Ethical, Medicolegal, and Organisational Pressures Shape Patient Safety at Hospital Interfaces: A Qualitative Study...

Patient safety at hospital interfaces is shaped by organisational fragility, ethical obligations, and anticipated legal exposure. Reporting, disclosure, and speaking up have been studied separately, yet the way these pressures converge in ordinary hospital work remains insufficiently described.

We conducted a qualitative study in a public hospital in Romania using semi-structured episodic interviews and the critical incident technique. Twelve clinicians participated: six nurses and six physicians working in intensive care, emergency medicine, general surgery, paediatrics, oncology day care, anaesthesia, obstetrics, and internal medicine/cardiology. Interviews were audio-recorded, transcribed verbatim in Romanian, anonymised, and analysed with the framework method from a critical realist perspective. A secondary cross-case coding of all 12 episodes was used for descriptive analytic displays.

Four mechanisms organised the material. First, local stop rules and cross-checks created temporary stability at fragile interfaces such as high-alert medication, patient identification, specimen labelling, and transfer documentation. Second, consent and confidentiality were repeatedly compressed by urgency, compromised capacity, public space, and family pressure; legitimacy depended on explicit reasoning rather than documentary completion alone. Third, speaking-up and near-miss reporting were governed by protocol-backed legitimacy, leader response, and the informal cost of interruption. Formal incident reporting was present in one episode, partial in one, and absent in 10. Fourth, documentation and disclosure redistributed accountability. Notes that recorded reasoning supported continuity of care, whereas protective opacity concealed near misses, infrastructural weakness, and interactional pressure. Documentation or disclosure pressure appeared in all 12 episodes.

Safety in everyday hospital work was assembled through local barriers, moral triage, and selective visibility. Interface redesign, protected near-miss reporting, psychologically safe escalation, and structured support for urgent consent and post-incident communication would make transparent safety work more sustainable. Trustworthiness was strengthened through reflexive memoing by the physician-interviewer, an audit trail of coding decisions, comparison across professional groups, active attention to negative cases, and iterative assessment of meaning saturation at the level of explanatory mechanisms.