Patient safety culture in a tertiary care hospital in Makkah, Saudi Arabia, a cross-sectional study | BMC Health Services Research

To our knowledge, this is the first study comparing responses from a large tertiary center in Makkah on the internationally recognized HSOPSC questionnaire, to those from global data in the US QHCA database. A number of previous studies, however, have attempted to assess patient safety culture in other regions and settings in Saudi Arabia. Examples include a study performed in 2022, by Alrasheadi et. al. to explore patient safety culture using the HSOPSC questionnaire among nurses in medical and surgical wards in four hospitals in Qassim [19]. Before that, in 2010, Alahmadi had published an evaluation of patient safety culture based on the HSOPSC questionnaire distributed in sixteen hospitals in Riyadh [20].

With slightly fewer than 190,000 responses in the global database, along with an adequate local sample of 350 from KAMC, this study had enough power to compare the KAMC data to the global data on individual patient safety domains. This provided a chance to pinpoint areas where the greatest efforts should be put for improvements and areas that can provide an optimistic view. Although the overall patient safety culture rating at KAMC was significantly lower than that obtained from the US QHCA, a closer look at the results obtained from the present research can provide a positive and promising image. The analysis of the current study showed that KAMC, in fact, performed better on the “Organizational learning and continuous improvement”, “Communication about error”, and “Hospital management support for patient safety” domains. Two of these domains, the first and the last, have great promise for accelerated improvement in the near future. The domain of “Staffing and work pace”, which scored lowest in comparison to global data, is a domain that can be easily rectified if adequate recruitment and staffing measures are instituted [21].

Differences from the results obtained globally can also stem from differences in the sample structure. Compared to the global sample, the sample in the current study had a significantly greater proportion of nursing staff. Among other members of healthcare teams, nurses might be the most knowledgeable and skillful regarding patient safety, based on their patient-centered education and direct work with patients [22, 23]. Compared to the global database, this study also revealed a significantly greater proportion of those working directly with patients. We assume that this would make results more authentic and responses more of a reflection of the real-world situation.

Teamwork has been recognized as one of the important determinants of patient safety, given the current complexity of healthcare processes [24]. The current study showed that teamwork scores were lower for KAMC than for global data. Makkah can be considered a cosmopolitan place, and pilgrims and healthcare workers alike come from all over the globe. It is not surprising that effective communication can sometimes pose a challenge, not only due to language barriers but also perhaps due to cultural differences. Bearing that in mind, positive scores of over 80% on teamwork questions should be viewed as an achievement.

In terms of the actual error reporting behavior, this study revealed no significant difference between the KAMC and the global data. This is the fruit of several years of work on healthcare quality in tertiary care institutions in the KSA (Kingdom of Saudi Arabia), for which KAMC stands as a representative. Healthcare quality and patient safety in Saudi Arabia has a long journey that was led and directed by its National Accreditation Program for Healthcare Organizations (NAHCO) and the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI).

An interesting finding in the current study came from the analysis of the participants’ reports about patient safety in their work units. Seventy-two (72%) healthcare workers at KAMC gave a “Very good to Excellent” rating for patient safety in their work units, in contrast to the value of 66.7% obtained from global data. In the study conducted in Qassim by Alrasheadi et al., 69% of the nurses who responded to the questionnaire rated patient safety in their hospital as “Excellent” or “Very good” [19]. Although the latter value was slightly lower than that at KAMC, it still exceeded the globally reported response. This similarity in the figures obtained from the KSA reassures the reader about the validity of the results. However, the percentage of staff reporting “zero adverse incidents” at KAMC was greater than that reported at Qassim, with values of 56% and 50%, respectively. This might also be because the Qassim study sample consisted exclusively of nurses. In the study conducted in 2010, by Alahmadi, in Riyadh, 59% of participants reported an overall positive perception of patient safety [20]. A study performed by Alswat et. al., also in Riyadh, but in a period from 2012-2015 in a medical city, on approximately 2600 employees, showed an overall positive patient safety rating of 67% [25]. Interestingly, Alswat et. al. reported a 56% “zero error reporting”, similar to the figure obtained in the present study. A lower patient safety perception was shown in central Saudi Arabia by Alquwezet al., who reported an overall percentage of positive responses of 49% from a survey distributed in 2016 [26]. Their sample came from three government-owned general hospitals. Differences in values from those of other studies, including the current study, might be due to differences in the settings or the time periods. The increase in the percentage of positive responses seen in successive studies should not be overlooked, and it might be optimistically viewed as an improvement in patient safety culture in Saudi Arabia, in general.

Factors that are known to promote error reporting include good teamwork, providing time for efficient reporting and the presence of mutual respect among staff, thus minimizing blame and punitive mindsets [27,28,29]. In Saudi Arabia, the management support of patient safety, which caused a blame culture, was identified in an analysis performed by Alaska and Alkutb [30] to be one of the barriers to developing a strong patient safety culture. They noted an absence of improvement in the reporting of safety events, an observation that can be noted from the current results, in which the percentage of events reported was like that obtained in Riyadh in 2015 [25]. The staffing domain scored lowest in the analysis by Alaska and Alkutb [30], a finding that was also noted in the current study.

In the current study, there were generally no significant differences among the different subgroups of participants regarding the composite scores of the safety domains. In a study conducted in Riyadh by Alsulami et. al., significant differences in patient safety perception were shown based on participant age and educational level [31]. Such differences were not demonstrated in the current study.

A possible limitation of the current study is that it was conducted in a single tertiary/quaternary care center, and thus, the results do not reflect the overall status of the primary and secondary levels of care in the KSA. KAMC has been established as an exemplary healthcare institution in the busy Makkah region of Saudi Arabia. Staff selection and healthcare quality implementation receive great attention from the higher administration at such institutions in general [11], including KAMC. The current results might thus be reasonably generalizable to the comparable levels of care. Yet, it is worthwhile to point out the diversity of participants in the current study, including doctors, nurses, and other types of healthcare workers. It can thus be reasonably assumed that the views of study participants adequately reflect reality on the ground.

Healthcare improvement in Saudi Arabia over the past decades can be noted by comparing some indicators such as life expectancy, which increased from 64 years in 1964 to 75 years in 2015 [32]. A more accelerated improvement in healthcare and hence, in patient safety culture, is expected with the healthcare transformation being currently implemented as a part of the Saudi Vision 2030 [33]. This transformation aims at managing healthcare at a cluster level, focusing on the delivery of value-based healthcare services [34].