“Unsafe and unspoken”- Exploring barriers to patient safety and incident reporting in resource-limited intensive care units: A qualitative study

INTRODUCTION: The burden of patient harm from unsafe care is disproportionately high in low-income countries, particularly in intensive care units (ICUs). Despite this, there is limited empirical evidence explaining the underlying challenges that make patient safety difficult to achieve in resource-limited ICUs. OBJECTIVES: To explore the barriers to patient safety and incident-reporting in ICUs at Ethiopian university hospital. METHODS: An exploratory qualitative descriptive study was conducted using in-depth interviews guided by a semi-structured protocol and informed by the Theoretical Domains Framework (TDF). Participants were purposively selected, and sample size was determined based on principles of data sufficiency. Reflexive thematic analysis with inductive orientation was employed following Braun and Clarke's approach. RESULTS: Thirty-nine healthcare professionals participated: 23 (59 %) nurses, 13 (33 %) physicians, and 3 (8 %) clinical pharmacists. The mean age of participants was 32 ± 5 years. Three overarching themes captured the barriers to patient safety and incident reporting in ICUs: (i) Fragile systems: Governance failure and resource constraints; (ii) Normalisation of deviance: teaching-hospital dynamics and clinical oversight, normalised communication lapses, and weak teamwork and relational context; and (iii) Silence trap: Fear in punitive and blame-oriented culture and lack of incident-reporting systems. CONCLUSION: Patient safety in Ethiopian ICUs is undermined by systemic, operational, and clinician-related obstacles. Structural and cultural barriers further hinder incident-reporting creating a vicious cycle where unsafe care remains hidden and opportunities for learning and improvements are lost. Breaking this cycle requires strong governance, coordinated resource investment, enhancing just culture, strengthening teamwork, establishing robust incident-reporting systems, and ongoing professional development focused on patient safety. IMPLICATIONS FOR CLINICAL PRACTICE: Identifying barriers to patient safety and incident reporting in ICUs may enables targeted interventions that reduce preventable harm, improve care quality, and promote incident reporting and learning to sustain safe clinical practice.