A medical error does not end when the mistake is discovered. For the patient, it may mark the beginning of uncertainty, harm or a difficult recovery. For the clinician involved, it can trigger fear, guilt and professional anxiety. And for the hospital, the way the event is handled can determine whether it becomes a source of learning—or disappears into silence. A qualitative study of healthcare professionals in Iranian teaching hospitals has now examined why disclosing medical errors remains such a difficult ethical challenge, even when clinicians recognize honesty as a fundamental duty. The research, conducted in 2025 by investigators affiliated with Bam University of Medical Sciences and published in BMC Nursing, suggests that disclosure is not simply a personal decision made by an individual healthcare worker. Instead, it is shaped by an interaction among professional ethics, workplace culture, management practices, psychological safety and broader structural pressures. The findings offer a detailed look at how hospitals can unintentionally make transparency feel dangerous.
Medical error disclosure generally refers to communicating with a patient or family after an unintended event in care, explaining what happened, acknowledging the consequences, expressing regret where appropriate and outlining steps taken to manage the harm and prevent recurrence. Such communication is central to patient autonomy because people cannot make informed decisions about their health if important information is withheld. It is also a core element of patient safety: hospitals can only identify recurring vulnerabilities when errors are reported and examined. Yet disclosure can expose clinicians to blame, disciplinary action, legal consequences, damage to their reputation or condemnation from colleagues. In teaching hospitals, these pressures may be intensified by hierarchical structures, multiple layers of supervision and the presence of students or trainees. The new study set out to understand these tensions from the perspective of professionals working inside that environment, where a single clinical incident may involve an entire chain of decisions rather than one isolated act.
The researchers used an inductive qualitative content-analysis approach, a method designed to identify patterns and concepts emerging directly from participants’ accounts rather than testing a predetermined hypothesis. Sixteen healthcare professionals were selected through purposive sampling with maximum variation, allowing the research team to include people with differing professional and contextual experiences. The participants took part in in-depth, semi-structured interviews, which give respondents a framework of questions while leaving room to describe events and perceptions in their own words. The investigators analyzed the interviews concurrently with data collection using the approach developed by Graneheim and Lundman. In this form of analysis, researchers break interview material into meaning units, condense and code those units, and then group related codes into categories and broader themes. The result is not a numerical estimate of how often a behavior occurs, but a map of how participants understand a complex phenomenon and the conditions that influence it.
Five major themes emerged from the interviews, encompassing 20 categories. The first was a conflict between an ethical commitment to honesty and a perception that the organization itself was unsafe. Participants understood that patients deserved truthful information, yet they also described disclosure as a potential threat to their employment, status or professional identity. This creates what researchers characterize as an ethical conflict: the duty to respect the patient’s right to know collides with the instinct to protect oneself in an institution perceived as punitive. In theory, professional codes can provide a clear answer. In practice, clinicians must judge whether their hospital will distinguish an unintended error from negligence, or whether every adverse outcome will be treated as evidence of incompetence. When that distinction is unclear, even ethically motivated professionals may hesitate, delay disclosure or seek informal guidance before speaking to the patient.
The second theme concerned blame-oriented organizational responses and the suppression of learning. A hospital that responds to every error by searching for an individual culprit may appear decisive, but it can undermine the reporting systems needed to detect hazards. Modern patient-safety science often uses a systems perspective, recognizing that errors can arise from multiple contributing factors: confusing instructions, inadequate staffing, faulty equipment, communication failures, interruptions, workload and poorly designed procedures. This does not eliminate individual accountability, particularly in cases involving reckless conduct, but it separates human error from deliberate violations and examines how the working environment shaped the event. The participants’ accounts indicate that when this distinction is absent, clinicians learn that openness carries personal risk. The likely result is under-reporting, defensive documentation and fewer opportunities to identify patterns before they harm another patient.
The study also found that errors may be selectively concealed or managed through informal channels as protective responses. This does not necessarily mean that professionals reject ethical standards; rather, it suggests that disclosure behavior can become an adaptive response to organizational insecurity. Clinicians may decide that some incidents are too minor to report formally, that certain supervisors are safer to approach than others, or that an error should be corrected quietly if possible. Informal management can sometimes resolve an immediate problem, but it also removes events from institutional records. Without reliable reporting, hospitals lose the data required for root-cause analysis, trend detection and safety redesign. A near miss—a mistake caught before reaching the patient—may be especially valuable because it reveals a system vulnerability without causing harm. If staff fear that reporting a near miss will invite punishment, the institution forfeits one of its most useful sources of preventive information.
The third major challenge described by participants was the psychological and moral burden that follows an error. Clinicians who believe they have harmed a patient may experience guilt, shame, anxiety, sleeplessness and fear of professional judgment. Patient-safety researchers sometimes refer to such individuals as “second victims,” although the term remains debated because it can unintentionally compare the clinician’s experience with the patient’s injury. Whatever terminology is used, the emotional consequences are real and can affect concentration, confidence and future clinical decisions. A professional who receives no structured support may become hypervigilant, avoid difficult cases or withdraw from colleagues. The burden can also complicate disclosure: a distressed clinician may focus on self-protection or may be too overwhelmed to communicate clearly. The findings therefore connect ethical transparency with staff wellbeing. Honest conversations are more feasible when clinicians are supported before, during and after the disclosure process.
The fifth theme involved structural and relational conditions that shape whether an error is disclosed. These conditions include the quality of communication between colleagues, relationships with managers, the availability of clear procedures and the wider organization of clinical work. Disclosure is rarely a single conversation delivered in isolation. It may require coordination among the treating clinician, nursing staff, senior physicians, risk managers and hospital administrators. If responsibilities are ambiguous, professionals may assume that someone else will speak to the patient. If senior staff model openness, junior clinicians may feel permitted to report and participate in review. If leaders evade responsibility or use humiliating language, silence can spread through the hierarchy. Teaching hospitals are particularly dependent on relational trust because care is delivered by teams that include professionals at different levels of experience. The study portrays psychological safety—the belief that one can speak up about a concern without disproportionate retaliation—as a practical prerequisite for ethical disclosure, not an optional feature of workplace culture.
Taken together, the findings support the idea of a “Just Culture,” an approach that seeks both accountability and learning. Just Culture does not mean that every action is excused, nor does it prohibit investigation after serious harm. Instead, it aims to respond proportionately by distinguishing slips and lapses from risky choices, repeated violations or intentional misconduct, while also examining the system conditions that made the event possible. In such an environment, disclosure policies would need to go beyond instructions to “be honest.” Hospitals would require clear, standardized procedures explaining who should communicate with patients, when disclosure should occur, what information should be documented and how clinicians can obtain assistance. Training could cover risk communication, apology, cultural expectations and the difference between expressing regret and making unsupported legal admissions. Independent reporting pathways, confidential debriefing and protection against retaliation could help convert individual experiences into organizational knowledge. The researchers’ conclusion is that transparency cannot be imposed on an unsafe system; it must be built through credible institutional responses.
The study has limitations that are important when interpreting its implications. It was qualitative, involved 16 professionals and focused on teaching hospitals affiliated with one Iranian university, so its findings are not statistical estimates of all healthcare workers or all medical errors. The interviews capture participants’ experiences and interpretations rather than independently verified accounts of specific incidents. Cultural, legal and institutional conditions may also influence disclosure differently in other countries or types of hospitals. Nevertheless, the themes echo a wider international concern: healthcare workers may support openness in principle while avoiding it when organizations equate error with personal failure. By showing how honesty, fear, guilt, hierarchy and system design interact, the research shifts attention away from the simplistic question of why one clinician did or did not confess. The more consequential question is whether hospitals create conditions in which telling the truth protects patients, supports professionals and makes the next error less likely. That is the test of a safety system—and, ultimately, of medical ethics in practice.
Subject of Research: Ethical challenges surrounding medical error disclosure among healthcare professionals in Iranian teaching hospitals
Article Title: Ethical challenges in medical error disclosure among healthcare professionals in teaching hospitals: a qualitative study
Article References: Fuladvandi, M., Malekyan, L. & Hamidian, P. “Ethical challenges in medical error disclosure among healthcare professionals in teaching hospitals: a qualitative study.” BMC Nursing (2026). Original research article
Image Credits: AI Generated
DOI: 10.1186/s12912-026-05257-9
Keywords: medical error disclosure, ethical challenges, patient safety, blame culture, psychological safety, Just Culture, healthcare professionals, teaching hospitals
Tags: ethical challenges in healthcarehealthcare professional disclosure practiceshealthcare workplace culture and transparencyhospital management and error disclosureimpact of hospital culture on error transparencymanaging medical errors ethicallymedical error disclosurepatient harm and medical error communicationprofessional ethics in medical error communicationpsychological safety in medical error disclosurestructural pressures influencing error transparencyteaching hospital patient safety
