Front-line staff's perspective on patient safety culture in Iranian medical centers: A systematic review and meta-analysis

Abstract

BACKGROUND:

The prerequisite for promoting safety culture is to assess the existing safety culture level of institutes, because safety precautions without appropriate evaluation increase costs and unforeseen risks.

OBJECTIVE:

This study aimed to systematically review the status of patient safety culture from the perspective of clinical personnel at Iranian hospitals through a meta-analysis of studies using the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire.

METHODS:

The present systematic review and meta-analysis was conducted in 2018. Data were gathered by searching Google Scholar, Scopus, PubMed, and Web of Science databases up to November 2018. Search keywords were “patient”, “safety”, “culture”, “healthcare”, “hospital”, “medical center”, “HSOPSC tool”, and “Iran”. The search protocol was limited to 10 years. To estimate the PSC score, computer software CMA:2 (Comprehensive Meta-Analysis) was used. The presence of heterogeneity across the studies was assessed with the I ² statistic. A forest plot was used to report the results. Publication bias was assessed through a funnel plot.

RESULTS:

The meta-analysis of studies showed that the PSC score based on the random effect model was 52.7% (95% CI: 50.2%–55.2%), (Q = 522.3, df = 54, P < 0.05, I ² = 89.6). A mean of 12 dimensions of HSOPSC showed that the “Teamwork within units” dimension had the highest PSC score (67.2%) and “Non-punitive response to error” had the lowest score (40.4%).

CONCLUSIONS:

Managers and policymakers should be directed towards non-punitive responses to errors and persuade staff to report errors and execute the approach to learn from mistakes. Also, a periodic government evaluation of the patient safety culture will help further its sustainable development.

Keywords

Patient safety safety culture HSOPSC medical staff Iran

1. Introduction

The safety culture is a global issue that affects countries at all levels of development [1]. One of the key elements in improving the quality of health services is the safety culture, which prevents patients from harm [2]. However, clinical team errors are among the common causes of death throughout the world. The World Health Organization (WHO) considers the unsafe clinical care and activities the main cause of death for a large number of patients worldwide [3]. For example, numerous cases of medical errors occur annually in hospitals in the USA, UK, and Australia. These errors impose a large burden on the patients and the health system and considerable financial sources should be spent to compensate for the preventable medical errors [4]. Although no clear data exist on the incidence of adverse clinical events in Iran, the Ministry of Health and Education stated that hospitalization of patients due to medical errors imposed high costs over the health system annually. This claim is supported by the increased rate of public complaints from clinical personnel [5].

The safety culture includes beliefs, values, and methods that lead the organization towards safety. In other words, a safety culture can increase patient safety and reduce harms. The high level of safety standards reduces the frequency of errors and helps the staff to report the errors more quickly [6]. The dimensions of patient safety culture include: (1) Overall perception of patient safety, (2) Conventions and practices promoting patient safety, (3) Frequency of reported events, (4) Support for patient safety, (5) Staff, (6) Transitions, (7) Communication openness, (8) Feedback and communication about errors, (9) Learning, continuous improvement, (10) Non-punitive response to errors, (11) Teamwork across units, and (12) Teamwork within units [7].

One of the reliable and valid questionnaires for measuring the safety culture is the Hospital Survey on Patient Safety Culture (HSOPSC), presented by the Agency for Health Research and Quality (AHRQ). Recent studies confirmed the validity of this questionnaire and HSOPSC was translated into various languages. This questionnaire consists of 12 dimensions and 42 questions [8]. Due to the importance of patient safety culture in improving patient safety and reducing harms, many studies have been conducted with this questionnaire. For example, Waleed Alharbi et al. conducted a study in Saudi Arabia and found that the strongest and weakest dimensions were intra- and inter-unit teamwork, respectively [9]. Similarly, Hayfaa Ali et al. in Kuwait reported that intra-unit teamwork and non-punitive response to errors were the strongest and weakest dimensions, respectively [10]. The results of the research by Alejandro Arrieta et al. in Peru also showed that teamwork within units was the strongest dimension, while the non-punitive response to errors was the weakest dimension [11]. The results of recent studies in Iran indicate that the patient safety culture does not have a favorable status. The clinical personnel are the largest workforce group in the health system and play a decisive role in monitoring the quality of patient care and preventing mistakes. The prerequisite for promoting the safety culture is to assess the existing level of safety in organizations, because safety precautions without appropriate evaluations increase the costs and unforeseen risks. Therefore, the purpose of this study was to conduct a systematic review of the status of patient safety culture from the perspective of clinical personnel among Iranian hospitals through a meta-analysis of studies using the HSOPSC questionnaire.

2. Methods

2.1. Study design

This systematic review and meta-analysis was conducted in 2018 and attempted to identify the dimensions of the patient safety culture in an Iranian medical center based on the preferred reporting items for systematic reviews and meta-analyses.

2.2. Search strategy

Data were gathered by searching Google Scholar, Scopus, PubMed, and Web of Science databases up to November 2018. To identify and cover more articles, a manual search of some credible key journals was also performed. Search keywords were “patient”, “safety”, “culture”, “healthcare”, “hospital”, “medical center”, “HSOPSC tool”, and “Iran”. The Boolean operators AND, OR, and NOT were used to combine or limit search results. The search protocol was limited to 10 years.

2.3. Inclusion and exclusion criteria

For the selection of articles related to the research area, the inclusion criteria were (1) studies performed in the field of patient safety culture in Iran within the last 10 years, (2) all sectional descriptive and analytical studies with different methodologies, and (3) only Persian and English studies. The exclusion criteria were (1) studies on patient safety related to other service areas in the health sector, (2) studies on patient safety that did not use the HSOPSC tool, and (3) articles whose full text was not easily accessible.

2.4. Review process

The articles with the key words: “patient”, “safety”, “culture”, “healthcare”, “hospital”, “medical center”, “HSOPSC tool” in their titles and abstracts were selected. Duplicate publications were identified and removed from the review process, and inclusion and exclusion criteria were applied. Finally, a list of titles of all searched articles in the databases was prepared. The list of selected studies was screened to determine the most relevant ones, and the irrelevant articles were rejected. We used the resource management software EndNote X6 to evaluate and organize the abstract titles as well as to find and remove duplicate records.

2.5. Quality assessment and data extraction

Two reviewers independently assessed the quality of the articles using the STROBE Statement (STrengthening the Reporting of OBservational studies in Epidemiology). The checklist acquired 22 items in the abstract, introduction, method, results and discussion sections. Articles that did not report more than 50% of the items in the checklist were excluded. Then, data were extracted and the quality was evaluated, after which 65 articles were selected. The required data including author/publication year, setting, sample size, score of patient safety dimensions and the total score of the patient safety culture were extracted. The HSOPSC tool dimensions and number of components are listed in Table 1.

2.6. Data analysis

To estimate the PSC score, computer software CMA:2 (Comprehensive Meta-Analysis) (Englewood, NJ, USA) was used. The presence of heterogeneity across the studies was assessed with the I ² statistic (I ² ≥ 50% indicates heterogeneity). For reporting the results, a forest plot was used. The meta-analysis was performed using a random-effects model to estimate the overall PSC score with a 95% confidence interval. Publication bias was assessed through a funnel plot and Excel 2010 was used to draw graphs.

Table 1
Composites and definition of patient safety culture [12]

No. Dimensions Number of components Definitions

1 Overall perception of patient safety 4 Methods and systems are effective in preventing mistakes.

2 Expectations and actions promoting patient safety 4 Observers/managers consider employee suggestions to enhance patient safety, encourage employees to adhere to patient safety principles and do not overlook patient safety issues.

3 Frequency of events reported 3 Mistakes are reported in the following types: (1) Mistakes before confronting the patient; (2) Mistakes without damaging potential to the patient; (3) Mistakes that can harm the patient.

4 Support for patient safety 3 Hospital management provides a work environment that promotes patient safety and indicates that patient safety is a priority.

5 Staff 4 There is enough staff to handle the workload and the hours worked to provide the best care for the patients.

6 Transition 4 Important information about patient care is disseminated throughout the hospital units during the course of the changes.

7 Communication openness 3 Employees can speak freely if they see something that may affect adversely on the patient.

8 Feedback and communication about errors 3 Employees are aware of the mistakes that occur, they give feedback on the changes made and discuss ways to avoid errors.

9 Learning, continuous improvement 3 Mistakes lead to positive changes and changes were evaluated in terms of efficiency.

10 Non-punitive response to errors 3 Employees feel that their mistakes and reports are not used against them and errors are not kept in their case file.

11 Teamwork across units 4 Co-ordination and co-operation between hospital units provide the best care for patients.

12 Teamwork within units 4 Employees support and respect each other and work as a team.

No.	Dimensions	Number of components	Definitions
1	Overall perception of patient safety	4	Methods and systems are effective in preventing mistakes.
2	Expectations and actions promoting patient safety	4	Observers/managers consider employee suggestions to enhance patient safety, encourage employees to adhere to patient safety principles and do not overlook patient safety issues.
3	Frequency of events reported	3	Mistakes are reported in the following types: (1) Mistakes before confronting the patient; (2) Mistakes without damaging potential to the patient; (3) Mistakes that can harm the patient.
4	Support for patient safety	3	Hospital management provides a work environment that promotes patient safety and indicates that patient safety is a priority.
5	Staff	4	There is enough staff to handle the workload and the hours worked to provide the best care for the patients.
6	Transition	4	Important information about patient care is disseminated throughout the hospital units during the course of the changes.
7	Communication openness	3	Employees can speak freely if they see something that may affect adversely on the patient.
8	Feedback and communication about errors	3	Employees are aware of the mistakes that occur, they give feedback on the changes made and discuss ways to avoid errors.
9	Learning, continuous improvement	3	Mistakes lead to positive changes and changes were evaluated in terms of efficiency.
10	Non-punitive response to errors	3	Employees feel that their mistakes and reports are not used against them and errors are not kept in their case file.
11	Teamwork across units	4	Co-ordination and co-operation between hospital units provide the best care for patients.
12	Teamwork within units	4	Employees support and respect each other and work as a team.

Fig. 1.

The flowchart of the literature search.

3. Results

The database search identified 1107 studies, of which 321 articles were rejected due to repetition. After screening the title and abstract, 776 studies were rejected, and then another 38 papers were rejected after screening the full text. Finally, 54 articles were selected which were fully consistent with the purposes of this study (see Fig. 1, Table 2).

All studies were conducted in Iran, of which 13 studies were conducted in Tehran. Seven studies were conducted in multiple cities. The ranks of Isfahan, Tabriz and Ilam are listed in Fig. 2.

Fig. 2.

Number of studies per city.

Fig. 3.

Prevalence of patient safety culture in Iran.

The meta-analysis of studies (Fig. 3) showed that the PSC score based on the random effect model was 52.7% (95% CI: 50.2%–55.2%), (Q = 522.3, df = 54, P < 0.05, I ² = 89.6). The lowest PSC score was 87.3% in Isfahan [63], and the highest PSC score was 31% in Kerman [18].

The mean of 12 dimensions of HSOPSC showed that the “Teamwork within units” dimension had the highest PSC score (67.2%) and “Non-punitive response to error” had the lowest PSC score (40.4%) (Fig. 4). The funnel plot of PSC shows that there is an asymmetry in the gathered data (Fig. 5).

Fig. 4.

The mean of 12 dimensions of HSOPSC in Iran.

Fig. 5.

The funnel plot of standard error by event rate.

Table 2

The results of the data extracted from the 54 articles

Ref. no.	Authors	Year	Setting	Sample	1*	2*	3*	4*	5*	6*	7*	8*	9*	10*	11*	12*	Total PSC score (%)
[13]	Baghaei et al.	2011	Urmia	500	59	67	42	49	36	62	45	56	69	31	55	80	54.25
[14]	Ebadi Fard Azar et al.	2011	Tehran	145	64	65	60	57	52	69	63	62	67	48	65	68	61.66
[15]	Yaghobi Far et al.	2011	Sabzevar	385	58.37	54.15	43.66	52.53	22.37	56.3	37.26	47.43	69.16	13.03	52.67	73.65	48.37
[16]	Arabloo et al.	2012	Qazvin	231	57	56	56	54	48	63	51	56	63	31	50	64	54.08
[17]	Faghihzadeh et al.	2012	Amol	530	60	70	33.33	44.33	22	52	35.66	68.33	73	24.67	44.75	58.25	49.00
[18]	Nekoei-Modhadam et al.	2012	Kerman	385	54.2	68.3	41.5	45.6	36.8	51.5	48.2	58.8	58	26.3	50.4	70.2	31.00
[19]	Adibi et al.	2012	Tehran	90	44.63	51.91	50.33	29.69	26.05	46.39	50.91	65.93	67.9	21.19	29.09	69.86	46.15
[20]	Tabrizchi et al.	2012	Multiple cities	120	60	65	50	77	28		61	44	78	12	80	76	52.58
[21]	Arabloo et al.	2012	Multiple cities	145	60	61	58	54	47	60	53	56	62	44	53	65	56.08
[22]	Moghri et al.	2013	Tehran	420	55	54	42	34	23	47	39	41	66	18	40	69	44.00
[23]	Arshadi Bostanabad et al.	2013	Tabriz	99	56.32	68.67	37.36	33	18.42	58.82	40.03	49.83	68.66	15.16	37.87	65.92	45.83
[24]	Moghri et al.	2013	Multiple cities	725	53	55	46	43	35	48	42	44	62	23	42	65	47.00
[25]	Almasi et al.	2013	Kermanshah	872	70.2	50.5	69.8	57.6	96.2	60.6	66.9	53	30.8	75.1	63.3	83.7	49.70
[26]	Nourmoradi et al.	2015	Ilam	208	30	40	39	44	19	49	37	43	56	11	44	70	40.00
[27]	Salavati et al.	2013	Ahvaz	142	56.15	43.67	33.47	64.44	64.6	41.92	56.27	26.7	71.54	81.1	54.4	76.03	55.85
[28]	Momeni et al.	2012	Tehran	332	73	69	75	65	45	60	56	68	71	44	57	71	63.00
[29]	Mozafari et al.	2013	Ahvaz	29	62.1	58.6	24.1	89.7	72.4	72.4	75.9	55.2	72.4	13.8	65.5	51.7	75.90
[30]	Moussavi et al.	2013	Tehran	200	37	42	33	42	22	39	27	38	46	12	39	48	35.00

Table 2 (Continued).

∼

Ref. no.	Authors	Year	Setting	Sample	1*	2*	3*	4*	5*	6*	7*	8*	9*	10*	11*	12*	Total PSC score (%)
[31]	Davoodi et al.	2013	Northeast Iran	922	56.56	69.53	42.85	55.27	26.36	51.55	45.46	51.31	79.85	21.57	55.09	71.92	52.27
[32]	Bahrami et al.	2014	Yazd	340	49.7	44.07	32.87	50.43	16.65	51.42	37.5	33.36	64.37	15.3	40.62	46.17	40.20
[33]	Homauni et al.	2014	Yazd	117	60.3	54.77	44.6	54.77	36.77	56.25	48.5	44.6	76.46	47.03	52.22	77.9	54.77
[34]	Sarhadi et al.	2014	Zahedan	400	65.8	37.5	40.8	55.8	35.6	25.8	31.1	36.1	42.7	30.2	29.3	45.8	39.70
[35]	Tourani et al.	2015	Tehran	270	72	86	87	53	66	58	77	87	64	75	66	62	40.00
[36]	Kiaei et al.	2016	Multiple cities	552	62.93	71.09	55.63	63.5	62.06	54.5	62.8	67.36	71.18	66.2	60.91	65.93	63.67
[37]	Dehghani et al.	2015	Hormozgan	190	49.44	65.7	53.46	61.5	40.25	64.84	60.95	60.95	64.95	53.46	41.5	85.6	49.01
[38]	Mohebi Far et al.	2015	Tehran	312	62	69	56	62	61	55	62	65	69	65	61	65	62.66
[39]	Ghahramanian et al.	2017	Tabriz	401	66.57	63.25	56.42	66.47	45.89	62.63	58.75	63.28	68.21	45.87	54.98	65.9	59.85
[40]	Ebrahimzadeh et al.	2017	Multiple cities	384	43.83	48.92	21.44	36	47.67	76.5	30.22	22.22	21.44	60.44	47.58	21.17	39.78
[41]	Jafarpanah et al.	2017	Kermanshah	214	57.14	61.69	41.7	55.33	27.33	56.89	24.63	45.64	75.86	15.59	50	66.62	48.93
[42]	Amiri et al.	2018	Shiraz	80	51.2	59.9	26.46	55.53	9.95	28.15	23.27	60.86	72.46	21.66	53.2	45.65	42.35
[43]	Raeissi et al.	2016	Tehran	298	65.25	69.68	53.33	78.58	32.56	65.12	47.74	55.83	79.66	34.24	63.37	73.81	59.93
[44]	Sharif et al.	2016	Kashan	200	35	56.5	64	43	32.5	52	65.5	47.5	35.5	64	60.5	41.5	49.79
[45]	Shamsadini Lori et al.	2016	Tehran	310	52.7	42	36.4	62.3	63	42.3	52.5	32.7	81	68.5	54.6	76.1	55.34
[46]	Borji et al.	2016	Ilam	150	72.45	60	58.65	55	52.43	70.74	71.26	60.98	78.54	48.93	50.93	68.63	62.37
[47]	Kabodi et al.	2017	Kermanshah	380	45	51	26	38	23	42	41	47	57	51	34	59	43.00
[48]	Raeissi et al.	2015	Tehran	270	58	69	58	98	88	49	66	84	73	70	65	54	40.00
[49]	Mirzaei et al.	2018	Zanjan, Ilam	421	46	41.5	30	32.5	15.5	43	24.5	42.5	51.5	13.5	39	57	36.00
[50]	Afshari et al.	2016	Isfahan	118	59.1	63.7	60.8	51.5	68.1	68.1	63.3	65.1	74.5	49.1	55.2	69.1	62.30

Table 2 (Continued).

∼

Ref. no.	Authors	Year	Setting	Sample	1*	2*	3*	4*	5*	6*	7*	8*	9*	10*	11*	12*	Total PSC score (%)
[51]	Farzi et al.	2016	Isfahan	156	60.7	68.9	78.8	67.5	37.1	15.3	53.8	80.3	87.8	21.5	54.5	98.5	60.39
[52]	Rezaei et al.	2017	Tabriz	101	50.5	48.25	32.67	56	17	44	38	42.67	58.67	12	35	54.25	40.75
[53]	Akbari et al.	2016	Ilam	350	73.7	45.4	56.93	47.46	26	65.2	58.8	66.53	73.06	35.6	53.3	81.1	56.92
[54]	Asefzadeh et al.	2017	Mazandaran	380	62.9	55.6	41.6	51.9	60.8	24.5	35.9	49.6	72.5	55.48	46.6	69.6	51.52
[55]	Bastani et al.	2018	Shiraz	165	52.5	82.2	73	58.3	36	68.3	54.7	79	88.3	34.7	60.2	82.5	64.10
[56]	Farsaraei et al.	2017	Tabriz	192	39.85	52.59	35.77	38.37	53.62	41.56	38.37	45.13	55.7	18.57	42.32	66.15	44.00
[57]	Raeissi et al.	2015	Multiple cities	461	60.1	59.87	51.92	65.15	34.82	59.47	39.99	51.41	79.3	26.54	63.83	73.75	55.51
[58]	Amiran et al.	2019	Tehran	132	35	57	50	52	60	51	81	30	70	57	73	61	52.00
[59]	Mostafaei et al.	2018	Tehran	600	56	61	62	61	60	61	62	60	60	58	62	62	60.41
[60]	Zareh Moayedi et al.	2018	Tehran	345	67	73	58	44	63	70	55	61	62	51	71	81	63.00
[61]	Elmi et al.	2018	East Azerbaijan	98	66.12	69.13	63.11	45.15	43.13	64.12	58.13	66.14	70.1	44.13	59.15	72.14	60.04
[62]	Khorami Markani et al.	2018	Multiple cities	100	66	75	63	72	57	45	62	64	72	44	58	80	63.16
[63]	Hemmat et al.	2015	Isfahan	83	70.16	82.8	61.07	75.9	64	61.75	67.5	71.06	77.7	79.5	71.58	81.7	87.30
[64]	Agharahimi et al.	2012	Isfahan	106	62	72.8	63.4	62.2	59.4	56.4	59.4	63.8	70.6	68.8	61.4	67.6	64.00
[65]	Saber et al.	2015	Kerman	439	63.27	67.07	63.9	72.2	57.68	59.08	62.45	68.11	63.45	56.3	58.57	68.55	63.38
[66]	Farzi et al.	2016	Isfahan	367	58.6	69.7	67.4	62.3	35.6	21.1	47.5	70.6	84	24.7	49.4	97.3	57.70
[67]	Rashidi et al.	2017	Urmia	85	70	62.5	57.3	77.3	59	64	66	68	67.3	74.6	59.5	54	64.40

1: Overall perception of patient safety, 2: Expectations and actions promoting patient safety, 3: Frequency of events reported, 4: Support for patient safety, 5: Staff, 6: Transitions, 7: Communication openness, 8: Feedback and communication about errors, 9: Learning, continuous improvement, 10: Non-punitive response to errors, 11: Teamwork across units, and 12: Teamwork within units.

4. Discussion

In the present study, patient safety culture status was systematically examined from the perspective of the clinical staff using HSOPSC. According to our results, the safety culture score (52.7%) was lower than the score reported in Kuwait (63.48%) [10], because some PSC concepts are stressed in Kuwait, which are not even known to many Iranian hospital personnel. In contrast, this score was higher than the one reported in Peru (36.18%) [11]. This discrepancy can be attributed to the significant differences in management in terms of organizational commitment between public and private hospitals. In addition, the results showed that the mean score of the positive responses to various dimensions of the questionnaire ranged from 9.95 to 98.5. The score for the “Overall perception of patient safety” dimension was 57.3, which is lower than the rates reported for Slovakia and France [68,69]. The “Expectations and actions promoting patient safety” dimension received a mean score of 60.5, which is consistent with a study conducted in Palestine. However, it is lower than the mean score reported for Hungary [70,71]. The mean score for the “Frequency of events reported” dimension was 50.2, which is higher than the mean scores of China and Norway [72,73]. The mean score of the “Support for patient safety” dimension was 55.9, which is lower than in Kuwait and France [69,74]. The mean score of the “Staff” dimension was 43.4, which is higher than the mean score in Slovakia and lower than the mean score in Egypt [68,75]. The mean score of the “Transitions” dimension was 53.4, which is consistent with the study in Norway [73]. However, the mean score in Hungary is lower than this rate [71]. The mean score of the “Communication openness” dimension was 51.3, which is in better than in China and Kuwait [72,74]. The “Feedback and communication about errors” dimension had a mean score of 55.3, which is lower than the mean scores of France and Oman [69,75]. The mean score of the “Learning, continuous improvement” dimension was 66.6, which is close to the mean score of Slovakia, but is higher than the mean score of Palestine [68,70]. The “Teamwork across units” dimension was 53.4, which is consistent with the study in Kuwait, but is higher than the mean score of Norway [73,74]. The “Non-punitive response to error” dimension had the lowest mean score (40.4) among the 12 dimensions of the questionnaire. The punitive response to errors is considered an important barrier to identify and reduce the mistakes in the health system. Due to the non-punitive responses, the employees do not feel that their errors are recorded in their occupation records to degrade them. The existence of a punitive response approach leads the personnel to avoid reporting errors or reports them to a lesser degree than is the case in reality [76].

A systematic approach to addressing the mistakes in organizations can promote the patient safety culture, prevent managers from punishing staffs, and help staff to learn from mistakes. The “Teamwork within units” dimension received the highest score (67.2%) among the 12 dimensions of the questionnaire. This score can be related to the sovereignty of the friendly atmosphere within the hospitals, which consequently makes the personnel feel free to talk about their mistakes. The results of these two dimensions are consistent with previous studies in Peru [11] and Kuwait [10].

In order to improve patient safety culture, managers, policymakers, and employees should be provided with appropriate training. Furthermore, the programs developed in this regard should be monitored continuously. In recent years, the attention of health system policymakers, decision makers, and managers has been drawn to the credibility program, which positively affected the patient safety culture. However, this culture needs a lot more promotion [77].

This study had some limitations. First, there was a lack of access to some databases. Second, the full text of some articles could not be accessed. Third, we only used articles that examined health care centers. Fourth, there was a lack of information about many hospitals in different provinces of Iran, where the patient safety culture had not been investigated.

5. Conclusion

Identifying the weaknesses and strengths of safety in hospitals allows to improve patient safety more effectively. The results of this study show that the strongest and weakest dimensions of patient safety culture in Iranian hospitals are “Teamwork in units” and “Non-punitive response to errors”, respectively, and efforts should be made to strengthen other dimensions, including “Frequency of reported events”, “Staff” and “Communication openness”. Also, the results indicate that the patient safety culture in Iran is not desirable, and that this should be prioritized by managers and policy makers. They should focus on non-punitive responses to errors and persuasion of staff, and report their mistakes and learn from mistakes and approaches. Considering a structured reporting system and a periodic assessment of patient safety culture by the state can help move toward this direction and contribute to its continuous improvement. Ultimately, changes in employee beliefs, values and behaviors according to the patient safety culture can occur great changes in hospitals.

Footnotes

Conflict of interest

There is no conflict of interest to be declared.

Nomenclature

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