# Patient Safety Culture in Hospital Settings Across Continents: A Systematic Review
## 1 Introduction
Timeliness focuses on reducing delays for both patients and providers. Efficiency maximizes resource use, preventing waste, while Equity ensures consistent quality care across diverse patient demographics. Together, these domains foster a comprehensive approach to PSC, necessitating commitment from all healthcare organization levels and embedding a culture valuing safety, accountability, and continual improvement. Numerous instruments and frameworks are available for assessing the perceptions of PSC within several healthcare settings [11; 12]. One of the most popular instruments in healthcare patient safety research, called the Hospital Survey on Patient Safety Culture (HSOPSC), was developed by the Agency for Healthcare Research and Quality (AHRQ) [13]. This model is a fundamental framework for assessing, improving, and monitoring PSC in healthcare facilities. Also, it identifies essential elements such as leadership commitment to safety, teamwork, organizational learning, open communication, and overall perceptions of patient safety. HSOPSC was first introduced in the 2004 version (1.0) by AHRQ and received an update in the 2019 version (2.0). The first HSOPSC (1.0) assessed PSC across twelve dimensions with 42 subitems. However, the revised HSOPSC (2.0) version streamlined the assessment to ten dimensions with 32 subitems. Both surveys used a 5-point agreement scale from \"strongly agree\" to \"strongly disagree\" on some items or a frequency scale from \"never\" to \"always,\" as well as an option for \"does not apply\" or \"does not know\". In addition, two items were used as outcome measures [14]. One is to rate the unit's overall patient safety, which is from poor to excellent, and another item focuses on the number of events reported in the previous 12 months [13]. These will provide a view and analysis of the effects of organizational culture, such as behavior and shared beliefs and values, and their intersections with PSC, identifying strengths and areas for improvement in the culture of patient safety [15; 16]. As a result, this will enhance patient outcomes, reduce medical errors, and create a safer environment for patients and healthcare professionals [13; 17]. Research on PSC has primarily been conducted within individual countries. A comprehensive view of PSC across continents is still lacking, making it difficult to identify regional trends and best practices that could enhance patient safety culture globally. Also, understanding the multifaceted nature of PSC is essential for its ongoing improvement. Therefore, this study aims to bridge that gap by providing a global perspective on PSC. This systematic review will identify key factors, recognized in previous studies, that contribute to or undermine a strong patient safety culture in hospitals worldwide. The review will offer a comprehensive exploration of these factors by meticulously examining research from diverse countries. Additionally, it will shed light on the current state of PSC worldwide, focusing on identifying variations across different continents and healthcare professional groups. The review will assess these variations by analyzing studies that use the standardized HSOPSC, given its widespread adoption and established psychometric properties [12]. By examining data from various countries, this analysis will provide aggregated results on global PSC variations. Moreover, this comprehensive overview will serve as a valuable foundation for future research and could inform the development of targeted interventions to improve PSC across diverse healthcare settings worldwide.