Introduction

One of the most important aspects in the provision of healthcare is the patient safety, but the medical errors have made the health care system insecure ( 1 ). Medical errors in any health system are recognized as an unavoidable event which can have a negative effect on the patient safety ( 2 ). Today, regarding the high prevalence of medication errors and its potential risks for patients, it is used as an indicator to determine the safety of the patients in hospitals ( 3 ). According to the studies conducted in the United States, about 7,000 people in the United States die each year due to medication errors, and the financial cost associated with this problem is close to $ 77 million per year. Evidence shows that in European countries, 19% to 28% of hospitalized patients fall victim to medication errors ( 4 ). Unfortunately, Iran lacks reliable information on the frequency of medication mistakes ( 5 ). According to a study from Iran's Ministry of Health and Medical Education, the cost of maintaining and caring for patients owing to pharmaceutical mistakes and the effects of extended hospitalization is billions of Rials each year. One indication of this assertion is the rise in patient complaints ( 6 ). Reporting the error and sharing it with the patient, family and medical staff is essential to plan the targeted interventions to prevent the error or its recurrence ( 7 ). Unfortunately, many mistakes are not reported ( 8 ). There are many reasons for the lack of reporting or reporting less than the actual error rate. Fear, the difficulty of the reporting process and management barriers ( 9 ), job burnout ( 10 ), professional commitment ( 11 , 12 ) and characteristics of the senior staff ( 13 ) are among these cases. Commitment is defined as a belief in the professional goals and values and striving to achieve these goals ( 14 ), and as honesty and conscientiousness that can be generalized to other health care professionals such as physicians ( 15 ). In this regard, many medical teachers believe that achieving professional identity depends on supporting the development of qualifications and the formation of the desired professional identity of health science graduates ( 16 , 17 ). Many measures have been taken in the medical education to enhance this commitment, but the desired and expected results, which are the manifestation of professional behavior in the performance of graduates, are not observed yet ( 18 ).

Despite the importance of medical errors and professional identity, few studies are conducted to evaluate the medical errors and their relationship with professional identity in the world. In fact, no study has been conducted in this regard among Iranian medical students yet. Such studies can be used in status assessment and education planning. This research was carried out to ascertain the association between professional identity, practice, and medical interns’ attitudes to self-reported medical mistakes in teaching hospitals of Ardabil University of Medical Science.

Methods

Research Sample

This cross-sectional analytical study was performed on 187 medical interns with census method studying in 5 teaching hospitals of Ardabil University of Medical Sciences in 2021.

Data Collection

Data collection tool was a questionnaire consisting of 3 parts, the first part included the demographic characteristics of students (grade point average, basic science scores, pre-internship scores, gender, college (Azad University, State University, and Pardis (tuition fee)). The academic performance average was defined as a qualitative variable: fewer than 14, 14-15, 15-17 and 17-19. The second part of the questionnaire was 15 questions of professional identity. The main version of this standard questionnaire was in English, designed by Tagawa (2019). Self-control, medical status awareness, physician rethinking, societal obligation fulfilment, and external and internal self-adjustment are the 5 criteria measured by this test. Each item was given a score between 1 and 7, with a minimum score of 15 and a maximum score of 105 for each area. The reliability of the tool with Cronbach's alpha coefficient is 0.72 ( 19 ). The validity of the questionnaire was evaluated and confirmed using Content Validity Index (CVI) and Content Validity Ratio (CVR). The reliability of the Persian version of instrument was obtained 0.86 using the Alpha Cronbach coefficient.

Another standard questionnaire was used to measure the self-reported attitude of medical errors. This was the questionnaire used in the study of Kaldjian (2007) with a reported reliability of 0.9. This tool consists of 15 questions with a 5-choice Likert scale (strongly disagree to completely agree). The reliability of the tool, using Cronbach's alpha coefficient, was 0.9 ( 16 ). In this instrument, each item was scored from 1 to 5 and the minimum and maximum score can be obtained from 15 to 75. Using the Content Validity Index (CVI) and the Content Validity Ratio, the questionnaire's validity was assessed and validated (CVR). Using the Alpha Cronbach coefficient, the reliability of the instrument in Persian was calculated to be 0.78. To evaluate students' performance in the medical error, the Kaldjian (2007) standard 4-item questionnaire is used, which assesses medical error experiences with 4 questions, assessed each item with a Yes/No Answer ( 20 ).

Statistical Analysis

Data Analyses were performed using the IBM SPSS Statistics, version 21 by descriptive statistics, such as mean and standard deviation and using independent T-test, chi-square and one-way ANOVA. P-values <0.05 were considered statistically significant.

Ethical considerations

To observe the ethical considerations, the study plan and objectives were explained to the participants. Participants gave their verbal agreement after being told that the research would keep their personal data private. This study was published in the University Ethics Committee on Research No. IR. ARUMS. REC. 1399. 529 have been approved. At the beginning of this activity, students were clearly informed that the voluntary submission of the online questionnaire indicated their consent to participate in the anonymized survey. Throughout the study, anonymity was maintained by treating the data with strict confidentiality, and participants' identifying information was not used in reporting the research.

Results

107 persons (57.2%) were women, 107 persons (57.2%) from free government college and 101 persons (54.01%) were with the Academic average B (Table 1).

The mean scores of professional identity and the attitude towards medical self-report were 55.6±8.8 and 60.4±9.8, respectively with and no significant difference was found between two genders due to the mean score of attitude towards self-report of medical error and professional identity. Furthermore, the results of ANOVA test showed that there was no significant difference in the mean scores of attitude and professional identity among the students due to the colleges (Table 2).

Moreover, the results showed that there is no significant difference in the mean scores of attitude and professional identity among the students based on grade point average, p=0.19 and 0.91, respectively. But, the mean score of attitude between the participants with high probability to report medical errors was significantly higher than that of others (p<0.001), and thus, the mean score of professional identity among the participants with very low level of probability for medical error reporting was significantly higher than that of others (p<0.001) (Table 3).

There was no significant difference among the medical students in the probability of self-reported medical errors (p=0.56) and 31.8% of national students (governmental), 32.4% of campus students and 37.3% of free students reported very high probability in medical errors. There was no significant difference in the probability of self-reported medical errors in terms of the gender (p=0.44) and grade point average (p=0.28) (Table 4).

There was no significant relationship between the mean score of attitude towards self-reporting of medical errors with that of performance and professional identity (Table 5).

The findings indicated that students were less likely than the general population to disclose medical errors, with 10.2% of students reporting no errors that resulted in death or disability and 21.4% reporting no errors that resulted in delayed treatment or patient suffering (Table 6).

Discussion

The mean scores of attitudes toward self-declaration of medical errors and professional identity were on average above the maximum achievable score. Consistent with this study, in the Kuhpayehzadeh, et al. study ( 21 ) in 2013 in Tehran University of Medical Sciences, the average score of most students was lower than average. Inconsistent with the present study, Alsulami, et al. (2019) showed that 90% of students in Saudi Arabia had a favorable attitude towards self-reported medical errors ( 22 ). Additionally, students in a recent study conducted in South Korea showed a good attitude toward reporting medical errors, as did participants in the Samsiah, et al. (2020) study conducted in Malaysia ( 23 ). Considering the similar results in three Iranian studies, it seems that in the clinical education of general medical courses in Iran, there is no specific plan to teach the medical errors and their legal and professional issues, as well as professional identity, so it is necessary to pay more attention to these areas.

There was no significant difference in the attitude score and professional identity of the two genders. Moreover, there was no significant difference in the mean score of professional identity and attitude among students with the GPA levels of students and separately for private, free-government-government-paid medical schools. To our knowledge, there was no study comparing the attitudes and professional identities of medical students by type of faculty (tuition-paying or government-free).

Consistent with the present study, in another study conducted in 2015 at Ahvaz Jundishapur University among 40 fourth year medical students in the field of knowledge, attitude and practice in the field of familiarity with medical errors, there was a significant relationship among students' knowledge, attitude and practice. There were no participants with demographic characteristics and in line with the present study; medical students had poor knowledge, attitude and practice about medical errors related to prescribing drugs. Students fared badly in comparison to their reports, despite having high understanding and attitudes regarding the negative impacts of drugs. Only 5% of respondents knew how to report medical mistakes that occur in hospitals ( 24 ).

Only 33.2% of them fully agreed or agreed with the self-declaration of medical errors, which was much less than the study of Kuhpayehzadeh among medical assistants in Tehran, 66.4% of which agreed with the self-declaration of medical errors and this difference can be in terms of the awareness. Most of the residents attributed the legal and moral consequences of not expressing medical errors to general medicine ( 21 ).

There was a significant relationship between the probability of reporting the medical errors and the mean score of professional identity. Consistent with the present study, Gulnar showed that there is a significant relationship between students' moral sensitivity score and medical error reporting ( 25 ). Moreover, Lee, et al. (2020) showed that there was a significant relationship between moral sensitivity and attitudes toward patient safety and students' perceptions of medical error reporting ( 26 ).

Students in the current research did not fare well when reporting medical mistakes. According to a comparable study done in 2021, 281 students from the nursing, medical, dental, medical rehabilitation, and pharmacy departments at Obafham University in Oulu, Nigeria, had a 64.1% unfavorable opinion of patient safety. There was a significant relationship between knowledge about medical errors of clinical students and their field of study ( 27 ). In the study by Sayed Umer Mohsin (2019), only 8.5% of medical students reported a medical error at least once throughout the year. After holding workshops, they identified and classified the errors, the causes of the errors, and suggested ways not to repeat them in the year-end survey, which was in accordance with official reports (18%). Students' advice to avoid similar errors was weak ( 28 ). In a similar study in Saudi Arabia (2019), the performance to report the medical errors was poor despite appropriate knowledge and attitude ( 22 ). Another similar study in Germany ( 29 ) and South Korea ( 30 ) reported functional impairment in medical students.

Despite the importance of the issue, there are few reports of medical errors in the evidence ( 31 ) and several reasons were presented as the facilitators of medical error reporting, including the simple reporting form ( 30 , 32 ), adequate training on the process of reporting ( 30 ), anonymity of the report form ( 31 ), adequate feedback received on the report ( 33 ), understanding the severity of the error, understanding the individual and patient benefit of the report and the supportive work environment ( 32 , 34 , 35 ) , self-confidence ( 29 ), and burnout and workload ( 36 ). A similar study in Germany among the medical students found that students were less likely to report an error when they themselves committed the error and did not expect serious consequences for the error ( 37 ).

According to this study’s findings, the need for intervention to review the curriculum or hold courses, such as error detection for medical students, communication courses and teamwork is strongly felt. The need to teach medical errors to students in the study was reported in Germany ( 29 ). It is advised, in light of the findings, to identify the educational requirements of students in a needs assessment study and to make the appropriate plans to improve professional identity and attitude toward medical mistake reporting in the curriculum and in the form of elective empowerment courses. The effects of organized patient safety education with the emphasis on the hidden curriculum on students' attitudes in a similar study have been shown ( 1 ).

Limitations and strengths

This study, similar to other cross-sectional studies, has limitations. Among other things, the questionnaires were completed by self-reporting, which may lead to over- or under-declaration. If the performance of students to report the medical errors was collected using the data available in the hospitals, it could better explain the relationship with the professional identity. To our knowledge, this is the first research in Iran to look at the connection between professional identity, attitudes to reporting medical errors, and the likelihood that errors would be reported among medical students.

Conclusion

The results show the weakness of medical curriculum and educational programs in teaching medical errors, their types, legal and ethical aspects due to lack of medical error reporting. Teaching this subject could make significant differences among the students with higher and lower grades. These results show the need for integrated training courses to be planned and developed within the general medicine curriculum to enhance future doctors' professional competence and alter attitudes and practices that contribute to medical errors in order to have a functional and effective healthcare system.

Authors’ Contributions

A.K developed the study concept and design. M.H collected the data. A.K, A.P analyzed and interpreted the data, and drafted the manuscript. All authors contributed to the discussion, read, and approved the manuscript and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgments

This work was supported by the research committee of Medical School of Ardabil University of Medical Sciences.

Conflict of Interest

None Declared.

References

1. Alser M, Böttcher B, Alfaqawi M, Jlambo A, Abuzubaida W, Abu-El-Noor N. Undergraduate medical students’ attitudes towards medical errors and patient safety: a multi-center cross-sectional study in the Gaza Strip, Palestine. BMC Medical Education. 2020; 20(1):1-9.
2. Vaziri S, Fakouri F, Mirzaei M, Afsharian M, Azizi M, Arab-Zozani M. Prevalence of medical errors in Iran: a systematic review and meta-analysis. BMC health services research. 2019; 19(1):1-11.
3. Stratton KM, Blegen MA, Pepper G, Vaughn T. Reporting of medication errors by pediatric nurses. Journal of pediatric nursing. 2004; 19(6):385-92.
4. Grissinger MC, Kelly K. Reducing the risk of medication errors in women. Journal of women's health. 2005; 14(1):61-7.
5. Johnstone MJ, Kanitsaki O. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper. International Journal of Nursing Studies. 2006; 43(3):367-76.
6. Najafi H. Medication prescription error is one of the most common errors in medical professional. Proceedings of the First International Congress Forensic Medicine: Filodiritto Publisher; 2009.
7. Wolf ZR, Hughes RG. Patient safety and quality: An evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US): Rockville (MD); 2008.
8. Joolaee S, Hajibabaee F, Peyrovi H, Haghani H, Bahrani N. The relationship between incidence and report of medication errors and working conditions. International Nursing Review. 2011; 58(1):37-44.
9. Chiang HY, Pepper GA. Barriers to nurses&#039; reporting of medication administration errors in Taiwan. Journal of Nursing Scholarship. 2006; 38(4):392-9.
10. Menon NK, Shanafelt TD, Sinsky CA, Linzer M, Carlasare L, Brady KJS, et al. Association of Physician Burnout With Suicidal Ideation and Medical Errors. JAMA Network Open. 2020; 3(12):e2028780.
11. Borrott N, Kinney S, Newall F, Williams A, Cranswick N, Wong I, et al. Medication communication between nurses and doctors for paediatric acute care: An ethnographic study. Journal of Clinical Nursing. 2017; 26(13-14):1978-92.
12. Levine KJ, Carmody M, Silk KJ. The influence of organizational culture, climate and commitment on speaking up about medical errors. Journal of Nursing Management. 2020; 28(1):130-8.
13. Chen YC, Issenberg SB, Issenberg Z, Chen HW, Kang YN, Wu JC. Factors associated with medical students&#039; speaking-up about medical errors: A cross-sectional study. Med Teach. 2021; 44(1):38-44.
14. Teng CI, Dai YT, Lotus Shyu YI, Wong MK, Chu TL, Tsai YH. Professional commitment, patient safety, and patient‐perceived care quality. Journal of Nursing Scholarship. 2009; 41(3):301-9.
15. Teng CI, Shyu YIL, Chang HY. Moderating effects of professional commitment on hospital nurses in Taiwan. Journal of Professional Nursing. 2007; 23(1):47-54.
16. Beagan B. “Even if I Don&#039;t Know What I&#039;m Doing I Can Make It Look like I Know What I&#039;m Doing”: Becoming a Doctor in the 1990s*. Canadian Review of Sociology/Revue canadienne de sociologie. 2001; 38:275-92.
17. Love CB, Thomson EJ, Royal CD. Ethical issues in research involving human participants. National Institutes of Health, National Library of Medicine: U.S; 1999.
18. Yazdani S, Sadeghi Avval Shahr H, Afshar L. A Critical Review of Professional Socialization Models for Medical Students. IJN. 2020; 33(126):82-102. Persian.
19. Tagawa M. Development of a scale to evaluate medical professional identity formation. BMC Medical Education. 2019; 19(1):63.
20. Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Disclosing medical errors to patients: attitudes and practices of physicians and trainees. J Gen Intern Med. 2007; 22(7):988-96.
21. Kuhpayehzadeh J, Soltani Arabshahi SK, Bigdeli S, Maryami F. Determine Attitudes of TUMS Residents towards Medical Errors Self-disclosure and Prevalent Factors affecting it (1391). Razi Journal of Medical Sciences. 2013; 20(108):53-60. Persian.
22. Alsulami SL, Sardidi HO, Almuzaini RS, Alsaif MA, Almuzaini HS, Moukaddem AK, et al. Knowledge, attitude and practice on medication error reporting among health practitioners in a tertiary care setting in Saudi Arabia. Saudi Med J. 2019; 40(3):246-51.
23. Samsiah A, Othman N, Jamshed S, Hassali MA. Knowledge, perceived barriers and facilitators of medication error reporting: a quantitative survey in Malaysian primary care clinics. International Journal of Clinical Pharmacy. 2020; 42(4):1118-27.
24. Aghakouchakzadeh M, Izadpanah M, Yadegari A. Knowledge, attitude, and practice towards medication errors and adverse drug reaction reporting among medical students. Journal of Pharmaceutical Care. 2015; 3(4):49-53.
25. Gülnar E, Özveren H, Özden D. The relationship between moral sensitivity and medical errors attitude in nursing students. Journal of Forensic and Legal Medicine. 2020; 73:101981.
26. Lee E, Kim Y. The relationship of moral sensitivity and patient safety attitudes with nursing students&#039; perceptions of disclosure of patient safety incidents: A cross-sectional study. PloS One. 2020; 15(1):e0227585.
27. Oyediran OO, Ofor HC, Ayandiran EO, Ojo IO. Knowledge and Attitude toward Patients’ Safety among Clinical Students in a South Western University, Nigeria. Journal of Patient Safety & Quality Improvement. 2021; 9(2):99-107.
28. Mohsin SU, Ibrahim Y, Levine D. Teaching medical students to recognise and report errors. BMJ Open Quality. 2019; 8(2):e000558.
29. Kiesewetter J, Kager M, Lux R, Zwissler B, Fischer MR, Dietz I. German undergraduate medical students&#039; attitudes and needs regarding medical errors and patient safety:A national survey in Germany. Med Teach. 2014; 36(6):505-10.
30. Lee HY, Hahm MI, Lee SG. Undergraduate medical students&#039; perceptions and intentions regarding patient safety during clinical clerkship. BMC Med Educ. 2018; 18(1):66.
31. Williams SD, Phipps DL, Ashcroft DM. Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. Research in Social & Administrative Pharmacy: RSAP. 2013; 9(1):80-9.
32. Samsiah A, Othman N, Jamshed S, Hassali MA. Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia. PloS One. 2016; 11(12):e0166114.
33. Kumar VD, Rajasekhar SSSN. Multiple facets of learning a skill–Amalgamation of learning theories in cadaveric surgical skill lab. Journal of Advances in Medical Education & Professionalism. 2021; 9(3):183-4.
34. Rea D, Griffiths S. Patient safety in primary care: incident reporting and significant event reviews in British general practice. Health & Social Care in the Community. 2016; 24(4):411-9.
35. Hartnell N, MacKinnon N, Sketris I, Fleming M. Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. BMJ Quality & Safety. 2012; 21(5):361-8.
36. Musunur S, Waineo E, Walton E, Deeds K, Levine D. When Bad Things Happen: Training Medical Students to Anticipate the Aftermath of Medical Errors. Acad Psychiatry. 2020; 44(5):586-91.
37. Kiesewetter I, Könings KD, Kager M, Kiesewetter J. Undergraduate medical students&#039; behavioural intentions towards medical errors and how to handle them: A qualitative vignette study. BMJ Open. 2018; 8(3):e019500.