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Assessment of a patient safety culture: a nationwide cross-sectional study comparing public and private hospitals in Kuwait

BMC Health Services Research volume 25, Article number: 579 (2025) Cite this article

Abstract

Background

Several international health bodies advocate measuring patient safety culture within an organisation as an effective strategy for sustainably improving safety. This study aims to assess and compare patient safety culture across public and private hospitals in Kuwait.

Methods

A cross-sectional study was conducted utilising the Hospital Survey of Patient Safety Culture. The questionnaire was distributed among clinical staff in public general and private hospitals. Data analysis using Microsoft Excel and SPSS 23 (α level = 0.05) provided an overview of participant characteristics and patient safety culture scores. A model for predicting the determinants of patient safety culture score was constructed from a regression analysis.

Results

A total of 890 questionnaires were distributed equally between the public and private sectors. The overall response rate was 94.9%. Assessment of the positive percentage of patient safety culture showed that nationally, five composites were areas of strength: “Teamwork within Units” (87.2%), “Organizational Learning—Continuous Improvement” (87.5%), “Management Support for Patient Safety” (77.8%), “Feedback & Communication about Error” (75.8%) and “Teamwork across Units” (75.0%). Private hospitals showed these same areas of strength, whereas public hospitals had fewer. Private hospitals scored statistically significant higher positive percentages than public hospitals in most of the composites. Benchmarking against a 2015 study in Kuwait indicates that the positive percentages of six composites increased at the national level, whereas four remained the same. “Staffing” and “Non-punitive response to errors” were strikingly low.

Conclusion

In this first national study to assess patient safety culture in public and private hospitals in Kuwait, many areas of safety culture had improved. However, some areas require special attention, although causality cannot be inferred, which is a limitation of the study's design. A comparison between the two sectors revealed differences in the patient safety culture, which might be relevant to the guidelines governing them. Policymakers should set unified guidelines governing staffing in both sectors and devise intervention strategies to develop a culture that establishes learning from adverse events and supports patient safety, incorporating a just culture and whistle-blower protection. In academia, Kuwait University should incorporate patient safety and quality-of-care topics into its curricula.

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Background

Patient safety is a critical determinant of the quality of healthcare [1]. In their report To Err is Human, the Institute of Medicine estimated that during the 1990s 44,000–98,000 deaths occurred annually from preventable medical errors at a cost of $17–19 billion [2]. Patient safety has garnered considerable international attention and has become a core value of many accreditation bodies, such as The Joint Commission and Accreditation Canada International [3, 4]. Significant global efforts have been directed at enhancing patient safety through establishing safety monitoring systems, identifying sources of error, and enforcing effective policy initiatives [1, 5]. Hence, promoting a "culture of safety" is now a major pillar of a healthcare system [6, 7].

Patient safety culture (PSC) is typically defined as the shared values, attitudes, norms, beliefs, practices, policies and behaviours concerning safety issues in daily practices [8, 9]. PSC is further shaped by leadership style and organisational culture [10]. The literature has frequently examined leadership, organisational culture, management and regulation in the private and public healthcare sectors and the impacts any differences have on safety, service quality, patient and staff satisfaction, and other outcomes [11,12,13,14,15]. Interestingly, the private sector typically outperforms the public sector in these outcomes.

Achieving a culture of safety requires an understanding of the values, beliefs, and norms regarding health and safety within an organisation [6, 7]. An organisation with a positive safety culture is operated by mutual trust, with effective communication and shared perception [16]. A number of studies associated a high level of PSC with a lower number of errors and lower mortality rates, showing its positive impact on patient clinical outcomes [17,18,19]. Frameworks, surveys, and assessment tools have been designed over recent decades to measure and understand the type of culture that exists within a healthcare organisation, and to identify areas of strength and gaps [20,21,22,23,24,25]. A systematic review assessing PSC in the Arab world identified the need to promote PSC to improve patient safety [26].

Kuwait is a high-income Arab country with an advanced healthcare infrastructure. Notably, the Ministry of Health (MOH) in Kuwait has strived to ensure that healthcare delivery meets international standards. In order to help facilitate such aims, Accreditation Canada International was commissioned in 2008 to establish a national accreditation program for public healthcare settings [27, 28]. Since then, the MOH has required all hospitals to adopt and improve patient safety policies and health management standards to achieve national accreditation.

Several studies have assessed the safety culture in Kuwait across different healthcare settings, including primary care centres [29, 30], public hospitals [31, 32] and community pharmacies [33]. Another study evaluated safety culture in private hospitals, albeit only in three [34]. Considering the extent to which healthcare services in Kuwait are provided by the private sector and the paucity of studies on this sector, conducting a countrywide study to assess safety culture is important. In addition, no studies have assessed changes in patient safety in Kuwait over time, therefore benchmarking against a previous study in Kuwait might identify trends. It is essential to assess if hospitals have successfully addressed the composites of PSC previously identified as requiring improvement: "Communication Openness" [29,30,31], "Non-Punitive Response to Errors", "Staffing" [29, 31, 33] and "Frequency of Events Reporting" [29].

Notably, this is the first national study in Kuwait comparing safety culture across public and private hospitals located in each of the five governorates of the country. In the present study, we aimed to characterise and compare the PSC at public and private hospitals in Kuwait. We also wished to know how the safety culture in these hospitals had evolved since they were last assessed. Finally, we asked if PSC score could be predicted based on participant and hospital characteristics. This study will help to identify gaps that hinder the delivery of optimal services and threaten patient safety in both sectors. In addition, it will highlight areas of strength in one sector that the other might seek to emulate.

Methods

Study design and settings

A cross-sectional study was conducted using a pre-tested self-administered questionnaire (Supplementary file 1). The adoption of a cross-sectional design allows different variables in the sample to be measured at a single time point, yielding accurate data that are less prone to the potential biases of case series and case reports [35]. This design is the most widely adopted for PSC studies. The questionnaire was distributed among clinical staff at private and public general hospitals. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist [36] was adhered to in the reporting of this observational study.

At the time of the study, there were six public general hospitals and 13 private hospitals among the five governorates of Kuwait. Healthcare services in Kuwait are provided to residents at public and private settings, both of which are governed by the MOH. The public healthcare system—owned and operated by the MOH [37]—provides comprehensive services through primary (primary care centres), secondary (general hospitals), and tertiary (specialised hospitals) healthcare settings. The private sector is comprised of hospitals located across different governorates of Kuwait. The 2021 Annual Health Statistical Report estimated the numbers of hospital beds to be 8,377 and 1,375 in the public and private hospitals, respectively; outpatient visits numbered 1,951,058 and 278,8514, respectively [38].

Sample size calculation and sampling strategy

The sample size was calculated based on the results of a similar previous study in Kuwait [29]. As calculated using the Raosoft software (with a 95% confidence interval and 5% margin of error), a minimum sample size of 356 was required from each sector (public general hospitals and private hospitals). Assuming a response rate of 80%, a larger sample was targeted.

Preliminary fieldwork was carried out prior to the main study to determine the numbers of main clinical staff (physicians, nurses and pharmacists); in total, these numbered 13,455 and 4,692 in public and private hospitals, respectively. A proportional number of participants to be recruited from each hospital was then calculated based on the population size of the working staff. The clinical staff were selected by convenience sampling during their working shifts and were invited verbally to take part in the study. Those agreeing to participate were asked to sign a consent form guaranteeing the participants’ confidentiality, data anonymity, and the right to withdraw at any time from the study.

Study tool

The study utilised the Hospital Survey of Patient Safety Culture (HSOPSC), a tool developed by the Agency for Healthcare Research and Quality (AHRQ) [39]. It includes 42 statements, measuring 12 composites: Teamwork within Units (4 items); Supervisor/Manager Expectations & Actions Promoting Patient Safety (4 items); Organizational Learning—Continuous Improvement (3 items); Management Support for Patient Safety (3 items); Overall Perception of Patient Safety (4 items); Feedback & Communication about Error (3 items); Communication Openness (3 items); Frequency of Events Reported (3 items); Teamwork across Units (4 items); Staffing (4 items); Handoffs & Transitions (4 items); and Non-punitive Response to Errors (3 items). The items are both positively and negatively worded and are scored using a five-point Likert scale presenting respondents’ agreement (“Strongly Disagree” to “Strongly Agree”) or frequency (“Never” to “Always”).

The questionnaire was written in its original language (English). Additional questions were added to the demographic section of the original questionnaire to include the various job titles/ranks, age, sex, nationality, country of graduation, and primary work area of the respondent. These were added to provide the information necessary to assess the relationship between socio-demographics and safety culture scores. The HSOPSC is a validated tool, and reliability estimates of its composites and items have been demonstrated [40].

Inclusion and exclusion criteria

PSC represents a set of actions taken by the healthcare organization to achieve safe delivery of care [1]. As patient care is usually provided by a member of the clinical staff, this study focused on assessing the PSC among physicians, nurses and pharmacists. Accordingly, data was collected in certain departments in all hospitals, such as outpatient pharmacies and internal medicine wards. Non-clinical staff, such as hospital managers, administrators and IT technicians, were excluded from the study.

Sample recruitment and data collection

Initially, a pilot study was carried out to ensure that the questions were clear and reflected our aims and objectives. No participant reported issues in completing the questionnaire and no changes to the questionnaire were required.

Staff were typically invited verbally to participate. Before issuing the questionnaire, the study’s aims and objectives were fully explained. The questionnaires were distributed face-to-face and collected back on the same day; this was not possible in some private hospitals that requested the questionnaires be distributed through their human resources departments. Data was collected over 3–4 days weekly between February and April 2018, at various times of day to ensure recruitment from a variety of work shifts.

Data management and analysis

Once the data were fully collected, participants' identities and hospital names were coded for anonymity. At least one section had to be completed for that questionnaire to be included in the analysis. Fortunately, all questionnaires returned were included as 24 items had been completed by all participants. The missing responses to the Background Information section and the remaining of the 42 items (18 items) are negligible (1 or 2 responses per item) and did not impact the analysis.

Participant responses were coded. The coding system ranged from 5 (Strongly Agree or Always) to 1 (Strongly Disagree or Never). Negatively worded items were reverse-coded. Excel (Microsoft) was used to clean and process data, whereas SPSS 23 was used for analysis (α level = 0.05).

We checked the internal consistency to assess the reliability of the tool. The Cronbach’s α value of the 12 composites together was found to be 0.861, which indicates an acceptable degree of internal consistency. The normality of data was checked by Shapiro–Wilk (for < 50 responses) and Kolmogorov–Smirnov (n ≥ 50) testing [41]. For both tests, a p-value greater than 0.05 indicates that data are normally distributed. Our data were found to be not normally distributed (p < 0.001). The respondents’ demographics were presented using descriptive statistics (frequencies, percentages, medians, and interquartile ranges). Bivariate analyses (chi-squared tests) were used to compare public and private sectors according to the demographic characteristics of the hospitals and participants. Non-parametric tests were used to examine how the percentages of positive PSC responses differ across hospitals and participants' characteristics. Specifically, Mann–Whitney U tests were used if the hospitals or participants' characteristic (the independent variable) consisted of two categorical, independent groups (i.e. sex and direct contact with patients), whereas Kruskal–Wallis H tests were used if the independent variable had three or more categorical, independent groups (i.e. the rest of the demographic charcharacteristics).

Calculation of frequencies of the survey’s 42 items (or the 12 composites) was carried out according to the user’s guide published by the AHRQ [42]. In brief, positive responses (Strongly Agree/Agree or Always/Most of the time) to each item were combined. Then, the percent positive response at the item level was calculated using the following formula:

$$\left(\mathrm{Number}\;\mathrm{of}\;\mathrm{positive}\;\mathrm{responses}\ /\ \mathrm{Number}\;\mathrm{of}\;\mathrm{total}\;\mathrm{responses}\right)\times100$$

Finally, averaging these item-level percentages of positive scores gave a composite score; averaging the composite-level percentage of positive scores resulted in an average percentage for PSC across all composites. Hereafter, we refer to the percentage of positive responses pertaining to an item or a composite as the “positive percentage”. According to published cut-off points [30, 43], the scores for the positive percentage scores were categorised as follows: composites with scores ≥ 75% were designated “areas of strength”, whereas “areas for improvement” were those scoring below 60%.

We benchmarked these results from the public and private hospitals against the national study conducted in 2015 [32]. Comparisons to the benchmark results were made using the following formula [30, 32]:

$$\begin{aligned} \%\;\mathrm{Distance}\;\mathrm{from}\;\mathrm{benchmark}=&\left[\left(\mathrm{current}\;\mathrm{result}-\mathrm{benchmark}\;\mathrm{result}\right) \right. \\&/ \left.\ \mathrm{benchmark}\;\mathrm{result}\right]\times100 \end{aligned}$$

Since there was no agreement in the literature for describing deviations in PSC score from the benchmark for changes in PSC score, this study selected its cut-off points to be as follows: results ≥ + 10% were categorised as “greatly exceeding the benchmark”, whereas results less than + 10% to + 5% were regarded as “slightly exceeding the benchmark”. Results within ± 5% were defined as “meeting the benchmark”. Those between − 5% and − 10% were categorised as “slightly below the benchmark”, whereas results less than − 10% were considered to be “greatly below the benchmark”. The 5% cut-off points were selected in reference to the AHRQ’s User Database Report [44] published in 2022. The report indicated a threshold change of 5 percentage points, above which a hospital was adjudged to have changed its PSC score. The 5% cut-off is favoured over other thresholds because it was conceived by the AHRQ, the agency that developed the HSOPSC tool used in this study. The 10% cut-off was selected as it is at least two standard deviations from the average score of the benchmark study [32], that is, it has a statistical derivation unlike other arbitrarily set cut-off points.

The analysis also included multivariate analysis (multiple regression) to construct a model for predicting the determinants of PSC scores. Before running the multiple regression, Spearman's rank-order correlation was conducted to identify the statistically significant associations between the participants’ socio-demographic characteristics (independent variables) with the average PSC positive percentage of public and private hospitals (dependent variables). Independent variables with statistically significant (p ≤ 0.05) correlation coefficients ≥ 0.100 in the correlational analysis were included in the regression model. The absence of multicollinearity was assessed by checking variance inflation factor (VIF) values.

Results

A total of 890 questionnaires were distributed equally between the public (six general hospitals) and private (13 hospitals) sectors. Of these, 427 (95.9%) from the public hospitals and 418 (93.9%) from the private hospitals were returned. The overall response rate was 94.9%.

Socio-demographics

The socio-demographic characteristics are shown in Table 1. Three-quarters of the respondents were of non-Arab Asian nationality (71.7% public; 77.7% private). A similar proportion graduated from non-Arabic Asian countries (71.2% public; 77.9% private) and worked as nurses (74.7% public; 76.6% private). Physicians were second in number (22% public; 18.7% private).

Table 1 Socio-demographic characteristics of participants (n = 845 unless otherwise stated)
Full size table

Other data in Table 1 represent numbers and percentages of participants categorised according to their sex, age, highest academic degree, primary work area, years of experience, total working hours per week, and the accreditation status of their hospitals. There were statistically significant differences between the public and private hospitals regarding all the socio-demographic characteristics measured except profession (p = 0.293), the nurse and pharmacist levels (p = 0.074 and p = 0.161 respectively), and whether the participant has direct contact with patients (p = 0.329).

Composite-level and item-level results

On the national level, five composites were found to be areas of strength (positive ratings in ≥ 75% of responses): “Teamwork within Units” (87.2%), “Organizational Learning—Continuous Improvement” (87.5%), “Management Support for Patient Safety” (77.9%), “Feedback & Communication about Error” (75.8%) and “Teamwork across Units” (75.0%; Fig. 1). However, four composites require improvement (positive ratings < 60%): “Overall Perceptions of Patient Safety” (59.8%), “Communication Openness” (51.6%), “Staffing” (36.2%), and “Non-punitive Response to Errors” (32.3%). Our results reveal that the areas of strength in private hospitals mirror the national level, and had a further composite—“Overall Perceptions of Patient Safety”, scoring 64.4%—that was adjudged better than an area requiring improvement. By contrast, three composites that were areas of strength at the national level were not in public hospitals: “Management Support for Patient Safety” (70.4%), “Feedback & Communication about Error” (70.8%) and “Teamwork across Units” (68.2%). Two others required improvement only in public hospitals: “Supervisor/Manager Expectations & Actions Promoting Patient Safety” (59.8%) and “Frequency of Events Reported” (58.1%).

Fig. 1
figure 1

Comparison of positive percentage (%) for all composites

Full size image

Regarding individual items, the highest positive percentage was achieved for the item “We are actively doing things to improve patient safety” under the composite “Organizational Learning—Continuous Improvement” at the national (96.8%), public (95.6%) and private (98.1%) levels. Conversely, the lowest positive percentage at the national (16.3%), public (17.3%) and private (15.3%) levels was assigned to the “Staffing” item “Staff in this unit work longer hours than is best for patient care” (Supplementary file 2).

There are statistically significant differences between public and private hospitals in the average PSC percentage across all composites, in addition to the positive percentage of all but two composites: “Staffing” and “Non-punitive Response to Errors”. It is notable that private hospitals scored higher than public hospitals on all such occasions (Fig. 1).

In addition to the public–private dichotomy in hospitals, there is one of accreditation status. Non-parametric tests show a statistically significant difference (p < 0.001) in the average PSC percentage across all composites based on the accreditation status. Accredited hospitals scored 64.3% (IQR: 50.0–73.8) and 69.0% (IQR: 57.1–81.0) under national and international accreditation, respectively, whereas the non-accredited hospitals scored 71.4% (IQR: 57.1–81.0).

Benchmarking

Figure 1 also shows the benchmarking of our results against those from the study in Kuwait in 2015 [32]. The national positive percentages of four composites meet the benchmark, whereas three composites exceed it slightly (≥ + 5% to < + 10%) and three exceed it greatly (≥ + 10%). The national positive percentages of two composites are below the benchmark, either slightly (> − 10% to ≤ − 5%) or greatly (≤ − 10%). However, the current national average PSC percentage across all composites is in line with the benchmark.

The results from the public hospitals are quite similar to the benchmark. The PSC positive percentage meets the benchmark in six composites, whereas the results are below the benchmark slightly (> − 10% to ≤ − 5%) or greatly (≤ − 10%) in three and one composites, respectively. The PSC positive percentages of the other two composites exceed the benchmark slightly (≥ + 5% to < + 10%) or greatly (≥ + 10%).

The private hospitals greatly exceed the benchmark in six composites. The other composites either slightly exceed (composites 4 and 5), meet (1 and 3) or are greatly below (2 and 10) the benchmark.

Predictors of PSC positive percentage

The regression model was constructed based on the findings of the correlation analysis. The correlation analysis showed that eight socio-demographic characteristics (age, nationality, country of graduation, physician level, primary work area, years of professional experience, years of experience in present hospital and years of experience in present unit) have statistically significant (p ≤ 0.016) weak positive correlations (ρ = 0.139–0.259) with the average PSC positive percentage of the public hospitals, whereas one socio-demographic characteristic (profession) has statistically significant (p = 0.005) weak negative correlation (ρ = 0.135) with it. By contrast, for the private hospitals, only two socio-demographic characteristics (age and years of professional experience) have statistically significant (p < 0.001) weak positive correlations (ρ = 0.172 and ρ = 0.193, respectively) with the average PSC positive percentage.

Table 2 reports the results of the multiple regression analysis and lists only the predictor variables included in the model (all VIF values < 5.00). In this regression analysis, the participant’s socio-demographic characteristics accounted for 28.1% of the variability in the national PSC positive percentage. Based on the standardised coefficients, “Graduation from other countries (excluding Kuwait)” is almost 2.5-fold more important than “Graduation from Arabic countries other than Kuwait” for predicting the national PSC positive percentage. The unstandardised coefficients represent how much the PSC score increases or decreases as a result of a unit change in the predictor variable. For example, being a Specialist/Senior Specialist physician can increase the PSC positive percentage by a value of 14.6 (SE = 5.4).

Table 2 Predictors of the participant’s average PSC positive percentage across all composites (dependent variable)
Full size table

The type of the hospital (private or public) was studied for its moderating effect. Working at a private hospital has a statistically significant moderating effect on three predictors: “Primary work area (Critical/Emergency)”, “Graduation from Arabic countries other than Kuwait”, and “Physician level (Specialist/Senior Specialist)”. Negative B-coefficients for the moderator indicate that the predictors become less positive if the participant worked at a private hospital; by contrast, “Graduation from Arabic countries other than Kuwait” becomes more positive (Table 2).

Discussion

For decades, patient safety has been at the forefront of healthcare research [6, 45, 46]. With the aim of making measurements as a basis for seeking improvements [47, 48], the present study was conducted to determine the level of PSC in Kuwait’s hospitals three years after it was measured in the public and private sectors [32, 34].

Two of the five composites found to be areas of strength in the current study were also identified as such in a systematic review: "Teamwork within Units" (78–89%) and "Organizational Learning—Continuous Improvement" (71–88%) [49]. Regarding “weak” composites, that systematic review reported 10 scoring 50% or fewer positive responses. Of these, the present study found four to require improvement: "Overall Perceptions of Patient Safety" (25–33.9%), "Communication Openness" (36–45.5%), "Staffing" (14–45%) and "Non-punitive Response to Errors" (3.5–47%) [49].

Regionally, results from two studies conducted in Saudi Arabia in 2015 support our findings. Alswat et al. [50] and Elsheikh et al. [51] recognised "Teamwork within Units" and "Organizational Learning—Continuous Improvement" as areas of strength, and "Non-Punitive Response to Error" and "Staffing" as areas requiring improvement. However, each study was conducted at a single facility with no private-sector representation. A more recent study in three Saudi public hospitals [52] reported the same two areas of strength (85.8% and 83.3% respectively), but six areas of weakness. Those areas were "Handoffs and Transitions" (46.1%), "Frequency of Events Reported" (20.3%) and four composites identified as such in the present study (16.6–48.8%). Interestingly, the Saudi study [52] reported a percentage of responses from a non-Arab Asian population (82.1%), which was close to our findings. However, unlike in the present study, nationality, in addition to highest academic degree, years of experience in the hospital and in the current work area, and direct patient contact, was a significant predictor of PSC score.

In this study, we hypothesised that PSC had improved upon the benchmark (Kuwait, 2015) [32], for several reasons. Making measurements is known to contribute to improvement [47, 48] and some of the hospitals were enrolled in accreditation programmes. Such programmes require a healthcare organisation to regularly assess its safety culture and improve it [20, 53, 54]. However, although many researchers have reported that accreditation is associated with improved PSC [55,56,57], some have excluded it as a factor [58]. A cross-sectional study of South Korean hospitals found a very weak relationship between accreditation and PSC [59]. Although our study showed that there was a statistically significant difference between hospitals based on accreditation status (national, international or no accreditation), hospitals that did not undergo accreditation processes showed the highest scores of PSC; notably, these are private-sector hospitals. Their PSC results were very similar to those of the accredited private hospitals (p = 0.49). Therefore, we can confirm that the previously mentioned statistically significant differences are most probably associated with the sector rather than accreditation status.

Our hypothesis was considerably accurate. The overall average might have shown improvement had it not been for the decline in the positive percentage of two composites. Consistent with literature, we found that PSC scores increase from the baseline assessment upon later reassessment [50]. Likewise, Jones et al. [60] and Hellings et al. [61] reported improved PSC after second assessments. Furthermore, they identified specific interventions that were implemented prior to measuring the improvement.

In the current study, the private sector reported higher scores than the public sector in all composites except “Staffing” and “Non-Punitive Response to Error”; however, the differences for these two composites were not statistically significant. These findings establish the private sector as a model to emulate.

The generally higher private-sector scores could be explained by the association between hospital size and PSC outcomes. Notably, studies have shown that medium and small-sized hospitals with fewer patients—typically private hospitals—had better PSC scores and outcomes compared to larger hospitals. The latter face bureaucratic challenges in implementing quality improvement initiatives. In addition, smaller hospitals have a more homogeneous culture and their staff members are more likely to share similar values [32, 62]. However, the structural differences between the two sectors might not entirely explain the generally higher PSC scores in the private sector, as management, leadership and organisational culture and operations can all contribute to PSC [10,11,12,13,14,15, 63], but to suggest any causative role is outside the scope of the present study.

The literature contains a range of findings. Whereas a study from Peru supports our results [64], other studies reported no differences between the public and private sectors [65,66,67] or, by contrast, better scores at public hospitals [13]. An Ethiopian study [68] reported a higher overall PSC at private hospitals, although 11 of the 12 composites received higher scores at public hospitals.

Notably, the latter study [68] reported the mean scores instead of positive percentages. The study conducted previously in three private hospitals in Kuwait in 2015 also reported the mean scores [34]. That prevents us from using the 2015 study as a benchmark for the results of private hospitals in the current study, and furthermore does not comply with AHRQ-recommended reporting guidelines, which suggest using the positive responses not the mean scores [42]. We question further the validity of reporting and comparing mean PSC scores. This is because—according to the AHRQ user’s guide [42]—we count only the positive responses (4 or 5). For instance, if a researcher received responses of 1 and 5 for an item, the positive percentage would be 50%, whereas the mean score would be 3. If the two responses were instead both 3, the mean score would again be 3, but the positive score would be 0%. This is clearly misrepresentative as it does not account for the contribution of individuals to a positive evaluation of culture.

Since the results suggest the private sector leads in matters of PSC, we can conclude that working in a private hospital has a positive moderating effect on the predictors of the average PSC positive percentage in the regression analysis. Such an effect was seen on the predictor “Graduation from Arabic countries other than Kuwait”. It was surprising to find a negative moderating effect on two predictors. One of those is working in critical/emergency areas. This might arise from the substantial differences between these areas in public hospitals and their private-sector counterparts. In public hospitals, these departments are larger, better equipped, and better able to deal with complex and difficult cases than the private sector, which often resorts to transferring these cases to public hospitals. This might be associated with a sense of uncertainty towards patient safeguarding, which could promote negativity among employees towards the PSC at their hospital.

Furthermore, working in a private hospital has a negative moderating effect on physicians at the specialist/senior specialist level. This could perhaps be attributed to the specialist-ranked physician being allowed to move from public to private hospitals or work in the two sectors simultaneously. In this scenario, the specialist observes the protection that the worker enjoys in public hospitals that is lacking in private hospitals.

One of the two composites that declined is composite 2, “Supervisor/Manager Expectations & Actions Promoting Patient Safety”. It is curious that this composite was previously an area of strength [32]. Some might attribute the decline to the rise in safety requirements, which has led to a widening of the gap between what is expected and what can be achieved. In addition, workers have become more knowledgeable about patient safety, so expectations from hospital management have increased. Upon closer inspection, we can attribute the decline to one of the composite’s four items: “My supervisor/manager overlooks patient safety problems that happen over and over” (item 2.4), which was particularly sharp (from 82.6% to 33.8%). We have no explanation for this other than the negative wording of the item, which might have been misunderstood by respondents [69]. Although a pilot study was carried out to ensure that the items were understandable to participants, cognitive interviewing might have been a preferred methodology for improving clarity and eliciting responses [70]. However, the study tool has other negatively worded items. As other negatively worded items did not sharply decrease their positive percentages from the benchmarks [32], this justification should be considered with caution.

The other composite to decline was 10, “Staffing”. It appears that the reallocation of staff to keep pace with new openings in public hospitals has aggravated a shortage of staff, which contributed to a decline in the positive percentage of item 10.1 “We have enough staff to handle the workload”. Also, financial incentives are moving some physicians into the private sector. Moreover, public hospitals have suffered staff shortages for years, especially nurses [71, 72]. The MOH’s staffing ratios are somewhat outdated [73] and do not mirror the advances introduced into the nursing profession in particular.

Private hospitals reported positive percentages similar to the benchmark. Private-sector clinical staff are licensed by the MOH, which owns and operates the public sector. Although not written, the MOH typically holds the private sector to more rigorous standards than the public sector when issuing medical/nursing licenses. Furthermore, the MOH sometimes adopts a conservative policy regarding the number of licenses granted to the private sector. Guided by cost and profit, the management of the private sector may find this policy favourable. For those reasons, we believe that the positive percentage for item 10.1 would have been higher if policies regarding licensing in private sector had changed between assessments.

Item 10.2 (“Staff in this unit work longer hours than is best for patient care”) also contributed to the decline of the Staffing positive percentage. Most participants in this study reported working 40 to 59 h per week. This indicates that there might be a significant percentage of staff who work more than the standard 40 h [74]. Studies have indicated that extending the working shift is an important factor in errors increasing and patient safety and quality of care being jeopardised [75,76,77]. Although the study tool did not explore the length of a single work shift, it is known that an extended working-shift policy is practised in some health professions, especially in the private sector. One can assume that the increase in weekly working hours and longer working shifts are manifestations of staff shortages.

In addition to staffing, composite 12, “Non-punitive Response to Errors”, also returned a positive percentage of less than 50%. Studies have highlighted the need for effective frameworks to protect whistle-blowers from the negative consequences of reporting errors [78,79,80]. Not only did a such framework not exist in Kuwait at the time of data collection, but the practices also still portray a culture of blame. Some staff continue to use incident reporting as a punitive tool [81]. Wider society is also biased against healthcare staff, a negative stance often fuelled by media reports [82]. Staff can be hesitant to accept responsibility for errors [83], especially because being insured against medical malpractice is not mandatory [84] and error-disclosure policy is often lacking.

Finally, attention must be paid to inadequate education on patient safety in graduate programmes in Kuwait. Patient safety courses were optional and did not receive sufficient support from university leadership. The results of this study show that higher PSC positive percentages were reported by graduates from other countries. Education and training on patient safety are the cornerstones of ensuring patient safety [6, 85].

Strengths and limitations

This study has various strengths. It is the first nationwide study in Kuwait to compare PSC in public and private hospitals and to involve a representative sample from various levels and professions. To obtain precise data that are less vulnerable to the potential bias of case series and case reports, the cross-sectional design allowed several variables in the population sample to be examined at one point in time [35]. Additionally, the study made use of a widely acknowledged, validated tool that permits global benchmarking.

However, there are certain limitations. Some of these are specific to the present study, whereas others are common to studies adopting the same study design and sampling strategy. In terms of study-specific limitations, the main challenge in collecting data in the private hospital setting was restricted access to departments, regardless of the MOH's ethical approval. The data was collected by personnel from the Human Resources departments. This may have introduced greater bias in responses compared to the public sector where questionnaires were administered face-to-face and collected by one of the authors, who was independent of the hospital. In addition, we think this resulted in fewer responses to the open-ended questions in the private hospitals (n = 31) compared to public hospitals (n = 59), where participants were asked to comment on patient safety, error, or event reporting in their hospitals (Section I in Supplementary file 1). However, this part of the questionnaire is not reported or discussed in the present study. In addition, the use of paper-based questionnaires requires a significant amount of data entry and cleaning work, and also is not environmentally friendly. Furthermore, participants could ignore questions, which resulted in a small number of incomplete responses. However, these limitations can be mitigated in future studies by collecting responses electronically.

Regarding the common limitations, the goal of this cross-sectional study was to identify correlations between the variables, not to infer causal relationships. To establish causation, future studies should fulfil three requirements: empirical association, temporal priority of the independent variable and nonspuriousness [86].

Finally, the use of a convenience sampling strategy as a method for data collection where participation is voluntary might have introduced some selection bias. Nevertheless, considering the workload of clinical staff, this method is widely adopted in most HSOPSC studies. In addition, to meet the study’s aims and objectives, a stratified sampling technique was used across hospital departments, by which certain departments were always visited (such as internal medicine and pharmacy) to ensure that staff with direct patient care were selected.

Despite the reported limitations, the study findings and conclusions are reasonably generalizable. The study was conducted nationally across public and private hospitals in Kuwait using a relatively representative sample from various professions. Regardless of the use of convenience sampling, sample stratification and proportional selection of participants from hospitals was undertaken. However, we suggest conducting follow-up studies on patient safety using mixed methods and experimental designs.

Practice and research implications

The plans and interventions for improving PSC after the first assessment that perhaps contributed to the improvement of results should be examined and disseminated. At the official level, we call on the MOH to initiate a Patient Safety Collaborative, which reportedly improve safety culture through sharing the experiences of healthcare organisations [87]. This is based on the MOH’s power to enforce patient safety policies and initiatives.

We call on officials to review licensing policies in the private sector, update staffing ratios, impose favourable working conditions, create attractive benefit packages for healthcare workers, and enforce maximum limits on daily and weekly working hours and patterns of changing working shifts. We also urge the relevant bodies to swiftly establish an effective framework to build a "just culture" [1] and protect whistle-blowers [88]. Institutions need to develop a comprehensive disclosure policy [88] and support programmes for "second victims" [89]. We encourage the media and society at large to engage with healthcare leaders and workers in open dialogues to change aggressive public attitudes towards medical errors.

Regarding patient safety education, we call on those responsible for university education programmes to include patient safety within their curricula. These educational courses should be mandatory and in line with international guidelines [90].

We call on researchers to conduct qualitative follow-up studies to better understand the differences in management, leadership and organisational culture and operations between public and private hospitals to determine the reasons for the superiority of private-sector PSC. We also encourage researchers to use other methods and approaches to explore the reasons for the negative moderating effect of working in private hospitals on specialist-level physicians and workers in critical/emergency areas. Further research is required to identify the relationships between PSC and incident reporting practices and patient outcomes, and to understand how the data produced can be translated into actions that improve patient safety and reduce adverse medical outcomes.

Finally, researchers should follow AHRQ guidelines in using positive percentages [42] instead of the arithmetic means to report PSC results. We also call on researchers to adopt caution when including negatively worded statements/questions in their study tools [91].

Conclusions

This is the first national study to assess and compare PSC in public and private hospitals in Kuwait. The study hypothesis was supported, as results showed that many PSC composites had improved since 2015. That improvement could have been remarkable had staffing issues and a culture of blame been properly addressed. The private sector is ahead of the public sector in most of the PSC composites. In addition to the structural differences such as hospital size and patient load, the difference in the PSC between the two sectors could also be linked to the different guidelines governing them, an aspect that needs further exploration. Policymakers should set unified guidelines governing staffing in both sectors and devise intervention strategies to develop a culture that establishes learning from adverse events and supports patient safety incorporating a just culture and whistle-blower protection. Furthermore, Kuwait’s universities should identify patient safety as a priority topic to be added to teaching curricula.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to MOH restrictions but are available from the corresponding author upon reasonable request.

Abbreviations

B:

Unstandardised regression coefficient

Beta:

Standardised regression coefficient

IQR:

Inter-quartile range

MOH:

Ministry of Health

n:

Number

PSC:

Patient safety culture

SE:

Standard error

STROBE:

Strengthening the Reporting of Observational studies in Epidemiology

t:

Student t-statistics

VIF:

Variance inflation factor

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Acknowledgements

The authors would like to thank all the respondents who took part in this study. They also gratefully acknowledge the MOH, Kuwait for the support and collaboration in conducting this survey.

Funding

The authors declare that they have not received any funding.

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Authors and Affiliations

  1. College of Pharmacy, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait City, Kuwait

    Fatemah M. Alsaleh

  2. Ministry of Health, Kuwait City, Kuwait

    Shaikha Albraikan, Hadeel Alzoubi & Eman A. Abahussain

  3. Quality and Accreditation Directorate, Kuwait City, Kuwait

    Hossam Elamir

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Contributions

F.M.A. designed the study and contributed to data analysis, manuscript writing, and revision; E.A.A. contributed to the study design and manuscript revision; Sh.A. and H.A. contributed to data collection and entry under the supervision of F.M.A. and E.A.A.; H.E. cleaned, validated and analysed data, and contributed to manuscript writing and revision; All authors contributed to the manuscript revision and approved the submitted version.

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Correspondence to Fatemah M. Alsaleh.

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Ethics approval and consent to participate

The study adhered to the ethical principles for medical research involving human subjects as stated in the World Medical Association's Declaration of Helsinki. Ethical approval was granted by the Standing Committee for Coordination of Health and Medical Research, MOH and the Health Science Centre (HSC) Ethics Committee for Student Research, Kuwait University (Ref. No. 324, December 17, 2017). In the absence of standalone ethics committees in hospitals, the aforementioned committee is the sole ethics committee that approves and oversees any student research conducted in healthcare institutions. We confirm that all methods were performed in accordance with the relevant guidelines and regulations of the Standing Committee for Coordination of Health and Medical Research in Kuwait. Participating hospitals provided permission for the study to take place and participant identities were kept confidential and coded to ensure anonymity. Participant identifiers were removed prior to data analysis and all reported data were kept anonymous. All participants provided voluntary informed consent after receiving an explanation of the study’s value, benefits and risks, and after their questions were satisfactorily answered. Verbalisation of informed consent was approved by the Standing Committee for Coordination of Health and Medical Research, MOH and the Health Science Centre (HSC) Ethics Committee for Student Research, Kuwait University.

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Alsaleh, F.M., Albraikan, S., Alzoubi, H. et al. Assessment of a patient safety culture: a nationwide cross-sectional study comparing public and private hospitals in Kuwait. BMC Health Serv Res 25, 579 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12913-025-12668-y

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12913-025-12668-y

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BMC Health Services Research

ISSN: 1472-6963

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