Ali Mirza

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Background Medical error under-reporting remains a critical barrier to patient safety, often driven by hierarchical organizational structures and fear-related mechanisms. This study aimed to examine the mediating role of fear of negative evaluation in the relationship between power distance and attitudes toward medical error reporting among healthcare professionals. Methods A multicenter study of physicians and nurses was conducted in five tertiary hospitals in Istanbul, Turkey. Data were collected using anonymous, paper-based questionnaires with a stratified quota-based convenience sampling approach. The survey included validated scales assessing organizational power distance, fear of negative evaluation, and attitudes toward medical errors. Mediation analysis was conducted using regression-based models with bias-corrected and accelerated (BCa) bootstrap confidence intervals based on 5,000 resamples. Statistical significance was set at p < 0.05. Results A total of 705 healthcare professionals participated (mean age: 32.3 [SD 8.5] years; 43.7% physicians, 56.3% nurses). More than half (51.9%) reported witnessing a medical error in the past year, whereas only 4.5% demonstrated positive attitudes toward error reporting. Internal medicine staff exhibited higher fear of negative evaluation and greater instrumental use of power compared with surgical staff (p < 0.01). Physicians reported higher fear of negative evaluation and greater use of instrumental power compared with nurses (p < 0.01). Fear of negative evaluation was positively associated with all power distance dimensions (p < 0.05). Mediation analysis showed that fear of negative evaluation mediates the relationship between instrumental use of power and medical error reporting attitudes (standardized β = 0.020, p = 0.013). Conclusion Despite the high prevalence of witnessed medical errors, negative attitudes toward error reporting remained live. The findings suggest that hierarchical organizational dynamics and fear-related mechanisms may contribute to barriers to transparent reporting, highlighting the importance of psychologically safe and nonpunitive communication environments in hospital settings. Clinical trial number Not applicable.

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