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Would your problem identified -Hospital Survey on Patients Safety Culture- lend itself to a qualitative or quantitative design? What level of evidence (research design) would best address the problem?

Use these 2 articles- are they qualitative or quantitave? What type of research is?

Research Article
Healthcare Professional’s Perception of Patient Safety
Measured by the Hospital Survey on Patient Safety Culture:
A Systematic Review and Meta-Analysis

Julia Hiromi Hori Okuyama ,1 Tais Freire Galvao ,2 and Marcus Tolentino Silva

1Universidade de Sorocaba, Graduate Program of Pharmaceutical Science, Sorocaba, Brazil
2Universidade Estadual de Campinas, Faculty of Pharmaceutical Sciences, Campinas, Brazil

Correspondence should be addressed to Marcus Tolentino Silva; marcusts@gmail.com

Received 18 January 2018; Revised 27 May 2018; Accepted 12 June 2018; Published 19 July 2018

Academic Editor: Xiang Gao

Copyright © 2018 Julia Hiromi Hori Okuyama et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Objective. To assess the culture of patient safety in studies that employed the hospital survey on patient safety culture (HSOPS)
in hospitals around the world. Method. We searched MEDLINE, EMBASE, SCOPUS, CINAHL, and SciELO. Two researchers
selected studies and extracted the following data: year of publication, country, percentage of physicians and nurses, sample size, and
results for the 12 HSOPS dimensions. For each dimension, a random effects meta-analysis with double-arcsine transformation was
performed, as well as meta-regressions to investigate heterogeneity, and tests for publication bias. Results. 59 studies with 755,415
practitioners surveyed were included in the review. 29 studies were conducted in the Asian continent and 11 in the United States. On
average studies scored 9 out of 10 methodological quality score. Of the 12 HSOPS dimensions, six scored under 50% of positivity,
with “nonpunitive response to errors” the lowest one. In the meta-regression, three dimensions were shown to be influenced by
the proportion of physicians and five by the continent where survey was held. Conclusions. The HSOPS is widely used in several
countries to assess the culture of patient safety in hospital settings. The culture of culpability is the main weakness across studies.
Encouraging event reporting and learning from errors should be priorities in hospitals worldwide.

1. Introduction

Health institutions, which are known to be complex organiza-
tions, have over the years devised improvement strategies and
added quality to the health care service [1]. Patient’s safety
culture reflects the perceptions of processes, norms, and
attitudes relating to a culture of preventable errors shared by
health professionals in the delivery of care [2]. In health envi-
ronments, behaviors and attitudes shape the culture of each
organization [3]. The sharing of beliefs, values, and attitudes
related to the patient’s safety culture influences the outcome
and organizational aspects [4].

Higher culture of patient safety has been shown to be
associated with better patient outcomes [5]. Quality in hos-
pital services means providing the patient with multidisci-
plinary care at minimal risk [6]. Therefore, implementing im-
provements in organizational and safety culture enhances
quality [7].

Surveys are widely used to assess the culture of safety by
identifying the perception of health practitioners [8]. Such
inquiries allow for a general assessment of the work climate,
the relationship between teams or in a given group, commu-
nications, professional relationships, and hierarchical rela-
tions. They can identify areas that need prioritization for in-
terventions.

Among the validated tools [8], the Hospital Survey on
Patient Safety Culture (HSOPS) and the Safety Attitudes
Questionnaire (SAQ), both created in the United States of
America (US), are widely cited in research that aims to assess
the safety culture of patients in different countries [9]. The
HSOPS was designed by the US Agency of Healthcare Re-
search and Quality in 2004 and proposes the assessment of
12 dimensions pertaining to the climate of patient safety in
hospital setting. Seven dimensions of the survey are related to
the work area, three dimensions explore aspects of the safety

Hindawi
e Scientific World Journal
Volume 2018, Article ID 9156301, 11 pages
https://doi.org/10.1155/2018/9156301

http://orcid.org/0000-0002-5862-7928

http://orcid.org/0000-0003-2072-4834

http://orcid.org/0000-0002-7186-9075

https://doi.org/10.1155/2018/9156301

2 The Scientific World Journal

culture in the hospital, and two are outcome variables [10].
The culture of safety is measured by the staff perspective. For
each dimension, percentages above 75% are considered as
strengths and below 50% are areas that need improvement
[10].

Since its inception, HSOPS has been translated and vali-
dated in several languages and settings [11–17]. To date, no
compilation of surveys that employed HSOPS in hospitals in
different countries. This comparison would bring valuable
sources of strengths and limitations of culture of patient
safety.

The aim of present study is to summarize surveys that
assessed the culture of patient safety by HSOPS in hospitals
worldwide, by means of a systematic review and meta-anal-
ysis.

2. Methods

2.1. Protocol and Registration. The protocol for this review
was prepared in advance and registered in the International
Prospective Register of Systematic Reviews (PROSPERO)
under registration number CRD42016047941.

2.2. Eligibility Criteria. Studies meeting the criteria were
selected as follows: Portuguese, Spanish, or English language;
publication date between 2008 and 2015; cross-sectional,
hospital-based design; full or partial use of the HSOPS ques-
tionnaire; inclusion of staff with direct or indirect patient con-
tact; and surveying one or more categories of health profes-
sionals.

Studies were excluded if they were performed outside of
the hospital setting, if they were conducted in a single area or
unit of the hospital, or if they were lacking in results for
each dimension. Additionally, validation studies, duplicate
studies, papers with no full-text available, or studies that used
qualitative approaches were excluded.

2.3. Information Sources and Search Strategy. The following
databases were searched: MEDLINE (via PubMed), EMBASE,
SCOPUS, CINAHL, and SciELO.

The search terms used for PubMed that were adapted for
the other databases were “HSOPSC OR (Hospital Survey on
Patient Safety Culture)”.

2.4. Study Selection. The Covidence software platform (www
.covidence.org) was used to organize the references and find
duplicates. Two independent reviewers screened the titles and
abstracts of the papers, with selected papers progressing to
the second phase, which was a full-text review. The articles
were evaluated according to pre-specified criteria and, in the
event of disagreements in either of the two phases, a third
reviewer determined the inclusion.

2.5. Data Collection Process. Two reviewers independently
summarized the data using a data extraction sheet. The
following information was collected from each paper: year,
country, proportion of physicians and nurses, sample size,
and results for the 12 HSOPS dimensions (Table 1).

2.6. Risk of Bias. Two reviewers evaluated the studies inde-
pendently using a validated 10-item tool, which assessed (i)
representativeness of the sample, (ii) appropriateness of the
recruitment, (iii) adequacy of the sample size, (iv) description
of both the study subjects and the setting, (v) response rate,
(vi) objective, standard criteria used for the measurement
of the condition, (vii) reliability of the measurement of the
condition, (viii) appropriateness of the statistical analysis, (ix)
important confounding factors/subgroups/differences that
were identified and accounted for, and (x) subpopulations
that were identified using objective criteria [18]. Disagree-
ments were resolved by consensus.

2.7. Summary Measures and Statistical Analysis. The out-
come measure for this study was the proportion of positive
responses in each dimension. STATA statistical software
V.14.2 was used for all calculations.

For each HSOPS dimension, meta-analyses were per-
formed by grouping the positive scores using the random
effects model described by DerSimonian and Laird and the
double-arcsine transformation for variance stabilization as
proposed by Freeman-Tukey [19, 20]. The prediction confi-
dence interval was also calculated [20, 21].

Heterogeneity was assessed by calculating the inverse
variance in a fixed-effects model, which was expressed as a
percentage of the I2 statistic [20, 22]. Among the study char-
acteristics, possible causes of heterogeneity were investigated:
year of publication, proportion of physicians, proportion of
nurses, quality scores, and continent where the study was
performed. A meta-regression was performed of the double-
arcsine transformed results in the method-of-moments
model with a restricted maximum likelihood and a modi-
fied coefficient variance as suggested by Knapp and Hartung
[23, 24]. Thus, the𝛽 coefficient, the probability (p value), and
the residual heterogeneity were calculated. Values of p<0.05 were deemed significant.

Publication bias (small study effect) was investigated
using three approaches for each dimension. The first con-
sisted of a regression of the log odds of the positive results
against their standard errors (Egger’s test). The second strat-
egy was a regression of the odds against the reciprocal of the
sample size (Peters’ test). For both tests, probability values
below 0.10 were deemed significant [25]. The third approach
included a visual assessment of asymmetry in two funnel
plots: one that compared sample size against log odds and the
other that compared the log odds against the standard errors
[25, 26].

3. Results

The search retrieved 582 studies, of which 59 were included
[5, 27–83] (Figure 1).

Eleven studies were published prior to 2011; and 48,
between 2011 and 2015 (Table 2). Twenty-nine were con-
ducted in Asia (of note, eight in Iran), 18 occurred in Europe,
and 14 occurred in American continent, of which 11 were in
the US. Two studies were located in Eurasia (Turkey) and one
was in Africa (Egypt).

http://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016047941

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The Scientific World Journal 3

582 references
identified

426 studies were excluded a�er title and
abstract screening and the removal of
duplicates

97 records removed:
24 studies did not investigate patient
safety
11 studies did not use the HSOPSC.
20 studies conducted the research in a
single area or in a single hospital unit
10 studies were not performed in a
hospital environment
9 articles in a language other than
Portuguese, Spanish or English
13 were abstracts written by a congress
9 studies were duplicates
1 study was not performed on the
health professionals of that hospital

59 studies were included in
the review

156 full-text references
were screened

Figure 1: Flowchart of included studies.

Table 1: Hospital Survey on Patient Safety Culture dimensions and what they are intended to measure.

Dimensions of patient safety culture related to the work area or unit
(1) Teamwork within units

Supervisors and managers consider employee suggestion about patient safety,
teamwork and open communication about errors, work hours are adequate to
provide the best patient care. Feedback from management, and continuous
improvement to avoid errors.

(2) Supervisor/manager expectations and actions
that promote patient safety
(3) Organizational learning and continuous
improvement
(4) Communication openness
(5) Feedback and communication about error
(6) Staffing
(7) Nonpunitive response to errors
Dimensions explore aspects of the safety culture in hospital
(8) Management support for patient safety

Hospital management support patient safety and patient care information are not
lost during shift change and from one unit to another(9) Teamwork across units

(10) Handoffs and Transition
Dimensions of outcome variables
(11) Overall perceptions of patient safety Existence of procedures to avoid the occurrence of errors, notifications of possible

problems and corrections before they affect the patient(12) Frequency of events reported

4 The Scientific World Journal

Table 2: Characteristics of included studies (n=59).

Continent Countries Author, year Sample size Proportion of
physicians

Proportion of
nurses

Quality score

Africa Egypt Aboul-Fotouh, 2012 510 50.0 32.4 10

America

Brazil Silva-Batalha, 2015 301 – 18.9 9
Colombia Gómez Ramı́rez, 2011 201 – 54.7 10

United States of America

Blegen, 2010a 368 40.0 33.0 9
434 34.0 30.0

Bump, 2015 955 100.0 – 7
Campbell, 2010 2,163 19.9 80.1 10

Dupree, 2011b
163 25.0 37.0

10234 21.0 48.0
325 – –

Halbesleben, 2008 148 – 100.0 10
Jones, 2013 2,137 9.4 32.0 10

Mardon, 2010 179 – – 10
Patterson, 2015 247,140 4.7 51.2 10
Ulrich, 2014 979 – 100.0 10
Wagner, 2013c 196,462 4.0 36.0 8
Wu, 2013d 106,710 – 100.0 9

Mexico Castañeda-Hidalgo, 2013 195 – 90.3 10

Asia

Saudi Arabia

Aboshaiqah, 2010 445 – 100.0 10
Aboshaiqah, 2013 498 – 100.0 10
Alahmadi, 2010 1,224 8.3 60.0 9
Al-Ahmadi, 2009 1,224 8.8 63.7 9
Al-Awa, 2012 605 – 100.0 7
El-Jardali, 2014 2,572 8.7 50.1 10

China
Nie, 2013 1,160 25.9 62.2 8
Shu, 2015 2,230 31.0 69.0 10
Wang, 2014 463 – 100.0 10

Iran

Adibi, 2012 90 7.8 71.1 3
Al-Mandhari, 2014 398 20.9 59.5 10
Ammouri, 2015 414 – 100.0 10

Bahrami, 2013e 135 – 100.0 9
135 – 100.0

Bahrami, 2014f
113 – 100.0 10
189 – 100.0

Davoodi, 2013 922 10.0 77.0 10
Moussavi, 2013 175 32.6 41.7 10
Raeissi, 2015 461 15.2 51.0 10

Japan
Fujita, 2013h 6,963 8.5 58.1 10
Fujita, 2014 8,700 9.3 46.4 9
Wu, 2013d 4,047 – 100.0 9

Jordan Khater, 2015 658 – 100.0 10
Saleh, 2015 242 – 100.0 10

Lebanon El-Jardali, 2010 6,807 3.7 57.8 10
Palestine Hamdan, 2013 1,408 20.0 49.2 10

Taiwan

Chen, 2012 788 29.2 60.7 10
Chen, 2010 788 29.2 60.7 10
Fujita, 2013h 10,019 9.7 57.0 10
Wagner, 2013c 10,146 10.0 58.0 8
Wu, 2013d 5,714 – 100.0 9

The Scientific World Journal 5

Table 2: Continued.

Continent Countries Author, year Sample size Proportion of
physicians
Proportion of
nurses
Quality score

Eurasian Turkey Günes, 2015 554 – 100.0 8
Ugurluoglu, 2012 108 27.8 42.6 9

Europe

Belgium

Vlayen, 2012 55,225 8.8 49.8 10

Hellings, 2010g 3,626 12.2 60.5 10
3,940 11.7 64.1

Vlayen, 2015 47,136 9.6 52.5 9

Croatia Brborovic, 2014 148 – 100.0 8
Sklebar, 2013 560 – – 5

Scotland Agnew, 2013 1,866 – 53.0 5
Western Slovakia Mikusová, 2012 1,787 13.6 50.5 9

Spain
Gama, 2013 1,113 24.7 45.0 10
Saturno, 2008 2,503 – – 8
Skodova, 2011 299 – 40.1 10

Finland Kuosmanen, 2013 283 6.4 82.2 6
Turunen, 2013 832 – 100.0 6

Italy Bagnasco, 2011 724 35.0 26.0 7

Norway Ballangrud, 2012 220 – 100.0 10
Farup, 2015 185 14.1 61.6 10

Netherlands Smits, 2012 542 16.5 74.0 6
Wagner, 2013c 3,779 12.0 53.0 8

United Kingdom Lawton, 2015 648 – 100.0 8
Note.a,b,g Different years: a2006 and 2007, b2005, 2008, and 2011, and g2005 and 2007; c,dsame study conducted on different continents; e,fsame study performed
in different hospitals; hsame study conducted on different countries.

The studies included 755,415 professionals who answered
the HSOPS, of which 55.4% were nurses and 5.2% were phys-
icians. Sample sizes ranged from 90 to 247,140 participants
(Table 2). The largest studies were conducted in the US [63,
64, 78] while the smallest studies were Iranian[41].

One study surveyed the same institution three times on
different years [37]. Thirty-three studies included a variety
of professionals, 22 surveyed nursing staff exclusively and
one surveyed only physicians [73]. Four investigations were
multi-center studies [31, 35, 51, 66] (surveys administered
at different hospitals in the same country) and three were
international multi-center surveys [54, 63, 64].

The mean score for methodological quality of the evalu-
ated articles, on a scale of 0 to 10, was 9.0 points, with 34 stud-
ies that achieved the maximum score (Table 2). Considering
the appraisal criteria, 19 studies showed errors in the par-
ticipant recruitment process, 12 neglected the calculation of
sample size, and nine failed to report response rates.

The results of the meta-analyses of the 12 HSOPS dimen-
sions are presented in Table 3. Five had less than 50% of pos-
itivity in the dimensions of “communication openness”, “fre-
quency of events reported”, “staffing”, “handoffs and transi-
tions”, and “nonpunitive response to errors”. Only the dimen-
sion of “teamwork within units” produced positive responses
in 75% of those surveyed, which was the highest percentage.

A survey that was conducted in Norway in 2012 produced
positive responses in 78.8% of the “nonpunitive response to
errors” dimension,[42] and an analysis performed in Spain,
reported 3.7% positivity for the dimension of “management
support for patient safety”[39], while seven others had posi-
tive scores of less than 30% [28, 36, 40–42, 55, 72].

The meta-analyses detected high heterogeneity values
across the HSOPS dimensions, with all that were above
97%. The meta-regression showed that three dimensions were
influenced by the proportion of doctors in the dimensions
of “overall perceptions of patient safety”, “feedback and
communication about error”, and the “frequency of events
reported” (Table 4). The continent where the survey was held
significantly affected the dimensions of “supervisor/manager
expectations and actions promoting patient safety” (America
72-76% versus others 42-67%), “overall perceptions of patient
safety” (America 58-67% versus others 30-55%), “communi-
cation openness” (America 59-63% versus others 31-63%),
“staffing” (America 47-64% versus others 31-63%), and “non-
punitive response to errors” Asia and Eurasian 23-32%
versus Europa and America 36-58%). Only the dimensions of
“organizational learning-continuous improvement”, “team-
work within units”, and “handoffs and transitions” were
not positive for small study effects. Funnel plot inspections
showed asymmetry in all dimensions (data not shown).

6 The Scientific World Journal

Table 3: Meta-analyses of the dimensions and respective heterogeneity (I2) of the Hospital Survey on Patient Safety Culture (n=59 studies).

Dimensions Positive responses, %(95% CI) I
2 (%)

Teamwork within units 75 (73-76) 97.9
Supervisor/Manager expectations and
actions that promote patient safety 61 (59-64) 99.0

Organizational learning and continuous
improvement 70 (67-73) 99.3

Management support for patient safety 53 (48-57) 99.6
Overall perceptions of patient safety 54 (51-56) 98.9
Feedback and communication about error 54 (51-57) 99.1
Communication openness 47 (44-51) 99.4
Frequency of events reported 48 (45-52) 99.5
Teamwork across units 50 (47-53) 98.9
Staffing 36 (33-40) 99.5
Handoffs and transitions 45 (44-47) 97.7
Nonpunitive response to errors 33 (30-37) 99.4
Note. Positive responses in percentage. 95% CI, 95% predictive confidence interval.

4. Discussion

The present review made it possible to identify studies that
used HSOPS and to evaluate the safety culture of patient
in hospital setting worldwide. There are still aspects in the
safety culture of patient that deserve attention to improve
patient care in these environments. HSOPS was used both in
a specific class of professionals as well as to all hospital staff.

The dimension “nonpunitive response to errors” was the
one with the lowest score and “teamwork among the units”
the highest score regarding the patient safety items addressed
in the survey. Similar results were found in a systematic
review and meta-analysis of the HSOPS conducted to assess
the patient’s safety culture in hospitals in Iran [84]. This
review included Iranian surveys conducted between 2000
and 2014 and used a writing tool as an instrument of critical
evaluation, with calculation of meta-analysis using simple
means of the domains.

The weakest dimensions were those that were related to
communication problems and staffing, with the “nonpunitive
response to error” the worst rated dimension. This may
reflect the culpability culture of the hospitals but also a com-
prehensiveness problem. This domain has only negative ques-
tions, which induces misunderstanding and less reliability
in questionnaires [85]. Dimensions with lower scores may
reflect the wording and not the limitation in safety culture.
External analyses of HSOPS [86] showed possible weaknesses
in its psychometric properties.

Evaluating perceptions of the culture of safety implies
the consideration of a number of factors and characteristics
pertaining to the hospital setting [87]. Management that is
committed to safety culture, effective leadership support,
effective communication, sufficient staffing, incentives to
capacity-building, and interdisciplinary teamwork are just

some of those factors [72]. Unities with different profiles
in terms of their constitution and organization (specialized
intensive care units, emergency departments, surgical suites,
and wards) are found in hospitals [88]. In those unities,
perceptions of patient safety vary between practitioners [32,
42]. In this review, the influence of the medical staff was noted
for some dimensions. Thus, to assess the perception of patient
safety through surveys, the influence of the context of each
unit and different professionals should also be considered.

Studies that evaluated the culture of safety have shown
contrasting perceptions regarding patient safety in different
professionals, and in one study, physicians showed a less pos-
itive perception compared to nurses [89] and more positive
perceptions compared to the nursing staff in another [90, 91].

The continent where the study was conducted was a
source of variability of results across studies. In international
multi-center studies [54, 63], a greater proportion of positive
scores was found in the US than elsewhere. In addition to the
cultural differences [63], the HSOPS was developed in the US;
hence its use is more disseminated in that country, a fact that
becomes evident in the sample sizes. Another factor detected
in those multi-center studies is the larger number of nurses in
US hospitals compared to other countries [54], a fact that is
attributable to the way hospitals adapt the numbers of nurses
to their demand and hire temporary staff.

In a Norwegian study [42], a salient strength was found
in the “nonpunitive response to error” dimension. Another
study conducted in the same country [92] found a similar
value for this dimension. In most studies that were con-
ducted in a variety of countries, this dimension yielded low
scores, which indicated the need for improvement. Other
investigations were pursued [28, 32, 55, 58, 60, 63, 70] with
higher positive percentages in this dimension and seven were
found with positive scores above 50%. It was noted that,

The Scientific World Journal 7

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8 The Scientific World Journal

in the settings where these surveys were administered, a
climate of encouragement existed in the management staff
who promoted reporting and learning from errors.

Included studies showed good methodological quality,
which showed no effect on the heterogeneity, partly attribu-
table to the proportion of physicians and the location where
the surveys were administered. The statistical tests indicated
that small study effect was present and publication bias may
have influenced the results. Studies published in scientific
conferences and in other gray literature were not included
and the restriction of only publications in Portuguese,
English, and Spanish may have stressed out this effect. With
the purpose of extending the usability and determining the
applicability of the HSOPS, all sample sizes and professional
categories were included, which influenced the high hetero-
geneity.

As a psychometric tool, HSOPS adaptation versions [93]
are subject to inconsistences due to language and cultural
particularities. A previous validation of the tool was not an
eligibility criterion in our review. This may have overesti-
mated or underestimated our findings and probably con-
tributed to the high heterogeneity. HSOPS showed good
psychometric properties of safety culture [10] when assessed
by its development group. Like other questionnaires, the link
between the society culture and patient safety may be an issue
and could be better explored by qualitative assessment.

The methods of this review were based on internationally
recommended standards [94]. Thus, paired reviewers worked
on the inclusion, evaluation, and data extraction steps. Data
analysis relied on statistical calculations grouped according
to relevant variables. The use of the HSOPS is still emerging
in some countries. In accordance with the worldwide trend
towards patient safety in the health services, this systematic
review could foster the use and dissemination of the HSOPS.

5. Conclusions

The culture of culpability is pervasive in most of the hospitals
that measured the culture of safety using the HSOPS. This
behavior reduces error reporting and the likelihood that cor-
rective measures would be implemented. Effective communi-
cation, feedback following reporting, engaged leadership, and
environments focused on learning from errors are factors that
can lead to improvement.

Data Availability

The data used to support the findings of this study are avail-
able upon request from the corresponding author.

Disclosure

This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors’ Contributions

Julia Hiromi Hori Okuyama selected the studies, extracted
the data, assessed the methodological quality of included
studies, and drafted the manuscript. Tais Freire Galvao
selected studies, extracted the data, and revised the manu-
script for important intellectual content. Marcus Tolentino
Silva designed the study, analyzed the data, mentored the
drafting of the manuscript, and revised it for important
intellectual content. All authors agree to be responsible for
all aspects of the study and approved the final version of the
manuscript.

Acknowledgments

The authors are grateful to graduate students in pharmacy,
Henderson Hirata, for his participation in data extraction and
Tathiany Torres, for her participation in critical appraisal of
included studies.

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International Journal for Quality in Health Care, 2018, 30(9), 660–677
doi: 10.1093/intqhc/mzy080

Advance Access Publication Date: 17 May 2018

Review

The patient safety culture: a systematic review

by characteristics of Hospital Survey on Patient

Safety Culture

dimensions

CLÁUDIA TARTAGLIA REIS
1,2

, SOFIA GUERRA PAIVA
2
,

and PAULO SOUSA
2,3

1Brazilian Minister of Health, SMS Cataguases, Rua José Gustavo Cohen, 70 Cataguases, MG 36772-014, Brazil,
2National School of Public Health, Universidade Nova de Lisboa, Avenida Padre Cruz, 1600-540 Lisboa, Portugal,
and 3CISP—Centro de Investigação em Saúde Pública, ENSP-Universidade Nova de Lisboa, Avenida Padre Cruz,
1600-540, Lisboa, Portugal

Address reprint requests to: Cláudia Tartaglia Reis, Rua Manoel Ramos Trindade 76/201 Cataguases, MG, Brazil.
Tel: +55 32-3421-3121; Fax: +55 32-3429-2600; E-mail: clautartaglia@gmail.com

Editorial Decision 22 March 2018; Accepted 3 May 2018

Abstract

Purpose: To learn the weaknesses and strengths of safety culture as expressed by the dimen-

sions measured by the Hospital Survey on Patient Safety Culture (HSOPSC) at hospitals in the

various cultural contexts. The aim of this study was to identify studies that have used the

HSOPSC to collect data on safety culture at hospitals; to survey their findings in the safety cul-

ture dimensions and possible contributions to improving the quality and safety of hospital

care.

Data sources: Medline (via PubMed), Web of Science and Scopus were searched from 2005 to

July 2016 in English, Portuguese and Spanish.

Study selection: Studies were identified using specific search terms and inclusion criteria. A total

of 33 articles, reporting on 21 countries, was included.

Data extraction: Scores were extracted by patient safety culture dimensions assessed by the

HSOPSC. The quality of the studies was evaluated by the STROBE Statement.

Results: The dimensions that proved strongest were ‘Teamwork within units’ and ‘Organisational

learning–continuous improvement’. Particularly weak dimensions were ‘Non-punitive response to

error’, ‘Staffing’, ‘Handoffs and transitions’ and ‘Teamwork across units’.

Conclusion: The studies revealed a predominance of hospital organisational cultures that were

underdeveloped or weak as regards patient safety. For them to be effective, safety culture evalu-

ation should be tied to strategies designed to develop safety culture hospital-wide.

Key words: patient safety, safety culture, survey, hospital care, quality improvement

Background

Patient safety is a critical component of the quality of healthcare. It
is increasingly recognised that strengthening safety culture in health
organisations is important to continuously improving the quality of

care. Strong safety culture is associated with achieving favourable
outcomes, especially in hospitals [1, 2].

Safety culture comprises an understanding of values, beliefs and
standards as regards what is important in an organisation and what

© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com 660

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safety-related attitudes and behaviour are valued, supported and
expected [3]. Organisations with a strong safety culture are charac-
terised by good communication among staff, mutual trust and com-
mon perceptions of the importance of safety and the effectiveness of
preventive measures [4, 5].

Safety culture is a multidimensional concept defined, in the
health service context, as the product of values, attitudes, percep-
tions, competences and standards of individual and group behaviour
that determine the administration’s commitment, style and profi-
ciency in managing patient safety [6].

Hospital safety culture assessment is being used as a manage-
ment tool and encouraged by health policymakers and managers in
countries around the world. The culture assessment has multiple
uses: (i) building staff awareness on patient safety; (ii) evaluating the
present state of patient safety culture (PSC) in the organisation; (iii)
identifying strong points of safety culture and areas for improve-
ment; (iv) analysing safety culture trends over time; (v) evaluating
the impact on safety culture of initiatives and interventions to

improve patient safety and (vi) drawing comparisons within and
between health organisations [3].

In the 2000s, questionnaires and assessment instruments were
developed to assist in understanding an organisation’s safety cul-
ture and whether it is ready to receive measures to improve the
safety and quality of care as well as to ascertain what factors may
favour or hinder efforts in this respect. These questionnaires are
based on a combination of dimensions; they are considered an effi-
cient strategy and offer methodological advantages, such as assur-
ing participant anonymity and lower costs than qualitative
approaches [7]. Since the mid-2000s, such instruments have been
the subject of a number of review studies, which have compared
their overall characteristics and examined their psychometric prop-
erties [8–11].

The Hospital Survey on Patient Safety Culture (HSOPSC) cre-
ated by the Agency for Healthcare Research and Quality (AHRQ) in
the USA [12], is applicable to hospital staffs whose work influences
patient care directly or indirectly—from housekeeping and security
to nurses and physicians (clinical staff or non-clinical staff, such as
unit clerks, staff in units such as pharmacy, laboratory/pathology,
staff in other areas, such as administration and management). The
HSOPSC has performed satisfactorily in psychometric analyses, as
demonstrated by a number of studies [9–11], and is accessible to
professionals the world over interested in assessing safety culture at
their hospital. It is being used by hundreds of hospitals in the USA
and several other industrialised and developing countries. By 2015,
more than 60 countries had published studies using this instrument,
which is available in some 30 different translations, backed by trans-
cultural adaptation studies [13].

In this context, the study question here is: as measured by the
HSOPSC in the various cultural contexts in which it has been used,

Table 1 Search strategy in MEDLINE via PubMed
a

Strategy Keywords

#1 ‘Safety culture’ (All fields) OR ‘safety climate’ (All fields) OR
organisational culture [MeSH Terms]

#2 Hospitals [MeSH Terms]
#3 Patient safety [All fields]
#4 #1 AND #2 AND #3

aPeriod: 1 January 2005–31 July 2016. Languages: English, Portuguese
and Spanish.

Table 2 Patient safety culture dimensions and definitions

Patient safety culture dimensions Definition: The extent to which…

Unit level dimensions
Communication openness Staff speak up freely if they see something that may affect a patient negatively and feel free to question

those with more authority.
Feedback and communication about error Staff are informed about errors that happen, are given feedback about changes implemented and discuss

ways to prevent errors.
Teamwork within units Staff support each other, treat each other with respect and work together as a team.
Non-punitive response to error Staff feel that their mistakes and event reports are not held against them and that mistakes are not

recorded in their personnel file.
Organisational learning–continuous

improvement
Mistakes have led to positive changes and changes are evaluated for effectiveness.

Supervisor/manager expectations and
actions promoting patient safety

Supervisors/managers consider staff suggestions for improving patient safety, praise staff for following
patient safety procedures and do not overlook patient safety problems.

Staffing There are enough staff to handle the workload and work hours are appropriate to provide the best care
for patients.

Hospital level dimensions
Teamwork across units Hospital units cooperate and coordinate with one another to provide the best care for patients.
Handoffs and transitions Important patient care information is transferred across hospital units and during shift changes.
Management support for patient safety Hospital management provides a work climate that promotes patient safety and shows that patient safety

is a top priority.

Outcome dimensions
Frequency of events reported Mistakes of the following types are reported: (1) mistakes caught and corrected before affecting the

patient, (2) mistakes with no potential to harm the patient and (3) mistakes that could harm the
patient, but do not.

Overall perceptions of patient safety Procedures and systems are good at preventing errors and there is a lack of patient safety problems.

Source: Adapted from Sorra et al. [3].

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what dimensions of safety culture in hospitals are classified as strong
and weak?

Study objectives

This article sought to identify studies that have used the HSOPSC to
collect data on safety culture at hospitals and to learn their chief
findings relating to safety culture dimensions and possible contribu-
tions to improving the quality of hospital care.

We believe the HSOPSC to be a useful and accessible manage-
ment tool for health personnel and managers interested in safer and
better quality healthcare for hospital patients.

Methods

The systematic literature review conducted to meet the stated aims
was guided by a protocol designed by the three authors.

The search methodology and related findings are described in
accordance with the relevant sections of the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) statement [14].

Articles were selected by consulting the following data bases:
MEDLINE (via PubMed), Web of Science and Scopus. The search
strategy included combined terms using the Boolean operator ‘OR’
between keywords or similar MeSH terms; and terms with different
meanings were combined using the Boolean operator ‘AND’ to
refine the search. The search strategy used for MEDLINE is shown
in Table 1. For the other data bases, the strategy was the same, but

Records identified by database search

MEDLINE (n = 239)

Scopus (n = 365)

Web of Science (n = 284)

Total (n = 888)

S
c

re
e

n
in

g
In

c
lu

d
e
d

E
li

g
ib

il
it

y
Id

e
n

ti
fi

c
a
ti

o
n

Additional records identified from other sources
(AHRQ Research Reference List)

(n = 69)

Records after duplicates removed
(n = 824)

Records screened

(n = 261)
Records excluded

(n = 179)

Full-text articles assessed for

eligibility

(n = 82)

Full-text articles excluded, with reasons

(n = 48)

– Did not assess culture (8)

– Did not present data on culture (12)

– Used another instrument (13)

– Used comparative database data (5)

– Assessed specific sectors (5)

– Included only one professional category
(3)

– Results presentedin article already
included (3)

Studies included

(n = 33)

Figure 1 Study selection flowchart.

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adapted to the characteristics of each. The search was complemen-
ted by consulting both the Research Reference List of articles that
have used the HSOPSC, which is posted on the AHRQ website [13],
and the references cited in the articles identified by the search.

Given the diversity of specific features displayed by instruments
available for assessing PSC [9–11], it was opted to select articles that
meet the following eligibility criteria: (i) studies using the HSOPSC to
measure the dimensions of safety culture among staff at acute care
hospitals and (ii) articles in English, Portuguese and Spanish. The fol-
lowing studies were excluded: those (i) in the form of letters, editor-
ials, commentaries, case studies and reviews; (ii) with no abstract
available; (iii) that focussed on only one category of hospital staff;
(iv) that focussed on only one specific hospital unit or sector; (v) that
focussed only on transcultural adaptation of the instrument, without
reporting findings on safety culture; (vi) that used information from
data bases for benchmarking, where eligibility and sampling criteria
are not given and (vii) published in languages other than Portuguese,
English and Spanish. The review period began in 2005, 1 year after
the instrument was provided by the AHRQ, and ended on 31 July
2016. The exclusion criteria were based on the concept of safety cul-
ture itself, one of whose dimensions is defined as teamwork, as it was
not the purpose of this review to learn about the safety culture of spe-
cific professional categories, but of members of the overall hospital
staff. In the same way, priority was given to studies that assessed
safety culture in several hospital units or sectors because the study
question here was to ascertain the safety culture status in hospitals
that had applied the HSOPSC for that purpose.

The HSOPSC measures 12 dimensions of safety culture, with
from three to four items on each, totalling 42 items. The AHRQ
recommends using the estimated mean percentage of positive
responses obtained in each dimension as the measure of safety cul-
ture status. As an evaluative parameter, it suggests that any dimen-
sion for which the percentage of positive responses is 75% or more
should be considered a strong or developed dimension of safety cul-
ture in the population studied. Meanwhile, any dimension for which
the percentage of positive responses is 50% or less should be con-
sidered ‘needing improvement’ and should be prioritised in related
investments [3]. However, early studies that assessed safety culture
in hospitals using the HSOPSC aimed primarily not to assess safety
culture, but to adapt the instrument transculturally for use in other
countries. Many of these studies evaluating safety culture dimen-
sions estimated mean scores ranging from 0 to 5 in each dimension,

where a mean score closer to 5.0 denotes a dimension in which
safety culture is strong among hospital staff.

Accordingly, the measures of interest to this systematic review
were: in studies that reported in percentage form, the mean percent-
age of positive responses obtained on dimensions of safety culture
and, in studies that opted to estimate measures ranging from 0 to 5,
the mean scores estimated by dimension.

The 12 safety culture dimensions measured by the HSOPSC and
their respective definitions are given in Table 2.

To begin with, two of the authors, independently, read the titles
of the articles. After exclusion of duplicate articles and those that
did not provide an abstract, the abstracts of articles not excluded at
this first stage were evaluated independently. Articles were selected
for inclusion in the review after independent readings of the com-
plete texts. In cases where one of the two authors raised doubts as
to whether or not to include an article in the review, a third evalu-
ator who participated in designing the study was consulted and a
final decision was taken by consensus among the three.

Data were drawn from the articles on the basis of the informa-
tion about their authors, year of publication, study design, study
period and site, study population characteristics, how the survey
was administered, response rate and main findings on the safety cul-
ture dimensions specified by the authors.

The quality of the studies selected was evaluated using the
Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) tool [15], adapted into Portuguese, which has a 22-item
checklist, known as the STROBE Statement. This option responded to
the fact that all the studies using the HSOPSC used observational
design as part of their method.

Results

The searches of the three data bases (MEDLINE, Web of Science
and Scopus), on 24 September 2016, identified 888 relevant titles.
To these were added 69 articles identified in the Research Reference
List posted on the AHRQ website [13]. After eliminating duplicate
titles, 824 articles were selected for reading. Of these, 563 were dis-
carded for meeting at least one of the exclusion criteria, leaving 261
whose abstracts were read. After reading all the abstracts, 82 articles
were selected for the complete text to be read. No additional articles
were included from examining the references of the articles selected.
Figure 1 shows a flowchart of the article selection process.

Figure 2 Studies by country and year of publication.

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Table 3 Characteristics of the selected studies

Reference (year) Study site
(HSOPSC
Language)

Study design and period Study population/setting/
sample size/participant
characteristics

Survey administration
mode/response rate/
number of HSOPSC
dimensions

Study results STROBE
instrument items
not fully covered

Stronger Weaker Obs.

Hefner, Hilligoss,
Knupp et al. [48]

USA (English) Cross-sectional study;
HSOPSC was
administered between
mid-2011 and 2013.

Eight departments at Ohio
State University Wexner
Medical Center
(OSUWMC),
comprising six hospitals
and two campuses/1425
employees were included
before Crew Resource
Management (CRM)
training and 1308
afterwards/Nurses
(advanced practice
registered nurses),
doctors (physicians,
including fellows and
some residents) and staff
were included.

Electronic mode/55%
response rate
(N = 784) pre-CRM
and 51% response rate
(N = 667)
post-CRM/12 HSOPSC
dimensions.

‘Teamwork within units’
(72% positive response
rate).

Low pre-CRM scores:
‘Non-punitive Response
to Errors’ (28%) and
‘Handoffs and
Transitions’ (35%)

‘Staffing’ (42%),
‘Teamwork Across
units’ (40%),
‘Frequency of Events
Reported’ (46%),
‘Overall Perceptions of
Patient Safety’ (48%)
and ‘Communication
Openness’ (49%).

Low post-CRM scores:
‘Non-punitive Response
to Errors’ (35%),
‘Handoffs and
Transitions’ (42%),
‘Staffing’ (43%) and
‘Teamwork Across
units’ (44%).

No dimension scored
≥75%, either pre-
or post-CRM.

No descriptive
statistics given
for
participating
professional
categories.

Kiaei, Ziaee,
Mohebbifar et al.
[47]

Iran (Persian) Cross-sectional study/
hospitals of three
central provinces of
Iran (Tehran, Alborz
and Qazvin) in 2013.

About 10 teaching
hospitals of central
provinces: Tehran,
Alborz and Qazvin/552
hospital personnel/292
nurses (53.4%), 47
auxiliary health workers
(8.6%), 36 physicians
(7.6%), 31 operation
room technicians
(5.7%), 22 unit
managers (4%), 15
speech therapists,
audiologists or
physiotherapists (2.7%),
nine technicians (1.6%),
five pharmacists (0.9%),
one nutritionist (0.2%)
and eight other jobs
(1.5%).

No information given on
survey administration
mode/none on response
rate/12 dimensions of
the HSOPSC.

No dimension scored
≥75%.

‘Handoffs and
Transitions’ (54.49%),
‘Frequency of event
reporting’ (55.63%).

‘Teamwork within
units’ is known to
be the strongest
point of patient
safety culture (PSC)
in most related
studies, but not in
this study.

Participant
inclusion
criteria not
stated.

Not stated in
what form
(e.g. paper or
electronic)
questionnaires
were
distributed.

Response rate
not reported.

Study limitations

not stated.

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Al-Mandhari,
Al-Zakwani,
Al-Kindi et al. [46]

Oman
(English),
compared
with
Taiwan
(Chinese),
Lebanon
(Arabic) and
USA
(English)

Cross-sectional study;
data collection period
was not stated.

Eight regional hospitals
operate under the Oman
Ministry of Health/
professional and allied
healthcare staff working
in government hospitals
in Oman/400 employees/
nurses (60.15%),
physicians (21.01%),
technicians (8.88%),
pharmacists (4.31%)
and others (5.58%).

Hard copy format/98%
response rate
(N = 390)/12
dimensions of the
HSOPSC.

‘Organisational learning–
continuous
improvement’ (84%)
and ‘Teamwork within
units’ (83%).

‘Hospital non-punitive
response to error’
(25.0%), ‘Staffing’
(30.0%) and ‘Handoffs
and transitions’
(25.0%).

—

Data collection
period not
stated.

El-Jardali, Sheikh,
Garcia, Jamal et al.
[45]

Saudi Arabia
(Arabic)

Cross-sectional study.
December 2011 to
March 2012.

The hospital comprises
two sites, Site A
(large—800 beds) and
Site B (small—104
beds)/3000 employees
were included/registered
nurses (50.1%),
technicians (12.0%),
attending or staff
physicians (6.1%) and
unit assistants, clerks or
secretaries (5.2%).

Mixed mode (electronic
and hard copy format)/
85.7% response rate
(N = 2572)/12
dimensions of the
HSOPSC

‘Organisational Learning
and Continuous
Improvement’ (79.6%)
and ‘Teamwork within
units’ (78.5%).

‘Hospital non-punitive
response to error’
(26.8%), ‘Staffing’
(35.1%) and
‘Communication
openness’ (42.9%).

When results on
survey composites
were compared with
results from
Lebanon and the
USA, several areas
requiring
improvement were
noted.

Participant
inclusion
criteria not
stated.

Fujita, Seto,
Kitazawa et al.
[44]

Japan
(Japanese)

Cross-sectional study in
2012.

Eighteen hospitals in
Japan/12 076 healthcare
workers/9.2%
physicians, 46.4%
nurses, 14.4%
administrative workers
and 30.0% other roles.

Hard copy format/72%
response rate
(N = 8,700)/12-
dimension HSOPSC.

The highest-scoring
dimension was
‘Teamwork within
hospital units’ (total
sample T = 70%; high
patient safety score
H = 79%; and lowest
patient safety score
L = 63%).

‘Hospital handoffs
and transitions’
(T = 36%; H = 41%;
L = 32%), ‘Staffing’
(T = 40%; H = 44%;
L = 38%), ‘Non-
punitive response to
error’ (T = 43%;
H = 50%; L = 37%)
and ‘Teamwork across
units’ (T = 44%;
H = 52%; L = 38%).

PSC scores were
estimated for the
total sample (T) and
for two clusters, by
two unit response
patterns: those with
the highest scores
(High PSC units

—

H) and lowest scores
(Low PSC units—L).

Reports that
hospital
participation
was voluntary,
but
participant
inclusion
criteria not
stated.

Eiras, Escoval, Grillo
et al. [43]

Portugal
(Portuguese)

Cross-sectional
psychometric study.

Three hospitals, 4057
questionnaires were
distributed; at the final
dataset totalled 884
questionnaires.

Hard copy format/24.6%
response rate (N =
884). The 12-dimension
HSOPSC was
confirmed.

‘Teamwork within units’
(70%), ‘Organisational
learning–continuous
improvement’ (65%)
and ‘Supervisor/
manager expectations
and actions promoting
patient safety’ (63%).

‘Non-punitive response to
error’ (25%),
‘Management support
for patient safety’
(37%) and ‘Staffing’
(39%).

Measurement of
healthcare safety
culture is still at a
relatively immature
stage in Portugal.

Data collection
period not
stated.

No descriptive
statistics of
participant
characteristics
given, possibly
because the
main aim was
psychometric
validation of
the instrument
used.

Table continued

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Table 3 Continued

Reference (year) Study site
(HSOPSC
Language)
Study design and period Study population/setting/
sample size/participant
characteristics
Survey administration
mode/response rate/
number of HSOPSC
dimensions
Study results STROBE
instrument items
not fully covered
Stronger Weaker Obs.

Agnew, Flin,
Mearns [42]

Scotland
(English)

Cross-sectional study in
2009.

A sample of National
Health Service (NHS)
acute hospitals, six NHS
acute hospitals in
Scotland/1866 clinical
staff from many work/
area units at/nurses
(53%), nursing or
healthcare assistants
(13%) and medical and
dental consultants
(22%).

Hard copy format/23%
response rate/12-
dimension HSOPSC.

‘Teamwork within units’
(73%).

‘Handover’ (32%),
‘Hospital management
support for patient
safety’ (38%),
‘Teamwork across
units’ (39%), ‘Non-
punitive response to
error’ (44%), ‘Staffing’
(45%) and ‘Feedback
and communication
about error’ (45%).

— Study design not
indicated in
title or
abstract.

Amarapathy,
Sridharan, Perera
et al. [41]

Sri Lanka (not
given)

Cross-sectional descriptive
study to assess current
PSC in a tertiary care
hospital in Sri Lanka.

A tertiary care hospital/of
389 respondents, 16 (the
smallest percentage,
4.1%) were consultants,
while 214 (the largest
percentage, 55%) were
nursing officers. The rest
were 52 medical officers
(13.4%), 42 house
officers (10.8%), 41
administrators (10.5%)
and 24 PG-trainees
(6.2%)

Hard copy format/no
information on response
rate/11-dimension
version of HSOPSC

‘Teamwork within units’
(84.8%), ‘Organisation
learning–continuous
improvement’ (82.5%)
and ‘Overall perception
of patient safety’ (81.3
%).

‘Workload and staff’
(15.7%), ‘Frequency of
events reporting as it
occurs’ (36.6%) and
‘Non-punitive response
to errors’ (39.4%).

— Data collection
period not
stated.

Survey response
rate not
reported.

Davoodi,
Mohammadzadeh,
Shabestari et al.
[40]

Iran (Persian) Cross-sectional,
analytical-descriptive
study in the 3-months
from April to June
2012

Twenty-five government
hospitals in Khorasa
Razavi Province (13 in
Mashad and 12 in other
cities) affiliated to
Mashhad University of
Medical Sciences/ 1200
clinical staff/nurses
(77%), physicians
(10%), laboratory staff
(5.9%), radiology staff
(3.5%), operation room
staff (0.3%), general
managers with no
specialty in therapeutic
procedures (0.2%).

Hard copy format/76%
response rate (N = 922)
12-dimension version of
HSOPSC

‘Organisational learning–
continuous
improvement’ (79.85%)
and ‘Teamwork within
units’ (71.92%).

‘Non-punitive response to
error’ (21.57%),
‘Staffing’ (26.35%),
‘Frequency of events
reported’ (42.85%) and
‘Communication
openness’ (45.46%).

— Possible study
limitations
were not
stated.

External validity
of results was
not discussed.

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Hamdan, Saleem [39] Palestine
(Arabic)

Cross-sectional design.
Data were collected
between July and
August 2011.

About 11 general public
hospitals in the West
Bank/1460 clinical and
non-clinical hospital
staff/most participants
were nurses and
physicians (69.2%).

Hard copy format/
response rate = 51.2%/
12-dimension version of
HSOPSC.

‘Teamwork within units’
(71%) and
‘Organisational learning
and continuous
improvement’ (62%).

‘Non-punitive response to
error’ (17%),
‘Frequency of events
reported’ (35%),
‘Communication
openness’ (36%),
‘Hospital management
support for patient
safety’ (37%) and
‘Staffing’ (38%).

— —

Jones, Skinneer, High
et al. [38]

USA (English) Quasi-experimental
design: a crossectional,
descriptive study in s-
sectional comparison of
HSOPSC results from
an intervention and
static group/from
February 2008 to
March 2009.

Thirty-seven hospitals/
4601 personnel/static
group: nurses (27.0%),
allied health staff
(21.7%), non-clinical
support staff (15.3%)
clinical support staff
(9.9 %), administration-
management (11.7%)
and the intervention
group: nurses (32.0%),
allied health staff
(23.3%), clinical
support staff (11.8%),
non-clinical support
staff (11.2%).

Hard copy format/
response rate = 75.3%
(N = 3465)/12-
dimension version of
HSOPSC

Intervention group vs.
static group:
‘Organisational
learning–continuous
improvement’ (76% vs.
71%), ‘Teamwork
within units’ (82% vs.
80%) and ‘Teamwork
across hospital
departments’ (67% vs.
62%).

— Mean positive
response scores are
not given for all
dimensions and it is
thus not possible to
identify mean scores
of <50%.

—

Nie, Mao, Cui et al.
[37]

China
(Chinese)

Cross-sectional study;
from July to December
2011.

Thirty-two hospitals in 15
cities across China/1160
healthcare workers,
physicians (surgical and
internal clinicians)/the
majority of respondents
were nurses (66%), then
surgical clinicians (33%)
and internal medicine
clinicians (30%).

Hard copy format/
response rate = 77% (N
= 1160)/10-dimension
version of HSOPSC

‘Organisation learning–
continuous
improvement’ (88%)
and ‘Teamwork within
units’ (84%).

‘Feedback and
communication about
error’ (50%) and
‘Staffing’ (45%).

— —

Occeli, Quenon, Kret
et al. [36]

France
(French)

Cross-sectional study in
January.

Seven hospitals in South-
western France. At the
selected hospitals/524
employees included:
nurses (45.8%),
auxiliary nurses
(32.7%), physicians
(13.9%) and others
(7.6%).

Hard copy format/
response rate = 76.5%
(N = 401)/10-dimension
version of HSOPSC

— ‘Overall perceptions of
safety’ (25.0–71.8%),
‘Non-punitive response
to error’ (3.5–47.1%),
‘Staffing’ (15.0–58.3%),
‘Hospital management
support for patient
safety’ (15.4–58.8%)
and ‘Teamwork across
hospital units’
(24.6–66.7%).

The article does not
mention whether the
findings revealed
dimensions classified
as stronger.

—
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Table 3 Continued
Reference (year) Study site
(HSOPSC
Language)
Study design and period Study population/setting/
sample size/participant
characteristics
Survey administration
mode/response rate/
number of HSOPSC
dimensions
Study results STROBE
instrument items
not fully covered
Stronger Weaker Obs.

Robida [35] Slovenia
(Slovene)

Cross-sectional
psychometric in 2010.

Three acute general
hospitals/all clinical and
non-clinical staff (n =
1745).

Hard copy format/
response rate = 60% (N
= 1048)/12-dimension
version of HSOPSC

— ‘Non-punitive response to
error’ (39% positive
response rate), ‘Staffing’
(31%), ‘Hospital
management support
for patient safety’
(39%) and ‘Teamwork
across hospital units’
(41%).

No PSC dimension
reached the
artificially set value
of 75% of positive
answers.

No descriptive
statistics given
on participant
characteristic.

Study limitations
not discussed.

External validity
of results not
discussed.

Abdelhai, Abdelaziz,
Ghanem [34]

Egypt (Arabic) Analytical, cross-sectional
design study; data was
collected from
December 2011 to
March 2012.

Cairo University Teaching
Hospitals—Cairo/400
healthcare providers/219
(54.8%) were
physicians, 99 (24.7%)
nurses and 82 (20.5%)
paramedical personnel.

Hard copy format/
response rate = 100%
(N = 400)/12-dimension
version of HSOPSC

‘Overall perceptions of
patient safety’ (74.3%).

‘Non-punitive response to
error’ (33.3%),
‘Supervisor/manager
expectations and
actions promoting
safety’ (36.8%),
‘Communication
openness’ (42%) and
‘Teamwork across
units’ (42.3%).

— Possible study
limitations not
reported.

Aboul-Fotouh,
Ismail, EzElarab
et al. [33]

Egypt (Arabic) Cross-sectional study;
data was collected from
November 2008 to
May 2009.

Ain Shams University
hospitals/738 healthcare
providers.

Hard copy format/
response rate = 69.1%
(N = 510)/12-dimension
version of HSOPSC

‘Organisational learning’
(78.2%).

‘Non-punitive response to
error’ (19.5%);
‘Handoffs and
transitions’ (24.6%),
‘Hospital management
support for patient
safety’ (27.2%),
‘Adverse event
reporting’ (33.4%),
‘Overall perception of
safety’ (33.9%),
‘Communication
openness’ (34.6%),
‘Teamwork across
units’ (38.0%),
‘Feedback and
communication about
error’ (39.7%),
‘Supervisor/manager
expectations and
actions promoting
safety’ (46.4%).

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Smits, Wagner,
Spreeuwenberg,
[32]

The
Netherlands
(Dutch)

A cross-sectional study
was conducted from
October 2006 to
February 2008.

Twenty-eight hospital
units of 20 hospitals in
the Netherlands/nurses
(74%), resident
physicians (10%),
medical specialists (6%)
and managers (2%),
other professions (5%).

Hard copy format/
response rate = 56% (N
= 542)/11-dimension
version of HSOPSC

‘Teamwork within units’
(3.83), ‘Communication
openness’ (3.72), ‘Non-
punitive response to
error’ (3.57).

‘Willingness to report’
(2.78), ‘Hospital
management support’
(2.82) and ‘Teamwork
across hospital units’
(2.85).

— —

Bagnasco, Tibaldi,
Chirone et al. [31]

Italy (Italian) Cross-sectional study. A hospital in Northern
Italy/1008
questionnaires were
distributed/directors/
coordinators,
physicians, nurses/
midwives,
physiotherapists and
technicians were
involved.

Hard copy format/
response rate = 71% (N
= 724)/12-dimension
version of HSOPSC.

‘Organisational learning—
continued improvement’
(74% positive
response).

‘Hospital management
support for patient
safety’ (28%), ‘Staffing’
(30%), ‘Teamwork
among hospital units’
(30%) and ‘Non-
punitive response to
error’ (35%).

No dimension scored
75% or more.

No descriptive
statistics of
study
participants
presented.

Occelli, Quenon,
Hubert et al. [30]

France
(French)

A cross-sectional,
descriptive study in
2007.

Six hospitals (three public
and three private) in the
Aquitaine region/488
professionals (268 were
nursing staff).

Hard copy format/
response rate = 65%/
12-dimension version of
HSOPSC.

— ‘Non-punitive response to
error’ (13–52%),
‘Staffing’ (14–64%),
‘Management support
for patient safety’
(7–67%), ‘Handoffs
and transition’
(27–70%).

No dimension scored
75% or more.
—

Bodur, Filiz [29] Turkey
(Turkish)

Psychometric cross-
sectional study in 2008

Three hospitals (one
general, one teaching
and one university
hospital) in the
metropolitan centre of
Konya Province/
physicians and nurses (n
= 309).

Hard copy format/by
hospital type, response
rates were 56% for
university hospitals,
72% for general public
hospitals and 86% for
teaching hospitals/10-
dimension version of
HSOPSC.

‘Teamwork within units’
(70%), followed by
‘Overall perceptions of
safety’ (62%).

Items in the ‘Frequency of
events reported’ (15%)
and ‘Non-punitive
response to error’
(24%).

— Study
participant
inclusion
criteria not
stated.

Campbell, Singer,
Kitch et al. [28]

USA (English) Cross-sectional study in
2008.

Massachusetts General
Hospital (MGH) a 900-
bed acute care hospital/
nurses and attending
physicians (N = 4 283)/
80% nurses and 20%
physicians.

Mixed mode (electronic
and hard copy format)/
73% response rate
(N = 2 163)/12
dimensions of the
HSOPSC

‘Teamwork within units’
(85%).

‘Handoffs and transitions’
(45%) and ‘Event
reporting’ (49%).

— —

Chen, Li [27] Taiwan
(Chinese)

Cross-sectional design in
2007.

Forty-two hospitals (10
medical centres, 16
regional hospitals and
16 community
hospitals)/1788
professionals included/
29.2% (N = 230)
physicians, 60.6% (N =
478) nurses and 10.2%
(80) administrators.

Hard copy format/
response rate = 78.8%
(N = 788)/12-dimension
version of HSOPSC

‘Teamwork within units’
(94%) and ‘Supervisor/
manager expectations
and actions promoting
patient safety’ (74%).

‘Non-punitive response to
Error’ (45%), ‘Hospital
Handoffs and
Transitions’ (48%) and
‘Staffing’ (39%).

— —
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EL-Jardali, Jaafar,
Dimassi et al. [25]

Lebanon
(Arabic)

Cross-sectional study in
2009.

Sixty-eight Lebanese
hospitals participated in
the study/sample
= 12 250 employees/
physicians, nurses,
clinical and non-clinical
staff, pharmacy and
laboratory staff, dietary
and radiology staff,
supervisors and hospital
managers.

Most respondents (57.8%)
were nurses.

Hard copy format/
response rate = 55.56%
(N = 6807)/12-
dimension version of
HSOPSC

‘Teamwork within units’
(82.3%), ‘Hospital
management support
for patient safety’
(78.4%) and
‘Organisational learning
and continuous
improvement’ (78.3%).

‘Non-punitive response to
error’ (24.3%),
‘Staffing’ (36.8%) and
‘Hospital handoffs and
transitions’ (49.7%).

— Only percentage
of respondents
available was
for nurses.
Percentages of
other
professionals
not given.

Hellings, Schrooten
Klazinga et al. [25]

Belgium
(Dutch)

Cross-sectional study
before and after
implementation
approach. First
measurement: between
September and October
2005, except for the
hospital five pilot
(April–May, 2005); the
second measurement:
between April and
August 2007.

Five hospitals- institutional
status (private and
public)/nurses (60.2%),
head nurses (3.9%),
nurse assistants (7.3%),
physicians (9.0%), head
physicians (1.8%),
junior physicians
(0.9%), pharmacists
(0.5%), pharmacy
assistants (1.1%),
middle management
(0.6%), technicians
(4.8%), paramedics
(5.3%) and others
(3.4%).

Hard copy format/77%
response rate in first
survey (N = 3940) and
68% (N = 3626) in
second survey/12-
dimension version of
HSOPSC

In both first and second
surveys, the highest
scoring was ‘Teamwork
within hospital units’,
even though no hospital
scored ≥75%.

Lowest scores (<50%) at the five hospitals in first and second measurement were ‘Non-punitive response to error’, ‘Staffing’, ‘Teamwork across hospital units’ and ‘Hospital handoffs and transitions’.

— —

Olsen [24] Norway
(Norwegian)

Cross-sectional study
validated two safety
climate instruments: (1)
Short Safety Climate
Survey (SSCS) and (2)
Hospital Survey on
Patient Safety Culture-
short form (HSOPSC-
short). The surveys
started in April 2006
and September 2007,
respectively.

A large regional hospital in
Norway.

The target group in the
hospital included health
workers and other
personnel employed in
the same working
environment as the
healthcare personnel/
nurses represented the
largest job category
(50%). ‘Non-nurses’
was not described.

Hard copy format/hospital
response rate was 55%
(N = 1919)/HSOPSC-
short form (five
dimensions).

At the hospital level, the
strong HSOPSC
dimensions were
‘Teamwork within
units’ (mean 3.84) and
‘Supervisor/manager
expectations and
actions promoting
safety’ (mean 3.82).

Meanwhile,
‘Organisational
management support
for safety’ was the
weakest dimension
(mean 2.85).

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Blegen, Gearhart, O.
Brien et al. [23]

USA (English)

Psychometric cross-
sectional study

Survey was administered
before the first
intervention (March to
June 2006) and again at
the end of the project
(March 2007).

Three hospitals; the survey
was administered to 454
healthcare staff before
and after a series of
multidisciplinary
interventions/(434
before, 368 after) were
mostly registered nurses
(30% before, 33%
after), followed by
medical residents (24%,
27%), pharmacists
(12%, 12%) and
attending physicians
(10%, 13%). The
remainder were other
nursing care providers
(12%, 5%), therapists
(5%, 6%),
administrators and
managers (2%, 2%) and
others (5%, 2%).

Hard copy format/
response rate pre-
intervention = 96% (N
= 434); response rate at
project end = 81% (N =
368/)/11-dimension
version of HSOPSC.

‘Teamwork within units’
(78%).

‘Non-punitive response to
error’ (40%) and
‘Hospital handoffs and
transitions’ (42%).

— —

Smits, Wagner,
Spreeuwenberg
et al. [22]

The
Netherlands
(Dutch)

Cross-sectional study
surveyed in May–June
2005 and 11 in May–
June 2006.

Nineteen hospitals (nine
general hospitals, nine
teaching hospitals and
one university hospital)/
a total of 1889 hospital
staff participated in the
study/participants were
1174 registered nurses
(62.7%), 50 resident
nurses (2.7%), 65
clerks/secretaries
(3.5%), 69 resident
physicians (3.7%), 109
medical specialists
(5.8%), 58 managers
(3.1%) and 346 others
(18.3%).

Hard copy format/1889
respondents at 87 units
in 19 hospitals
completed the
questionnaire. Response
rates were scored for 67
of the 87 units: there
was no reliable
information about the
number of people
having received a
questionnaire in 20
units. The mean
response rate (known
for 67 units) was 80%
(25–100%). The
number of respondents
per unit ranged from
seven to 53 (mean of
22)/11-dimension
version of HSOPSC.

‘Teamwork within units’
(mean 3.88) and
‘Openness of
communication’ (mean
3.78).

‘Teamwork across
hospital units’ (mean
2.85), ‘Hospital
management support’
(mean 2.97) and
‘Frequency of event
reporting’ (mean 2.99).

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Al-Ahamadi [21] Saudi Arabia
(English)

Cross-sectional study
during May–August,
2008.

The study population
comprised all medical
and administrative staff
at all public and private
hospitals in Riyadh/
nurses (63.7%),
physicians (8.8%) and
technicians (8.1%); the
last category was
dieticians (0.4%).

Hard copy format/
response rate = 47.4%
(N = 1224)/12-
dimension version of
HSOPSC.

‘Organisational learning’
(75.9%), ‘Teamwork
within units’ (70%).

‘Handoffs and transitions’
(47.6%),
‘Communication
openness’ (44.2%),
‘Staffing’ (31.2%) and
‘Non-punitive response
to error’ (21.1%).

— Study limitations
not stated.

Sine, Northcutt [20] USA (English) Mixed method study:
cross-sectional study
(Phase 1); focus group
using techniques of
interactive qualitative
analysis (Phase 2).

A medium-sized urban
hospital setting.

Hard copy format/
response rate not given/
12-dimension version of
HSOPSC.

‘Teamwork within units’
(89%), ‘Management
Support for Patient
Safety’ (81%) and
‘Organisational
Learning’ (80%).

‘Non-punitive response to
error’ (45%).

— Study
participant
characteristics
not given.

No information
given on
sample size.

Saturno, Gama, De
Oliveira-Sousa
et al. [19]

Spain
(Catalan,
Basque
Galician
and
Spanish)

Cross-sectional study.
No information on data
collection period is
given.

Twenty-four hospitals (5
large—>500 beds, 13
medium—200–499 beds
and six small—<200 beds)/6257 health professionals (N = 6257) (physicians, nurses, pharmacists, physiotherapists, psychologists, etc.). The sample comprised mostly nurses (61.1%).

Hard copy format/
response rate = 40%/
12-dimension version of
HSOPSC.

‘Teamwork within units’
(71.8%) ‘Supervisor/
manager expectations/
actions’ (61.8%).

‘Adequate staffing’
(27.6%) and ‘Hospital
management support
for patient safety’
(24.5%).

— Data collection
period not
specified.

Smits, Christiaans-
Dingelhoff,
Wagner, Wal,
Groenewegen [18]

The
Netherlands
(Dutch)
Psychometric cross-
sectional study

The Dutch version of the
HSOPSC was
distributed at eight
hospitals in the
Netherlands in June
2005.

Eight hospitals (four
general, three teaching
and one university) in
the Netherlands of eight
hospitals/nurses
(59.8%), medical
consultants (6.8%),
resident physicians
(6.0%), administrative
staff (4.3%), trainee
nurses (2.6%) or in
management (2.4%).

Hard copy format/583
staff members
completed the
questionnaire (response
rate not available)/11-
dimension version of
HSOPSC.

‘Teamwork within units’
(3.89), ‘Communication
openness’ (3.76);
‘Adequate staffing’
(3.73), ‘Non-punitive
response to error’ (3.61)
and ‘Supervisor/
manager expectations/
actions’ (3.58).

‘Teamwork across
hospital units’ (2.82).

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Jones, Skinner, Xu,
Sun, Mueller [17]

USA (English) Cross-sectional study in
2005 and 2007.

Twenty-four Critical
Access Hospitals
(CAHs) in 2005 (1995
eligible employees); in
Spring 2007, 21 of these
24 CAHs chose to
participate in a
reassessment (1963
eligible employees).

Respondent demographics
by position were
consistent in 2005 and
2007: respectively,
nurses (35 and 37%);
allied health personnel
(28 and 24%); support
personnel (12 and
12%); administrators
and managers, (12 and
12%); providers, (7 and
6%); and others (7 and
8%).

Hard copy format/
response rate (2005) =
70.4%; response rate
(2007) = 70.0%/12-
dimension version of
HSOPSC.

In the first assessment
(2005): ‘Teamwork
within departments’
(80%).

In the second assessment
(2007): ‘Teamwork
within departments’
(81%), while
‘Organisational
learning–continuous
improvement and
‘Supervisor/manager
expectations and
actions promoting
patient safety’, achieved
75% scores.

‘Non-punitive response to
error’ scored lowest
(50% in 2005 and 52%
in 2007).

No dimension scored
<50%.

—

Hellings, Schrooten,
Klazinga et al. [16]

Belgium
(Dutch)

Cross- sectional study was
conducted from March
to November 2005.

Five general hospitals/
3940 individuals: 2813
nurses and assistants
(71.40%), 462
physicians (11.73%),
397 physiotherapists,
laboratory and
radiology assistants,
social workers (10.08%)
and 64 pharmacists and
pharmacy assistants
(1.62%).

The questionnaire was
distributed on paper/
response rate = 77% (N
= 9940)/11 dimensions
of HSOPSC version.

‘Teamwork within
hospital units’ scored
highest (70%).

‘Hospital management
support for patient
safety’ (35%), ‘Non-
punitive response to
error’ (36%), ‘Hospital
transfers and
transitions’ (36%),
‘Staffing’ (38%) and
‘Teamwork across
hospital units’ (40%).

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Finally, 33 studies [16–48] were included, which had been pub-
lished between 2007 and 2016, all in English, except one in Spanish
[19]. Figure 2 shows the studies by country where they were carried
out and year of publication.

The 33 studies [16–48] originated from 21 countries at varying
stages of development. The characteristics of the 33 studies are
shown in Table 3.

All the studies included observational epidemiological design in
their methodology and presented findings on the status of safety
culture in their study sample. However, the studies’ focus varied:
(i) 11 studies focused primarily on evaluating the status of safety cul-
ture among hospital staffs [19, 22, 25–27, 30, 33, 34, 39, 41, 47]; (ii)
10 studies focused on psychometric validation of the HSOPSC [16, 18,
23, 24, 29, 31, 35–37, 43]; (iii) five studies evaluated safety culture by
investigating relations between dimensions of the culture and charac-
teristics of the hospitals or participants [28, 40, 42, 44, 45]; (iv) four
studies evaluated the effects on PSC of investments in improving the
quality and safety of healthcare at hospitals [17, 20, 38, 48]; (v) two
studies investigated associations between safety culture and outcome
variables [21, 32] and (vi) one study [46] evaluated safety culture
among hospital staffs and made comparisons with studies in other
countries.

Regarding their participants, 26 (78.8%) of the 33 studies stated
that these were mainly nurses [16–19, 21–30, 32, 36–42, 44–47], in
proportions ranging from 27% [38] to 80% [28]. Five studies did not
give the demographic characteristics of the sample [20, 31, 35, 43, 48].

Approximately 85% of the studies (N = 28) collected their data
using the instrument on paper [16–19, 21–27, 29–44, 46], achieving
response rates ranging from 23% [42] to 100% [34].

Quality assessment of the studies

Of the articles included in this review, 45.5% (N = 15) contem-
plated the criteria of the STROBE Statement [16, 18, 21–25, 27, 28,
30, 32, 33, 37–39]. Of those that did not contemplate the STROBE
criteria; four presented no descriptive statistics on the participants
[17, 26, 31, 48]; three did not state the study participant inclusion
criteria [29, 44, 45]; two failed to specify the data collection period
[19, 46]; two did not discuss the study’s external validity or limita-
tions [34, 40]; one did not state the study design in their title or
abstract [42]; one did not report the response rate [41]; one stated
neither the data collection period nor descriptive statistics on the
participants [43]; one did not discuss the study’s limitations [21];
one stated neither the inclusion criteria, how data were collected,
response rate nor the study’s limitations [47]; one did not give
descriptive statistics on the participants nor discuss its limitations
and external validity [35] and lastly, one study did not give descrip-
tive statistics on its participants or information on sample size and
response rate [20] (Table 3).

As regards the status of PSC, which was the main focus of this
review, most of the studies were found to estimate scores for safety
culture dimensions as mean percentages of positive responses to
their component items, with the exception of four [18, 22, 24, 32]
which estimated mean scores from 0 to 5 (Table 3).

The main safety culture dimensions that scored highest percen-
tages of positive responses in the studies and, therefore, are classified
as strong or developed dimensions, were: (i) ‘Teamwork within units’
(78–89%) [20, 23, 26–28, 37, 38, 41, 45, 46] (ii) ‘Organisational
learning–continuous improvement’ (71–88%) [17, 20, 21, 26, 33,
37, 38, 40, 41, 45, 46]. In studies that estimated dimension scores
from 0 to 5, the strongest dimensions were: (i) ‘Teamwork within

units’ (3.78–3.89) [18, 22, 24, 32]; (ii) ‘Communication openness’
(3.72–3.78) [18, 22, 32] and (iii) ‘Supervisor/manager expectations
and actions promoting patient safety’ (3.58–3.82) [18, 24] (Table 3).

The main safety culture dimensions that scored 50% or fewer
positive responses and, therefore, can be classified as weak, were: (i)
‘Non-punitive response to error’ (3.5–47%) [16, 20, 21, 23, 25–27,
29–31, 33–36, 39, 40, 42–46, 48]; (ii) ‘Staffing’ (14–45%) [16, 19,
21, 25–27, 30, 35–37, 39–43, 45, 46, 48]; (iii) ‘Handoffs and transi-
tions’ (24.6–49.7%) [16, 21, 23, 26–28, 30, 33, 42, 44, 46, 48]; (iv)
‘Teamwork across units’ (24.6–44%) [16, 25, 31, 33–36, 42, 44, 48];
(v) ‘Hospital management support for patient safety’ (15.4–39%)
[16, 19, 31, 33, 36, 39, 42, 43]; (vi) ‘Frequency of event reported’
(15–49%) [28, 29, 33, 39–41]; (vii) ‘Communication openness’
(36–45.5%) [21, 34, 39, 40, 45] and ‘Feedback and communication
about error’ (39.7–50%) [37, 42]; (viii) ‘Supervisor/Manager
Expectations and Actions Promoting Patient Safety’ (36.8–46.4%)
[33, 34] and (ix) ‘Overall Perceptions of Patient Safety’ (25–33.9%)
[33, 37]. In studies that estimated scores from 0 to 5, by dimension,
the weakest dimensions were (i) ‘Hospital management support for
patient safety’ (2.82–2.97) [22, 24, 32] and (ii) ‘Frequency of event
reported’ (2.78–2.99) [22, 32] (Table 3).

Discussion

Interest in PSC has been growing since the 2000s, when health sys-
tems were challenged to offer safe, better quality care. This interest
arose from a concern over safety shortcomings in structures and
work processes, recognition of the high risk of incidents and com-
plexity inherent to healthcare provision.

There is mounting evidence of the influence of safety culture on
patient clinical outcomes, examples of which are rates of infection
and readmission [49–51]. In this regard, developing and strengthening
safety culture is a prominent means of managing and minimising risk
in health organisations. The first step in setting this whole process in
motion is to assess the current status of safety culture [52]. Safety cul-
ture assessment makes it possible to identify significant safety issues in
work routines and working conditions and to manage them prospect-
ively and to monitor safety-related changes and outcomes.

Nurses accounted for the largest proportion of participants
in ~80% of the studies included in this review [16–19, 21–30, 32,
36–42, 44–47], suggesting that this professional category is inclined
to collaborate and engage with surveys on patient safety, as has
been found in other contexts [53]. Nonetheless, when the intention
is to ascertain the status of culture at the level of the organisation as
a whole, all professional categories should be encouraged to partici-
pate in safety culture surveys.

In 10 of the 33 studies included in this review [16, 18, 23, 24,
29, 31, 35–37, 43], the main aim was the psychometric validation
of translated versions of the HSOPSC, pointing to an interest in the
various countries in assessing safety culture among hospitals staffs.

Although all the studies offered findings on safety culture among
hospitals staffs, they differed in focus, illustrating how broadly
safety culture assessment is applicable to management. For example,
Hefner et al. [48] evaluated the impact on PSC of implementing
Crew Resource Management (CRM), a strategy that is being used
to strengthen PSC by applying a systematic approach to training
teams in interpersonal communication, teamwork, leadership and
decision-making [54]. One quasi-experimental study [38] evaluated
how training applied to a set of 23 hospitals impacted PSC and then
compared this with a static group of 14 hospitals. Intervention
group HSOPSC scores were significantly higher than static group

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scores in three dimensions assessing the flexible and learning compo-
nents of safety culture [38]. In one US study [17], the authors used
results from a rural-adapted version of the HSOPSC to plan, execute
and evaluate a 2-year patient safety programme in 24 Critical
Access Hospitals. The HSOPSC detected changes in safety culture
over time when managers used a change strategy to execute specific
practices that support the four components of an informed, safe
culture.

The data collection method most used among the studies (85%
N = 28) was administration of the questionnaire on paper, which is
shown by comparative data usually to produce a higher response
rate than when web surveys are used [3]. The response rates in these
studies ranged from 23 to 100%. Two studies are particularly not-
able for having used a mixed method [28, 45] and obtaining
response rates of 85.7% and 73%, respectively. Response rates are
important because low values can limit the ability to generalise find-
ings to the hospital as a whole. When response rates are low, there
is a danger that the large number of staff who did not respond to
the survey might have responded very differently from those who
did respond, which is one of the major possible biases of cross-
sectional studies. Accordingly, the decision to use a survey on paper,
a web survey or a mixed data collection method should consider the
various factors that may influence the response rate, such as the
available resources, the means used to assure respondent anonymity,
the hospital’s experience with web surveys and so on [3].

Of the 33 studies included, nine used random surveys [18, 19,
22, 26, 27, 40, 41, 46, 47]. Random samples are one efficient (low-
cost) option for cross-sectional studies in that they enable character-
istics of the population to be determined from a small number of
participating units [55]. The probable explanation is that the studies
using random sampling included larger numbers of hospital units
[18, 19, 22, 26, 27, 40, 47]. Put differently, the User’s Guide pro-
vided by the AHRQ [3] recommends that, if the hospital has a staff
of fewer than 500, efforts should be made to include them all in the
study.

Against the STROBE Statement checklist, the studies were gener-
ally of good quality and about half the studies met all the require-
ments listed for observational epidemiological studies [16, 18,
21–25, 27, 28, 30, 32, 33, 37–39]. It should be noted, however, that
some editors have proven reticent in view of the fact that the
STROBE initiative seeks to formalise the description of studies con-
ducted in such a heterogeneous field of research as epidemiology,
particularly as regards observational studies. This initiative, they
claim, may not favour the execution and description of singular, cre-
ative studies [15]. The studies included were found to feature a
diversity of objectives and methods, which may have contributed to
whether or not they met the items listed in the STROBE Statement.

Characteristics of the patient safety culture

dimensions

The central aim of this review was to ascertain the characteristics of
PSC at hospitals in the various cultural contexts. Dimensions in
which safety culture was classified as strong and weak were
identified.

‘Teamwork within units’ scored higher in countries at various dif-
ferent stages of development and in studies with different temporal
characteristics [20, 23, 26–28, 37, 38, 41, 45, 46]. The process of
providing healthcare is intrinsically interdisciplinary. Teams generally
comprise people who work together to achieve definite, shared goals,
where each component has specific competences, tasks and functions

in specialised work, uses shared resources and communicates in order
to coordinate and adapt to change. Observational studies of team
behaviour as it relates to high standards of clinical performance have
identified patterns of communication, coordination and leadership
that provide support for effective teamwork [56].

‘Staffing’ scored low in ~60% of the studies (N = 18) [16, 19,
21, 25–27, 30, 35–37, 39–43, 45, 46, 48]. The results suggest that,
in the contexts of more than half the hospitals participating in the
studies, staff felt overloaded by the unsuitability of personnel to
their work activities, which can prejudice the quality of care
provided.

‘Organisational learning–continuous improvement’ was per-
ceived as strong by participants in 33% (N = 11) of the studies
[17, 20, 21, 26, 33, 37, 38, 40, 41, 45, 46]. This dimension relates
to learning in health organisations, which does not consist in a sin-
gle intervention, but is a continuous phenomenon occurring in for-
mal and informal learning. It is fundamentally important to manage
learning requirements in healthcare systems because these are com-
plex, interconnected, dynamic systems where all have tasks and
responsibilities in executing the assigned functions, communicating
and conveying the flow of relevant information and collectively pro-
viding safe care for patients [57]. In the context of patient safety,
where the main goal is to reduce avoidable harm resulting from
healthcare, ‘Frequency of Events Reported’ (an outcome decision)
has the potential to contribute continuously to learning. Safety inci-
dent reports make it possible to identify the possible causes of fail-
ures in work processes and structures. However, the outcome
dimension ‘Frequency of Events Reported’ did not prove strong in
all the studies included in this review, but needed improvement in
the various countries represented.

‘Teamwork across units’ captures respondents’ perceptions of
coordination and cooperation among hospital units with a view to
providing the best possible healthcare to patients. This dimension
could be improved in all the organisations considered in the set of
studies included in this review, while in 30% (n = 10) of the studies,
this dimension was considered weak and scored <50% positive responses [16, 25, 31, 33–36, 42, 44, 48].

Similarly, ‘Handoffs and transitions’ proved weak in 36%
(N = 12) of the studies [16, 21, 23, 26–28, 30, 33, 42, 44, 46, 48]
and needing improvement in all the studies included. ‘Handoffs and
transitions’ are targeted by quality improvement efforts in health
organisations because they entail high risk of safety incidents and
can lead to loss of important information and to fragmentation of
patient care [58].

Lastly, a culture of blame appears to exist in the hospitals over-
all. In nearly 70% of the studies (N = 22) [16, 20, 21, 23, 25–27,
29–31, 33–36, 39, 40, 42–46, 48], the dimension ‘Non-punitive
response to error’ proved weak. A punitive culture with regard to
the occurrence of safety incidents discourages staff from reporting,
makes it difficult to discover possible causes and thus prevents learn-
ing from mistakes. In a strong safety culture, individuals feel com-
fortable about drawing attention to potential risks or actual
failures, with no fear of censure by managers [59]. Wachter (2013)
claims the ‘no-blame’ approach was responsible for many of the
advances made by the patient safety movement in its first decade,
but argues that most adverse events result from multiple causes and
are unintentional. Occasionally, however, blame may be appropri-
ate in certain situations that involve individuals who commit fre-
quent, careless errors, who fail to accompany developments in their
speciality or who choose to ignore sensible safety standards.
Wachter (2013) cites the emergence of the concept of a ‘just culture’

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(instead of a ‘no-blame’ culture) as a way to shift the (appropriate)
no-blame focus back onto the care process. The assumption is that
competent collaborators make mistakes and there is a need to make
individuals (and institutions) accountable for blameworthy errors or
conditions.

In this connection, the HSOPSC is being reviewed to construct a
new version absorbing suggestions from user feedback from around
the world, which include incorporating the ‘just culture’ concept
(https://www.ahrq.gov/professionals/quality-patient-safety/patientsaf
etyculture/hospital/update/index.html).

Study limitations

The authors recognise that this study has a number of limitations.
Firstly, as regards the data bases consulted, it was decided to restrict
the search to the three bases because they were considered suitable
for collecting all the eligible articles according to the proposed subject
and objectives and because they were available to the authors in their
academic setting. With a view to correcting any kind of selection
bias, we consulted the Research Reference List available on the
AHRQ website at https://www.ahrq.gov/professionals/quality-pati
ent-safety/patientsafetyculture/resources/index.html and, from it,
added another 69 articles to those obtained in the database searches.

Another issue that should be highlighted is that this review
searched for articles in English, Portuguese and Spanish only. It is
possible that this search strategy may have failed to retrieve some
articles, although we have identified no articles published in other
languages, not even in the Research Reference list posted on the
AHRQ website, leading us to believe that, by and large, such articles
have been published in English and Spanish. No published article
using the HSOPSC in Latin American countries was identified.

Another important potential limitation of this review was the
authors’ choice not to conduct a meta-analysis. The rationale behind
this is that the findings of the studies included are difficult to gener-
alise and compare, for the following reasons: the studies occurred in
different time periods, they used different sampling strategies and
were conducted in hospital contexts in countries at different stages
of development, which entail different capacities for investment in
improving the quality and safety of care at the study hospitals.

Conclusion

This systematic review demonstrated that the assessment of safety
culture in health organisation settings had received special interest
on the part of health researchers, managers and practitioners in vari-
ous parts of the world.

The set of studies included in this review reveals that hospital
organisational cultures are predominantly underdeveloped or weak
as regards patient safety and comprise dimensions that require
strengthening. In particular, it underlines the need to think about:
(i) strategies directed to prepare personnel to offer safe, quality
healthcare; (ii) work processes surrounding shift changes and hand-
overs, so as to prevent loss of important information about patients
and their treatment; (iii) cooperation, integration and coordination
of teamwork among the hospital units, in order to prevent fragmen-
tation of care; and lastly and (iv) the culture of blame, which should
give way to a ‘just culture’ approach, which would counter the urge
to blame, enhance professional and institutional accountability and
prioritise the identification of systemic failures and, consequently,
proceed to mitigate them.

Use of the HSOPSC to measure safety culture in hospital organi-
sations proved efficient, applicable to the various objectives of the
studies included in this review and adaptable to the different cultural
and organisational development contexts. The findings of these
safety culture assessment studies are highly useful and constitute a
knowledge base for taking specific improvement action.

Acknowledgements

This paper is part of the result of the Postdoctoral Research done by C.T.R. at
the National School of Public Health—Universidade NOVA de Lisboa, super-
vised by Professor P.S. and supported by the Brazilian Minister of Health.

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677Patient safety culture • Patient Safety Culture

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The patient safety culture: a systematic review by characteristics of Hospital Survey on Patient Safety Culture dimensions

Purpose
Data sources
Study selection
Data extraction
Results
Conclusion
Background
Study objectives
Methods
Results
Quality assessment of the studies
Discussion
Characteristics of the patient safety culture dimensions
Study limitations
Conclusion
Acknowledgements
References

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