**3. Results**

#### **3.1. Characteristics of the participants**

In total, 214 professionals provided survey feedback (85%). Seventy six (35.5%) participants were general practitioners, 92 (43%) were nurses, and 46 (21.5%) were technicians and midwives. As for gender, the majority of respondents 154 (72%) were female with a sex ratio of 0.39. More than half of the professionals (67.8%) had a work experience of more than 10 years (**Table 1**).

**3.2. The staff perception of patient safety quality and the frequency of reported AEs**

**Characteristics n %**

Urban 164 76.6 Rural 50 23.4 Total 214 100

any event in the last 12 months (**Table 2**).

**The district of the primary healthcare center**

**Table 1.** Characteristics of participants.

**3.4. Factors associated with PSC in PHC**

**Staff perception of patient safety quality**

**Number of events reported**

**3.3. PSC dimensions**

Staff perception of patient safety quality in the PHC was ranked as good in 59.3% and poor in 15.9%. Regarding reported AEs, 75.2% of the participants declared that they did not report

Concerning "overall perception of safety," it had a score of 52.45%. The percentage of positive responses was the highest for "teamwork within units" (71.47%), so this dimension was a potential area for improvement. The lowest scores were for "frequency of event reporting" (31.43%) and "nonpunitive response to error" (35.36%). Results of all dimensions are shown in **Table 3**.

All dimensions of PSC have not been significantly associated with professional title, gender, work experience, the region of the PHC, and participation to a risk committee, except for the

Excellent 12 5.6 Very good 40 18.7 Good 127 59.3 Poor 34 15.9 Failing 1 0.5

No event reported 161 75.2 1–2 29 13.6 3–5 9 4.2 6–20 8 3.7 More than 20 7 3.3

**Table 2.** Staff perception of patient safety quality and number of reported adverse events during the last 12 months.

**n %**

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**Table 1.** Characteristics of participants.

#### **3.2. The staff perception of patient safety quality and the frequency of reported AEs**

Staff perception of patient safety quality in the PHC was ranked as good in 59.3% and poor in 15.9%. Regarding reported AEs, 75.2% of the participants declared that they did not report any event in the last 12 months (**Table 2**).

#### **3.3. PSC dimensions**

**Characteristics n %**

mittees. Statistical significance was defined at p ≤ 0.05.

**3.1. Characteristics of the participants**

The chi-square test was also used to examine the association between total score of PSC dimensions and participants' demographic and professional variables such as gender, age, professional title/specialty, work experience, region of the PHC, and participation in risk management com-

In total, 214 professionals provided survey feedback (85%). Seventy six (35.5%) participants were general practitioners, 92 (43%) were nurses, and 46 (21.5%) were technicians and midwives. As for gender, the majority of respondents 154 (72%) were female with a sex ratio of 0.39. More than

half of the professionals (67.8%) had a work experience of more than 10 years (**Table 1**).

General practitioners 76 35.5 Healthcare technicians 46 21.5 Nurses 92 43 Total 214 100

Females 154 72 Males 60 28 Total 214 100

>40years 124 58.2 ≤40years 90 41.8 Total 214 100

<10 years 69 32.2 ≥10 years 145 67.8 Total 214 100

Yes 34 15.9 No 180 84.1 Total 214 100

**Professional title/specialty**

**3. Results**

80 Vignettes in Patient Safety - Volume 3

**Gender**

**Age**

**Work experience**

**Participation into risk management committees**

Concerning "overall perception of safety," it had a score of 52.45%. The percentage of positive responses was the highest for "teamwork within units" (71.47%), so this dimension was a potential area for improvement. The lowest scores were for "frequency of event reporting" (31.43%) and "nonpunitive response to error" (35.36%). Results of all dimensions are shown in **Table 3**.

#### **3.4. Factors associated with PSC in PHC**

All dimensions of PSC have not been significantly associated with professional title, gender, work experience, the region of the PHC, and participation to a risk committee, except for the


**Table 2.** Staff perception of patient safety quality and number of reported adverse events during the last 12 months.


dimension of "Frequency of adverse events reported," which was significantly higher among

**Items of patient safety culture dimensions in the primary healthcare centers Average positive** 

When an event is reported, it feels like the person is being written up, not the problem 42.1 Staff worry that mistakes they make are kept in their personnel file 29.4 **D8: Staffing 38.43** We have enough staff to handle the workload 50.5 Staff in this facility work longer hours than is best for patient care 19.6 We work in 'crisis mode' trying to do too much, too quickly 40.2 **D9: Management support for patient safety 50.22** Management provides a work climate that promotes patient safety 47.2 The actions of management show that patient safety is a top priority 55.1 Management seems interested in patient safety only after an adverse event happens 41.6 Units work well together to provide the best care for patients 57 **D10: Teamwork across units 44.23** There is good cooperation among units that need to work together 49.5 Units do not coordinate well with each other 41.6 It is often unpleasant to work with staff from other units 39.7 Things 'fall between the cracks' when transferring patients from one unit to another 36 Important patient care information is often lost during shift changes 59.8 Problems often occur in the exchange of information across units 38.8

**response (%)**

83

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Recently, patient safety in primary care has been given increasing attention [12]. Due to the fact that many studies who have investigated the quality of care in primary healthcare settings, have detected a high level of AEs leading to miserable and lethal consequneces [14, 15].

Moreover, it is directly accessible to patients and consists of several professions such as general practice, dental care, physiotherapy, and midwifery. Indeed, this study is the first to assess PSC in Tunisian PHC. It was carried out in urban and rural PHC of the listed cities. A high participation rate (85%) (n = 214) was acceptable and run counter to the results from

professionals involved in risk management committees (p = 0.01).

**Table 3.** Scores and items of the 10 dimensions of safety culture (n = 214).

**4. Discussion**

previous studies [13, 14].


**Table 3.** Scores and items of the 10 dimensions of safety culture (n = 214).

dimension of "Frequency of adverse events reported," which was significantly higher among professionals involved in risk management committees (p = 0.01).

#### **4. Discussion**

**Items of patient safety culture dimensions in the primary healthcare centers Average positive** 

**D1: Overall perceptions of safety 52.45** Patient safety is never sacrificed to get more work done 61.2 Our procedures and systems are good at preventing errors from happening 57 It is just by chance that more serious mistakes do not happen around here 53.3 We have patient safety problems in this facility 38.3 **D2: Frequency of events reported 31.43**

When a mistake is made, but is caught and corrected before affecting the patient, it is

When a mistake is made, but has no potential to harm the patient, it is reported… 28 When a mistake is made that could harm the patient, but does not, it is reported… 32.7 **D3: Supervisor/Manager expectations and actions promoting patient safety 51.25**

Manager seriously considers staff suggestions for improving patient safety 51.4

My manager overlooks patient safety problems that happen over and over 49.8 **D4: Organizational learning and continuous improvement 45.01** We are actively doing things to improve patient safety 64.5 Mistakes have led to positive changes here 58.9 After we make changes to improve patient safety, we evaluate their effectiveness 72 We are given feedback about changes put into place based on event reports 10.3 We are informed about errors that happen in the facility 34.1 In this facility, we discuss ways to prevent errors from happening again 30.3 **D5: Teamwork within units 71.47** People support one another in this facility 68.2 When a lot of work needs to be done quickly, we work together as a team to get the work

In facility, people treat each other with respect 70.1 When one area in this unit gets really busy, others help out 66.8 **D6: Communication openness 44.56** Staff will freely speak up if they see something that may negatively affect patient care 53.3 Staff feel free to question the decisions or actions of those with more authority 29.9 Staff are afraid to ask questions when something does not seem right 50.5 **D7: Non-punitive response to error 35.36** Staff feel like their mistakes are held against them 34.6

Manager says a good word when he/she sees a job done according to established patient

Whenever pressure builds up, my manager wants us to work faster, even if it means

reported…

82 Vignettes in Patient Safety - Volume 3

safety procedures

taking shortcuts

done

**response (%)**

33.6

54.7

49.1

80.8

Recently, patient safety in primary care has been given increasing attention [12]. Due to the fact that many studies who have investigated the quality of care in primary healthcare settings, have detected a high level of AEs leading to miserable and lethal consequneces [14, 15].

Moreover, it is directly accessible to patients and consists of several professions such as general practice, dental care, physiotherapy, and midwifery. Indeed, this study is the first to assess PSC in Tunisian PHC. It was carried out in urban and rural PHC of the listed cities. A high participation rate (85%) (n = 214) was acceptable and run counter to the results from previous studies [13, 14].

The dimension of "overall perception of patient safety" had a score of 52.45%. This reflects the lack of security of care in these PHC and the need to implement corrective measures to increase awareness of this issue among professionals.

These two dimensions appear to be closely related to each other because of the "blame and shame" culture and the punitive environment where failure is punished or concealed and peo-

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Actually, we found that among all participants working in 30 different PHC, 75.2% of them declared that they did not report any event in the last 12 months in their facilities. And it is only normal that in this punitive culture, people will not be willing to report AEs due to the

In this study, the only dimension influenced by one associated factor was "frequency of adverse events reported." In fact, participants who were engaged in risk management committees had a significant higher score of this dimension (21.81 vs 40.19%, p = 0.01). This finding goes hand in hand with results from the PSC survey that was conducted in operating rooms in Tunisia [17]. Actually, risk management describes a dynamic process that includes all measures for systematic identification, analysis, assessment, surveillance, and control of risks. An effective risk management should not start only after the evaluation of an incident but when failure can still be avoided and damage can be prevented. A successful example of effective risk management is the World Health Organization's safe surgery checklist," which is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to

This study provides an overall assessment of safety perceptions among PHC staff. Based on its reflections, we recommend a systematic improvement of staff qualification by providing training opportunities and educational interventions to promote a better understanding of the principles of teamwork, help staff acknowledge each other's roles and perspectives, and develop effective communication strategies. Moreover, regarding the underreporting, if incident reporting process is perceived as a supportive and formative opportunity, and where protected time is allocated to discuss incidents, then professionals are willing to participate. That is why it is essential to establish a culture where individuals are supported to identify

Also, we recommend the implementation of continuous training programs concerning risk management and patient safety guides. As well, we find it useful to introduce a medical curriculum safety culture in the educational programs of undergraduate healthcare professionals. Actually in 2011, the WHO published the "Multi-professional Patient Safety Curriculum Guide" with 11 themes related to patient safety to be integrated into healthcare universities [26]. One of the study's limitations was that the instrument tool used was, actually, developed for use in hospitals setting and not for PHC [16]. The assessment of PSC using a self-administered questionnaire can be associated with a declaration bias. Indeed, self-administered questionnaire may influence the reaction of those who, for fear of reprisal or prosecution, will give social answers that do not reflect reality. Furthermore, HSOPSC does not calculate an overall score of PSC. The validation of such score is complex and raises the problem of choosing the

In conclusion, the study findings demonstrate that none of PSC dimensions is developed in our PHC. We highlighted different areas of concern such as "frequency of adverse events reported," "nonpunitive response to error," and "staffing." It also shed the light on the lack of

ple refuse to acknowledge that problems do exist [9, 13].

information deficit [25].

fear of blame and obstruction of any possibility to learn from error.

and report errors without threat of punitive action or blame.

dimensions to be considered and their weightings.

reporting in primary care due to the punitive culture regarding errors.

Our results reveal that the dimension of "teamwork within units" had the highest score (71.47%) and this statement was similar to what was found in literature [2, 9, 13, 14]. However, it was developed in almost all the studies in PHC [2, 9, 11, 13] and this may be due to the fact that PHC are small buildings with less staff compared to hospitals and an unsophisticated environment, which are the factors that encourage teamwork [15]. Actually, teamwork is known as a dynamic process of healthcare professionals with complementary backgrounds and skills sharing common health goals and exercising concerted efforts in patient care through interdependent collaboration and shared decision-making through open communication, which is critical to teamwork [16].

Concerning the dimension of "communication openness," it was an area of concern in studies in Kuwait and Turkey [2, 9]. Responses have shown that professionals were not encouraged to express disagreement or to say alternative viewpoints. In a recently published study, only 28% of the staff members dared to speak with their superior regarding their concerns about the risk of a planned measure while the other staff members remained silent. In nearly 90% of the cases, the silence led to a near miss [17–19].

As a matter of fact, openness, in general, is found to be a problem in low-resource countries. Disagreement and criticism against supervisors or team members are frequently interpreted as blame or as a fight against them and may lead to loss of personal relationship or career, so most employees tend to avoid it [3].

According to literature, failures in teamwork and communication lead directly to compromised patient care, staff distress, tension, and inefficiency, make a substantial contribution to medical error [21].

Results of the current study show that all safety culture dimensions are potential areas for the improvement but with prioritization; there are three safety dimensions with very low scores and need to be considered of high priority. These dimensions are "frequency of adverse events reported" (31.43%), "nonpunitive response to errors" (35.36%), and "staffing" (38.43%). These results go hand in hand with several studies [9, 17].

Patient safety is a center of interest in healthcare, internationally, and error reduction can be improved by reporting and learning from errors [22]. A very low positive response for event reporting is expected in primary care because it is known to lack standardized reporting systems and reporting culture [20, 24]. Although primary care may imply lower risks compared to hospitals, the large volume of contacts in this sector suggests that safety incidents can be expected to occur [23].

Also, this underreporting can be explained by the fact that the commission of error is always considered as a lack of skill and rarely seen as a learning opportunity. A number of barriers exist to reporting, including insufficient time to report, lack of feedback, fear of blame, and damage to reputations and patient confidence in a competitive environment [24]. Here, we highlight the dimension of "nonpunitive response to error," which as mentioned above, has the second lowest score.

These two dimensions appear to be closely related to each other because of the "blame and shame" culture and the punitive environment where failure is punished or concealed and people refuse to acknowledge that problems do exist [9, 13].

The dimension of "overall perception of patient safety" had a score of 52.45%. This reflects the lack of security of care in these PHC and the need to implement corrective measures to

Our results reveal that the dimension of "teamwork within units" had the highest score (71.47%) and this statement was similar to what was found in literature [2, 9, 13, 14]. However, it was developed in almost all the studies in PHC [2, 9, 11, 13] and this may be due to the fact that PHC are small buildings with less staff compared to hospitals and an unsophisticated environment, which are the factors that encourage teamwork [15]. Actually, teamwork is known as a dynamic process of healthcare professionals with complementary backgrounds and skills sharing common health goals and exercising concerted efforts in patient care through interdependent collaboration and shared decision-making through open communication, which is

Concerning the dimension of "communication openness," it was an area of concern in studies in Kuwait and Turkey [2, 9]. Responses have shown that professionals were not encouraged to express disagreement or to say alternative viewpoints. In a recently published study, only 28% of the staff members dared to speak with their superior regarding their concerns about the risk of a planned measure while the other staff members remained silent. In nearly 90% of

As a matter of fact, openness, in general, is found to be a problem in low-resource countries. Disagreement and criticism against supervisors or team members are frequently interpreted as blame or as a fight against them and may lead to loss of personal relationship or career, so

According to literature, failures in teamwork and communication lead directly to compromised patient care, staff distress, tension, and inefficiency, make a substantial contribution to

Results of the current study show that all safety culture dimensions are potential areas for the improvement but with prioritization; there are three safety dimensions with very low scores and need to be considered of high priority. These dimensions are "frequency of adverse events reported" (31.43%), "nonpunitive response to errors" (35.36%), and "staffing" (38.43%). These

Patient safety is a center of interest in healthcare, internationally, and error reduction can be improved by reporting and learning from errors [22]. A very low positive response for event reporting is expected in primary care because it is known to lack standardized reporting systems and reporting culture [20, 24]. Although primary care may imply lower risks compared to hospitals, the large volume of contacts in this sector suggests that safety incidents can be

Also, this underreporting can be explained by the fact that the commission of error is always considered as a lack of skill and rarely seen as a learning opportunity. A number of barriers exist to reporting, including insufficient time to report, lack of feedback, fear of blame, and damage to reputations and patient confidence in a competitive environment [24]. Here, we highlight the dimension of "nonpunitive response to error," which as mentioned above, has the second

increase awareness of this issue among professionals.

the cases, the silence led to a near miss [17–19].

results go hand in hand with several studies [9, 17].

most employees tend to avoid it [3].

medical error [21].

expected to occur [23].

lowest score.

critical to teamwork [16].

84 Vignettes in Patient Safety - Volume 3

Actually, we found that among all participants working in 30 different PHC, 75.2% of them declared that they did not report any event in the last 12 months in their facilities. And it is only normal that in this punitive culture, people will not be willing to report AEs due to the fear of blame and obstruction of any possibility to learn from error.

In this study, the only dimension influenced by one associated factor was "frequency of adverse events reported." In fact, participants who were engaged in risk management committees had a significant higher score of this dimension (21.81 vs 40.19%, p = 0.01). This finding goes hand in hand with results from the PSC survey that was conducted in operating rooms in Tunisia [17].

Actually, risk management describes a dynamic process that includes all measures for systematic identification, analysis, assessment, surveillance, and control of risks. An effective risk management should not start only after the evaluation of an incident but when failure can still be avoided and damage can be prevented. A successful example of effective risk management is the World Health Organization's safe surgery checklist," which is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit [25].

This study provides an overall assessment of safety perceptions among PHC staff. Based on its reflections, we recommend a systematic improvement of staff qualification by providing training opportunities and educational interventions to promote a better understanding of the principles of teamwork, help staff acknowledge each other's roles and perspectives, and develop effective communication strategies. Moreover, regarding the underreporting, if incident reporting process is perceived as a supportive and formative opportunity, and where protected time is allocated to discuss incidents, then professionals are willing to participate. That is why it is essential to establish a culture where individuals are supported to identify and report errors without threat of punitive action or blame.

Also, we recommend the implementation of continuous training programs concerning risk management and patient safety guides. As well, we find it useful to introduce a medical curriculum safety culture in the educational programs of undergraduate healthcare professionals. Actually in 2011, the WHO published the "Multi-professional Patient Safety Curriculum Guide" with 11 themes related to patient safety to be integrated into healthcare universities [26].

One of the study's limitations was that the instrument tool used was, actually, developed for use in hospitals setting and not for PHC [16]. The assessment of PSC using a self-administered questionnaire can be associated with a declaration bias. Indeed, self-administered questionnaire may influence the reaction of those who, for fear of reprisal or prosecution, will give social answers that do not reflect reality. Furthermore, HSOPSC does not calculate an overall score of PSC. The validation of such score is complex and raises the problem of choosing the dimensions to be considered and their weightings.

In conclusion, the study findings demonstrate that none of PSC dimensions is developed in our PHC. We highlighted different areas of concern such as "frequency of adverse events reported," "nonpunitive response to error," and "staffing." It also shed the light on the lack of reporting in primary care due to the punitive culture regarding errors.

More attention should be paid to PSC in primary healthcare because changing values and attitudes needs time and motivation through training and improving risk management skills within healthcare providers. Also, as well, the results obtained bring up the necessity of the implementation of quality management system in Tunisian primary healthcare centers.

[8] El-Jardali F, Jaafar M, Dimassi H, Jamal D, Hamdan R. The current state of patient safety culture in Lebanese hospitals: A study at baseline. International Journal for Quality in Health

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