Patient Safety Culture in a Tunisian Teaching Tertiary Care Hospital

Objectives: Our study aimed to investigate patient safety attitudes and perceptions amongst health care providers in Tunisian tertiary care hospitals. Methods: This cross-sectional study was conducted during April May and June 2015 in Sahloul University hospital in Sousse: a 630-beds tertiary hospital in Eastern Tunisia. This survey included 344 cares providers. The French version of the Hospital Survey on Patient Safety Culture questionnaire was used to identify dimensions of patient safety culture. Results: Areas with potential for improvement were overall perception of security, Teamwork within units, organizational learning/continuous improvement, open communication and underreporting of events. Teamwork across hospital units had the lowest score. No signifi cant differences between physicians and nurses were found for all composites in our study. Conclusion: Patient safety culture remains underdeveloped in our hospital. Leaders must implement a development strategy by creating the culture and commitment needed to identify and solve underlying systemic causes related to patient safety. Research Article Patient Safety Culture in a Tunisian Teaching Tertiary Care Hospital Mohamed Ben Rejeb1,2*, Dhekra Chebil1, Latifa Merzougui1,2, Balsem Kacem3, Selwa Khefacha-Aissa1, Lamine Dhidah1,2 and Houyem SaidLaatiri1,2 1Department of Prevention and Care Safety, Sahloul Hospital, Sousse, Tunisia 2Department of Community and Preventive Medicine, Faculty of Medicine of Sousse, University of Sousse, Tunisia 3Department of Pharmacy, Sahloul Hospital, Sousse, Tunisia Dates: Received: 27 July, 2017; Accepted: 30 August, 2017; Published: 31 August, 2017 *Corresponding author: Mohamed Ben Rejeb, Department of Prevention and Care Safety, Sahloul Hospital, Sousse, Tunisia, Tel: +216 54 098 709; Fax: +216 73 367 451; E-mail:


Introduction
In developed countries patient safety is now recognized as a top priority in their healthcare systems [1]. Patient safety aims to protect patients against care-associated adverse events (AEs). They are defi ned as unintended injuries or complications caused by health care management, rather than by the patient's underlying disease and that lead to death, disability at the time of discharge or prolonged hospital stay [2]. While, 35 to 70% of AEs have been judged to be preventable [3][4][5], they appear to be responsible for 44,000 to 98,000 accidental deaths and over one million excess injuries each year [6,7]. The situation is thought to be more challenging in developing countries with higher risk of patient harm due to the limitation of resources and lack of adequate infrastructures [8].
One aspect of patient safety that has been increasingly of interest is the "culture" of safety. Patient safety culture is defi ned as the product of individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and profi ciency of, an organization's safety management [9]. A positive patient safety culture guides the behaviours of healthcare professionals towards viewing patient safety as one of their highest priorities [9]. Safety culture assessment surveys allow hospitals to

Survey instrument
We used the French version of HSOPSC for data collection [15]. HSOPSC has been tested on a large sample in United States, and has good supporting documentation [16][17][18]. HSOPSC has good psychometric criteria testing, including item analysis, exploratory factor analysis, confi rmatory factor analysis, and inter-correlation and reliability analysis [16,17,19,20]. It also has been used and validated in different countries [20][21][22][23][24]. The French version of HSOPSC displays the perceptions of patient safety climate in 10 factors or dimensions ( Table 1). The patient safety climate factors contain between three and six items each (a total of 40 items) and are all measured on a Likert scale, with a score from 1 to 5 on level of agreement: strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5).

Data collection
We distributed a paper-based questionnaire to the selected participants. They could freely and anonymously fi ll in the questionnaire and return their responses directly to the investigator.

Statistics analyze
Demographic data and the scores of patient safety culture dimensions were summarized using descriptive statistics. For each positively worded item, the percentage of positive responses was calculated-that is, the percentage of respondents answering the question by checking "strongly agree" and "agree" or "always" and "most of the time". The scores of negatively worded items were reversed to ensure that higher scores always refl ect more positive responses. Finally, a score was calculated for each dimension. It corresponds to the average proportions of positive responses per item. If the average was 75% or more, the dimension was developed. If it is between 50 % and 74%, the dimension needs to be improved. If it is under 50%, the dimension is non-developed. To compare the dimensions' scores between physicians and paramedical personnel, the chi-square test was used, and p < 0.05 was recognized as statistically signifi cant. All statistical analyses were carried out using SPSS Version 19 software.

Ethics
The study was approved by the ethics committee of Sahloul hospital. Verbal consent of the participants was obtained before administering the questionnaires.
Respondents reported having over than 10 years of experience at the hospital (31.1%). Table 2 lists the sample's characteristics.
The percent of average positive responses (agree, strongly agree) varied between 43.3% and 59.4% across the ten patient safety dimensions of the HSOPSC ( Figure 1). The highest percentage of positive responses was obtained from the "Frequency of events reported", whereas items in the "Teamwork across units" dimension received the lowest percent of positive responses (Table 3). Areas with potential Table1: Patient safety culture dimensions of the HSOPSC used at Sahloul hospital Sousse (Tunisia)

Patient safety dimensions of the HSOPSC Items
Overall perception of safety 4 Frequency of events reported 3 Supervisor or manager expectations and actions promoting patient safety 4 Teamwork within units 4 Teamwork across hospital units 6 Staffi ng 3

Communication openness 3
Non-punitive response to error 3 Hospital management support for patient safety 4 Organizational learning -continuous improvement 6 for improvement were "overall perception of security", "Teamwork within units", "Organizational learning/ continuous improvement", "Open communication and "Frequency of events reported". There were no differences between physicians and nurses regarding all dimensions of the patient safety culture (Table 4).

Discussion
The measurement of safety culture and climate in healthcare is still in a relatively immature stage of development as compared to other domains (eg, offshore installations, manufacturing) [25,26]. Measuring of patient safety perception   When a mistake is made, but is caught and corrected before affecting the patient, it is reported...

58.2
When a mistake is made, but has no potential to harm the patient, it is reported… 59 When a mistake is made that could harm the patient, but does not, it is reported… 61.1

Supervisor/Manager expectations and actions promoting patient safety 48.2
Manager says a good word when he/she sees a job done according to established patient safety procedures 46 We are actively doing things to improve patient safety 56.9 Mistakes have led to positive changes here 60.2 After we make changes to improve patient safety, we evaluate their effectiveness 50.5 We are given feedback about changes put into place based on event reports 59. 3 We are informed about errors that happen in the unit 53.8 In this unit, we discuss ways to prevent errors from happening again 56.1

Teamwork within units 57
People support one another in this facility 60.2 When a lot of work needs to be done quickly, we work together as a team to get the work done 55.8 In facility, people treat each other with respect 55 When one area in this unit gets really busy, others help out 57

Communication openness 55.3
Staff will freely speak up if they see something that may negatively affect patient care 53.8 Staff feel free to question the decisions or actions of those with more authority 55.9 Staff are afraid to ask questions when something does not seem right 56.1

Non-punitive response to error 48.1
Staff feel like their mistakes are held against them 50.5 When an event is reported, it feels like the person is being written up, not the problem 49.4 Staff worry that mistakes they make are kept in their personnel fi le 44.5

Staffi ng 45.3
We have enough staff to handle the workload 44.4 Staff in this facility work longer hours than is best for patient care 45.9 We work in 'crisis mode' trying to do too much, too quickly 45.6 Management support for patient safety 46 is the fi rst step of a long process of cultural change and improvement of quality care. The safety culture environment is considered the most important barrier to improving patient care safety [27]. The starting point for developing a safety culture should be the evaluation of the current culture by using an appropriate instrument [21]. Few studies were conducted in Tunisian health facilities. One of them, our study is the fi rst survey on patient safety culture among health professionals of Sahloul Hospital (Sousse, Tunisia).
Overall, we generally found low patient safety culture scores in our hospital. Our results suggested negative perception of the ten dimensions. No signifi cant differences on patient safety culture perception levels between physicians and paramedical staff have been demonstrated. Similar results were reported in Iranian hospitals [28]. Whereas, the professions differed in their perception of patient safety climate in others studies [29][30][31][32]. This could be explained by the lack of effective communication and collaboration between physicians and other medical personnel, which has a profound effect on workplace environment and patient care [30]. Our results suggested that the same improvement strategies of patient safety culture are likely to have an impact for both physicians and paramedical staff. Our responses rate (73%) was higher than those reported in several other studies [21,[32][33][34]. They varied from 37% to 63%. The undeveloped dimensions in our study were "Supervisor or manager expectations and actions promoting patient safety", "Hospital management support for patient safety", "Non-punitive response to error", "Staffi ng" and Teamwork across hospital units which is a similar result as in other studies [20,35]. However, literature has shown different results and a wide variation between countries ( Table   5). The differences regarding the perception of patient safety may be explained by the differences in organizational behaviour between cultural settings, organizational commitments,   [30]. Furthermore, management practices are essential to the creation of safety within the organization, and these practices include creating and sustaining trust throughout the organization [48].
In our organization, 56.9% of professionals perceived positively the need to take action to improve patient safety. This present study has several limits. The quantitative assessment of patient safety culture using a self-administered questionnaire can be associated with a declaration bias. Indeed, self-administered questionnaire may infl uence the reaction of those who, for fear of reprisal or prosecution, will give social answers that do not refl ect reality. However, this bias is more important in quantitative surveys based on interviews [49].
We used the French version of HSOPSC. This version may have measured different patient safety culture's constructs in our sample from those meant by AHRQ [15]. The fi nal structure of the tools does differ. This corroborates the need to adapt the tool to each country according to local ways of being, thinking, behaving and communicating [15]. Furthermore, HSOPSC does not calculate an overall score of patient safety culture. The validation of such score is complex and raises the problem of choosing the dimensions to be considered and their weightings.
Finally, this study is carried out in a single hospital, which limits the external validity.

Conclusion
This study was an opportunity to familiarize health professionals with this concept of patient safety and to initiate a refl ection on the current level of safety culture and its possible improvement. Our results suggest that the fi rst step to patient safety improvement in our organization should be obtaining the support of hospital management, assuming a non-punitive approach to those who make and report medical errors and considering communication and teamwork.