Assessment of patient safety culture in Iranian academic hospitals:

Strengths and weaknesses

Pouran Raeissi 1*, Nahid Reisi 2, Amir Ashkan Nasiripour 3,

1- Associate Prof., Department of Health Services Research, School of Health Management and Medical
Information Science, Iran University of Medical Sciences, Tehran, Iran.

Email: raeissi2009@yahoo.com,
raeissi.p@iums.ac.ir

2- Associate Prof., Department of Pediatrics, Hematology and Oncology, School of Medicine, Isfahan University
of Medical Sciences, Isfahan, Iran. Email: reisi@med.mui.ac.ir

3- Associate Prof., Department of Health Services Management, School of Medical Sciences, Science and
Research Branch, Islamic Azad University, Tehran, Iran. Email: nasiripour@srbiau.ac.ir

*Corresponding Author: Pouran Raeissi, Department of Health Services Research, School of Health Management
and Medical Information Science, Iran University of Medical Sciences, Vali-ye-Asr Ave., Rashid Yasami St.,
Tehran, Iran.

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Abstract:
Background
In the relevant literature, the establishment of a patient safety culture (PSC) is a vital step in
providing quality service to patients. The goal of this study is to establish a baseline for PSC in
Iranian academic hospitals and to determine its strength and weaknesses.
Methods
A survey was distributed in 26 academic hospitals linked to the Iran and Tehran Universities of
Medical Sciences, of which 18 participated. The questionnaire, the Hospital Survey on Patient
Safety Culture (HSOPSC), was used to collect the data. The questionnaire contained 14
dimensions and 43 items, and the questions were scored using a five-point Likert scale in which
1= strongly disagree and 5= strongly agree.
The results were expressed in terms of the percentage of positive responses (%), or the percentage
of positive responses (e.g., agree, strongly agree) to positively worded items (e.g., “Hospital units
work well together to provide the best care for patients”) in relation to the percentage of negative
responses (e.g., disagree, strongly disagree) to negatively worded items (e.g., “When an event is
reported, it feels like the person is being written up, not the problem”). To score each item, the
following formula was applied: % of Positive Responses = [(No. of Agree + No. of Totally
Agree)/Total No. of Subjects Responding to the Question)]* 100). For the negatively worded
items, the answers were reversed. To score each dimension, a composite mean score of positive
responses were estimated. The same methodology was applied to the scoring of the PSC of each
hospital. (i.e., the composite mean score of positive responses on 12 dimensions was obtained).
Note that the data reported in the tables of this manuscript represent percentages, and for ease of

2
communication, (%) are omitted from the stated tables. In the text, however, we have used %
wherever needed.

To categorize the hospitals’ safety culture from very weak to very strong, a range of 0.0% to
100% positive responses on the PSC questionnaire was divided by five ((100% - 0.0%)/5= 20%),
and five equally spaced intervals were defined (i.e., 0.0 % - 20.0% = very weak, 21.0 % - 40.0 %
= weak, 41.0 % - 60.0 % = intermediate, 61.0% - 80.0 % = strong, 81.0 % - 100.0 %. = very
strong).
The convenience sampling method was utilized to select the samples. For the purpose of this
research, 35 questionnaires were randomly distributed in each hospital; 15 among nurses and
assistant nurses (as the frontline personnel having the most direct contact with patients) and 20
among other clinical and paraclinical personnel as well as other groups (physicians, residents,
interns, ward secretaries, lab personnel, radiology personnel, and managers). The questionnaires
were distributed and collected by the hospitals’ head nurses. The data were analyzed using a one-
sample and independent t-test.

Results
The mean score of the hospitals on the PSC ranged from 42.74 to 67.22, 12 of 18 hospitals
obtained an “intermediate” ranking position, and six obtained a “strong” ranking position on the
PSC. The overall mean score for the entire hospital for patient safety culture was 56.74, with
SD=18.41. No significant difference was observed between the Iran and Tehran Universities of
Medical Sciences hospitals for the PSC. However, significant differences were observable at the
dimension and item levels.

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 A hospital’s strengths lie in the “organizational learning-continuous improvement,” “teamwork
within hospital units” and “hospital management support for patient safety” dimensions.
Dimensions including “feedback and communication concerning errors,” “communication
openness,” “staffing,” and “non-punitive response to error” were shown to be weak points of all of
the hospitals in this study.

Conclusion
The patient safety culture of the investigated hospitals is not at an ideal level and is in need of
serious improvement, particularly in the dimensions of “feedback and communication regarding
errors,” “communication openness” “staffing” and “non-punitive response to error.” The same
conditions hold true for other Iranian hospitals (i.e., the Afshar and Sadoughi hospitals in the city
of Yazd, Iran), and American hospitals were used for comparison purposes in this paper.
Keywords: Patient, patient safety, safety culture, hospital, healthcare safety, healthcare
organization

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Background
In the relevant literature, the establishment of a patient safety culture (PSC) is a vital step in
providing quality service to patients. Consequently, much focus has been given to this concept by
researchers over the last two decades. Currently, many nations are aware of the importance of this
issue and are investing time and effort with the goal of measuring and improving PSC in their
hospitals (1-5).
The U.S. and the UK are pioneers in this movement. The promotion of a safety culture was
initiated after a publication by the American Institute of Medicine (IOM) in 1999 that estimated
the annual deaths in U.S. hospitals to be between 44,000 to 98,000, many of which were
preventable (Institute of Medicine (IOM)(6)). However, what do the concepts of “patient safety”
and “patient safety culture” mean, and why is patient safety worthy of attention?
Patient safety is defined by the UK Department of Health as: “freedom from harm whilst receiving
health care” (DOH) (7). Some authors view patient safety as: “freedom from accidental injury
stemming from the processes of health care. These events include “errors,” “deviations,” and
“accidents.”” (8).
However, what is patient safety culture? Patient safety culture can be thought of as a culture in
which staff members have positive perceptions of psychological safety, teamwork, and leadership
and feel comfortable discussing errors (9). In addition, there is a “collective mindfulness”
regarding safety issues in which leadership and frontline staff share responsibility for ensuring that
care is delivered safely (10)
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From the viewpoint of the Agency for Healthcare Research and Quality (AHRQ), an
organizational culture consists of the values, beliefs, and norms that are important to the
organization. The AHRQ describes culture as a critical component of healthcare quality and
safety. An organizational culture consists of the values, beliefs, and norms that are important to
the organization. A culture of safety includes the attitudes and behaviors that are related to patient
safety and that are expected and appropriate in the promotion of patient safety (11).
Some researchers contend that there are no clear criteria for what constitutes a culture of safety;
however, the term represents an organization that has adopted measures to decrease actual or
potential adverse events. These measures may include transparency, employee involvement in
practice decisions, the reinforcement of safe behavior, and a reporting system that is non-punitive
and focused on system failure (12).
In this study and for practical purposes, we adapted a patient safety culture defined by the AHRQ
in the U.S., which places a high value on the following attributes as the main components of safety
culture in hospitals:
1- Communication openness (transparency), 2- Feedback and communication regarding error, 3-
The frequency of events reported, 4- Handoffs and transitions, 5- Management support for patient
safety, 6- Non-punitive response to error, avoiding a culture of blame, 7- Organizational learning
(from accidents), and continuous improvement, 8- Overall perceptions of patient safety, 9-
Staffing related to patient safety, 10- Supervisors’/managers’ expectations and actions promoting
safety, 11- Teamwork across units, 12- Teamwork within units (13).
The stated dimensions are defined as follows:

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1. Communication openness: The extent to which staff members freely speak up if they see
something that may negatively affect a patient and the extent to which they feel free to question
those with more authority.
2. Feedback and communication regarding error: Staff members are informed regarding errors
that occur, given feedback regarding changes implemented, and discuss ways to prevent errors.
3. Frequency of events reported: The following types of mistakes are reported: (1) mistakes that
are identified and corrected before they affect the patient, (2) mistakes with no potential to harm
the patient, and (3) mistakes that could harm the patient but do not.
4. Handoffs and transitions: Important patient care information is transferred across hospital
units and during shift changes.
5. Management support for patient safety: Hospital management provides a work climate that
promotes patient safety and shows that patient safety is a top priority.
6. Non-punitive response to error: Staff members feel that their mistakes and event reports are
not held against them and that mistakes are not retained in their personnel files.
7. Organizational learning - Continuous improvement: Mistakes have led to positive changes,
and those changes are evaluated for effectiveness.
8. Overall perceptions of patient safety: Procedures and systems are good at preventing errors,
and there is a lack of patient safety problems.
9. Staffing: There is sufficient staff to handle the workload, and work hours are appropriate to
provide the best care for patients.
10. Supervisors’/managers’ expectations and actions promoting safety: Supervisors/managers
consider staff suggestions to improve patient safety, praise staff for following patient safety
procedures, and do not overlook patient safety problems.

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11. Teamwork across units: Hospital units cooperate and coordinate with one another to provide
the best care for patients.
12. Teamwork within units: Staff members support each other; they treat each other with respect
and work together as a team.
Given the definition of a patient safety culture, one can understand its inherent link to the concepts
of “patient safety” and “quality service.” Where do these links potentially exist? In the literature,
many view “quality health care” as the overarching umbrella under which patient safety resides.
Some researchers view patient safety as the cornerstone of high-quality health care (14), and in the
most recent work of the IOM, “Quality care for the 21st century,” quality care is introduced as
being safe, effective, patient-centered, timely, efficient, and equitable. Thus, safety is the
foundation upon which all other aspects of quality care are built (15). Some researchers also view
“patient safety” as a critical component of health care quality (16).
Researchers in the U.S. tested the hypothesis that improving patient safety begins at the highest
levels of organizations. This approach includes a transformational leadership style that promotes a
culture of safety associated with adopting patient safety initiatives, ultimately with improved
outcomes. Data from a survey of over 200 hospitals supported this theory (17, p. 9 & 18). Other
researchers discovered that a safety culture and other contextual factors influence handovers,
white board use and the coordinator role, which are the key processes that facilitate team
coordination (19). Research conducted in 72 nursing homes in the U.S. indicated that a good
perception of safety culture was associated with increased reports of falls, although no association
was observed for pressure ulcer rates (20). The available statistics also suggest that there is a
relation between safety culture and safety outcomes. For example, patient safety culture was
shown to have a positive impact on patient safety behavior among the staff (21). A relation
between aspects of safety culture and the number of adverse events is also reported (22). Overall,
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the general feeling regarding the safety culture in hospitals is that it is a vital element in attaining
patient safety and quality service and has the potential to influence both patient and staff
outcomes.
Iranian health personnel and researchers have noticed the importance of patient safety primarily
since 2009, when the World Health Organization patient safety initiatives were launched in
Iranian hospitals, followed a year later by the clinical governance program. Available statistics,
however, reveal that a limited number of studies focused on safety culture in Iranian hospitals (23-
26). The goal of this study is to evaluate the safety culture status in hospitals related to the Iran
University of Medical Sciences (IUMS) and the Tehran University of Medical Sciences (TUMS).
Methods
To achieve the above goal, a survey was conducted in 26 academic hospitals linked to Iran and the
Tehran Universities of Medical Sciences (n1=10 and n2=16, respectively). The questionnaire, the
Hospital Survey on Patient Safety Culture (HSOPSC) (27), was used to collect the data. The
convenience sampling method was utilized to select the samples. For the purpose of this research,
35 questionnaires were randomly distributed in each hospital: 15 among nurses and assistant
nurses (as the frontline personnel having the most direct contact with patients) and 20 among other
clinical and para-clinical personnel, and other groups (physicians, residents, interns, ward
secretaries, lab personnel, radiology personnel, and managers). The questionnaires were
distributed and collected by the hospital managers and head nurses on behalf of the researcher.
The questionnaire contained 14 dimensions and 43 items. The stated dimensions were classified
into three major areas: safety culture at the unit level, safety culture at the hospital level, and
outcome measures, which contained seven, three and four dimensions, respectively. The
Cronbach’s alpha reliability coefficients for the stated dimensions ranged from 0.63 to 0.83.

9
The HSOPSC questions were scored using a five-point Likert scale, where 1 = strongly disagree
and 5 = strongly agree. To score each question, the percent of positive responses was calculated
(20) as follows:
(No . of Agree+ No . of Strongly Agree )
% of Positive Responses= × 100
(Total No. of Respondents¿the Question)

To score each dimension, the mean scores of the percent of positive responses were calculated. As
an example, for a dimension with three questions (Q 1 to Q3), the percent of positive responses was
calculated and then divided by three to obtain the mean.
To compute the score for the safety culture in each of three major areas (i.e., unit level, hospital-
wide and outcome measures), the mean percents of positive responses were calculated for each
area.
To score the patient safety culture of each hospital, the mean score for the percent of positive
responses on 12 dimensions (having a Likert scale) was calculated. Note that the data reported in
the tables of this manuscript represent percentages and are omitted from the stated tables for ease
of communication (%). In the text, however, we have used % wherever needed.
To score the hospital safety culture from very weak to very strong, the following cut points were
used (0.0% - 20.0%) = very weak safety culture, (21.0% - 40.0%) = weak, (41% - 60.0%) =
moderate, (61% - 81%) = strong, and (81% - 100%) = very strong. For this classification of the
hospitals, the 0.0% to 100% range of positive responses on the patient safety culture questionnaire
was divided by five ((100%- 0.0%)/ 5= 20%) to obtain a distance to define five equally spaced
intervals of very weak to very strong (i.e., 0.0 % - 20.0% = very weak, 21.0 % - 40.0 % = weak,
41.0 % - 60.0 % = intermediate, 61.0% - 80.0 % = strong, 81.0 % - 100.0 % = very strong).

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Ethical Considerations
Approval for the study was obtained from the Iran University of Medical Sciences’ Research
Ethics Committee (Letter No. 91-1-136-17544-90062, Dated 2014-01-20). All hospital managers
were informed regarding the research intent prior to the study by the Iran University of Medical
Sciences’ Department of Research Office. All investigated subjects were also informed of the
research objectives through the cover letter and were free to decide whether to complete the
questionnaire. Anonymity was guaranteed for the respondents of the questionnaires.
Results
Eighteen of 26 academic hospitals participated in this study. Of the eight that were omitted, five
showed a lack of interest in participating, three placed unreasonable conditions on the researchers,
and one was busy with renovation construction.
From the 18 hospitals that participated in this research and of the 630 questionnaires distributed in
the stated hospitals, 488 were returned to the researcher. Of these, 461 were complete and
analyzed in this report. Those omitted were poorly completed with much missing data, sometimes
as much as 50% (potential reasons for this shortcoming could be a lack of interest, a lack of time,
or a lack of motivation, as there was no financial compensation provided).
Of the 18 participating hospitals, six were general hospitals, and 12 were specialized (Table 1).
Hospitals H1 to H8 were linked to the Iran University of Medical Sciences (IUMS), and H 9 to H18
were connected with the Tehran University of Medical Sciences (TUMS).
Table (1) to be inserted here
Table (2) represents the frequency distribution of participants according to their working unit or
department. The category called “others” in the last row of Table (2) represents personnel, such as
11
secretaries of wards, who are nurses that perform the administrative jobs of the ward, non-clinical
managers of hospitals, and service department personnel that provide services to patients.
Table (2) to be inserted here
Demographic information of the participants is presented in Table (3).
Table (3) to be inserted here
The mean score for the ages of the subjects was 34.06 years with SD=28.8 years; the mean score
for the length of their working careers was 9.3 years with SD=7.57; the mean score for their years
of working in the current hospital was 6.9 years with SD=5.57; the mean score for working in the
same unit or department was 5.11 years with SD=4.68; and the mean score for the number of
working hours in the current hospital was 48.27 hours with SD=22.35 hours.
In regard to the safety culture statutes in the investigated hospitals, the findings revealed that the
mean score for 12 dimensions of the safety culture was 56.74. This placed these hospitals at an
intermediate ranking position based on the cutoff scores used in this research. Table (4) represents
the mean scores of the hospitals (mean of positive responses) on the 12 dimensions of the safety
culture.
Table (4) to be inserted here
As the findings in Table (4) indicate, the hospitals received the highest mean score on
“organizational learning-continuous improvement” and the lowest score on the “non-punitive
response to error” dimension. The dimension with the highest mean score was ranked #1, and the
dimension with the lowest mean score was ranked #12 on the table. Based on this ranking
methodology, the dimensions of “non-punitive response to error,” “staffing,” “feedback” and
communication regarding errors” received ranks of 12, 11 and 10, respectively. The responses of
12
the staff surveyed suggested that the hospital safety culture is not adequate in these areas. The
findings in Table (4) also indicate that the strengths of the hospitals were in the areas of
“organizational learning.” These are: continuous improvement,” “teamwork within hospital units,”
and “hospital management support for patient safety”; these received ranks of (1) to (3),
respectively. It must be noted that none of the dimensions of safety culture in Table (4) obtained a
mean score of 80% or above in this research. Overall, among the 12 dimensions of safety culture
and using this study’s cutoff scores, four dimensions (33.33%) received a rating of strong; five
dimensions (41.67%) received a rating of intermediate, and 3 dimensions (25%) received a rating
of weak.
With regard to the “number of events reported,” the findings indicated that approximately 40% of
the subjects reported one or more medical errors, and seven persons (1.52%) reported 21 or more
errors.
Concerning the “patient safety grade” provided to the work area/unit, 34% of the subjects
provided a “weak” or “unacceptable” grade to their work area/unit; this is a notable statistic.
Table (5) represents the mean scores of safety culture for each hospital on the 12 dimensions of
safety culture overall, as well as mean scores for the areas at the unit level, hospital-wide, and
outcome measures.
Table (5) to be inserted here
The mean scores for the stated hospitals for patient safety culture are also shown in Figure (1).
Figure (1) to be inserted here
In this research, the overall mean score for all hospitals on the safety culture questionnaire was
56.74 with SD=18.41.
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In regard to variations between the IUMS and TUMS hospitals, the findings revealed that the
mean score for the IUMS hospital was 58.34 with SD= 5.96, and that for the TUMS hospital was
55.46 with SD=7.18. The independent t-test showed no significant difference between the overall
mean score for the patient safety culture of the IUMS and TUMS academic hospitals (t = 0.91, df
= 16, P=0.38).
In this research, the mean scores for the safety culture of the hospitals (i.e., the overall mean on 12
dimensions) range from 42.74 to 67.22; in addition, based on this study’s cutoff points, 12 of the
18 hospitals (66.67%) received an intermediate ranking position, and six (33.33%) received a
strong one.

Safety Culture at the Unit Level

The mean score of the safety culture of all of the hospitals at the unit level was also 54.42 with
SD=21.29 (Table 6). These findings indicated that the status of the investigated hospitals on
patient safety at the unit level was moderate. It should be noted that those hospitals labeled as
“strong” in safety culture in Table (6) occupied the lower end of the category.

Patient Safety Culture at the Hospital-Wide Level

For patient safety culture at the hospital-wide level, the overall mean score was 62.78 with
SD=13.29 (Table 6). This score placed the safety culture of the hospitals at the lower end of the
“strong” ranking category.

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Patient Safety Culture on Outcome Measures
In regard to the “outcome measures” of the safety culture, the overall mean score of the hospitals
was 56.74 with SD=18.41, which put them at an average ranking. In this area, 66.67% of the
hospitals obtained an intermediate ranking position.
Safety Culture by Ward/Department/Work Unit
Regarding the status of safety culture by ward/department (or work unit), the findings revealed
that the laboratory unit had the highest safety culture score with an overall mean score = 62.06,
SD=12.45, and the obstetrics and gynecology ward had the lowest with mean= 46.96, SD=17.51
(Table 6).

Table (6) to be inserted here

Variations between the Hospitals on each Dimension of the Patient Safety Culture
Regarding the variations between the hospitals in each dimension of the patient safety culture (or
their related items), we focused solely on the variation of the “non-punitive response to error”
dimension in this article. These findings revealed that there are many variations to the “non-
punitive response to error” dimension across the hospitals (Table 7 & Figure 2) .
Table (7) to be inserted here
Figure (2) to be inserted here
The independent t-test showed a significant difference between the mean scores of the IUMS and
TUMS hospitals for the “non-punitive response to error” dimension (P=.030). In a further analysis

15
at the item level, our findings revealed that the differences originated from differences in item
A12: “when an event is reported, it feels like the person is being written up, not the problem”
(P= .018). The stated dimension contained three items (Table 8).
Table (8) to be inserted here
Discussion
This study’s findings revealed that the safety culture status in the Tehran (TUMS) and Iran
(IUMS) Universities of Medical Science Hospitals had an intermediate ranking. These findings
support the results of other studies (24, 28) conducted in educational hospitals in Iran in the cities
of Shiraz and Yazd, respectively. For the educational hospitals of Shiraz, the mean scores on the
12 dimensions of safety culture ranged from 1.8 to 3.7 on the five-point Likert scale, and most
dimensions were below the mean score of 3.0 (i.e., 10 of 12 safety culture dimensions (83.33%)
had a mean score below 3.0).
In addition, for educational hospitals in Yazd, the mean scores for safety culture were documented
to have low to average rates (i.e., 19.45 to 71.86% at Afshar Hospital and 25.00% to 75.00% at
Shahid Sadoughi Burns Hospital).
Table 9 and Fig. 3 show the results of this study’s safety culture dimensions; in addition, the table
shows results for Iranian educational hospitals in the city of Yazd (Afshar and Shahid
Sadoughi Burns Hospital) and in American hospitals, as reported by the AHRQ 2012 (29).
Table (9) to be inserted here
Figure (3) to be inserted here

16
To compare the mean score of PSC in this study with other hospitals, a one-sample t-test was used
with µ0 = 70. Table (10) shows the results of the t-test on the mean score of 12 PSC dimensions,
seven on the unit level, three hospital-wide, and two outcome measures.

Table (10) to be inserted here

As the findings in Table (10) indicate, this study’s PSC scores and those of the other two Iranian
Hospitals were below 70. These differences were significant at 99% (i.e., P˂0.01), and for the
American equivalent, the differences were almost significant (i.e., P = 0.06).

The same condition holds true for the patient safety culture at the unit level with 95% confidence
(i.e., P˂0.05); for the American equivalent, the results were not significant (P = 0.68).

At the hospital-wide level, only the Afshar Hospital mean score had any significant difference
with the test value of µ0 = 70 (i.e., the mean was below 70); in addition, the mean score for the
Sadoughi Hospital was almost significant.

Regarding outcome measures, none of the hospitals had a significant difference with the test value
of µ0 = 70; however, the difference for the Afshar Hospital was almost significant.

Overall, these findings signify that the status of PSC in Iranian and American hospitals is in need
of serious improvement. Using a test value of 70 (i.e., µ0 = 70) is a conservative index for PSC;
however, public expectation may be higher because we discuss the safety of patients in hospitals
as it relates to the harm to and death of patients.

17
Patient Safety Culture Status in Three Major Areas
With regard to the three major areas of PSC, this study’s findings reveal that the status of the
safety culture at the unit/department level and outcome measures are at an intermediate level, and
for the hospital level, there is a strong ranking, although it is at the lower end of the strong range.

Patient Safety Culture at the Unit Level

This study’s findings show that the mean score of the safety culture in unit-level dimensions (n=7)
varied from 39.08 to 64.24 across hospitals. This signifies that at the unit level, not a single
hospital received a score above 65% on any of the seven related dimensions, putting them all into
weak to medium rankings in this dimension.
The statistics for the hospitals in the city of Yazd were as follows: 19.45 to 71.86 for the Afshar
Hospital, and 25.0 to 75.0 for the Shahid Sadoughi Burns Hospital. In the AHRQ 2012 report (29),
the scores on the unit-level dimensions ranged from 44.0 to 75.0 for hospitals in the city of Yazd,
and the lowest mean was in the staffing dimension (19.45 and 25, respectively), whereas in this
study and in the AHQR 2012 report, the lowest mean was in the “non-punitive response to error”
dimension, with 34.82 and 56.00, respectively.
Regarding safety culture at the unit/department level‚ the findings reveal that the “organizational
learning - continuous improvement” dimension received the highest overall mean score, and “non-
punitive response to error,” received the lowest. The same statistics hold true for all 18 hospitals.
This indicates that the members of staff in educational hospitals are attempting to learn and
improve themselves in patient safety and are committed to continuous improvement, which is very

18
promising regarding the promotion of patient safety and the improvement of the quality of health
services. However, these hospitals are not in a suitable condition with regard to the practice of
non-punitive response to error because of the absence of a non-punitive culture in reporting
medical errors. This alone is a serious threat to patient safety.
This study’s findings also reveal that the status of the investigated hospitals was not promising
concerning the “feedback and communication regarding errors” dimension of PSC. The mean
score on this dimension, which was far from ideal, was 51.41.
The findings of this study also indicate that the investigated hospitals have not made a serious
attempt to make their personnel aware of medical errors or to prevent the reoccurrence of these
errors. In this study, the “communication openness” dimension received a mean score of 40,
reflecting the shortcomings of the PSC in the investigated hospitals. Some researchers contend
that the patient safety culture can be identified by a few characteristics, including communication
openness regarding medical error and the use of a systematic method of prevention (30). These
researchers believe that such a safety culture can be used as the main foundation for the
continuous and sustainable improvement of patient safety, which can help reduce medical errors.

Safety Culture at the Hospital-Wide Level

At the hospital level, the composite mean scores (on three dimensions) varied from 42.41 to 78.06,
and six hospitals (33.33%) had an overall mean score of 70 or higher, which reflects the dominant
status of hospitals in this area in comparison to the safety culture on the unit level or outcome
measures.

19
As previously stated, the PSC of the investigated hospitals was ranked “strong” in the hospital-
wide area and “intermediate” in unit/department-level and outcome measures areas.
With regard to the dimensions of safety culture at the hospital-wide level‚ the participating
hospitals obtained the highest mean score in the dimension of “hospital management support for
patient safety”( 65.15), and the lowest score on “hospital handoffs and transitions” (= 59.47). This
indicates that the management of the hospitals provides some support for a safety culture in the
investigated hospitals; however, this support is not at its ideal level. Obviously, the mean score of
65.15 for management support is not as strong as it should be for the serious promotion of safety
culture in educational hospitals. The mean score for this dimension in this research is much higher
than it is for other Iranian hospitals, such as the Afshar Hospital (65.15 vs. 37.00) and the Shahid
Sadoughi Burns Hospital (65.15 vs. 58.33), but it is lower than the AHRQ 2012 report (21) (65.15
vs. 72.00) and 24 critical access hospitals (31) (65.15 vs. 73.00). However, in both Iranian and
American hospitals, the status of the patient safety culture on the “hospital handoffs and
transitions” dimension is not at its ideal level, and both need improvement.
For “hospital handoffs and transitions,” the mean score obtained in this research was 59.47, which
is not low in comparison with other research findings. The mean scores on this item were 54.20
and 57.00 in the American studies (29 and 31), respectively, and, in Iranian hospitals, the mean
scores in this area were 58.35 in the Afshar hospital and 53.12 in the Shahid Sadoughi Burns
Hospital. Iranian mean scores compared satisfactorily with international statistics for “hospital
handoffs and transitions.” However, patient safety cannot be compromised at any rate. Perhaps it
should be said that in the U.S., the condition of hospitals is not as high as it should be in this
dimension. Using this study’s cutoff scores, the mean score obtained for the dimension of
“hospital handoffs and transitions” is classified as an intermediate ranking.

20
The dimension “teamwork across hospital units” also received a mean score of 63.83, which is
nearly the same as the scores obtained in 24 critical access hospitals in the U.S. (31) (63.83 vs.
64.00). In the AHRQ 2012 report (29), this item had a mean score of 58.00, and in the Afshar and
Shahid Sadoughi Burns Hospitals, this item had mean scores of 55.55 and 37.50, respectively.
Comparatively, the score for “teamwork across hospital units” is not as low in the AHRQ 2012
report as in the investigated academic hospitals.
In this study, the mean scores for “hospital management support for patient safety” and
“teamwork across hospital units” have a strong ranking (although they are at the lower end of the
stated category), whereas “hospital handoffs and transitions” holds an intermediate ranking.

Safety Culture on Outcome Measures

In the area of the “outcome measures” of the safety culture (on two dimensions), the mean scores
across the investigated hospitals range from 44.40 to 72.0, and the overall mean score is 55.57
with SD=11.12, which put all hospital mean scores at an intermediate ranking. In this area, two of
18 hospitals (11.11%) had an overall mean score of 70 positive responses or above; all others had
below 70.

Overall Perceptions of Safety

On the “overall perceptions of safety” dimension, the mean score of positive responses for all
hospitals was 60.10, which is comparable with other research findings in this area. In Iranian
hospitals (Afshar and Shahid Sadoughi Burns Hospital), the corresponding statistics were 66.22

21
and 50.00, respectively, and for American hospitals (29 and 31), the mean scores were 66.00 and
69.00, respectively.

Frequency of Event Reporting

For the dimension of the “frequency of event reporting,” the mean score was 51.92, which is an
average ranking. Given that the dominant culture in Iranian hospitals tends towards a punitive
response to error (28), these statistics are admirable for educational hospitals in Tehran. The mean
scores of the “frequency of event reporting” dimension were 34.90 and 16.66 for the Afshar
Hospital and Shahid Sadoughi Burns Hospital in the city of Yazd, respectively, and 63.00 and
61.00 for American hospitals (29 and 31), respectively.
With regard to the dimension of the “number of events reported‚” the findings revealed that
approximately 40% of the respondents had reported one event or more within the previous 12
months, seven of whom (1.52%) claimed to have reported 21 or more incidents. These findings
indicate that hospital personnel (clinical, para-clinical, and others who provide care to patients) are
aware of the importance of reporting medical errors, and some report these errors based on their
high moral standing despite the culture of blame that dominates Iranian hospitals (28).
This study’s findings indicate that “overall perception of safety” has a better mean score than
“frequency of event reporting” and “non-punitive response to error.” The mean score on these
dimensions obtained a rank score of 5th, 8th, and 12th, respectively. These findings indicate that the
investigated subjects believe that safety is being prioritized in their work area/organization;
however, the lack of a culture for non-punitive response to error in this hospital more than likely
prohibits them from reporting medical errors.

22
The rank order of the mean scores of the stated three dimensions was the same in other studies (28
and 29), i.e.:

Mean score of the Mean score of Frequency Mean score of

Overall Perception › of Event Reporting › Non-punitive Response
of Safety dimension dimension to Error dimension

It should be noted that the differences between the mean scores for the stated dimensions were
greater in Iranian hospitals than in U.S. hospitals.

Patient Safety Culture in

IUMS versus TUMS Hospitals

In regard to variations between the IUMS and TUMS hospitals, the findings revealed that there
was no significant difference between the mean score of patient safety culture for the two;
however, at the “dimension” and “item” levels of the patient safety culture, a significant difference
was observed between the two. The latter differences were reported solely for the “non-punitive
response to error” dimension and its components, which contained three items.
This study’s findings also revealed that in the Tehran University of Medical Sciences hospital, the
condition was worse regarding the presence of non-punitive response to error than it was in the
Iran University of Medical Sciences hospital, and these differences were significant. In a further

23
analysis of items of the stated dimension, the findings indicated that the differences were
significant for item A12 (i.e., “when an event is reported, it feels as if the person is being written
up, not the problem”), and not for the other two items. This paper’s findings also indicate that
there is a notable variation on the stated dimension between the hospitals (i.e., lowest mean =
10.3, and highest mean = 49.30).

Strengths and Weaknesses of the Hospitals

On Patient Safety Culture
This study’s findings revealed that among the 12 dimensions of patient safety‚ “organizational
learning, continuous improvement‚” “teamwork within hospital units‚” “hospital management
support for patient safety‚” and “teamwork among hospital units” ranked from 1 to 4, respectively.
This indicates that the staff of the investigated hospitals attempt to learn about patient safety and
have continuous improvement in this area, while they benefit from teamwork within and among
units/departments and have management support for achieving their patient safety goals and
objectives. However, their greatest challenge in reaching such goals and objectives is limited
staffing, the absence of non-punitive responses to error and communication openness. Clearly, the
practice of error reporting does not possess sufficient support in these hospitals. The domination
of such a culture does not simply impede the prevention of harm to patients, the presence of a
culture of blame and cover-up in the investigated hospitals supports the occurrence of medical
errors.

24
Consistent with other researchers (32), these authors believe that the organizational culture in the
health care sector should be changed in favor of patient safety and safer health care services. In
addition, the health care industry should view itself as an industry that is inherently associated
with risk‚ such that we abandon the notion that error-free performance can be expected from
individual health care providers and instead build a health system that better assures the safety of
patients. In fact‚ the Institute of Medicine (IOM) suggests that the biggest challenge to moving
towards a safer health care system is in changing the patient safety culture from one in which
people are blamed for errors to one in which errors are treated as opportunities to improve the
system and prevent harm (33). In another study conducted by these researchers, it was shown that
a lack of incentives, a lack of trust in hospital officials, a fear of punishment, and the presence of a
culture of blame have created low motivation in the investigated subject to report medical errors in
these hospitals; in addition, it is probable that the same conclusions hold true for other Iranian
hospitals. In an unpublished study conducted by these researchers in one of the TUMS academic
hospitals, it was shown that a “lack of incentives, lack of trust in hospital officials, fear of
punishment, and the presence of a culture of blame” were, in fact, the main reasons why nurses
were not reporting medical errors. To understand the barriers to physician error reporting and
disclosure, some researchers (34) contend that
Transparency initiatives will require vigorous, interdisciplinary efforts to address the
systemic and pervasive nature of the problem. Several ethical and social-psychological
barriers suggest that medical schools and hospitals should collaborate to establish continuity
in education and ensure that knowledge acquired in early education is transferred into long-
term learning. At the institutional level, practical and cultural barriers suggest the creation
of supportive learning environments and private discussion forums where physicians can
seek moral support in the aftermath of an error. To overcome resistance to culture
25
 transformation, incremental change should be considered. For example, replacing arcane
transparency policies and complex reporting mechanisms need to be replaced with clear,
user-friendly guidelines.

Our final point is that if one aims to truly understand the safety culture of a particular organization
and the groups within it, she/he needs to understand all facets, elements, and levels of the culture
within that organization (35). Some reasons can be found in the following arguments:
The assumption [that culture is uniformly distributed] is unwarranted for two reasons, one is
sociogenic (having to do with social groups and institutions) and the other is psychogenic
(having to do with cognitive and affective processes characteristic of individuals). The first
reason is a corollary of the social complexity issue noted above: Insofar as two individuals
do not share the same sociological location in a given population (the same class, religious,
regional, or ethnic backgrounds, for example), and insofar as these locations entail (sub)
cultural differences, the two individuals cannot share all cultural content perfectly. This is
the sociogenic reason for the non-uniform distribution of culture. Culture is socially
distributed within a population. The second reason, psychogenic, is that culture is never
perfectly shared by individuals in a population (no matter how, sociologically, the
population is defined). This concerns the ways in which culture is to be found “in there”,
inside the individual (36; PP. 18–20).

... Culture is as much an individual, psychological construct as it is a social construct. To

some extent, culture exists in each and every one of us individually, as much as it exists as a
global, social construct. Individual differences in culture can be observed among people by

26
 the degree in which they adopt and engage in the attitudes, values, beliefs, and behaviors
that, by consensus, constitute their culture. If you act in accordance with those values or
behaviors, then that culture resides in you. If you do not share those values or behaviors,
then you do not share that culture. While the norms of any culture should be relevant to all
the people within that culture, it is also true that those norms will be relevant in different
degrees for different people. It is this interesting blend of culture in anthropology and
sociology as a macro concept and in psychology as an individual construct that makes
understanding cultures difficult but fascinating (37; P. 18).
Culture has both universal (etic) and distinctive (emic) elements. Humans have largely
overlapping biologies and live in fairly similar social structures and physical environments,
which create major similarities in the way they form cultures. But, within the framework of
similarities, there are differences. The same happens with language. Phonetics deal with
sounds that occur in all languages. Phonemics are sounds that occur in only one language.
The linguist Pike (1967) took the last two syllables of these terms and coined the words
“etics” for universal cultural elements and “emics” for the culture-specific, unique elements.
Although some students of culture assume that every culture is unique and in some sense
every person in the world is unique, science deals with generalizations...To summarize
emics and etics, when we study cultures for their own sake, we may well focus on emic
elements, and when we compare cultures, we have to work with the etic cultural elements
(38; P. 20).
In this article, we need to answer an important question regarding culture: “is culture local or
global?” Our answer is that culture is both local and global. Given the above arguments, we
should say that each hospital holds a unique safety culture as well as a global one, and we need to
understand both of these cultures. Clearly, each hospital holds a safety culture unique to itself,
27
which is why variation exists among the patient safety culture of various hospitals or between the
subgroups within hospitals, whereas it also holds a safety culture that is shared with other
hospitals (i.e., a global one). Therefore, if one truly wants to understand the patient safety culture
of any hospital, one needs to understand both local and global dimensions. This means that we are
interested in variations as well as similarities. Similarities are important because they provide a
common ground for the evaluation of each subgroup, department/work area in hospitals, or the
safety culture of hospitals around a nation or across nations.
Given that “patient safety” is a widespread concern of many countries around the world,
undertaking cross-cultural studies or comparisons on patient safety culture for the purposes of
benchmarking is a well-accepted action. In Iran, we have adapted many JCI standards for
accreditation in our hospitals, and in a recent version of the accreditation standards booklet (i.e.,
2014 version), “patient safety standards” (recommended by the World Health organization) have
also been added. This means that our health system is attempting to align itself more closely to
other nations in the accreditation of its hospitals. Therefore, a study of this nature, which provides
an opportunity to compare the status of the Iranian hospital safety culture with that of America, is
justified.
Our goal in this paper was not to focus on the differences between Iranian and American hospital
patient safety cultures and their contributing factors but rather to focus on their similarities, which
promotes the challenges of the patient safety culture to a universal level. Because patient safety is,
in fact, a problem shared by nearly all countries around the world, we need to address it at a
universal level as well as a local level.

28
Conclusions
(1) The state of the patient safety culture in the investigated hospitals was at a medium level
according to this research’s cutoff scores.
(2) Among the 12 dimensions of the patient safety culture, the highest mean score belonged to
“organizational learning-continuous improvement,” and the lowest belonged to “non-punitive
response to error.”
(3) The strengths of the hospitals were in the areas of “organizational learning-continuous
improvement,” “teamwork within hospital units” and “hospital management support for patient
safety,” which obtained rankings of (1) to (3), respectively.
(4) The dimensions of “communication openness,” “staffing” and “non-punitive response to
error,” were shown to be the weak points of all hospitals on the HSOPSC questionnaire. These
dimensions obtained rankings of 10 to 12 among the 12 dimensions of patient safety culture.
(5) The dimension of “overall perception of safety” had a better mean score (5th ranking among
12 patient safety culture dimensions) than the “frequency of event reporting” (ranked 8th) and
“non-punitive response to error” (ranked 12th). This indicates that the personnel of the
investigated hospitals are aware of the importance of patient safety; however, the absence of a
culture of non-punitive response to error mainly discourages them from reporting medical errors.
(6) The dimensions of “staffing,” “non-punitive response to error,” “communication openness,”
and “feedback and communication regarding errors” were not only weak points of Iranian
hospitals, but of American hospitals also, and are in need of serious improvement.
(7) Overall, the available statistics support the idea that we should change our strategies for
solving patient safety challenges around the world. Obviously, the present policies and regulations
29
are ineffective in preventing patients from harm and death, and much needs to be done in this area.
For example, international laws and regulations need to be developed to help create policies that
address patient safety challenges around the world.
Limitations
This study was conducted on a limited number of subjects at each hospital (i.e., 35 per hospital: 15
nurses and 20 others, such as physicians, lab personnel, and radiology personnel), which may
affect the generalizability of the results. Given the small sample size from each hospital, it
becomes problematic to draw definitive conclusions regarding true differences in the safety
culture between each individual hospital.
Furthermore, the convenience sampling technique used to select the samples from each hospital is
another shortcoming of this study.

Competing Interests
The authors declare that they have no competing interests.

Authors’ Contributions
PR and NR were responsible for this study’s concept and design and supervised this study. The
statistical analysis and interpretation were performed by PR and AAN. NR drafted the manuscript,
which was critically revised by PR and AAN. All authors have read and approved the final
manuscript.

30
Acknowledgements
The authors would like to thank Iran University of Medical Sciences (IUMS) for financial support.
We also would like to thank all hospital managers, clinical and paraclinical staff of the
investigated hospitals in Iran University of Medical Sciences (IUMS) and Tehran University of
Medical Sciences (TUMS) for their upfront and sincere cooperation with the researcher.
Our sincere thanks also goes to Mr. Erfan Shakibaei and Ms. Maryam Cheraghi, our students, for
their patient, help in the data collection and transfer of the data to computer databases.

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Table 1. NO. Of Participants, Type of Hospital, NO. Of Total Beds, and Active Beds
For Participating Hospitals

Hospital No. of % of total University Total No. of No. of

Participants staff at that & Hospital

36
 hospital Type Beds Active Beds
who filled
out the
survey
H1 23 5.0 IUMS*- 659 500
General
H2 18 3.9 IUMS- 557 450
General
H3 28 6.1 IUMS- 250 150
Orthopedic
H4 30 6.5 IUMS- 213 213
Midwifery
H5 29 6.3 IUMS-Burns 120 108
H6 27 5.9 IUMS- 180 150
Pediatric
H7 20 4.3 IUMS- 109 100
Regenerative
H8 29 6.3 IUMS-Mental 120 120
Health
H9 18 3.9 TUMS*- 330 260
General
H10 32 6.9 TUMS- 330 222
General
H11 25 5.4 TUMS- 351 351
General
H12 27 5.9 TUMS- 1230 1000
General
H13 13 2.8 TUMS- 69 69

37
 Dermatology
H14 28 6.1 TUMS- 128 128
Midwifery
H15 29 6.3 TUMS-Eye 220 220
A16 28 6.1 TUMS- 400 232
Pediatric
Center
H17 30 6.5 TUMS- 211 190
Cancer
H18 27 5.9 TUMS- 204 195
Mental Health
No. of Subjects =461

*IUMS= Iran University of Medical Sciences, TUMS= Tehran University of Medical Sciences

Table 2. Frequency distribution of participants according to Working Unit or Department

No. Name of Department Frequency %

or Unit

38
1 Internal Medicine 51 11.1
2 Surgery 88 19.1
3 Obstetrics & 46 10.1
Gynecology
4 Pediatric 17 3.7
5 Neurology 12 2.6
6 Special Care Unit 44 9.5
7 Emergency 12 2.6
8 Laboratory 41 8.9
9 Radiology 19 4.1
10 Others 131 28.4
Total 461 100

Table 3. Demographic Information of the Participants (n=461)

Variables F %
Sex Female 349 75.7
Male 112 24.3

39
 Marital Single 185 40.1
Status
Married 276 59.9
Diploma 33 7.2
College Degree 38 8.2
Education Bachelor’s degree 277 60.1
Level Master’s degree 22 4.8
General MD 21 4.6
Ph.D. 40 8.7
Medical Interns & 30 6.5
Residents
≤30 194 42.1
Age 31-41 175 38.0
41-50 75 16.3
Physician 29 6.3
Medical Resident 22 4.8
Medical Intern 19 4.1
Nurse 235 51.0
Respondent’
Assistant Nurse 29 6.3
s
Role Ward Secretary 11 2.4
Laboratory Personnel 42 9.1
Radiology Personnel 16 3.5
Non-clinical Manager 9 2.0
Others 49 10.6
Direct Yes 337 73.1

40
contact with
patients
No 124 26.9

Table 4. Composite Scores for each Dimension of Safety Culture

For Entire Hospitals (n=18)

41
 Major Areas of Dimension Mean Rank
Safety Culture Score

A. Supervisor/Manager Expectations & Actions 59.87 6

Promoting Safety

Safety Culture Dimensions:

B. Organizational Learning—Continuous Improvement 79.3 1

C. Teamwork within Hospital Units 73.75 2

Unit Level
D. Communication Openness 39.99 10

E. Feedback and Communication about Errors 51.41 9

F. Non-punitive Response to Error 26.54 12

G. Staffing 34.82 11

H. Hospital Management Support for Patient Safety 65.15 3

Safety Culture

Hospital-Wide
Dimensions:

A. Teamwork across Hospital Units 63.83 4

B. Hospital Handoffs & Transitions 59.47 7

A. Frequency of Event Reporting 51.92 8

Measures
Outcome

B. Overall Perceptions of Safety 60.10 5

*Mean Scores in Table 4 are Representing % of Positive Responses on Each Item of HSOPSC

Table 5. Mean Score of the Positive Responses on 12 Dimensions of Safety Culture,

42
 Hospital Entire Safety Safety Culture Safety Culture Safety Culture on
Culture at Unit Level Hospital-Wide Outcome
on (7 Dimensions) Measures the Unit Level,
(12 Dimensions)
Hospital-Wide, and
(3 Dimensions) (2 Dimensions)
Outcome Measures
by Hospital

H1 X =59.70 X =54.71 X =67.87 X =64.89

SD=21.13 SD=27.05 SD=5.81 SD=5.08

H2 X =60.15 X =56.08 X =70.37 X =59.03

SD=16.25 SD=19.71 SD=7.65 SD=4.91

H3 X =57.24 X =51.83 X =73.91 X =51.19

SD=21.52 SD=23.25 SD=16.67 SD=13.46

H4 X =65.98 X =59.40 X =78.06 X =70.87

SD=23.45 SD=29.34 SD=1.73 SD=9.47

H5 X =63.58 X =61.54 X =68.39 X =63.80

SD=16.39 SD=21.60 SD=98.40 SD=2.44 *All Data in Table 5
Represent % of Positive
H6 X =50.00 X =51.41 X =48.46 X =47.38
Responses on Each Item of
SD=12.87 SD=16.31 SD=3.51 SD=12.88 HSOPSC

H7 X =49.34 X =48.27 X =46.67 X =57.09

SD=20.10 SD=26.25 SD=8.87 SD=0.59

H8 X =60.73 X =60.47 X =66.00 X =56.90

SD=19.95 SD=26.06 SD=7.20 SD=4.48

H9 X =56.40 X =56.88 X =61.73 X =46.76

SD=18.10 SD=21.50 43
SD=12.05 SD=16.36

H10 X =62.44 X =59.19 X =73.18 X =57.69

SD=15.54 SD=19.04 SD=1.628 SD=3.50
 Table 6. Percent of Positive Responses on 12 Dimensions of Patient Safety Culture
According to Ward/ Department/ or Unit of Work Area

NO. Ward Unit Level Hospital- Wide Outcome

Name Measures Mean SD

A* B C D E F G H A B A B

1 Internal 75.98* 81.04 72.05 46.40 52.94 37.90 28.92 62.09 68.62 61.76 52.29 60.78 58.40 15.51
Medicine

2 Surgery 63.06 80.68 71.87 37.87 51.13 17.42 28.97 71.59 66.47 61.93 50.75 64.48 55.52 17.90

3 Obstetrics & 67.93 68.84 42.75 60.14 36.95 18.11 34.05 73.18 38.40 38.40 54.35 30.43 46.96 17.51
Gynecology
4 Pediatric 82.35 86.27 73.52 52.94 45.09 31.37 19.11 72.54 60.29 75.00 47.06 66.18 59.13 20.71

5 Neurology 60.41 91.66 85.41 38.88 69.44 13.88 25 66.66 75 58.33 72.22 54.17 58.40 15.51

6 Intensive 67.61 87.87 76.13 49.24 54.54 26.51 30.68 66.66 81.81 70.45 54.54 60.23 60.52 18.77
Care Unit
7 Emergency 47.91 66.66 66.66 47.22 52.77 66.16 29.16 61.11 56.25 58.33 55.56 47.92 50.52 14.72

8 Laboratory 69.51 73.17 78.04 49.59 58.53 34.95 60.36 77.23 63.41 53.04 58.54 68.29 62.06 12.45

9 Radiology 81.57 80.70 82.89 47.36 24.56 31.57 40.78 56.14 46.05 47.36 35.09 75.00 54.09 20.90

44
10 Others 62.21 62.59 75.19 47.07 58.26 26.20 31.29 55.47 63.93 53.05 48.35 61.45 53.76 13.93

*All data in Table 6 are Representing % of Positive Responses on Each Item of Patient safety Culture Survey Questionnaire (HSOPSC)

*All alphabet listed in columns heading of table are corresponding with alphabets used in the Patient safety Culture Survey Questionnaire (HSOPSC) for
identifying each dimension (27)

Table 7. Percent of Positive Responses on Each Item of the Nonpunitive Response to

Error Dimension with Their Mean and SD
Hospital A8r* A12r A16r Mean SD

H1 10.70 50.00 00.00 20.20 26.30

H2 33.30 28.60 22.20 28.00 5.60
H3 61.100 05.60 00.00 22.20 8.50
H4 43.300 00.00 03.30 15.50 4.10
H5 16.70 27.80 22.20 22.20 5.60
H6 07.70 07.70 15.40 10.30 4.40
H7 07.10 03.60 46.40 19.00 3.80
H8 17.20 20.70 13.80 17.20 4.60
H9 46.900 46.90 34.30 42.70 7.30
H10 39.30 42.90 35.70 39.30 3.60
H11 48.30 32.90 27.60 37.90 10.30
H12 20.00 26.70 26.70 24.50 3.90
H13 37.00 40.70 29.60 35.80 5.70
H14 13.00 21.70 13.00 15.90 5.00
H15 20.00 20.00 10.00 16.70 57.80
H16 60.00 48.00 40.00 49.30 10.00
H17 25.90 29.60 14.80 23.40 7.80

45
H18 10.30 34.50 20.70 21.80 12.10
Mean 28.77 27.38 20.87 26.15 10.30
*Nonpunitive Response To Error contains three items as follows:
A8r. Staff feels like their mistakes are held against them. (Reverse worded)
A12r.When an event is reported, and it feels like the person is being written up, not the problem. (Reverse worded)
A16r.Staff worry that mistakes they make are kept in their personnel file. (Reverse worded)
*All the data in Table 7 are representing % of Positive Responses on Each Item of the Nonpunitive Response to
Error Dimension

Table 8. Results of t-test on Nonpunitive response to Error Dimension, and its

Components between IUMS, and TUMS Universities

Item University Mean SD t df P- Value

A8r IUMS 20.44 3.87 -.872 16 .396

TUMS 30.72 11.69

A12r IUMS 24.64 19.49 -2.625 16 .018

TUMS 32.07 16.69

A16r IUMS 18.00 17.03 -1.618 16 .125

TUMS 34.89 10.07

Total IUMS 15.41 15.48 -2.37 16 .030

TUMS 25.24 10.26

*Means in Table 8 are representing % of Positive Responses of Nonpunitive Response to Error Dimension

46
 Table 9. Mean Scores on 12 Dimensions of Patient Safety Culture
in the Iranian and American Hospitals
Present Study: Iranian academic Hospitals AHRQ 2012
Report
Dimensions 18 Academic (20)
(21)
of PSC Hospitals
Afshar Shahid
Hospital Sadoughi B
urns
Hospital
Overall Perceptions 60.10 66.22 50.00 66.00
of Safety
Frequency of Events 51.92 34.90 16.66 63.00
Reported
Supervisor/Manager 59.87 36.12 62.5 75.00
Expectations &
Actions Promoting
Safety
Organizational 79.03 71.86 75.00 72.00
Learning—
Continuous
Improvement

47
 Teamwork within 73.75 68.87 62.50 80.00
Hospitals Units
Communication 39.99 37.06 45.83 62.00
Openness
Feedback and 51.41 33.56 54.16 64.00
Communication
about Errors
Non-punitive 26.54 21.46 25.00 44.00
Response to Error
Staffing 34.82 19.45 25.00 56.00
Hospital 65.15 37.00 58.33 72
Management
support for Patient
Safety
Teamwork across 63.83 55.55 37.50 58.00
Hospital Units
Hospital Handoffs & 59.47 58.35 53.12 45.00
Transitions
Patient Safety Grade
Excellent 10.00 11.10 0.00 30.00
Very Good 31.99 31.10 25.00 45.00
Acceptable 24.00 51.10 Not reported 20.00
Poor 26.20 0.00 Not reported 4.00
Failing 7.81 6.70 Not reported 1.00
Number of Events Reported
No Event Report 60.3 71.10 Not reported 55.00
1 to 2 Event 27.55 22.20 Not reported 27.00

48
 Report
3 to 5 Event 7.81 6.60 Not reported 12.00
Report
6 Event Report 4.34 0.00 Not reported 7.00
or more

Table 10. Result of One-Sample t-test on the Patient Safety Culture score
In the Iranian and American Hospitals
H0 : µ0 = 70
95% Confidence Interval
of the Difference

Dimension t df P-Value
Studies Lower Upper
s Mean SD
12 Patient Raeissi et al. 55.49 15.50 -3.24 11 .008 -24.36 -4.66
Safety Culture Study-Iran
Dimensions AfsharHospital- 45.03 18.28 -4.73 .001 -36.58 -13.35
Iran
11
Sadoughi 47.13 17.76 -4.46 11 .001 -34.15 -11.58
Hospital-Iran
AHQR Hospital- 63.06 11.14 -2.15 11 .055 -13.99 .16
USA
7 Unit – Level Raeissi et al. 59.44 13.47 -2.08 6 .083 -23.02 1.90
Dimensions Study-Iran
AfsharHospital- 49.80 18.05 -2.96 6 .025 -36.90 -3.51
Iran
Sadoughi 52.38 18.46 -2.53 6 .045 -34.69 -0.55
Hospital-Iran
AHQR Hospital- 68.86 6.89 -.44 6 .676 -7.52 5.23
USA
3 Hospital – Raeissi et al. 42.17 20.33 -2.37 2 .141 -78.33 22.67
Wide Study-Iran

49
Dimensions AfsharHospital- 25.97 9.60 -7.94 2 .015 -67.89 -20.17
Iran
Sadoughi 36.11 19.24 -3.05 2 .093 -81.69 13.91
Hospital-Iran
AHQR Hospital- 57.33 14.05 -1.56 2 .259 -47.56 22.23
USA
2 Outcome Raeissi et al. 61.65 3.08 -3.83 1 .163 -36.05 19.35
Measure Study-Iran
Dimensions AfsharHospital- 56.95 1.98 -9.32 .068 -30.84 4.74
Iran
1
Sadoughi 45.31 11.05 -3.16 1 .195 -123.93 74.55
Hospital-Iran
AHQR Hospital- 51.50 9.19 -2.85 1 .215 -101.09 64.09
USA

50
 Fig 1 : Mean Score of the Investigated Hospitals on
12 Dimensions of the Patient Safety Culture
67.2 68.8
70 66
63.6 62.4
59.7 60.2 60.7
57.2 56.7
60 56.4 54.8 56.6 54.5
Mean Score (% of Positive Responses)
50 49.3 51.8
47.3
50 42.7

40

30

20

10

0
l 1 l 2 l 3 l 4 l 5 l 6 l 7 l 8 l 9 10 11 12 13 14 15 16 17 18 an
i ta ita ita ita ita ita ita ita ita tal tal tal tal tal tal tal tal tal Me
sp sp sp sp sp sp sp sp sp pi pi pi pi pi pi pi pi pi all
Ho Ho Ho Ho Ho Ho Ho Ho Ho Hos Hos Hos Hos Hos Hos Hos Hos Hos ver
O

Hospital

51
 Fig 2 . Mean score on 'Nonpunitive Response to Error'
Dimension according to Hospital
49.3
50
42.7
45
39.3 37.9
Mean Score (% of Pisitive Responses) 40 35.8
35
28
30 26.2
24.5 23.4
25 20.2 22.2 22.2 21.8
19
20 17.2 15.9 16.7
15.5
15 10.3
10
5
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 an
pita pita pita pita pita pita pita pita pita ita ita ita ita ita ita ita ita ita Me
s s s s s s s s s p p p p p p p p p ll
Ho Ho Ho Ho Ho Ho Ho Ho Ho Hos Hos Hos Hos Hos Hos Hos Hos Hos era
Ov

Hospital

52
 Fig 3 . Mean Scores on 12 Dimensions of the Patient safety
culture for Present study and three other Ones

80
70
60
50
40 Present Study( Iran)
Afshar Hospital (Iran)
Mean Score (% of Positive Responses)

30
20 Shahid Sadughi Burns H.
( Iran)
10
AHRQ 2012 Report
0 (USA)

Dimensions of the Patient Safety Culture

53