Building on social exchange and social identity theory, we examined how leader–member exchange (LMX) influences intention to report incidents in healthcare organizations through two different mechanisms. Using survey data of 15 hospitals in Germany (N = 480) and multilevel structural equation modelling, we found as expected that LMX positively related to reporting-specific trust and organizational identification of employees. However, only reporting-specific trust but not organizational identification was directly related to incident reporting intention. Furthermore, top management support for patient safety moderated the link between LMX and reporting-specific trust, indicating a compensatory mechanism of top management support for followers with a low-quality leadership relationship. In addition, codification of patient safety regulations moderated the link between organizational identification and incident reporting intention. As expected, the institutionalization of patient safety norms through a strong follow-through of the organization is related to increased reporting only for employees with high organizational identification. Results are discussed in terms of how safety leadership can be enacted at both the supervisory and top management level in order to promote safety behaviour in healthcare organizations.
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