Under-reporting in healthcare stems from two interconnected roots: (1) cultural reluctance – fear of retaliation, emotional fatigue, time pressure, and uncertainty, and (2) infrastructure failures – unclear workflows, fragmented tools, and unreliable systems that make reporting inconsistent or difficult.
Most conversations focus on culture. But cultural change is nearly impossible with a broken system. Before organizations can address emotional and behavioral barriers, they must confront the more fundamental issue: the design flaws that make accurate, consistent reporting nearly impossible.
These issues aren’t separate. Broken infrastructure creates or magnifies cultural barriers. When documentation is confusing, reports disappear, and follow-up is inconsistent, staff understandably lose trust – and reluctance grows from those experiences.
If there’s no unified place to submit incidents, no consistent path to move them forward, and no mechanism to ensure follow-up, the problem isn’t staff willingness at all.
When we talk about “infrastructure,” most people think of software or IT tools. But in the context of incident reporting, infrastructure is much more fundamental. It’s the processes that move an incident from the moment it happens to the moment someone takes action on it.
Infrastructure is:
In many healthcare environments, that machinery is missing pieces– or never existed at all.
None of these breakdowns stem from a lack of effort, and they certainly don’t stem from staff “not caring.” These are system design issues– and they make consistent reporting nearly impossible.
To see how easily reporting breaks down, consider a scenario that mirrors patterns documented across research in clinical incident reporting:
A nurse experiences a threatening outburst from a visitor during an evening shift. She alerts the charge nurse, who agrees it should be documented. There’s no quick reporting mechanism on the unit, so she waits until she can log into a shared workstation. She enters a note into the EHR under “patient behavior,” because the violence reporting tool isn’t embedded in her workflow. She plans to complete a formal report later, once admissions slow down.
Hours pass. More tasks pile up. When she finally returns to document her experience, the form requires fields she can’t complete without supervisor input. She pushes it to the end of her shift, but the handoff arrives before she can finish. By morning, three different people know pieces of the story– but the incident isn’t formally recorded anywhere.
This isn’t reluctance. It’s a system that could not withstand the weight of the report.
Repeated experiences like this– echoed widely in research– shape staff expectations. Over time, they internalize that reporting is exhausting, unclear, or ignored.
When reporting isn’t captured in a single, reliable system, organizations lose visibility into the high risks they need to mitigate. Without a structured workflow to move incidents from submission to action, reporting relies on individual memory– a deeply unreliable mechanism in busy environments. Emails get buried, drafts sit unfinished, and follow-up hinges on whether someone happens to check at the right moment.
These gaps create serious operational blind spots, including:
These aren’t minor oversights. They are early warning signs that allow leaders to intervene before something more serious happens– and without visibility, they simply never appear.
The consequences are predictable. When staff see incidents fall through the cracks, they interpret it as a lack of priority. One study found that 41% of staff chose not to report incidents because previous reports never elicited a meaningful response, reinforcing that when follow-up is uncertain, reporting becomes a risk-to-benefit calculation.
In fragmented systems, the organization isn’t just missing data; it’s missing the chance to act.
The 41% of staff who said they chose not to report because previous reports never elicited a meaningful response aren’t describing a cultural problem– they’re expressing an infrastructure problem that became a cultural one. When the system repeatedly fails to acknowledge or act on what staff share, reluctance isn’t resistance. It’s learned self-protection.
Cultural barriers emerge directly from how the system behaves:
These attitudes don’t come out of nowhere. They form after dozens of moments where the system signals that reporting is slow, complicated, or ineffective. Over time, staff internalize that message, and cultural reluctance becomes the rational choice.
It is difficult to fix the culture of reporting when the mechanics of reporting are still broken. A reliable system is what makes cultural change possible. When reporting becomes predictable, when follow-up is visible, and when outcomes are communicated, trust slowly returns– and participation naturally increases.
The next part of this series will go deeper into these cultural dynamics and explore how organizations can rebuild trust once the infrastructure is strong enough to support it.
A single, reliable home for reporting doesn’t replace incident-management tools– it strengthens them. Not every incident unfolds inside an incident management system, and not every concern comes through an alert. But every incident does need a clear, consistent path once the moment has passed. Whether the report begins at the bedside, in a hallway conversation, or inside a digital workflow, it must move from “what happened” to “what needs to happen next” without guesswork or gaps.
That’s the value of a true home base for reporting. It provides structure long after the immediate situation is resolved, ensuring that every submission integrates cleanly into a predictable, accountable process.
Reliability comes from features that remove ambiguity and keep information moving:
These aren’t conveniences; they’re the backbone of a system that actually works. When every report follows the same pathway, leaders gain the visibility they’ve been missing. Trends emerge sooner. Risks are easier to compare across units. Follow-up becomes a built-in expectation, not something someone has to remember.
Structural integrity– not volume– is what turns reporting into action.
Cultural barriers to reporting are real: fear, doubt, fatigue, uncertainty. These barriers are slow and difficult to overcome without a reliable system underneath. Staff can’t believe reporting matters until the process consistently shows that it does. Infrastructure is the fastest, most controllable place for leaders to intervene, and it sets the conditions for the cultural change that comes later.
Strengthening that foundation doesn’t require a complete system overhaul. It starts with a series of practical, high-impact steps:
By strengthening the mechanics of reporting first, organizations not only capture more accurate data– they create the reliability and predictability required for meaningful cultural change to take root.
Many people who work in healthcare, from front-line staff to executives, chose this field because they care deeply about providing safe, high-quality care. They want to keep doing that work, but they need an environment that supports and protects them. They also need to know that if something does happen, it will be taken seriously, documented reliably, and acted on. When the reporting process is unclear or technically unreliable, the system quietly teaches them that reporting isn’t worth their limited time – and over time, those system flaws harden into cultural reluctance.
Infrastructure isn’t just one half of the underreporting problem – it’s the foundation that determines whether cultural improvements can succeed. When the process is consistent, predictable, and followed by visible action, staff become more willing to report because they trust the system to take their concerns seriously. And as that trust grows, something important happens: leaders don’t simply receive more reports. Reporting becomes more meaningful – and fewer incidents escalate to the point of requiring a report at all.
Next up in this series: a deeper look at the cultural barriers behind under-reporting and how they can be rebuilt.