Challenges to Patient Safety Incident Reporting and Learning in South African Public Hospitals – Transitioning from Blame Culture to Just Culture!
1
Clinton Health Access Initiative, Pretoria, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
Hospitals are complex environments, and gaps in systems, processes, or human factors can lead to Patient Safety Incidents (PSIs). While global evidence suggests that up to 80% of PSIs can be prevented, only 7–15% are formally reported, limiting opportunities for organizational learning. In South Africa, high levels of medico legal litigation and fear of consequence management, amongst others, drives significant underreporting. The Clinton Health Access Initiative (CHAI), the National and provincial Departments of Health, and North West University initiated a project aimed at addressing barriers to effective implementation of Reporting, Recording, Reviewing and Responding (4Rs) to PSIs.
METHODS:
Ten hospitals were purposively selected across three provinces. The National PSI Guideline provided the framework for implementation. PSI data was analyzed to assess reporting trends, incident types, contributory factors, and outcomes. CHAI convened structured sessions with each facility, presenting hospital-specific PSI data to management. Operational challenges, system gaps, and opportunities to strengthen PSI processes were identified. A virtual platform to foster sharing experiences, learning and building networks was created. Monthly reporting trends was tracked to assess improvement.
RESULTS:
Preliminary findings show substantial underreporting relative to international benchmarks (1 PSI per 10 patients). Contributing factors included fear of blame, high workloads, PSI reporting perceived as an administrative burden rather than a learning opportunity. Misclassification of incidents reflected limited familiarity with PSI definitions. Other challenges included weak integration with morbidity and mortality meetings and inadequate follow-up on remedial actions. Broader system constraints included a dominant narrative of the fear of consequence management, staff and equipment shortages.
CONCLUSIONS:
Improving PSI reporting requires a shift from blame culture to a just culture that promotes safe spaces for learning and accountability. Embedding the 4 Rs into routine practice and using PSI data to inform improvement can support safer care, strengthen clinical governance and reduce avoidable harm.
Hospitals are complex environments, and gaps in systems, processes, or human factors can lead to Patient Safety Incidents (PSIs). While global evidence suggests that up to 80% of PSIs can be prevented, only 7–15% are formally reported, limiting opportunities for organizational learning. In South Africa, high levels of medico legal litigation and fear of consequence management, amongst others, drives significant underreporting. The Clinton Health Access Initiative (CHAI), the National and provincial Departments of Health, and North West University initiated a project aimed at addressing barriers to effective implementation of Reporting, Recording, Reviewing and Responding (4Rs) to PSIs.
METHODS:
Ten hospitals were purposively selected across three provinces. The National PSI Guideline provided the framework for implementation. PSI data was analyzed to assess reporting trends, incident types, contributory factors, and outcomes. CHAI convened structured sessions with each facility, presenting hospital-specific PSI data to management. Operational challenges, system gaps, and opportunities to strengthen PSI processes were identified. A virtual platform to foster sharing experiences, learning and building networks was created. Monthly reporting trends was tracked to assess improvement.
RESULTS:
Preliminary findings show substantial underreporting relative to international benchmarks (1 PSI per 10 patients). Contributing factors included fear of blame, high workloads, PSI reporting perceived as an administrative burden rather than a learning opportunity. Misclassification of incidents reflected limited familiarity with PSI definitions. Other challenges included weak integration with morbidity and mortality meetings and inadequate follow-up on remedial actions. Broader system constraints included a dominant narrative of the fear of consequence management, staff and equipment shortages.
CONCLUSIONS:
Improving PSI reporting requires a shift from blame culture to a just culture that promotes safe spaces for learning and accountability. Embedding the 4 Rs into routine practice and using PSI data to inform improvement can support safer care, strengthen clinical governance and reduce avoidable harm.
| eISSN: | 2654-1459 |
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