# Unraveling Patient Safety Culture Trends in U.S. Hospital Settings: A Yearly Retrospective Analysis
## 4 Discussion
A notable connection has been observed between both professional and personal burnout and an increased risk of patient safety issues and medical errors, as well as diminished perceptions of safety culture. A previous study found that the slow development of PSC is primarily due to challenges related to organizational structure, leadership, and teamwork [30]. Cultivating a \"Just Culture\" that prioritizes learning over blame, alongside addressing staffing shortages, is essential for enhancing PSC and improving patient outcomes [25; 31]. Regarding hospital characteristics, hospitals in the southern and central U.S. regions consistently showed higher perceptions of PSC than those in other regions. Smaller-sized hospitals exhibited more positive perceptions compared to larger hospitals, and non-teaching hospitals demonstrated higher scores in PSC dimensions than teaching hospitals. These findings could be supported by the correlations between hospital characteristics and the identified PSC dimensions [32]. The results over the years showed that 2013 had the highest overall PSC scores and the highest ratings for workers' grades within their work units. This may be attributed to the relatively low number of participating hospitals that year, with two-thirds being small,non-teaching hospitals located in central regions. Two distinct trends emerged over time. First, there was a positive trend in overall PSC scores from 2014 to 2017, accompanied by an increase in positive safety grade perceptions that extended into 2018. However, this was followed by a downward trend in subsequent years. The decline in hospital participation in 2020 may be attributed to the adoption of the latest HSOPSC (version 2.0), which was released in 2019 [33]. Additionally, the drop in PSC scores could be influenced by the impact of the COVID-19 pandemic [34]. The global effects of COVID-19 on patient safety were widely anticipated, prompting the development of frameworks and initiatives aimed at improving healthcare quality and patient safety [35; 36]. Interestingly, while event reporting is generally considered a positive indicator of PSC [9], this study observed that reporting rates tended to move in the opposite direction of safety grades and overall PSC scores over time. Given these findings, further research is strongly recommended to explore the underlying dynamics between these factors and their implications for strengthening PSC. The results of tracking changes in PSC across participating hospitals revealed that, although many PSC dimensions showed statistically significant changes over time, not all reflected meaningful shifts. Guided by the HSOPSC manual [9], this analysis determined changes greater than 5%, which are considered practically significant and more indicative of real progress or decline in the dimensions of PSC. The 5% threshold was adopted because it reflects a meaningful and practical change, helping this study distinguish hospitals that showed actual improvement or deterioration in safety culture over time. While the overall perception of PSC remained moderate--ranging from 64.2% to 66.5%, with an average of approximately 65%--some hospitals with repeated participation demonstrated noticeable improvement in specific areas. Key enhancements were seen in dimensions related to communication and feedback (such as Communication Openness, Feedback and Communication About Error, and Nonpunitive Response to Error), leadership and management support (including Supervisor/Manager Expectations and Actions Promoting Patient Safety and Management Support for Patient Safety), and teamwork (such as Teamwork Within Units, Teamwork Across Units, and Handoffs and Transitions). Additionally, the proportion of participating hospitals reporting \"Excellent\" safety grades increased, signaling advancements in safety perceptions and practices. Event reporting trends also pointed to a shift toward more frequent and transparent reporting, with more hospitals documenting 3 to 5 events annually.