Patient safety (PS) is a worldwide public health topic. According to the World Health Organization, unsafe medical care leads to disabling injuries or deaths in millions of patients.¹

Patient safety is the prevention and avoidance of patient injuries or adverse events caused by delivery processes of healthcare workers (HCWs).² The safety culture of the organisation serves as a guide on how employees should perform in the workplace, and their behaviour will be influenced or determined by which behaviours are rewarded and acceptable in the workplace. Organisational positive attitude culture is characterised by trust-based communications, shared perceptions of the importance of safety and faith in the efficacy of preventive measures.³

Despite the importance of PS in health care, only few organisations have assessed how well their staff culture promotes PS. Assessing the current safety attitudes enables organisations to gain a clear picture of PS issues that require immediate attention, address the strengths and weaknesses of their safety culture, and improve continuous quality management.⁴

Positive attitudes of PS can be enhanced by targeted training as well as creating an openness of workplace culture, being aware of potential hazards and changing behaviour. This should include an approach to mistakes that is open for learning and development, adapting a non-punitive response to error, which deals with errors as an opportunity to learn.⁵

Patient safety is a major issue by health policymakers in many Arab countries, necessitating the identification and analysis of factors that contribute to its occurrence.⁶ According to the Organisation for Economic Cooperation and Development report, the situation in low- and middle-income countries is direr, with approximately 2.6 million deaths occurring because of 134 million adverse events occurring in hospitals each year.⁷ In Africa, information is limited about the scope of PS culture. The study in Ethiopia showed a very low-positive PS grade.⁸ Patient safety in Kenya remains a challenge, with an increasing number of medical errors being reported in the media.⁹ South Africa is among the developing countries that has a higher percentage of PS incidents.¹⁰ Moreover, Eastern Mediterranean and African Study found that unsafe care affects around 10% of patients, most of those incidents were preventable.¹¹

Patient safety requires knowledge and skills in various areas, including human factors and system management, because most preventable errors, such as medication errors, investigation errors and nosocomial infections, are related to these areas.¹² Patient safety attitude is a significant key influencing factor for improving physician–patient relationship and the quality of service that patients obtain. Reviewing PS attitude regularly enables the organisation management council to realise and monitor the progress of PS within the healthcare processes. In Egypt, different studies highlighted the need for improving the PS culture among healthcare providers. Moreover, relevant research is needed to evaluate the PS attitudes and awareness. This study was designed to assess PS attitude and identify its determinants among HCWs in Sharqia Governorate at various levels of care, including primary health care (PHC) units (primary level) and Zagazig General Hospital (tertiary level). Also, the findings of this study may also be used as an input for the Ministry of Health and population (MOHP) and administrators of the hospitals and healthcare units to make informed decisions regarding PS issues at the study site and in other similar sites in Egypt.

This study included 240 participants, including 120 primary HCWs (PHCWs) (i.e., 40 physicians, 32 nurses, 28 pharmacists, 12 dentists and 8 technicians) and 120 tertiary HCWs (THCWs) (i.e., 40 physicians, 24 nurses, 32 pharmacists, 8 dentists and 16 technicians). The mean age of the PHCWs was 34.7 ± 6.5 years, and that of the THCWs was 35.7 ± 7.8 years. Most respondents were females, were married, did not attend any PS training courses and had direct contact with patients. More than half of them had morning work shifts and worked in the current place for ≥ 6 years. Almost one-third of the PHCWs had university education and working experience ranging from 5 years to < 10 years. The THCWs had high school education (31.7%) and university education (31.7%) and had working experience ranging from 10 years to < 15 years (Table 1).

Table 2 displays the participants’ mean scores for each item on the seven PS scales, as well as the percentage of positive responses. The scale with the most positive responses was safety climate 49.59%, which was followed by job satisfaction 49.5%, teamwork climate 49.17%, stress recognition (41.8%), burnout (41%), perception of management (40.63%) and working conditions (40.6%). The average percentage of positive responses per the CSAQ is shown in Figure 1.

There were significant statistical association between the level of health care and the mean scores of Teamwork climate, Perception of management, Job satisfaction, working condition, Stress recognition and the overall CSAQ score (p = < 0.001, 0.003, < 0.001, 0.002, < 0.001, 0.001, respectively), as the THCWs had a significantly higher mean score (Table 3). The total mean score of PS attitude was significantly higher among those aged ≥ 40 years (132.98 ± 25.12; p < 0.001), male respondents (131.90 ± 30.65; p = 0.009), married (125.79 ± 20.64; p = 0.014), MD educated (143.50 ± 14.92, p = < 0.001), nurses (131.00 ± 16.32; p = < 0.001) and those who had PS training (130.52 ± 17.75; p = 0.005) (Table 4).

In the regression analysis, educational degree and job type were significant predictors of PS attitude among the HCWs under study. Non-significant R² indicates a good fit model of PS attitude (Table 5).

Patient safety is an important aspect of healthcare quality. As healthcare organisations strive to improve, the importance of fostering a safety culture within them is becoming more widely recognised.¹⁸ This study showed a difference between PHCWs and THCWs regarding the level of education and duration of working experience, which attributed to different structural job distribution between PHC units and hospitals. In terms of previous PS training, approximately 20% have prior training .This result indicates the need for continuously establishing more training programmes on PS issues for all HCWs at all healthcare organisations. This result conforms to that of a study by the Faculty of Medicine of Cairo University.²

The overall percentage of positive responses in the current study indicated a poor scale (score ≤ 75%) regarding PS attitude across six domains (40% – 49.6%) and associated with relatively increase of burn-out score (41.4%) because positive safety attitude associated with burn out absence and high ability to handle stressful situations.¹⁹ This result revealed a negative safety perception among physicians, nurses and laboratory technicians and showed the demanding improvement of all PS domains. Furthermore, this finding reveals the state of PS in the Egyptian health system, as well as most of the developing countries where PS is not given enough attention.

This study’s overall PS score is lower than that stated by the Agency for Healthcare Research and Quality (2014) (64%), Palestine (63.5%), Saudi Arabia (60%), Lebanese private hospitals, (72.5%), and Hospital Survey on Patient Safety Culture (2012) in China (63%) and study in a Kenya (65.8%).^9,20,21,22 One of the possible explanations for the disparity between the results of this study and those of other studies is a lack of PS culture awareness, training programmes for HCWs and institutional performance improvement strategies.

In this study, the safety climate score was higher than those of other domains, implying that creating a non-punitive culture, developing prompt networks, providing training and motivating HCWs to discuss and report adverse events and timely. However, this scale scored low, indicating the need for more attention to infrastructure and leadership attitudes towards dealing with errors and learning from adverse events.

The job satisfaction score was the second highest; the higher response rate was related to the statement, ‘I like my job’, suggesting that when the workplace facilitates HCWs to feel family warmth, several HCWs will love their work and behave well, which would be beneficial to PS.

The perception of management and working conditions domains were rated lower than other domains, implying that supervising and training new workers and the preservation of diagnostic and therapeutic data would be valuable to PS. Furthermore, to foster a better working environment, we must train and supervise new employees, and ensure that therapeutic information is readily available.²³

In this study, a significant difference in the mean score of PS attitude was observed between PHCWs and THCWs in terms of teamwork climate, perception of management, job satisfaction, working conditions and stress recognition. Furthermore, the overall score in the seven PS scales of the CSAQ was higher at the tertiary level than that at the primary level. This finding conforms to that of a study conducted in Turkey, which found that the average overall score of PS culture in PHC units is lower than that of hospitals.²⁴ This finding explained why healthcare units do not handle severe clinical cases that can only be handled by intensive care units, emergency departments or hospitals. Because most dangerous medical interventions are performed in hospitals, hospital workers may receive additional training and specialisation in safety-related issues.²⁵ This result is expected because PS topics have largely been identified at the hospital level, with less emphasis placed to the primary care level, where adverse outcomes are less common, and the greatest volume of care is delivered with infrastructure restrictions and guidelines and criteria for safe practices.²⁶

This study showed that older age groups had higher attitude scores; this may be explained by higher working experiences, which lead to an increase in tolerance to changes in working conditions. Furthermore, it is expected that the increasing age of HCWs will make them more appreciative of their jobs and push them to improve their performance.²⁷ Moreover, new workers may be less sensitive to safety issues, according to El Shafei and Zayed’s and Abdi et al.’s studies.^14,24,28 This study showed that male participants had higher attitude scores than females. This can be explained by difference in specialties and responsibility distribution and duration of work between them.

In this study, a link was observed between previous PS training courses and caregivers’ perceived influence on PS. This result is suspected and related to the fact that education about PS impacts the attitude of healthcare worker which determines how they act and behave. This finding conforms to that stated by Asem et al.,² Zhao et al.,²⁹ and Biresaw et al.³⁰ in Ethiopia, which reported that nurses who received information on PS were 4.39 times more likely to have good knowledge and attitude as compared with those who had not.

Regarding job type, this study showed that staff holding master’s degree had higher attitude scores than those with lower educational levels, and regression analysis revealed that educational level is a significant predictor, which explained by highly educated health professionals having a broader range of ideas and thinking more about the problems, which may lead to more pressure, negatively affecting teamwork climate.²⁹

Another predictor revealed by regression analysis was that nurses had a more positive attitude towards PS than physicians. This finding is as a result of the nurses being the first point of contact with clients for most basic benefit packages and services.³¹ Furthermore, because most nurses were younger and received more information about safety culture, they may be more resilient and could handle stressful working conditions.³² The findings conform to those of the studies by Abu-El-Noo and El Shafei and Zayed, who reported relatively high mean scores among nurses, particularly in the stress recognition domain, working in PHC centres. In contrast, various studies have revealed that physicians outperformed nurses.^28,33,34

The current study showed that the PS score is low among HCWs at both healthcare units and hospitals, and no domain had a score higher than 75. Moreover, hospital HCWs had significantly higher scores in most PS domains and overall score than PHCWs. Personnel with master’s degree and nurses were predictors of good PS attitude.

All PS domains necessitate improvement beginning with continuous PS culture assessment along with regular monitoring and increasing the awareness of PS culture. Other studies are required in different regions and healthcare settings to generalise the results to other units and hospitals in Egypt.

Training and learning by providing skills for healthcare professionals is a key for optimising quality and PS. Thus, hospitals and healthcare units’ management should be prepared to all new staff and they should be given a general orientation programme and training to outline the policies, procedures, and their role and responsibilities in order to improve quality of patient care. Also, it is necessary to create an open and non-punitive culture to encourage and train health professionals to report adverse events. Moreover, it is necessary to establish scientific and reasonable hierarchical diagnosis and treatment system, arrange health professionals’ workload reasonably, increase the number of health professionals reasonably and reduce the stress of health professionals.

Further research is recommended to include staffing and the work environment factors to predict the outcomes of care.