Breaking the silence: Revealing drivers and barriers to medical students' speaking up in medical error

Speaking up about medical errors is a critical behaviour for medical students, as it plays a vital role in enhancing patient safety. Few studies have explored the drivers and barriers affecting their willingness to speak up in clinical training, particularly within hierarchical Asian cultures. The purpose of this study was to explore drivers and barriers shaping medical students' speaking up behaviours about medical errors to inform education, mentorship and patient safety practices. This qualitative study using a descriptive phenomenological approach was conducted at a teaching hospital in Northern Taiwan between October 2023 and April 2024. Sixth-year medical students, with 20 months of clinical rotations and simulated speaking-up training, were invited to participate in semi-structured interviews. The interview process was concluded after the 10th participant, as data saturation had been achieved. Data were analysed using thematic analysis to explore factors influencing students' willingness and behaviour to speak up in clinical settings. Three main themes were observed: (1) predisposing features, such as personal traits and prior experiences, which may influence students' speaking up behaviour; (2) psychological processes, highlighting the role of professional knowledge, attitudes towards clinical work and ethical and legal considerations; and (3) contextual interaction, emphasising the influence of patient urgency, supervisor characteristics and team atmosphere. The research team also found that the themes are interconnected and collectively influence novices' speaking-up behaviours when faced with a medical error. Confidence and responsibility promote speaking up, but barriers such as hierarchy and fear of criticism hinder it. Although ethical and legal training is designed to promote patient advocacy, it may unintentionally prioritise self-preservation, thereby discouraging speaking-up behaviour in medical error events. These findings may prompt medical educators to re-evaluate the hidden curriculum within ethical and legal training as well as clinical rotations.