Perception of Front-line Healthcare Providers Toward Patient Safety: A Preliminary Study in a University Hospital in Egypt

Hanan Abdullah Ezzat Abbas, PhDN, MScN; Nora Ahmed Bassiuni, PhDN, MSN, BScN; Fatma Mostafa Baddar, PhDN, MSN, BScN


Topics in Advanced Practice Nursing eJournal. 2008;8(2) 

In This Article


Objective: Increasing focus on improving patient safety in healthcare organizations makes it crucial to first create a positive safety climate. The current study targeted the perceptions of front-line healthcare providers toward safety climate, and management and clinical staff commitment to patient safety.
Methods: This study was conducted at Alexandria Main University Hospital, Alexandria University, Egypt, during the period from March, 2006 to December, 2006. Subjects were a convenience sample of 400 front-line clinical staff members working in the general medical and surgical wards, intensive care units (ICUs), and paramedical departments at Alexandria Main University Hospital. The "Safety Climate Survey" was used to gain information about the front-line health care providers' perceptions toward patient safety in the clinical settings.
Results: The majority of participants conveyed negative perceptions toward patient safety. Physicians' perceptions about patient safety were high compared to those of nurses and paramedical personnel. Respondents perceived a significantly stronger commitment to patient safety from their managers and surrounding safety climate than from clinical personnel. Perceptions of subjects working in the general wards reflected a significantly poorer commitment to safety from their managers compared with those working in the ICUs and paramedical departments. Moreover, negative correlations were found between subjects' years of experience and perceptions about patient safety climate and management commitment to patient safety.
Conclusion: Achieving an acceptable standard of patient safety requires that all healthcare settings develop patient safety systems that include both a positive culture of safety and organizational support for safety processes. This will not be possible unless the perceptions of the front-line health care providers and management are positively managed and directed.


Safety in healthcare has received substantial attention worldwide since the late 1990s.[1] Rapid change in healthcare has mandated greater attention to safety, which is essential for quality patient care, employee welfare, and morale.

Safety is a condition or state of being resulting from the modification of human behavior and/or designing of the physical environment to reduce hazards, thereby reducing the chance of accidents (Khatab M, unpublished data, 2005). The Institute of Medicine (IOM) report, "To Err Is Human,"[2] described the magnitude of the patient safety problem in some detail, yet it provided only a high level view of how organizations might change in order to improve care delivery. The IOM report also highlighted an actionable conclusion that "the biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm."[2]

The IOM estimated that 98,000 preventable deaths occur each year due to medical errors, with no significant improvement in 5 years due to failure to improve patient safety.[3,4] Since the IOM report, organizations have struggled to develop effective programs for improving safety.[2]

A study conducted by Khatab in 2005 (personal communication) in a teaching hospital affiliated with Alexandria University assessed the facility's safety management system and developed a manual for safety practices for nurses in critical care units. This study concluded that the hospital safety management system was insufficient. Only 36% of safety measures to prevent susceptibility to hospital-acquired infection were followed. None of the safety measures that applied to the physical structures of the studied units were followed. Moreover, Khatab learned that needle-stick injuries were the main source of hazard for both technical and professional nurses, while insufficient equipment, medication errors, improper preparation of the patient for procedures, and nursing malpractice were identified as frequent hazards for patients in the ICUs.

Promoting a culture of safety has become a pillar of the patient safety movement. Patient safety was defined by Batcheller and colleagues[5] as "the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery. Patient safety also means prevention of harms to patients."

In recent years, there has been increasing understanding within the healthcare field that various factors create a culture that contradicts the requirements of patient safety. These factors include the emphasis on production, efficiency, and cost controls;[6] organizational and individual failure to acknowledge fallibility;[7] and professional norms for perfectionism among healthcare providers.[8] Increasingly, the culture of healthcare organizations is regarded as a potential risk factor that threatens the patients for whom they provide care.[9,10]

Although there is no firm consensus on the definition of safety culture, the Advisory Committee on the Safety of Nuclear Institutions provides the following definition that can easily be adapted to the context of patient safety in healthcare: "The safety culture of an organization is the product of individual and group values, attitudes, perceptions, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures."[11]

Two important concepts affect the culture of safety: error reporting and disclosure of errors. The acceptance of and means by which errors are identified, reported, and communicated to those involved or affected, have much to do with how well safety is ingrained in the healthcare organization's culture.[12]

Increasing the focus on improving patient safety in healthcare organizations made it crucial to first create a positive safety climate. According to Flin and colleagues,[13] a climate of safety can be regarded as the surface features of the safety culture, discerned from the workforce attitudes and perceptions at a given point in time.

In 2004, the Center of Excellence for Patient Safety Research and Practice at the University of Texas established a conceptual framework to transform patient safety.[14] They believe that most medical errors result not from the errors of individuals, but from numerous latent errors that exist within complicated systems of care delivery. This approach to medical error is well supported and consistent with historical efforts in healthcare quality improvement.

Medical errors can be caused by factors at several different levels of a system.[11] On one level, individual processes may trigger errors. However, an individual who triggers an error at the "sharp end" may not be the root cause of that error. Instead, the error may be related to the interactions of individuals with inadequately designed medical devices, for example. Factors related to the functioning of teams reflect a third, even wider level that can also lead to errors, as can organizational policies and structures (eg, resource allocation, staffing and scheduling, and training). Finally, societal laws and regulations influence all the other levels and may affect the frequency and types of errors.[14] The current study targeted the individual level; it focused on studying perceptions of front-line healthcare providers toward safety culture, and management and clinical staff commitment to patient safety.

Safety culture surveys are useful for measuring organizational conditions that can lead to adverse events and patient harm in the healthcare organization. In addition, these surveys can be used to raise awareness about patient safety issues and track changes over time. The ultimate goal, to develop a positive culture of safety, has tremendous potential to benefit patients.[12]

In the Middle East, efforts to transform the healthcare system are ongoing. These efforts require health administrators to consider the role of front-line care providers' perceptions about safety, since these can both positively and negatively affect efforts to improve safety. In March 2007, the Eastern Mediterranean Regional Office (EMRO) of the World Health Organization (WHO) planned and conducted a "Regional Patients for Patient Safety" workshop in Cairo for all 6 of the WHO geographic regions.[15] This event brought together 30 participants from 8 countries within the Eastern Mediterranean region. The event created a network of consumer champions in the Eastern Mediterranean who are actively engaged in contributing their experience, wisdom, and knowledge to improving patient safety. The meeting culminated in several discussions around the topic of patient safety with particular emphasis on the engagement of patients in shaping the healthcare system.

Moreover, in Egypt, various studies in the patient safety field have been conducted.[16] However, less attention has been focused on handling patient safety issues from the front-line healthcare provider's perception. Furthermore, in order to advance patient safety in healthcare organizations, collaborative efforts must begin with an assessment of the current culture to identify the positive and negative perceptions and attitudes toward the safety environment and relationships that promote or hinder safe patient care. Thus, this study was carried out to identify perceptions of front-line healthcare providers toward patient safety, in order to propose actions that can be implemented to improve behaviors, attitudes, and policies that support patient safety culture, and to reinforce and sustain a commitment to safer care.


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