the intention to report errors: a cross-sectional survey. BMC Nurs. 2020;19(1):89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12912-020-00472-4\u003c/span\u003e\u003cspan address=\"10.1186/s12912-020-00472-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen R, Sela Y, Nissanholtz-Gannot R. Addressing the second victim phenomenon in Israeli health care institutions. Isr J Health Policy Res. 2023;12(1):30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13584-023-00578-5\u003c/span\u003e\u003cspan address=\"10.1186/s13584-023-00578-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiCicco-Bloom B, Crabtree BF. Making sense of qualitative research. Med Educ. 2006;40(4):314\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDionisi S, Di Simone E, Franzoso V, Caldarola E, Cappadona R, Di Muzio F, Giannetta N, Di Muzio M. The application of the Theory of Planned Behaviour to prevent medication errors: a scoping review. Acta Bio Medica: Atenei Parmensis. 2020;91(Suppl 6):28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi/10.23750/abm.v91i6-S.9290\u003c/span\u003e\u003cspan address=\"https://doi/10.23750/abm.v91i6-S.9290\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdmondson A. The Fearless Organization: Creating Psychological Safety in the Workplace. Wiley \u0026amp; Sons; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlarcher M, Vaismoradi M. Promoting just culture in nursing education: A systematic integrative review on enhancing patient safety. Nurse Educ Today. 2025;106776. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nedt.2025.106776\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2025.106776\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeydarikhayat N, Ghanbarzehi N, Sabagh K. (2024). Strategies to prevent medical errors by nursing interns: A mixed-methods study. \u003cem\u003eBMC Nursing\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(48), 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12912-024-01726-1\u003c/span\u003e\u003cspan address=\"10.1186/s12912-024-01726-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodkinson A, Tyler N, Ashcroft DM, Keers RN, Khan K, Phipps D, Abuzour A, Bower P, Avery A, Campbell S, Panagioti M. Preventable medication harm across health care settings: A systematic review and meta-analysis. BMC Med. 2020;18(1):313. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12916-020-01774-9\u003c/span\u003e\u003cspan address=\"10.1186/s12916-020-01774-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoffmann M, Schwarz CM, Schwappach D, Banfi C, Palli C, Sendlhofer G. Speaking up about patient safety concerns: View of nursing students. BMC Health Serv Res. 2022;22(1):1547.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHonkavuo L. Nursing students\u0026rsquo; perspective on a caring relationship in clinical supervision. Nurs Ethics. 2020;27(5):1225\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0969733019871695\u003c/span\u003e\u003cspan address=\"10.1177/0969733019871695\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones JR, Boltz M, Allen R, Van Haitsma K, Leslie D. Nursing students\u0026rsquo; risk perceptions related to medication administration error: A qualitative study. Nurse Educ Pract. 2022;58:103274. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nepr.2021.103274\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2021.103274\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaiser K. Protecting respondent confidentiality in qualitative research. Qual Health Res. 2009;19(11):1632\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1049732309350879\u003c/span\u003e\u003cspan address=\"10.1177/1049732309350879\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiernan LC. Evaluating competence and confidence using simulation technology. Nursing. 2018;48(10):45\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi/10.1097/01.NURSE.0000545022.36908.f3\u003c/span\u003e\u003cspan address=\"https://doi/10.1097/01.NURSE.0000545022.36908.f3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMistri IU, Badge A, Shahu S. Enhancing patient safety culture in hospitals. Cureus. 2023;15(12). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7759/cureus.51159\u003c/span\u003e\u003cspan address=\"10.7759/cureus.51159\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunn LT, Lynn MR, Knafl GJ, Willis TS, Jones CB. A study of error reporting by nurses: the significant impact of nursing team dynamics. J Res nursing: JRN. 2023;28(5):354\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/17449871231194180\u003c/span\u003e\u003cspan address=\"10.1177/17449871231194180\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, Bower P, Campbell S, Haneef R, Avery AJ, Ashcroft DM. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019;366:l4185. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.l4185\u003c/span\u003e\u003cspan address=\"10.1136/bmj.l4185\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePolit D, Beck C. Essentials of nursing research: Appraising evidence for nursing practice. 9th ed. Lippincott Williams \u0026amp; Wilkins; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobichaux C, Vittone S. Ethics: Addressing error: Partnership in a Just Culture. OJIN: Online J Issues Nurs. 2023;28(2). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3912/OJIN.Vol28No02EthCol01\u003c/span\u003e\u003cspan address=\"10.3912/OJIN.Vol28No02EthCol01\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRusdi R, Said FM, Umar NS. The effect of empowerment to improve patient safety culture among hospital nurses. Int J Public Health. 2024;13(4):1903\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.11591/ijphs.v13i4.24418\u003c/span\u003e\u003cspan address=\"10.11591/ijphs.v13i4.24418\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSecginli S, Nahcivan NO, Bahar Z, Fernandez R, Lapkin S. Nursing students' intention to report medication errors: Application of theory of planned behavior. Nurse Educ. 2021;46(6):E169\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/NNE.0000000000001105\u003c/span\u003e\u003cspan address=\"10.1097/NNE.0000000000001105\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilvestre J, Spector N. Nursing student errors and near misses: Three years of data. J Nurs Educ. 2023;62(1):12\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStolic S, Ng L, Southern J, Sheridan G. Medication errors by nursing students on clinical practice: An integrative review. Nurse Educ Today. 2022;112:105325. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nedt.2022.105325\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2022.105325\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVabo G, Sletteb\u0026oslash; \u0026Aring;, Fossum M. Nursing students\u0026rsquo; professional identity development: An integrative review. Nordic J Nurs Res. 2021;42(2):62\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1177/20571585211029857\u003c/span\u003e\u003cspan address=\"https://doi:10.1177/20571585211029857\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoo MW, Avery MJ. Nurses\u0026rsquo; experiences in voluntary error reporting: An integrative literature review. Int J Nurs Sci. 2021;8(4):453\u0026ndash;69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.ijnss.2021.07.004\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.ijnss.2021.07.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang L, Peng X, Song W, Su H, Wang C, Yang S, Wu D. The barriers to medication error reporting by nurses and factors associated with it: a cross-sectional study in a tertiary hospital of south-west China. BMJ open. 2025;15(4):e091058.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medication errors, Error reporting, Nursing students, Patient safety culture, psychological safety","lastPublishedDoi":"10.21203/rs.3.rs-8892299/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8892299/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: While the 'Just Culture' approach promotes reporting medical errors as a learning opportunity rather than punishment, studies indicate a gap between recognizing the importance of reporting and actual implementation. This study examined the barriers and facilitators to error reporting among nursing students.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: Using a descriptive-naturalistic approach nursing students who had reported experiencing a medication error or near-error during their clinical placements were interviewed and the data analysis was conducted using a thematic approach.\u003c/p\u003e\n\u003cp\u003eResults: All participants experienced errors or near-errors, mostly during medication preparation and administration. Fears of negative impacts on grades or professional reputation, and concern about negative responses from instructors or peers, led some students to downplay events or avoid reporting. When instructors were empathetic, the atmosphere supportive, and dialogue encouraged, students were more likely to report incidents and view reporting as a means of professional growth and ethical responsibility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusion: Nursing students report that errors are common. Avoiding reporting often reflects tension between formal expectations and informal norms, emotional discomfort, and organizational culture, rather than lack of responsibility. Future strategies should simplify reporting procedures, provide timely feedback, train instructors to foster empathy, and create safe spaces for discussing mistakes to strengthen a culture of reporting.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Learning or blaming? Understanding Nursing Students’ Barriers to Reporting Medication Errors: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 17:39:56","doi":"10.21203/rs.3.rs-8892299/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b4c3f1af-595b-4b9b-9562-2a525ffe538b","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-24T12:27:11+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 17:39:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8892299","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8892299","identity":"rs-8892299","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}