Patient Safety Culture: Current Status and Associated Fators Among Healthcare Workers at Kien An Hospital – Hai Phong, Vietnam - A Cross-Sectional Study

1. Introduction

Patient safety is a crucial determinant of high-quality healthcare. Preventable medical incidents pose a sighnicant threat to both patieng well-being and the integrity of the healthcare system. According to the Vietnamese Ministry of Health, from 2019 to August 2022, 540 out of 1,539 hospitals (35%) had implemented medical incident reporting systems. These systmes documented 96,815 incidents nationwide, a significant proportion of which were potentially preventable [1]. As the healthcare sector rigorously strives for quality improvement and error reduction, the imperative of fostering a robust Patient Safey Culture (PSC) has become increasingly recognized and prioritized globally.

Patient safety within healthcare organizations garnered considerable attention following the seminal 1999 Institute of Medicine’s report, “To Err is Human: Building a Safer Health System” [2]. Nieva and Sorra considered PSC as the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the proficiency of, an organization’s health and safety management. A truly mature safety culture is characterized by organizational openness and fairness toward staff following adverse events, a demonstrate willingness to learn from mistakes, and a clear focus on identifying and correcting system failures rather than assigning individual blame [3].

Patieng safety culture fundamentally refers to how safety is managed and perceived in the workplace reflecting the shared attitudes, beliefs, perceptions, and values of employees regarding safety [4]. The World Health Organization (WHO) defines patient safety as the reduction of unnecessary risk and harm associated with healthcare to an acceptable minimum. PSC is a complex framework encompassing multiple dimensions that collectively influence a wide range of discretionary behaviors related to patient safety [3]. According to Agency for Healthcare Reserch and Quality (AHRQ) [5], PSC involves understanding the values, beliefs, and norms about what is important within an organization, as well as recognizing which attitudes and behaviors related to patient safety are supported, rewarded, and expected. Measuring patient safety culture is widely regarded as the crucial first step toward enhancing the quality of healthcare delivery. Therefore, healthcare providers are increasingly urged to make PSC a top priority in their organizational practices [6].

The study utilized the Hospital survey on Patient Safety Culture (HSOPSC), a validated instrument initially developed by AHRQ in the United States and widely applied across numerouscountries [5]. This comprehensive instrument is designed to measure 12 dimensions of PSC categorized across different organizational levels, including 7 dimensions at the unit level focus on teamwork, communication, and management support within the clinic unit; 3 dimensions at the hospital level addressing hospital-wide teamwork, staffing, and organizational learning; and 2 outcome dimensions capturing the overall perception of safety and the frequency of reported events [7]. The HSOPSC tool has been previously translated, subjected to reliability validation, and successfully utilized in assessing PSC across various hospitals settings throughout Vietnam [8].

This study specifically focuses on evaluating the status of PSC in a Vietnamese hospital setting. The main objectives of this research are (1) to assess the current status of PSC among healthcare workers at Kien An Hospital, Hai Phong, Vietnam; (2) to analyze demographic and professional factors independently associated with PSC scores. The findings are expected to furnish healthcare organizations and policy makers in Vietnam with evidence-based insights into the current state of PSC, thereby facilliating targeted improvement in quality and safety within Vietnamese hospitals.

2. Materials and Methods

2.1. Study Design and Setting

This was a cross-sectional study conducted at Kien An Hospital, Hai Phong, Vietnam.

2.2. Study Population and Sampling

The study population included all eligible healthcare professionals working across clinical and non-clinical departments of the hospital, specifically physicians, nurses, midwives, technicians, and pharmacists. The minimum required sample size was determined based on the number of healthcare workers (HCPs) following the AHRQ’s recommendation, which suggests a minimum of 250 respondents for hospitals with 501–699 employees [7].

Inclusion criteria: Employed full-time; At least 6 months of experience, and voluntarily participation.

Exclusion criteria: Healthcare workers who declined to participate in the study, and those who were attending training courses, on business trips, or on maternity leave during the data collection period.

Sampling procedure and participants: Initially, simple random sampling was planned, targeting 250 participants selected from a complete list of eligible healthcare workers using Microsoft Excel. However, to maximize the statistical power and coverage the target population, the research team subsequently invited all eligible healthcare workers to participate in the study. Ultimately 324 healthcare professionals who met all inclusion criteria successfully completed the survey.

To ensure the privacy and minimize self-report bias (STROBE 8), the survey was conducted under strict confidentiality protocols and was completely anonymously. In addition, to maintain confidentiality, participants were instructed to place their completed questionnaires in sealed envelopes. The study coordinators were responsible for collecting these seal envelopes andtransfering them directly to the research team for data entry and analysis.

2.3. Measurement Instrument and Internal Consistency

The PSC was measured using the HSOPS–VN 2015, ain instrument officially recognized by AHRQ for use in Vietnam [9].

The HSOPS-VN instrument consists of 42 items designed to measure 12 dimensions of PSC, utilizing a 5-point Likert scale based on either agreement (from “Strong disagree” to “Strongly agree”) or frequency (from “Never” to Always).

Internal Consistency: According to Fleming [10], the reliability of the AHRQ data, as measured by Cronbach’s α, ranges from 0.63 to 0.84. In the present study, the Cronbach’s α values for the 12 dimensions ranged from 0.62 to 0.82. While this demonstrates acceptable internal consistency, the slightly lower values than compared to the AHRQ reference datat suggest that a marginally lower internal consistency of responses within this specific cohort.

Scoring Method and Dimensions: The primary outcome of each dimension was reported as the percentage of positive response (PPR).. Responses were scored as follows:

Positive Responses (Scores 4–5):

For positively worded items, “Strongly agree/Always” and “Agree/Often” were scored as positive.

For negatively worded items (reverse-scored), “Strongly disagree/Never” and “Disagree/Rarely” were scored as positive.

Non-Positive Responses (Scores 1–3):

For positively worded items, “Neutral/Sometimes,” “Strongly disagree/Never,” and “Disagree/Rarely” were considered non-positive.

For negatively worded items (reverse-scored), “Neutral/Sometimes,” “Strongly agree/Always,” and “Agree/Often” were considered non-positive.

The survey dimensions were structured as follows:

(A) Seven Unit-Level Dimensions of PSC: Supervisor/Manager Expectations and Actions Promoting Patient Safety (4 items); Organizational Learning – Continuous Improvement (3 items); Teamwork Within Units (4 items); Communication Openness (3 items); Feedback and Communication About Error (3 items); Non-Punitive Response to Error (3 items); Staffing (4 items)

(B) Three Hospital-Level Dimensions of PSC: Hospital Management Support for Patient Safety (3 items); Teamwork Across Hospital Units (4 items); Hospital Handoffs and Transitions (4 items)

(C) Two Outcome Dimensions: Overall Perceptions of Patient Safety (4 items); Frequency of Event Reporting (3 items)

2.4. Data Analysis

Data analysis was performed using SPSS version 20.0 (IBM Corp., Armonk, NY, USA). Initially, descriptive statistics were used to summarize participant demographic characteristics and calculate the PPR for each HSOPSC dimension. For comparative analysis, independent samples t-tests were utilized to compare the study’s PSC score with the AHRQ benchmark data, and to examine differences in the mean positive response rates between key professional groups (physicians vs. nurses). Finally, multivariate logistic regression analysis was employed to identify demographic and professional factors independently associated with the overall positive perception of PSC (using dichotomous dependent variable derived from the overall average PRR).

Ethical Considerations:

This study was conducted after receiving approval from the Biomedical Research Ethics Committee of Kien An Hospital, Hai Phong, Vietnam, on April 25, 2025, under Decision No. 364/QD-BVKA.

3. Results

A total of 324 healthcare workers successfully completed the survey, with a distinct female predominance, accounting for 78.1% of the cohort, while males made up 21.9%. The study population was relatively young, with the largest proportion (53.4%) falling in to the 30 to <40 years age group. In the terms of professional background, the majority of respondents were nurses (58.6%), and an overwhelming 87.0% worked in clinical departments. Reflecting substantial experience, 62.3% of the healthcare workers reported havingbeen employed for more than 10 years. Regarding workload and patient engagement, most respondents (81.5%) worked ≤ 40 hours per week, and high percentage (90.1%) confirmed having direct contact with patients. Extended demographic and professional characteristics are detailed in Table 1.

The analysis of positive responses among healthcare workers across the 12 dimensions of PSC,measured by the HSOPSC-VN2015 instrument, revealed a wide range of perception. The highest positive response was observed in “Teamwork within units” at 98.5%, indicating a strong consensus on internal team collaboration. Conversely, the dimension with the lowest positive response was “Non-punitive response to errors” at 55.6%, suggesting a perceived or punitive environment regarding to error reporting Detailed positive response percentages for all the 12 dimensions of PSC are presented in Table 2.

The comparison of mean PSC perception between physicians and nurses was conducted using the Independent-Samples T-Test. The results (presented in Table 3) indicated that physicians’ mean PSC scores were significantly higher than those of nurses in the dimensions of “Feedback and communication about error” and “Overall perceptions of patient safety” (p < 0.01). No statistically significant differences were found between the two professional groups across the remaining ten dimensions.

The multivariate logistic regression analysis (results presented in Table 4) was conducted to identify factors associated with a favorable overall perception of PSC (positive response). The results indicated that direct patient contact was the only demographic or professional characteristic significantly associated with PSC scores. Specifically, healthcare workers who had direct contact with patients demonstrated a 0.12-fold lower likelihood of providing positive responses regarding PSC compared to those without patient contact (OR=0.12, p <0.01). This strong negative association suggest that direct care providers perceive the safety culture less favorably.

No statistically significant associations were found between any other analyzed factors (e.g., age, gender, years of experience, or working hours) and the overall PSC of healthcare workers (p > 0.05).

4. Discussion

The overall average positive response rate across the 12 HSOPSC dimensions was 81.5%, indicating a generally high level of positive Patient Safety Culture (PSC) perception among healthcare workers at Kien An Hospital. The analysis revealed marked variation across the dimensions: the highest positive response rate was observed in “Teamwork within units” at 98.5%, signaling a significant strength in unit-level collaboration. Conversely, the critical dimension of “Non-punitive response to error” recorded the lowest positive rate at 55.6%, suggesting a potential barrier to error reporting and organizational learning. Comparative statistical analysis, using logistic regression to assess professional group differences, identified significant disparities in two dimensions between physicians and nurses. Physicians demonstrated a significantly higher likelihood of reporting a positive perception in “Feedback and communication about error” (OR = 1.92; 95% CI: 1.66–2.52; p < 0.05) compared to nurses. Furthermore, in “Overall perceptions of patient safety”, physicians’ scores were also significantly differentiated, with an associated Odds Ratio of 0.12 (95% CI: 0.16–0.89; p < 0.01) compared to the reference group, although the interpretation requires careful consideration of the reference category used in the model.

4.1. High-Performing PSC Dimensions

The dimension “Teamwork within units” received an exceptionally high PRR of 98.5%. This rate is notably higher than those reported in previous studies conducted in the United States (72.0%) [11], El-Jardali’s study (78.5%) [12], and Taiwan (94.0%) [13]. This result aligns with a common finding across both international and Vietnamese research, which consistently identifies effective internal teamwork as a fundamental strength of PSC. This strong internal consensus suggests that, regardless of the specific healthcare context, personnel within the same department or unit highly value collaboration. This reflects the critical dependence of PSC outcomes on effective collaboration and communication among team members at the unit level.

The PRR for “Supervisor/manager expectations and actions promoting patient safety” was also very high at 95.2%. This score is significant greater than the findings from similar studies such as the United States (75.0%) [11], Taiwan (84.0%) [13], and El-Jardali’s study (79.6%) [12]. These consistently strong findings across diverse cultural settings suggest that there are no substantial cross-cultural differences in the recognized importance of leadership commitment regarding PSC. Both globally and in Vietnamese context, leaders’ supportive attitudes and clear expectation toward their staff are essential not only for guiding the creation of a safe working environment but also for serving as an vital source of motivation and encouragement, thereby fostering both individual accountability and organizational improvement.

“Organizational learning – continuous improvement” received a PRR of 94.7%. This rate is higher than that reported by Xiyao Zhong et al. (92.9%) [14] and significantly higher than the 2023 study conducted in Palestinian hospitals (55.8%) [15]. These robust results indicate a proactive environment where departments and units within the hospital are likely to be actively implementing patient safety assurance activities. Furthermore, this high score reflects a strong culture of systematic learning, where staff are encouraged to continuously lean from errors and evaluate the effectiveness of corrective actions, thereby reinforcing ongoing improvement in patient safety practices.

The dimension “Feedback and communication about error” received a PRR of 89.0%, which is notably higher than the 2018 AHRQ database rate of 69.0% [11]. This strong finding reflects a high level of comfort and transparency among healthcare workers at Kien An Hospital – Hai Phong, Vietnam when sharing and discussing incident-related information with their unit leaders. Crucially, the data suggest that staff are regularly informed and updated by unit leaders about reported events, and team discussions are actively held to develop corrective and preventive actions aimed at avoiding recurrence. The robust exchange of information within departments demonstrates a well-functioning feedback loop, which is a key component a sustainable PSC and should be further encouraged and instituonalized..

In contrast to the strong feedback mechanism, “Communication Openness” received a significantly lower PRR of 60.1%. This result is particularly noteworthy as numerous studies on PSC, both globally and in Vietnam, have consistently identified “Communication Openness” as one of the weakest dimensions across most hospital settings. For instance, Hefner (2017) reported a PRR of 49.0% [16], while Xiyao Zhong et al. at Peking University Hospital, China, found a rate of 52.2% [14].

The lack of openness in communication, as Xiyao Zhong noted, poses major challenges to patient safety during healthcare delivery [14]. Several factors may contribute to this pervasive weakness, especially within Asian context. I-Chi Chen [13] suggested that a general fear of making mistakes and a strong cultural desire to maintain harmony often lead individuals to avoid open discussions about errors, resulting in less objective evaluations. Additionally, cultural characteristics prevalent in many Asian settings, where employees tend to adhere strictly to hierarchical norms, may contribute to this challenge. In such environments, reporting an error that occurs within a department may be perceived as “whistleblowing”, which consequently discourages open communication about mistakes and safety risks.

The PRR for the “Staffing” dimension was 73.1%, which is notably higher than the results reported in studies conducted at Peking University Hospital, China (53.7%) [14] and at Palestine Hospital (2023) (34.8%) [15]. Since human resources are a crucial component contributing significantly to the healthcare system’s capacity, this result suggest that current staffing levels at Kien An hospital are perceived more favorably than in comparative international settings.. However, considering that work overload due to insufficient staffing can lead to fatigue, stress and compromised patient care quality, any future decline in this dimension should be treated as a critical early warning indicator of potential patient safety risks, necessitating the implementation of proactive and long-term workforce planning strategies.

The assessment of leadership commitment and organizational coordination also revealed high positive score. “Hospital Management Support for Patient Safety” achieved 89.5%, surpassing rates reported in China by Xiyao Zhong et al. (83.7%) [14] and in the U.S by Sorra Joann et al.. (72.0%) [17]. This highlights that sustained leadership commitment is vital role in fostering a robust PSC. The high response rate suggests that leaders at both departmental and hospital levels actively provide professional guidance and motivational support, which successfully promotes a sense of security and confidence among staff.

Similarly, “Teamwork Across Hospital Units” received a PRR of 91.0%, significantly outperforming the AHRQ 2018 benchmark (62.0%) [11], and the Palestine study (63.1%) [15], while being slightly higher than the Chinese study (89.7%) [14]. This finding confirms that effective inter-unit collaboration is a recognized organizational strength. Given that patient safety in complex healthcare systems relies heavily on seamless collaboration and coordination among multidisciplinary teams, this result reflects a positive organizational climate that actively fosters mutual support, communication, and shared responsibility across different departments.

In sharp contrast to the high-scoring organizational dimensions, “Non-punitive Response to Error” reccorded the lowest PRR of 55.6%. Although this score numerically higher than several international benchmarks (e.g AHRQ (47.0%) [11], Xiyao Zhong et al. (51.1%) [14], and a U.S. study (28.0%) [16]. It remains the most critical area for targeted intervention, signifying a substantial perception gap regarding fairness and accountability.

The qualitative aspect of this finding suggests a duality: staff members generally do not feel personally blamed for errors at the departmental level, which indicates a positive shift toward a systems-based approach focused on understanding what went wrong and why. However, this positive philosophy is undermined by the lingering staff concern that their errors might be formally recorded in personnel files and subsequently used in performance evaluations. This fear severely compromises the system’s integrity, creating a persistent disincentive for open, honest, and comprehensive incident reporting, which is essential for systematic and continuous safety improvement.

5. Conclusions

In conclusion, the assessment of Patient Safety Culture (PSC) at Kien An Hospital revealed a relatively high level of overall positive perception among healthcare workers, driven by exceptionally strong scores in dimensions related to interpersonal collaboration, notably “Teamwork within units”. However, a critical gap was identified in the organizational approach to incidents; the dimension “Non-punitive response to error” recorded the lowest positive rate. Furthermore, multivariate analysis highlighted that direct patient contact was significantly associated with a less favorable PSC perception. Based on these findings, interventions should prioritize improving the non-punitive response to error system to explicitly foster a culture of reporting, trust, and continuous learning, ensuring that safety efforts are aligned with the perspectives of direct patient care personnel.

Recommendation

1. Enhance openness in communication about errors to reduce individual blame when mistakes occur.

2. The Quality Management Department should continue to develop roadmaps and training plans for healthcare workers to learn patient safety procedures and understand PSC.

3. Department and unit leaders should encourage healthcare workers to voluntarily report adverse events and near misses.

4. Healthcare workers should actively participate in all patient safety training sessions to strengthen awareness and understanding of PSC.