Assessment of Patient Safety Culture in Iranian Academic Hospitals: Strengths and Weaknesses
Authors: Raeissi Pouran , Reisi Nahid , Nasiripour Amir Ashkan 
Published: July 2015

Background
In the relevant literature, the establishment of a patient safety culture (PSC) is a vital step in providing quality service to patients. The goal of this study was to establish a baseline for PSC in Iranian academic hospitals and to determine its strength and weaknesses.

Methods
A survey was distributed in 26 academic hospitals linked to the Iran and Tehran Universities of Medical Sciences, of which 18 participated. The questionnaire, the Hospital Survey on Patient Safety Culture (HSOPSC), was used to collect the data. The questionnaire contained 14 dimensions and 43 items, and the questions were scored using a 5-point Likert scale in which 1 = strongly disagree and 5 = strongly agree.
The results were expressed in the percentage of positive responses (%), or the percentage of positive responses (e.g., agree, strongly agree) to positively worded items (e.g., “Hospital units work well together to provide the best care for patients”) in relation to the percentage of negative responses (e.g., disagree, strongly disagree) to negatively worded items (e.g., “When an event is reported, it feels like the person is being written up, not the problem”). To score each item, the following formula was applied: % of Positive Responses = [(No. of Agree + No. of Totally Agree) / Total No. of Subjects Responding to the Question)] × 100). For the negatively worded items, the answers were reversed. To score each dimension, a composite mean score of positive responses were estimated. The same methodology was applied to the scoring of the PSC of each hospital. (i.e., the composite mean score of positive responses on 12 dimensions was obtained). Note that the data reported in the tables of this manuscript represent percentages, and for ease of communication, (%) are omitted from the stated tables. In the text, however, we have used percent wherever needed.
To categorize the hospitals' safety culture from very weak to very strong, a range of 0.0% to 100% positive responses on the PSC questionnaire was divided by 5 ((100% − 0.0%) / 5 = 20%), and 5 equally spaced intervals were defined (i.e., 0.0%–20.0%, very weak; 21.0%–40.0%, weak; 41.0%–60.0%, intermediate; 61.0%–80.0%, strong; 81.0%–100.0%, very strong).
The convenience sampling method was used to select the samples. For the purpose of this research, 35 questionnaires were randomly distributed in each hospital: 15 among nurses and assistant nurses (as the frontline personnel having the most direct contact with patients) and 20 among other clinical and paraclinical personnel as well as other groups (physicians, residents, interns, ward secretaries, laboratory personnel, radiology personnel, and managers). The questionnaires were distributed and collected by the hospitals' head nurses. The data were analyzed using a one-sample and independent t test.

Results
The mean score of the hospitals on the PSC ranged from 42.74 to 67.22, 12 of 18 hospitals obtained an “intermediate” ranking position, and 6 obtained a “strong” ranking position on the PSC. The overall mean (SD) score for the entire hospital for PSC was 56.74 (18.41). No significant difference was observed between the Iran and Tehran universities of medical sciences hospitals for the PSC. However, significant differences were observable at the dimension and item levels.
A hospital's strengths lie in the “organizational learning–continuous improvement,” “teamwork within hospital units,” and “hospital management support for patient safety” dimensions. Dimensions including “feedback and communication concerning errors,” “communication openness,” “staffing,” and “nonpunitive response to error” were shown to be weak points of all of the hospitals in this study.

Conclusions
The PSC of the investigated hospitals is not at an ideal level and is in need of serious improvement, particularly in the dimensions of feedback and communication regarding errors, communication openness, staffing, and nonpunitive response to error. The same conditions hold true for other Iranian hospitals (i.e., the Afshar and Sadoughi hospitals in the city of Yazd, Iran), and American hospitals were used for comparison purposes in this paper.