Patient safety is one of the fundamental pillars of high-quality healthcare, and ensuring it is an integral part of nurses' work. AEs, defined as undesirable situations that cause harm to the patient, may have physical, psychological, emotional, and financial consequences (Giardina et al., 2020). They are most often associated with staff exhaustion, failure to comply with standards, communication errors, and high workload (Zanetti et al., 2021; Floréz, López, Bernal, 2022; Al-Mugheed et al., 2022). The studies by Moosavi et al. (2023), Gao et al. (2019), and Rafter et al. (2019) clearly indicate that a significant portion of AEs is preventable. Their persistent occurrence reveals shortcomings in the implementation of a patient safety culture. As Zhu et al. (2020) and Archer (2017) point out, nurses play a crucial role in identifying, documenting, and reporting adverse events, thereby creating the conditions for system improvement. Effective and systematic reporting provides healthcare facilities with valuable data on the occurrence of risks and enables the introduction of corrective measures aimed at eliminating them (Abreu, 2021). As Floréz, López, Bernal (2022) add, AEs may also occur when nursing standards are followed, but nurses' attitudes toward their identification and subsequent prevention play an important role in the continuous improvement of the quality and safety of the care provided.
Objective The aim of our study was to analyze nurses' attitudes toward risk factors for the occurrence of AEs.
Sample and Methodology
The sample included 200 nurses working in inpatient departments of healthcare facilities. Nurses were most represented in the age group 50 and over (39.5 %). A total of 80 nurses (40 %) had a first-cycle university education. Professional practice of 11 years or more was reported by 116 nurses (58 %). The largest proportion of nurses worked in internal medicine wards (30.5 %), followed by surgical wards (23 %) and long-term care wards (17 %). The data collection method was a self-constructed questionnaire focused on the causes, reporting, and resolution of AEs. The questionnaire was administered in printed form, contained 24 items, and used a five-point Likert scale aimed at assessing agreement with the statements presented. Data collection took place in May and June 2024, after permission to conduct the survey had been granted in healthcare facilities in Veľký Krtíš, Levice, and Žiar nad Hronom. In total, 250 questionnaires were distributed, of which 200 (80 %) were fully completed and included in the study. For statistical analysis and data processing, we used SPSS Statistics version 26. We performed descriptive statistical analysis of the data using frequencies (n), arithmetic mean (x̄), and standard deviation (sd). To verify differences between groups, the non-parametric Kruskal-Wallis test was used. Statistical significance was assessed at p = 0.05.
Results
Table 1 Perception of risk factors for the occurrence of AEs according to nurses' age
Table 1 shows the mean values of individual risk factors for the occurrence of AEs in inpatient care according to nurses' age groups. All age groups agreed that fatigue and exhaustion represent a significant factor in the occurrence of AEs. The highest mean value for this item was reported by nurses aged 41–50 years (x̄ = 4.06), which may indicate that sensitivity to this risk factor increases with age. In contrast, the lowest mean was reported by the 31–40 age group (x̄ = 3.64). Despite these differences, no statistically significant differences were found between age groups (p = 0.804). The 41–50 age group also most strongly pointed to inattentiveness at work as a factor influencing the occurrence of AEs (x̄ = 3.73). Nurses aged 50 and over rated the item concerning fast work pace highest (x̄ = 3.66), which, in their view, creates conditions for the occurrence of AEs. In contrast, all age groups agreed that failure to comply with care standards does not have a major impact on the occurrence of AEs, as the values remained below the mean x̄ = 3.25 and statistical significance was also not demonstrated (p = 0.231). Although no statistically significant differences were confirmed in the respondent sample (n = 200) between age groups (all p-values exceeded the threshold of 0.05), the differences in mean values point to the existence of certain age-related trends in how nurses perceive individual risk factors for the occurrence of adverse events.
Table 2 Perception of risk factors for the occurrence of AEs according to nurses' length of practice
Table 2 shows how nurses with different lengths of practice perceive individual risk factors for the occurrence of AEs in inpatient care. The highest mean in all items was recorded among nurses with longer practice (11 years and more). These nurses most often identified exhaustion and fatigue (x̄ = 3.96) as a significant risk factor for the occurrence of AEs. Similarly, fast work pace (x̄ = 3.54) was rated in this group as the second most important factor. Another factor is inattentiveness when administering medication, which was reported by nurses with 6–10 years of practice (x̄ = 3.64). Nurses with the shortest practice (0–5 years) also perceived fatigue and exhaustion as a risk factor (x̄ = 3.83), but overall reported lower mean values in other areas. An interesting finding was the factor "failure to comply with care standards," which showed borderline statistical significance (p = 0.052). While nurses with 0–5 years of practice perceived this factor as the least risky (x̄ = 2.81), nurses with 11 or more years of practice attributed greater importance to it (x̄ = 3.17). In contrast, the other examined factors did not show statistically significant differences between groups, as confirmed by p-values far above the significance threshold (p > 0.05).
Discussion
By understanding the seriousness and prevention of risk factors for the occurrence of AEs, space is created for implementing effective strategies aimed at their elimination. Our findings showed that the most significant factors that nurses in inpatient care perceive as contributing to the occurrence of AEs are primarily exhaustion and fatigue, inattentiveness when administering medication, and fast work pace. The greatest agreement among nurses was recorded precisely for the factor of fatigue and exhaustion, which was perceived as the most critical across all monitored groups. The highest mean values were reported by nurses aged 41–50 years (x̄ = 4.06), with more than 11 years of practice (x̄ = 3.96). This trend is also confirmed by the study by Catania et al. (2024), which recorded 36 % of nurses with high emotional exhaustion (score >27), with an average exhaustion score of 22.9 (±12.6). Similarly, Dall'Ora et al. (2020) identify burnout as a consequence of high work strain, low support, and poor interpersonal cooperation, which negatively affects the quality of care provided and increases the incidence of AEs.
The second most prominent factor, which proved significant in terms of perceived risk for the occurrence of AEs, was inattentiveness when administering medication. The highest values were recorded among nurses aged 41–50 years (x̄ = 3.73), with 6–10 years of practice (x̄ = 3.64). These results are in agreement with the study by Mikos et al. (2020), which identified 20.2 % of AEs associated with pharmacotherapy. Panagioti et al. (2019) showed in their research that as many as 39 % of AEs were related to medication and 22.7 % could have been prevented. Catania et al. (2024) additionally add that medication errors may occur as a result of exhaustion, which directly relates to our finding concerning fatigue. These factors are also closely linked to another risk factor identified in our study, namely fast work pace, which was perceived as most problematic by nurses aged 50 and over (x̄ = 3.66) and with more than 11 years of practice (x̄ = 3.54). Interestingly, our results contradict the conclusion of Al-Mugheed et al. (2022), who stated that nurses with shorter practice experience perceive a higher workload. This discrepancy may be explained by different work environments, organizational culture, or the subjective perception of work demands among less experienced nurses.
In our study, it was shown that failure to comply with care standards is not perceived as a significant risk factor across the entire nursing population (x̄ < 3.25). Nurses with 0–5 years of practice perceived this factor as the least risky (x̄ = 2.81), while nurses with 11 or more years of practice attributed greater importance to it (x̄ = 3.17). This difference may indicate that with increasing experience, nurses become more aware of the importance of adhering to nursing standards and their impact on patient safety. Borderline statistical significance was found (p = 0.052). Zanetti et al. (2021) report that as many as 33.7 % of AEs were directly associated with non-compliance with standards, and as many as 58.3 % of them could have been prevented. Similarly, Nantssupawat et al. (2022) confirm that adherence to standards is of crucial importance for patient safety and care quality. However, non-compliance with standards is often related to another significant factor, namely an unfavorable patient-to-staff ratio. Our findings also pointed to the fact that this imbalance is perceived as a risk particularly by nurses with 11 or more years of practice (x̄ = 3.44) and those aged 41–50 years (x̄ = 3.33). The results support the conclusions of Kiviliene et al. (2024), according to which an increased staffing ratio is associated with a lower incidence of AEs. Nantssupawat et al. (2022) also showed that a higher number of patients per nurse leads to poorer care quality, higher error rates, and nurse dissatisfaction. Wang et al. (2020) further added that a weak structure and insufficient number of nursing staff are directly related to the number of falls and pressure ulcers in inpatient care.
Conclusion
The study results confirmed that nurses, as direct care providers, perceive the most prominent risk factors for the occurrence of AEs primarily in the form of fatigue, exhaustion, inattentiveness, and fast work pace. Perception of these factors was influenced by the length of professional practice and the nurses' age, which points to the need for targeted support in individual stages of professional life. Based on the findings, we believe that systematically reducing risks through effective workload management, support for a safety culture, and improvement of the organizational environment can significantly contribute to eliminating the occurrence of AEs. An important part of these measures is also creating conditions for an open, informal, and supportive environment for reporting AEs without sanctions. Nurses, as professionally competent persons, play a crucial role not only in identifying risks but also in actively participating in the development of AE prevention strategies. Encouraging their participation and building trust represent fundamental prerequisites for maintaining the quality, safety, and continuity of care.
Authors: prof. PhDr. Mária Kilíková, PhD., MPH PhDr. Tatiana Katriňáková PhDr. Monika Štefanová VŠZaSP sv. Alžbety v Bratislave n.o. Detached workplace bl. Sáry Salkaházi in Rožňava
References
ABREU, Tamu. 2021. Adverse event reporting and root cause analysis. In American Nurse Journal. [online] 2021, vol. 16, no. 6. [cit.2025-04-06]. p. 44–46. Dostupné na internete: ˂https://www.myamericannurse.com/wp-content/uploads/2021/04/an6-Root-cause.pdf˃ ISSN 2688-5757.
AL-MUGHEED, Khalid et al. 2022. Patient Safety Attitudes among Doctors and Nurses: Associations with Workload, Adverse Events, Experience. In Healthcare (Basel). [online] 2022, vol. 10, no. 4. [cit. 2025-04-05]. p. 631. Dostupné na internete: ˂https://pubmed.ncbi.nlm.nih.gov/35455809/˃ ISSN 2227-9032.
ARCHER, Stephanie et al. 2017. Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature. In BMJ Open. [online] 2017, vol. 27, no. 7(12) [cit. 2025-04-06]. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/29284714/˃ISSN 2044-6055
CATANIA, Gianluca et al. 2024. Nurses' intention to leave, nurse workload and in-hospital patient mortality in Italy: A descriptive and regression study. In Health Policy. [online] 2024, vol. 143. [cit. 2025-04-06]. p. 105032. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/38460274/˃ ISSN 0168-8510.
DALL'ORA, Chiara et al. 2020. Burnout in nursing: a theoretical review. In Human Resources for Health. [online] 2020, vol. 18, no. 1. [cit. 2025-04-05]. p. 41. Dostupné na internete: ˂https://pubmed.ncbi.nlm.nih.gov/32503559/˃ ISSN 1478-4491.
FLÓREZ, Fredy – LÓPEZ, Lucelly – BERNAL, Catalina. 2022. Prevalence of adverse events and their manifestations in health professionals as second victims. In Biomedica. [online] 2022, vol. 42, no. 1. [cit. 2025-04-05]. p. 184–195. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/35471180 ISSN 0120-4157.
GAO, Xinqiang, et al. 2019. Implications from China patient safety incidents reporting system. In Therapeutics and Clinical Risk Management. [online] 2019, vol. 15. [cit. 2025-04-05]. p. 259–267. Dostupné na internete: https://pmc.ncbi.nlm.nih.gov/articles/PMC6371930/˃ ISSN 1176-6336.
GIARDINA, Traber D. et al. 2020. Health Care Provider Factors Associated with Patient-Reported Adverse Events and Harm. In Joint Commission Journal on Quality and Patient Safety. [online] 2020, vol. 46, no. 5. [cit. 2025-04-05]. p. 282–290. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/32362355 ISSN 1553-7250
KIVILIENE, Juste et al. 2024. The Relationship between Clinical Environment and Adverse Events Reporting: Evidence from Lithuania. In Healthcare (Basel). [online] 2024, vol. 12, no. 2. [cit. 2025-04-05]. p. 252. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/38275531 ISSN 2227-9032
MIKOS, Marcin et al. 2020. Occurrence of adverse events in the activity of hospital wards in the opinions of doctors and nursing management staff. In Annals of Agricultural and Environmental Medicine. [online] 2020, vol. 27, no. 2. [cit. 2025-04-06]. p. 306–309. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/32588611 ISSN 1232-1966.
MOOSAVI, Saeideh et al. 2023. The relationship between patient safety culture and adverse events in Iranian hospitals: a survey among 360 nurses. In Patient Safety in Surgery. [online] 2023, vol. 17, no. 1, [cit. 2025-04-05]. p. 20. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/37496060 ISSN 1754-9493.
NANTSUPAWAT, Apiradee et al. 2022. Nurse staffing, missed care, quality of care and adverse events: A cross-sectional study. In Journal of Nursing Management. [online] 2022, vol 30, no. 2, [cit. 2025-04-05]. p. 447–454. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/34719833 ISSN 0966-0429.
PANAGIOTI, Maria et al. 2019. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. In BMJ. [online] 2019, vol. 366, no. l4185. [cit. 2025-04-05]. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/31315828 ISSN 1756-1833.
RAFTER, Natasha et al. 2017. The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals—a retrospective record review study. In BMJ Quality & Safety. [online] 2017, vol. 26, no. 2. [cit. 2025-04-06]. p. 111–119. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/26862223 ISSN 2044-5415.
WANG, Limin et al. 2020. The effect of nurse staffing on patient-safety outcomes: A cross-sectional survey. In Journal of Nursing Management. [online] 2020, vol. 28, no. 7. [cit. 2025-04-06]. p. 1758–1766. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/32853457 ISSN 1365-2834.
ZANETTI, Ariane Cristina Barboza et al. 2021. Incidence and preventability of adverse events in adult patients admitted to a Brazilian teaching hospital. In PLoS One. [online] 2021, vol. 16, no. 4, s. e0249531. [cit. 2025-04-05]. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/33857137 ISSN 1932-6203.
ZHU, Lin et al. 2020. Extension to 'combined SNA and LDA methods to understand adverse medical events': Doctor and nurse perspectives. In International Journal of Risk & Safety in Medicine. [online] 2020, vol. 31, no. 4. [cit. 2025-04-06]. p. 221–246. Dostupné na internete: https://pubmed.ncbi.nlm.nih.gov/32538872 ISSN 0924-6479.