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lay solely with departmental leadership to follow-up on and address incidents. A few still expressed fear of retribution, describing being told not to document an incident by a co-worker. Other barriers such as time and accessibility were commonly described. Learning was often described as increased awareness, resulting from expanded communication, and less frequently from explicit teaching. Practice improvement was rarely perceived as learning. Conclusion: Overall, the opportunity to influence patient safety was perceived as highly relevant by participants. Barriers included logistics and inadequate feedback, but also, despite marked progress, some persistence of hierarchical beliefs and behaviors more consistent with "shame and blame" culture. These results identify the need for procedural, cultural, and educational changes, e.g., web access, more specific and timely feedback to clearly demonstrate positive outcomes, and more transparency, to be made within the department so that all staff members continue to feel comfortable reporting incidents and meaningfully engaging in the system.

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