INTRODUCTION:

The Institute of Medicine Report, To Err is Human: Building Safer Health System, highlight the high rate of medical errors in US and the costly consequences of these medical errors were huge. Preventing the adverse events cannot be achieved unless there is a Safe Health System in place, including: Electronic Health Record (EHR), safety culture, and monitoring the safety measures in regular basis.¹

The Patient Safety defined by Institute of Medicine (IOM) as “Prevention the harm to the patients through the care delivery system that learns from past adverse events and near misses, communicate effectively and involving the healthcare professionals and the patients”.²

The Patient safety means; to protect the patients and the staff from the physical and emotional harm, but there is no specific definition which can shape the patient safety into specific measures. It should be part of the culture from the leaders, the healthcare providers, the administrative staff, and the patients.³

Measuring the patient safety by using specific indicators will result in reducing and preventing the adverse events which in return will improve the patient safety in the healthcare organizations. In previous study done on 927 hospitals, found that the high rate of patient satisfaction had strong relationship with measuring the hospital quality and safety level (Correlation Coefficient range from 0.15 to 0.63 for the different medical specialties, with P-value <.05).⁴

A study done by Bodur and Filiz in Turkey to explore the general perceptions of the patient safety in the public hospitals, the findings revealed that the overall score reached 44% which is lower than the Agency for Healthcare Research and Quality (AHRQ) benchmark score. This low score of the patient safety perceptions was because of the low rate on the frequency of errors reported.⁵

Another Study was done in Oman, to explore the nurse’s perception of the patient safety; the results found that when there was high support from their managers, good communication and teamwork within and between the units had positive perception of patient safety culture in their facilities.⁶

Another study in Sweden hospitals about the perceptions of the patient safety among the healthcare staff, concluded that the highest rate of the patient safety dimensions was: teamwork and the non-punitive response to errors. While the lowest rate was in: leadership support and the staffing dimensions.⁷

A study was done in one of the Public hospitals in Saudi Arabia at Adult Oncology department, to assess and compare the patient safety culture among the physicians, nurses, and pharmacists. The results reveled that the physicians rated the patient safety culture higher than the nurses and the pharmacists. While, the nurses had lower rate comparing to the pharmacists.⁸

One of the interesting studies was about the patient safety culture perspective in two of the Ministry of Health (MOH) hospitals in Riyadh, within Emergency Departments. The findings showed that they had low rate in: stress recognition and leadership support dimensions. Nurses had lower rate of teamwork within the units than the physicians, while the physicians had lower rate on the effective work environment than the nurses.⁹

From the patient perspective side about the safety culture, a study was done in 2013 among 1000 inpatients from 5 Saudi public hospitals and 5 Saudi private hospitals. The general perceptions about the safety, empathy and the responsiveness were high and positive. The factors behind the high satisfaction level of the patients in this study were: the high education level, the good income, and the comfort occupation.¹⁰

According to the Central Board for Accreditation of Healthcare Institutions (CBAHI), using a tool for assess the patient safety culture in the hospitals should be done every year.¹¹ The Agency for Healthcare Research and Quality (AHRQ) provide an opportunity to assess the Patient safety culture and the perceptions of their staff through their own surveys and compare their final results to the international benchmark results.

There are many studies, focused on the healthcare provider’s perception of the patient safety culture, few studies focused on the patient’s perspective about the patient safety culture. There is no published study in Saudi Arabia focus on the discrepancy between the healthcare provider’s and the patient’s perspective about the patient safety culture. The aim of this study is to explore the discrepancy between the healthcare providers and the patient’s perceptions about the patient safety culture in Eastern Region of Saudi Arabia.

MATERIAL AND METHODS:

The study design was cross-sectional, quantitative through survey to explore and identify the discrepancy in the perceptions of the patient safety culture between the healthcare providers and the patients. The survey and data collection spanned from 04 October to 24 October 2018. Two separate questionnaires were used, one for the HCPs and the other targeted the patients.

Consent:

The consent was about not to disclose the names or identifying characteristics under any circumstances of patient and healthcare providers and completion of the survey deemed to be informed consent.

Ethical Approval:

The study protocol was reviewed and approved by the Institutional review board (IRB) at Imam Abdulrahman Bin Faisal University, Saudi Arabia with IRB number “IRB-PGS—2019-03-256”.

Healthcare Providers Survey:

We used a customized version of the Patient Safety Culture survey provided by (AHRQ) to explore the healthcare provider perceptions about the patient safety culture in their facilities at Eastern Region of Saudi Arabia.

The survey was available in both English and Arabic languages, and accessed through web-based by using Google form. The questionnaire was tested to improve its face validity through disseminating it to the course instructor, Dr. Sana Al Mahmoud, who is an expert in the topic, and to numerous healthcare professionals. Their feedbacks were collected and reviewed, and then few changes were made in accordance.

The survey randomly given to the healthcare providers in Eastern Region of Saudi Arabia. The healthcare providers including the staff working in the following area: Physician- Medical, Nurse, Radiology, Pharmacy, Laboratory, Anaesthesiology, Rehabilitation, Dietitian, Administration- Management, and Other area.

The survey includes the demographic information of the participant section and 27 items grouped into different patient safety dimensions: (teamwork within the working units, the management support, the organization learning and improvement, the feedback about the errors reported, the frequency of errors reported, the overall perceptions of the patient safety in the working area, the communication openness, and the non-punitive response to errors). Items are scored by using five-point Likert scale reflecting the agreement on the statements (strongly agree, agree, neutral, disagree, and strongly disagree) or the frequency (never, rarely, sometimes, most of the time, always), The survey includes three important questions asking the healthcare providers to provide a score on the patient safety in their working unite, assess the commitment level of the health staff about the patient safety procedures, and to identify the number of errors reported over the last 12 months. The highest score means high level of patient safety culture in the hospital.

The perceptions of the patient safety dimensions were analysed by comparing the average mean of the positive answers among the participants to the average mean of the positive answers to the same dimension in AHRQ database of the Hospital Survey on Patient Safety Culture (HSOPSC). This was done through SPSS version 17.1 by using [T-test, P-value < 0.05]

Patients Survey:

The patients’ questionnaire targeted all adults, and residents of Eastern Region, who are at the age of 18 and above, and who have visited and use healthcare services of the area. A web-based questionnaire was developed using Google Forms and was constructed by using items from several literatures which has been customized to fit the purpose of the study and local customs. The questionnaire was tested to improve its face validity through disseminating it to the course instructor, Dr. Sana Al Mahmoud, who is an expert in the topic, and to numerous patients. Their feedback was collected and reviewed, and then few changes were made in accordance. There data input was also statistically analyzed to make sure its validity and no changes needed further. We used the aid of English language expert to translate the questionnaire into local language which is Arabic. The questionnaire was divided into five component, demographic data, outpatient-visit related questions, inpatient-related questions, safety procedures and errors, and finally overall perception of the patient safety procedures being applied in local hospitals. It’s then been distributed through online channels. Descriptive statistics and another statistics analysis were conducted using SPSS version 17.1.

RESULTS:

Healthcare Providers Survey Results:

A total of 195 randomly participants, completed the survey according to the following working areas: [Physicians (26.15%), Nurses (15.9%), Radiology (10.26%), pharmacy (7.7%), Laboratory (13.85%), Anesthesiology (5.12%), Rehabilitation (4.6%), administrative (12.82%) and other working area (3.6%)]. More participants were from 26-30 age group (29.74 %), and majority of them were female (68.72%). Most of the participants were working in Armed Forces Hospitals (54.36%). Around (40%) of the study participants had a work experience from 11-15 years and (79.49%) had a direct interaction with the patients. Most of the participants lived in Dammam city (75%) (Table.1)

The total composite positive perceptions of patient safety culture among the healthcare providers was (60.44%). The dimensions of teamwork within units, organizational learning, and the managers expectation and actions to promote the patient safety showed the highest positive perceptions (77.75%), (73.77 %), and (72%) respectively. The dimensions of non-punitive response to errors, the communication openness, and the frequency of events reported had the lowest positive perceptions (34.33%), (48.66%) and (50%) respectively. (Figure.1)

The positive responses about the frequency of the events reported by the healthcare providers during the last 12 months (at least 1 event reports or more) was; (22 %). We compare the overall positive responses to the main patient safety dimensions with our benchmark which is the published results of Hospital Survey on Patient Safety Culture by the Agency of healthcare and research Quality. ¹² The T-test was used to compare the mean of the positive responses for each patient safety dimension to our Benchmark, by using SPSS software (Figure.1)

According to (Figure.1), the dimension which differ significantly with the benchmark score of the positive responses was: the frequency of the events reported [T-value= -2.97, P-Value=.059, DF=3]

Patients Survey Results:

During a month, 584 responses were collected for the patient survey, 90% of them were female and 77% were between the ages of 18–30 years. Most of the participants were Bachelor and High school holder with 44.3% and 40.8% respectively, and the majority of them (76.2%) were not related to health sector by working or studying. Dammam and Khobar residents represent half of the participants with slightly higher in Dammam 30.3% than Khobar 20.2% which in turn the same percentage of Ahsa participants 20%. Eighty percent of the participants had never encountered a medical error, however, almost half of them had relatives who did encountered one with 46.2% of the total participants.

The second and third sections were perceptions of patient safety procedures in Outpatient and Inpatient settings. As it can be seen in (Table.2), all the outpatient and inpatient safety procedures have higher level of commitment (All the times, Sometimes) than other categories (Rarely/Never, Recently, I asked for it) as perceived by patients, except for “providing alternative treatment” and “Informing patient about their rights, duties and hospital rules” where almost half of the participants rarely or never receive such information from HCPs. Highest criteria in which HCPs recently started to provide such information without patient asking is “Clarifying Medication prescribed usages”, while the lowest one is “informing patient about post admission care”. Apparently as in (Table.2), patients tend to ask about alternative treatment, since it has the highest rate in “I asked for it”, followed by asking to discuss treatment plan and provide information about current health condition respectively.

As it can be seen in (Figure.3) and (Figure.4), the highest fall type was due to dizziness, whereas for the errors encountered during hospitalization, catching allergy is the highest among other errors.

Table 1 Sociodemographic and Professional Characteristics of the Healthcare Providers

The Characteristics	Frequency	Percentage
The Working Area
Medical Field	51	26.15
Nursing	31	15.9
Radiology	20	10.26
Pharmacy	15	7.7
Laboratory	27	13.85
Anesthesiology	10	5.12
Rehabilitation	9	4.6
Administrative	25	12.82
Other Area	7	3.6
Gender
Male	61	31.28
Female	134	68.72
Age Group
20-25	11	5.65
26-30	58	29.74
31-35	47	24.1
36-40	41	21.02
41-45	16	8.2
46-50	13	6.67
Above 5O	9	4.62
Years of Experience
Less than 1 year	12	6.15
between 1-5 years	38	19.5
between 6-10 years	58	29.74
between 11-15 years	78	40
between 16-20 years	6	3.07
21 years or more	3	1.54

For the fourth part, three questions were asked “If they felt safe during last visit, if they trust healthcare services in the area, and if they would recommend visiting hospitals for patient with the same condition”. In all three criteria, percentage of agreed patients outweighed disagreed ones, however, for the second criteria “if they trust the HCS” the percentage was almost equal. Further bivariate analysis was conducted for these three criteria against “level of education (High, Low)” and “if they work/study in health field (Yes, No)” using Pearson Chi-Square test. Two of the six tests have statistically significant difference, they are trusting the healthcare service with education level (X² = 14.6, P-value = 0.002), and recommending to visit hospital with education level also (X² = 10.5, P-value = 0.01). The rest of the tests has no significant difference. We conducted Binary Logistic regression to calculate odds ratio and the result was patient with higher education had less trust on healthcare services and were 30% less likely to recommend other patients with the same condition to visit hospitals compared to low level educated patients.

In both questionnaires (HCPs, and patients’ questionnaire), two unified questions were used to measure their overall

perceptions toward patient safety procedures applied in the hospitals, and their evaluation of the staff commitment to those procedures.

The overall positive grade on patient safety culture in the healthcare organizations as perceived by the healthcare providers was (74%), while the positive responses on the commitment level of the medical staff toward the patient safety procedures in their facilities was (83%). In contrast to these scores, patients were more pessimistic about patient perceived safety culture in healthcare organization with only (34%) positive responses, and (36%) for medical staff commitment level.

Table 2: Patients’ perceptions of Outpatient and Inpatient settings safety procedures

Health Care Provider Actions	Degree of commitment n (%)
Health Care Provider Actions	All the Time Some Times	Rarely Never	Recently	I asked for it
Outpatient Visit
Provide alternative treatment approach	218 (37.3)	270 (46.2)	5 (0.9)	91 (15.6)
Discuss treatment plan	370 (63.4)	160 (27.4)	9 (1.5)	45 (7.7)
Gave information about my health condition	464 (79.5)	79 (13.5)	7 (1.2)	34 (5.8)
Asked about current medication and allergies	424 (72.6)	129 (22.1)	5 (0.9)	26 (4.5)
Clarify medications prescribed and how to use	359 (61.5)	183 (31.3)	13 (2.2)	29 (5.0)
Encouraged commitment and involvement in my own care	400 (68.5)	165 (28.3)	10 (1.7)	9 (1.5)
Inpatients Admission
Ask about my name for identification	370 (84.3)	64 (14.6)	3 (0.7)	2 (0.5)
Explain hazardous related to staying at hospital	249 (56.7)	175 (39.9)	5 (1.1)	10 (2.3)
Orient about safety procedure (bed sides, hed hell, fall cautious)	256 (58.3)	163 (37.1)	2 (0.5)	18 (4.1)
Inform about my rights, duties and hospital rules	206 (46.9)	221 (50.3)	5 (1.1)	7 (1.6)
Inform about importance of wrist ID label	264 (60.1)	167 (38.0)	3 (0.7)	5 (1.1)
Inform me about post admission care	329 (74.9)	94 (21.4)	1 (0.2)	15 (3.4)
Encouraged commitment and involvement in my own care	325 (74.0)	103 (23.5)	6 (1.4)	5 (1.1)
Confidentiality and privacy were assured	325 (74.0)	103 (23.5)	6 (1.4)	5 (1.1)

DISCUSSION:

The results of this study are highly matched with a study conducted in 13 hospitals in Riyadh, Saudi Arabia, where the area highly perceived as positive were organizational learning/ continuous improvement, teamwork within units, feedback and communication about errors. While, the areas received low positive responses were underreporting of events, non-punitive response to error, staffing and teamwork across hospital units.¹³Both studies highlighted numerous opportunities to improve the underreporting of events and building non-punitive response to errors culture, which relies mainly on healthcare leadership and management support due to the extensive amount of efforts and resources needed to achieve better patient safety culture.¹⁴

The results of this study showed that the culture of reporting incidents in the Saudi Hospitals at Eastern Region needs to be improved and motivated starting by the leadership support and commitment to enhance the patient safety culture. Also, by developing the rules and regulations to protect the healthcare professionals when they report for any adverse incidents.^16,17

For the patient survey, we observed that the majority of the participants were female (90%), this could be justified by the nature of the survey distribution, since the most authors are female, the majority of the contacts received the questionnaires were females, despite the efforts of encouraging the dissemination of the questionnaires among all contacts. Since the study targeted the Eastern Region in Saudi Arabia, this would explain the high percentage of the participants from the main cities (Dammam, Khobar and Ahsa). Most of the participants between the age of 18 – 30, this could be the reason that only 20% encountered a medial error. However, the question of did any of your relatives encountered medical errors could be biased and the results could be overestimated, due to the possibility of two participants reporting the same error of their relatives.

It appears from the results in (Table.2) that patients are appreciating, to high extent, the safety procedures performed by hospitals and healthcare providers. All the measured criteria in outpatient and inpatient settings perceived high rates of satisfaction except of two procedure:” providing alternative treatment” and “Informing patient about their rights, duties and hospital rules”. With the increased patients’ empowerment, they would prefer to hear other treatments options if available, and for the lack of knowledge about rights, duties and hospital rules, could be due to the fact that they don’t know about their existence in first place. So, awareness about their rights and duties must be improved as it has been seen on other study where patients suggested to increase the awareness and knowledge about their rights.¹⁸

Our results found that patients with higher education had relatively less trust on healthcare services compared to low educated patients, this coincide with a study found that patients with low education are less involved in their healthcare decision making in addition to their beliefs that they should not be part of it.¹⁹ This is might be due to that patients with high education are more empowered and seek health services that involve them in the process, answer their questions, and not treating them passively.

Smith, Yount and Sorra studied if there is a relationship between the HCPs perceptions of patient safety against patient experience survey and outcomes, they found, in opposite of our results, that there is strong relationship between them. ²⁰ In our study, Patients questionnaire present high percentage of appreciation to the safety procedure provided by HCPs, meanwhile in the last two questions (Figure, 2) they expressed high dissatisfaction to the patient safety evaluation in general. This could be due to other factors related to the implicit communication and relationship, as in a study conducted to elicit the key factors that depreciate patient safety and upsurge the opportunity of medical errors, the authors concluded that loss of listening, loss of trust and loss of voice are the ones that matter the most to the patients. This matches with our results where half of the patient participants express their distrust on the healthcare services.²¹ This also coincide with the findings of another study where they find empirical evidence that patients conceive safety in different perspective than HCPs.²²

The highest fall type was due to dizziness, whereas for the errors encountered during hospitalization, catching allergy is the highest among other errors (Figure.3) and (Figure.4). This matches with our results where simple prescribing errors are common, although their nature differs from site to site. Clinical pharmacists target patients with the most complex health situations, and their involvement leads to improved documentation and the presence of dizziness in patient is a strong cause of falls.^23,24

Limitation of this study:

The study had several limitations, which are, relatively small sample size in HCPs, and low male responses in patients survey. The generalizability of the study is questionable due to the limited representation of each hospital in the eastern region. The internal consistency of the healthcare provider’s data was lower than that of the AHRQ data. The main reason behind this is the huge and heterogeneous samples made up from different facilities and different countries. Expanding the scale of the survey in Saudi Arabia to cover more different providers, facilities, and cities is necessary for future studies.

Figure 1 Comparison between the Averages of Positive

Responses on the Patient Safety Dimensions with AHRQ Scores- 2018.

Figure 2 Comparison between the Average of the HCPs and Patients Perceptions in Patient Safety Culture.

Figure 3 Percentage and Type of falls in Saudi hospitals.

Figure 4 Percentage and type of Errors during admission.

CONCLUSION:

There is critical gap between what healthcare providers perceived of positive patient safety culture against what the patients perceived. This is should be taken into consideration while providing care to the patients. The issues of underreporting are still in existence despite the long span between this study and the study conducted in Riyadh eight years ago, that conclude the same results.¹²

The main findings from this study, that the healthcare providers perceptions of patient safety culture were high and positive comparing to the patient perceptions which was poor or almost failing. This study represents a ground work that further researches could be conducted to abstract barriers to positive patient safety culture, and how to improve event reporting systems in the area in a way that less punitive than it is now. Further studies in future are needed to identify the reasons behind this discrepancy of the HCP’s and the patient’s perceptions of Patient safety culture in Saudi Hospital.

Efforts to develop and maintain strategies to enhance the patient safety culture in Saudi Arabian Hospitals are needed. The culture of patient safety cannot be improved without a no punitive culture; where the employees could openly discuss the patient incidents and the potential incidents.

ACKNOWLEDGEMENT:

We would like to thank Dr Mohammed Yusuf for extensive checking and editing the manuscript.

AUTHOR CONTRIBUTIONS:

All authors contributed to data analysis, drafting or revising the article, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

DISCLOSURE:

There is no any conflict of interest among authors.

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Received on 19.12.2019 Modified on 03.03.2020

Research J. Pharm. and Tech. 2020; 13(12):5816-5822.

DOI: 10.5958/0974-360X.2020.01014.8