**2. Methods**

#### **2.1. Design, settings, duration, and participants**

A cross-sectional multicenter study was conducted from January to April 2016 in the PHC in the Tunisian center (Sousse, Kasserine, and Kairouan). These structures were chosen because they were partners of the Faculty of medicine of Sousse, and therefore, they were responsible for mentoring future family doctors.

All PHC of these listed cities were included in the study (n = 30) and all the healthcare providers in them (physicians, healthcare technicians, and nurses) were invited to participate in the study (n = 251). Workers who are not involved in healthcare practices and those with less than 1-month experience were excluded.

#### **2.2. Measures**

**1. Introduction**

78 Vignettes in Patient Safety - Volume 3

showed that the rate of AEs is 11.3% [1].

aspects that require attention [8, 9].

**2. Methods**

Sousse (Tunisia) and to determine PSC's associated factors.

**2.1. Design, settings, duration, and participants**

Adverse events (AEs) still remain as a global challenge and no country has yet overcome all of its patient safety problems [1]. So, many studies have shown the severity of these accidents, in terms of cost, frequency, and serious consequences [2]. The overall incidence of AEs in various high-resource countries varies between 2.9 and 16.6% [1]. The situation is more difficult and serious in low-resource countries with higher risk of patient harm due to the limitation of resources and lack of adequate infrastructures [1, 3]. In Tunisia, a study conducted in Sousse

As for the area of primary healthcare, which provides the first contact for the patient [2], it goes without saying that quality and patient safety are vital goals and challenges [3]. In fact, errors and AEs are common in the outpatient setting [4, 5]; it has been identified that a significant proportion of safety incidents caught in hospitals had originated in the earlier levels of care [3]. Actually, a study in Spain deemed that 64.3% of AEs in primary care are preventable [5]. As a result, the World Health Organization (WHO) Safety Program has initiated the "Safer Primary Care" project, whose goal is to advance the understanding and knowledge about the risks to patients in primary care and the magnitude of the preventable harm due to unsafe practices in these settings [6]. Furthermore, in order to enhance primary care safety, the National Patient Safety Agency developed a best practice guide that describes how to "build a safety culture" as the first of the seven key steps for primary care organizations to protect the patients they care for [3]. Indeed, the success of any intervention with the ultimate goal of securing care and reducing

AEs must go through the development of a patient SC with healthcare workers [4].

mitment to the style and proficiency of an organization's safety management [7].

Nieva and Sorra defined patient safety culture (PSC) as the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the com-

However, undertaking a baseline assessment of PSC of the organization is the first step to start with in building safety culture [3]. Actually, assessing allows healthcare institutions to identify their strengths and weaknesses in terms of patient safety and to provide a clearer view of the

Several studies found in literature that have been interested to PSC in primary healthcare centers (PHC) and reported variations between countries [2, 3, 9–11]. To our knowledge, there is currently no study that investigated PSC in PHC in Tunisia. We conducted this study to respond to the following research questions: "What is the level of PSC in Tunisian PHCs? And what are the PSC's associated factors?" Therefore, our objectives were to assess PSC through exploring perceptions and attitudes of professionals in the PHC of the healthcare centers in

A cross-sectional multicenter study was conducted from January to April 2016 in the PHC in the Tunisian center (Sousse, Kasserine, and Kairouan). These structures were chosen The current study used the French version of Hospital Survey of Patients' Safety Culture (HSOPSC) questionnaire, which was translated and validated by the Coordination Committee of the Clinical Evaluation and Quality in Aquitaine (CCCEQA). Internal consistency reliability was of 0.88 for the questionnaire, Cronbach's alpha values varied between 0.46 and 0.84 in 10 dimensions [12].

Ten PSC dimensions were explored by the French version through 45 items. Dimensions were about: overall perception of patient safety (D1), frequency of events reported (D2), supervisor/manager expectations and actions promoting patient safety (D3), organizational learningcontinuous improvement (D4), teamwork within units (D5), communication openness (D6), nonpunitive response to error (D7), staffing (D8), management support for patient safety (D9), and teamwork across units (D10). The survey also examined staff perception of patient safety quality (1 item), the number of AEs reported during the last 12 months (1 item), and characteristics of participants (6 items). A Likert scale of five points was used to explore professionals' patient safety culture perception.

#### **2.3. Data collection, ethical consideration, and analysis**

This study was approved by the common ethics committee of the High School of Sciences and Techniques of Health of Sousse and the university hospitals of Sousse. Administrative authorizations have been obtained from heads, head chiefs, and PHC directors.

A self-reported paper-based questionnaire was distributed to the participants that accepted to take part in the study. The study purposes, outcomes, and instructions were explained to participants. They could freely and anonymously fill in the questionnaire and return their responses directly to the investigator. According to the user guide of the French version of HSOPSC questionnaire, if none of the dimensions' sections was entirely filled, the questionnaire would not be taken into account. Also, if less than half of the items in the questionnaire have been completed, or the same answers were given to all the items, the questionnaire would be illegible and excluded.

#### **2.4. Data analysis**

The data analysis was conducted using SPSS version 20 and Epi info 6 for windows. Descriptive statistical analysis such as frequencies and percentages of positive responses for each item and dimension were used to examine healthcare professionals' perceptions about PSC. Items were worded in both positive and negative directions. For items with a positive formulation, answers "Strongly Agree/Agree" or "Most of the time/Always" were considered positive. For items with a negative formulation, the answers "Strongly Disagree/Disagree" or "Never/ Rarely" responses were considered positive for PSC.

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 committees. Statistical significance was defined at p ≤ 0.05.
