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Assessing patient safety culture in 18 Tunisian adult intensive care units and
determination of its associated factors: A multi-center study

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DOI: 10.1016/j.jcrc.2020.01.001

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 Journal of Critical Care 56 (2020) 208–214

Contents lists available at ScienceDirect

Journal of Critical Care

journal homepage: www.journals.elsevier.com/journal-of-critical-care

Assessing patient safety culture in 18 Tunisian adult intensive care units

and determination of its associated factors: A multi-center study
Mohamed Ayoub Tlili, PhD (c) a,b,c,⁎, Wiem Aouicha, PhD (c) a,b,c, Mohamed Ben Rejeb, MD a,d,
Jihene Sahli, MD a,c,e, Mohamed Ben Dhiab, Professor a, Souad Chelbi, Professor a,b, Ali Mtiraoui, Professor a,c,e,
Houyem Said Laatiri, Professor a,d, Thouraya Ajmi, Professor a,c,e, Chekib Zedini, MD a,c,e, Manel Mallouli, MD a,c,e
a
University of Sousse, Faculty of Medicine of Sousse, Tunisia
b
University of Sousse, Higher School of Health Sciences and Techniques of Sousse, Tunisia
c
Laboratory of research LR12ES03, Tunisia
d
University Hospital of Sahloul, Department of Prevention and Care Safety, Tunisia
e
Department of Community and Family Health, Faculty of Medicine of Sousse, Tunisia

a r t i c l e i n f o a b s t r a c t

Available online xxxx Purpose: This study aimed to assess patient safety culture (PSC) in intensive care units (ICUs) and to determine
the factors affecting it.
Materials and methods: This is a cross-sectional study, conducted from October to November 2017 among profes-
Keywords: sionals practicing in the ICUs of the Tunisian center. After obtaining institutional ethics committee's approval and
Patient safety culture administrative authorizations, an anonymous paper-based questionnaire was distributed to the participants after
Intensive care units obtaining their consent to take part in the study. The measuring instrument used is the French validated version
Critical care of the “Hospital Survey on Patient Safety Culture” questionnaire.
Patient safety Results: A total of 402 professionals, from 18 ICUs and 10 hospitals, participated in the study with a participation
Healthcare quality rate of 82.37%. All dimensions were to be improved. The most developed dimension was teamwork within the
unit (47.87%) and the least developed dimension was the non-punitive response to error (18.6%). Seven dimen-
sions were significantly more developed in private institutions than in public ones. Results also show that when
workload is reduced, the PSC was significantly increased.
Conclusion: This study has shown that the PSC in ICUs needs improvement and provided a baseline results to get a
clearer vision of the aspects of security that require special attention.
© 2020 Elsevier Inc. All rights reserved.

1. Introduction Actually, the complexity of the care in these environments, their

Ensuring patient safety and healthcare quality has become a priority
for healthcare systems and providers worldwide [1,2]. Especially in In-
tensive Care Units (ICUs), known as a high risk environments, adverse
events (AEs) and medical errors remain a major concern, not only be-
cause of their high frequency and cost but also because of their dreadful
consequences [3-5].
Moreover, patients admitted to ICUs are more likely to experience
AEs than other patients [3-5]; Roque et al. [5] report an incidence of
AEs which varies between 0.87% and 34.7%. As well, Molina FJ et al.
found that the incidence of AEs in ICUs was of 52.1% with 48.9% of
these being preventable [6].
⁎ Corresponding author.
E-mail address: medtlili@hotmail.fr (M.A. Tlili).
high technicality, and the medical conditions of the patients admitted
to ICUs increase the probability of occurrence of errors and complica-
tions [7,8]. The severe conditions of the patients and the complexity of
the care provided are not enough to explain this phenomenon; older
age, comorbidities, low levels of consciousness, polypharmacy, inappro-
priate drug administration, invasive procedures and prolonged hospital
stays are risk factors associated with AEs in intensive care settings [5,9].
In the Tunisian context, Letaief et al.'s study [10] that aimed to deter-
mine the incidence, nature and consequences of AEs in a university hos-
pital, showed that 41.1% patients admitted to ICUs suffered from at least
one AE. For the avoidance of AEs, they confirmed that 60% were
preventable and that this preventability was significantly different be-
tween specialties (45% in medical services, 50% in surgical departments
and 70% in ICUs).
To counter the problem, the literature agrees on the importance of
the development of a patient safety culture (PSC) as a strategic focus

https://doi.org/10.1016/j.jcrc.2020.01.001
0883-9441/© 2020 Elsevier Inc. All rights reserved.
 M.A. Tlili et al. / Journal of Critical Care 56 (2020) 208–214
to improve patient safety and healthcare quality and to prevent the
onset of AEs [11,12].
Moreover, several studies have shown the relationship between a
developed PSC and the improvement of the patient safety state such
as the decrease in the length of stay, in the patients' falls and the de-
crease in hospital complications including healthcare-associated infec-
tions [13]. In ICUs, researchers in the United States have confirmed the
impact of a developed PSC on reducing length of stay and mortality [14].
Furthermore, it is admitted that the improvement of the PSC begins
with its assessment and the determination of the level of development
of each of its dimensions [15]. In fact, the assessment of PSC and its di-
mensions enables health institutions, the stakeholders and the profes-
sionals to identify their strengths and weaknesses in terms of safety,
and thus allowing them to have a clearer vision of the aspects of patient
safety and healthcare quality that require special attention [16].
In this context, this study aimed to assess PSC among healthcare pro-
fessionals working in Tunisian ICUs and to determine its associated
factors.
2. Materials and methods
2.1. Study design, settings and participants
A cross sectional multi-center study, was conducted from October to
November 2017. All the 17 healthcare institutions (public and private)
which include ICUs in the Center of Tunisia (Sousse, Kairouan, Mahdia,
Monastir and Kasserine) were contacted to participate in the survey.
We included in this survey all professionals working in ICUs (n =
488). Professionals who aren't involved in healthcare practices and
those with less than one-month experience were excluded.
2.2. Study instrument
The current study used the French validated version of Hospital Sur-
vey of Patient Safety Culture (HSOPSC) questionnaire [17]. It is the most
broadly used instrument to evaluate PSC, due to its favorable psycho-
metric properties; it presents attributes as reliability and validity,
which allow for accurately and faithfully measuring the studied phe-
nomenon [17].
HSOPSC consists of 45 items grouped into 10 dimensions. These di-
mensions were about: Overall perception of patient safety (D1), Fre-
quency of events reported (D2), Supervisor/manager expectations and
actions promoting patient safety (D3), Organizational Learning-
Continuous Improvement (D4), Teamwork within units (D5), Commu-
nication openness (D6), Non-punitive response to error (D7), Staffing
(D8), Management support for patient safety (D9), Teamwork across
units (D10). The survey also explored professionnals' perception of pa-
tient 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 5 points was used to determine participants' PSC with agree-
ment or a frequency scale [17,18].
The different socio-demographic and professional variables with
which an association with the 10 dimensions was sought are: age, sex,
work experience, seniority in the service, nature of the institution (pub-
lic / private), specialty (medical, surgical or general ICU), participation
in risk management committees, training on patient safety, function
(medical or paramedical professionals), certification of the institution,
workload and the unit size (number of beds).
2.3. Definitions
Dimensions that obtain a score of 50% or below are considered as “to
be improved” and those with a score of 75% or superior are considered
as “developed” [18]. The nature of the institution refers to its private
or public character. ICU specialty can be medical, surgical or general
209
ICU. Medical staff refers to physicians and paramedical staff refers to
nurses, healthcare technicians and assistant caregivers.
The unit size is explored according to the number of beds; a unit is
considered small if the number of beds is b10 beds and is considered
large if the number of beds is N10. As for workload, it is calculated
based on a formula mentioned in an earlier research and refers to the
ratio staff per patient [19].
2.4. Data collection and ethical consideration
After obtaining institutional ethics committee's approval and admin-
istrative authorizations from different hospitals and units' head chiefs,
an anonymous self-reported paper-based questionnaire was distributed
to the participants after obtaining their consent to take part in the study.
The study purposes, outcomes and instructions were explained to the
participants.
2.5. Data analysis
The data analysis was conducted using SPSS version 20 and Epi info
6.04d for windows, with descriptive analysis displaying the frequencies,
percentages, means and standard deviations. Items were worded in
both positive and negative directions. For items with a positive formula-
tion, answers “Strongly Agree/Agree” or “Most of the time/Always”
were considered positive. For items with a negative formulation, the an-
swers “Strongly Disagree/Disagree” or “Never/Rarely” responses were
considered positive for PSC. The evaluation of each dimension is esti-
mated based on the percentage of positive responses.
Differences in the scores of PSC domains between the different sub-
groups were tested by chi-square test. The level of significance was set
at 0.05.
3. Results
3.1. Characteristics of the participants
In total, 402 professionals provided survey feedback with a response
rate of 82.37%. The mean age of respondents was 35.92 ± 9.097 years.
The minimum age was 22 and the maximum was 60 years. Participants
were distributed over 10 hospitals and 18 ICUs. Most of them (61.9%,
n = 249) represented paramedical staff (nurses, healthcare technicians
and assistant caregivers) and 38.1% were physicians. Participants work-
ing in public hospitals represented 78.4% (n = 316) and 60.7% (n =
244) had b6 years' work experience (Table 1).
3.2. Perception of patient safety quality and the frequency of reported AEs
Workers' perception of patient safety quality in the ICUs was ranked
as acceptable in 46.8% of cases. According to 36.6% of professionals, the
level of safety quality was qualified between “poor” and “failing”. Re-
garding reported AEs, 91.5% of the participants declared that they did
not report any event in the last 12 months (Table 2).
3.3. Scores of PSC domains
All PSC dimensions had a score below 50% and so, considered as “to
be improved”. The score of the dimension ‘overall perception of safety’
was 32.3%. The average positive response rate was the highest for ‘team-
work within units’ (47.9%). The dimension with the lowest score was
‘non-punitive response to error’ (18.6%). Two other dimensions had
also a low score which are “communication openness” (24%) and “fre-
quency of event reporting” (19.2%) with reporting being voluntary
and anonymous. Results of all domains and items are shown in Table 3.
210 M.A. Tlili et al. / Journal of Critical Care 56 (2020) 208–214

Table 1
Characteristics of participants. Table 3
Scores and items of the 10 dimensions of patient safety culture.
Characteristics Frequency (n) Percentage (%)
Scores of PSC domains Average
Total 402 100 positive
Gender response (%)
Males 180 44.8
Females 222 55.2 D1: Overall perceptions of safety 32.3
Age Patient safety is never sacrificed to get more work done 42.6
21–40 271 67.4 Our procedures and systems are good at preventing errors from 32.7
41–60 131 32.6 happening
Professional grade It is just by chance that more serious mistakes do not happen 34.6
Physician 153 38.1 around here
Nurse 139 34.6 We have patient safety problems in this facility 19.5
Healthcare technician 75 18.7 D2: Frequency of events reported 19.2
Assistant caregiver 35 8.7 When a mistake is made, but is caught and corrected before 20.4
Work experience in the ICU affecting the patient, it is reported...
b 6 years 231 60.6 When a mistake is made, but has no potential to harm the patient, it 14.2
≥ 6 year 158 39.4 is reported…
ICU Specialty When a mistake is made that could harm the patient, but does not, 22.9
Surgical ICU 142 35.3 it is reported…
Medical ICU 133 33.1 D3: Supervisor/Manager expectations and actions promoting 37.6
General ICU 127 31.6 patient safety
Participation into risk management committees Manager says a good word when he/she sees a job done according 39.6
Yes 86 21.4 to established
No 316 78.6 patient safety procedures
Status of the hospital Manager seriously considers staff suggestions for improving patient 38.8
Public 316 78.4 safety
Private 86 21.3 Whenever pressure builds up, my manager wants us to work faster, 30.3
Certification of the hospital even if it means taking shortcuts
Yes 25 6.2 My manager overlooks patient safety problems that happen over 41.5
No 377 93.8 and over
Training in patient safety D4: Organizational learning and continuous improvement 36.9
Yes 121 30.1 We are actively doing things to improve patient safety 47.6
No 281 69.9 Mistakes have led to positive changes here 44.5
After we make changes to improve patient safety, we evaluate their 33.9
effectiveness
We are given feedback about changes put into place based on event 29.6
3.4. Factors associated with PSC in ICUs reports
We are informed about errors that happen in the facility 33.9
In this facility, we discuss ways to prevent errors from happening 31.9
Seven dimensions were significantly more developed in private hos-
again
pitals than in public ones. However, the “frequency events reporting” D5: Teamwork within units 47.9
dimension was significantly higher in the public sector than in the pri- People support one another in this facility 48.3
vate one (p = .04). Moreover, PSC was significantly more developed When a lot of work needs to be done quickly, we work together as a 49.1
in the certified hospitals for the domains of overall perception of safety team to get the work done
In facility, people treat each other with respect 46.8
(p = .1 × 10−5), staffing (p = .042) and management support for pa- When one area in this unit gets really busy, others help out 47.3
tient safety (p = .044). We also found that the dimensions frequency D6: Communication openness 24
events reporting, communication openness, and teamwork across Staff will freely speak up if they see something that may negatively 32
units were significantly increased among professionals participating in affect patient care
Staff feel free to question the decisions or actions of those with 13.3
risk management structures or committees (p = .043, p = .049, p =
more authority
.036, respectively). Two dimensions were significantly more developed Staff are afraid to ask questions when something does not seem 26.8
among professionals who had received training on patient safety: team- right
work within the unit (p = .035) and staffing (p = .049). Results of the D7: Non-punitive response to error 18.6
association between PSC domains and demographic and professional Staff feel like their mistakes are held against them 20.6
When an event is reported, it feels like the person is being written 13.4
factors are shown in Table 4. up, not the problem
Staff worry that mistakes they make are kept in their personnel file 21.8
D8: Staffing 31
Table 2 We have enough staff to handle the workload 32.8
Professionals' perception of patient safety quality and number of reported adverse events Staff in this facility work longer hours than is best for patient care 29.6
during the last 12 months. We work in ‘crisis mode’ trying to do too much, too quickly 30.8
D9: Management support for patient safety 33.8
Professionals' perception of patient safety quality n % Management provides a work climate that promotes patient safety 39.2
Excellent 28 7 The actions of management show that patient safety is a top 40.4
Very Good 39 9.6 priority
Acceptable 188 46.8 Management seems interested in patient safety only after an 24.4
Poor 102 25.4 adverse event happens
Failing 45 11.2 Units work well together to provide the best care for patients 31.4
Total 402 100 D10: Teamwork across units 32
There is good cooperation among units that need to work together 37.2
Number of events reported n % Units do not coordinate well with each other 38.4
No event reported 368 91.5 It is often unpleasant to work with staff from other units 21.7
1 to 2 20 5 Things ‘fall between the cracks’ when transferring patients from 34.8
3 to 5 10 2.5 one unit to another
6 to 20 4 1 Important patient care information is often lost during shift 27.8
N20 0 0 changes
Total 402 100 Problems often occur in the exchange of information across units 32
 M.A. Tlili et al. / Journal of Critical Care 56 (2020) 208–214 211

Table 4
Factors associated with PSC.

Factors Dimensions Subgroups p value

Males (n = 155) Females (n = 213)

SEX D1: Overall perceptions of safety 30.51% 35.12% 0.32

D2: Frequency of events reported 21.11% 17.57% 0.34
D3: Supervisor/Manager expectations and actions promoting patient safety 34.23% 40.5% 0.22
D4: Organizational learning and continuous improvement 34.41% 37.2% 0.56
D5: Teamwork within units 45.02% 50.18% 0.33
D6: Communication openness 26.28% 23.4% 0.51
D7: Non-punitive response to error 20.19% 17.6% 0.52
D8: Staffing 29.43% 32.66% 0.51
D9: Management support for patient safety 29.67% 35.79% 0.22
D10: Teamwork across units 30.36% 33.13% 0.54

AGE b40 ans (n = 271) ≥40 ans (n = 131)

D1: Overall perceptions of safety 36.17% 28.99% 0.15
D2: Frequency of events reported 24.23% 17.22% 0.12
D3: Supervisor/Manager expectations and actions promoting patient safety 37.95% 37.02% 0.79
D4: Organizational learning and continuous improvement 39.9% 32.44% 0.13
D5: Teamwork within units 51.13% 45.11% 0.23
D6: Communication openness 28.1% 21.93% 0.2
D7: Non-punitive response to error 18.93% 18.15% 0.9
D8: Staffing 31.18% 30.29% 0.92
D9: Management support for patient safety 34.12% 33.52% 0.94
D10: Teamwork across units 32.5% 30.31% 0.69

Medical (n = 153) Paramedical (n = 249)

PROFESSIONAL TITLE D1: Overall perceptions of safety 28.26% 34.13% 0.207
D2: Frequency of events reported 25.87% 17.23% 0.032
D3: Supervisor/Manager expectations and actions promoting patient safety 38.06% 37.37% 0.9
D4: Organizational learning and continuous improvement 33.59% 38.68% 0.29
D5: Teamwork within units 43.95% 50.09% 0.21
D6: Communication openness 30.05% 17.85% 0.0037
D7: Non-punitive response to error 16.55% 19.04% 0.51
D8: Staffing 30.27% 31.55% 0.72
D9: Management support for patient safety 27.53% 37% 0.06
D10: Teamwork across units 30.38% 32.6% 0.6

b6 years (n = 244) ≥ 6 years (n = 158)

WORK EXPERIENCE IN THE ICU D1: Overall perceptions of safety 32.73% 30.79% 0.7
D2: Frequency of events reported 19.26% 18.98% 0.94
D3: Supervisor/Manager expectations and actions promoting patient safety 39.44% 34.33% 0.29
D4: Organizational learning and continuous improvement 33.97% 34.59% 0.5
D5: Teamwork within units 41.48% 52.77% 0.028
D6: Communication openness 18.99% 28.14% 0.034
D7: Non-punitive response to error 18.16% 18.56% 0.98
D8: Staffing 30.59% 31.43% 0.84
D9: Management support for patient safety 35.24% 30.69% 0.31
D10: Teamwork across units 32.71% 30.48% 0.8

Public (n = 316) Private (n = 86)

STATUS OF THE HOSPITAL D1: Overall perceptions of safety 31.87% 81.13% b10−6
D2: Frequency of events reported 21.3% 11.23% 0.04
D3: Supervisor/Manager expectations and actions promoting patient safety 37.25% 58.81% 2.5 × 10−4
D4: Organizational learning and continuous improvement 32.17% 55.46% 6.3 × 10−5
D5: Teamwork within units 46.73% 61.18% 0.014
D6: Communication openness 24.15% 22.86% 0.87
D7: Non-punitive response to error 20.15% 17.82% 0.66
D8: Staffing 23.27% 41.1% 0.0013
D9: Management support for patient safety 30.32% 54.62% 3.1 × 10−5
D10: Teamwork across units 31.95% 48.58% 0.0037

Certified (n = 25) Non-certified (n = 377)

CERTIFICATION D1: Overall perceptions of safety 77.12% 29.28% 0.1 × 10−5
D2: Frequency of events reported 11.33% 19.41% 0.51
D3: Supervisor/Manager expectations and actions promoting patient safety 46% 36.75% 0.26
D4: Organizational learning and continuous improvement 46.66% 36.15% 0.23
D5: Teamwork within units 50% 47.61% 0.95
D6: Communication openness 24% 23.87% 0.98
D7: Non-punitive response to error 9.33% 18.91% 0.27
D8: Staffing 38.33% 22.20% 0.042
D9: Management support for patient safety 51% 32.48% 0.044
D10: Teamwork across units 44% 31.07% 0.17
212 M.A. Tlili et al. / Journal of Critical Care 56 (2020) 208–214

Yes (n = 86) No (n = 316)

PARTICIPATION INTO RISK MANAGEMENT COMMITTEES D1: Overall perceptions of safety 33.13% 32.05% 0.91
D2: Frequency of events reported 27.7% 18.15% 0.043
D3: Supervisor/Manager expectations and actions promoting patient safety 35.75% 38.04% 0.74
D4: Organizational learning and continuous improvement 38.94% 36.07% 0.69
D5: Teamwork within units 51.74% 46.67% 0.44
D6: Communication openness 30.18% 20.12% 0.049
D7: Non-punitive response to error 18.99% 18.14% 0.9
D8: Staffing 31.77% 30.9% 0.94
D9: Management support for patient safety 35.46% 33.14% 0.77
D10: Teamwork across units 39.46% 37.76% 0.036

Yes (n = 121) No (n = 281)

TRAINING IN PATIENT SAFETY D1: Overall perceptions of safety 33.23% 30.97% 0.67
D2: Frequency of events reported 14.87% 20.99% 0.15
D3: Supervisor/Manager expectations and actions promoting patient safety 39.45% 36.74% 0.56
D4: Organizational learning and continuous improvement 39.81% 29.11% 0.03
D5: Teamwork within units 53.69% 42.26% 0.035
D6: Communication openness 25.23% 22.72% 0.53
D7: Non-punitive response to error 19% 17.99% 0.83
D8: Staffing 37.97% 28.17% 0.049
D9: Management support for patient safety 32.84% 33.98% 0.88
D10: Teamwork across units 32.81% 30.95% 0.67

Small unit (b10beds) Large unit (≥10 beds) (n = 292)

(n = 110)
ICU SIZE D1: Overall perceptions of safety 37.27% 26.01% 0.026
D2: Frequency of events reported 20.98% 14.24% 0.11
D3: Supervisor/Manager expectations and actions promoting patient safety 35.9% 38.18% 0.63
D4: Organizational learning and continuous improvement 40.52% 29.99% 0.04
D5: Teamwork within units 54.53% 41.67% 0.021
D6: Communication openness 28.99% 19.9% 0.047
D7: Non-punitive response to error 18.18% 18.37% 0.94
D8: Staffing 38.52% 27.04% 0.03
D9: Management support for patient safety 34.61% 32.29% 0.65
D10: Teamwork across units 32.41% 31.67% 0.81

WORKLOAD b0.2 (n = 167) ≥0.2 [Max: 0.4] (n = 235)

D1: Overall perceptions of safety 22.54% 34.2% 0.01
D2: Frequency of events reported 18.44% 19.14% 0.88
D3: Supervisor/Manager expectations and actions promoting patient safety 34.48% 29.51% 0.25
D4: Organizational learning and continuous improvement 29.12% 30.1% 0.85
D5: Teamwork within units 37.14% 50.89% 0.005
D6: Communication openness 24.7% 37.19% 0.008
D7: Non-punitive response to error 18.16% 21.31% 0.41
D8: Staffing 20.17% 34.51% 0.002
D9: Management support for patient safety 28.14% 30.1% 0.65
D10: Teamwork across units 32.61% 29.53% 0.52

Surgical ICU Medical ICU General ICU (n = 127)

(n = 142) (n = 133)
ICU SPECIALTY D1: Overall perceptions of safety 22.22% 36.12% 38.97% 0.009
D2: Frequency of events reported 21.3% 20.54% 15.63% 0.49
D3: Supervisor/Manager expectations and actions promoting patient safety 32.02% 35.39% 45.74% 0.051
D4: Organizational learning and continuous improvement 32.79% 35.21% 41.8% 0.31
D5: Teamwork within units 46.16% 44.73% 56.4% 0.1
D6: Communication openness 26.39% 22.72% 21.96% 0.69
D7: Non-punitive response to error 16.37% 19.9% 18.14% 0.76
D8: Staffing 31.45% 30.32% 31.49% 0.95
D9: Management support for patient safety 27.98% 35.18% 37.59% 0.21
D10: Teamwork across units 27.69% 34.83% 33.46% 0.4

4. Discussion 4.1. PSC domains

Recently, patient safety in ICUs has been given increasing attention
due to the increase of AEs frequency which they have a severe conse-
quences [3-5,20]. Knowing the importance of assessing PSC to enhance
patient safety in these structures, many studies have been interested to
determine the professionals' PSC at these units. To the best of our
knowledge, this study is the first of its kind conducted to measure PSC
in Tunisian and Arab ICUs and to determine its associated factors. It is
also among the few studies that assess PSC in ICUs using the HSOPSC
which explore more domains related to patient safety compared to
other instruments. The high response rate (82.37%) demonstrates the
interest accorded by our professionals to PSC.
According to this study, no dimension has reached a level of devel-
opment of 50% and therefore all dimensions are to be improved. This
demonstrates that there are many failures in term of patient safety
and healthcare quality and that the situation is alarming in the ICUs
where the study was conducted. This could be explained by the lack of
information and awareness of professionals regarding the different do-
mains of PSC.
According to our study, only 32.3% of participants had an overall pos-
itive perception of safety (D1) in their units. Other studies carried out in
ICU environment have shown that the overall perception of safety was
also not developed; the score was 68.8% in Norway [21], 64.9% in
 M.A. Tlili et al. / Journal of Critical Care 56 (2020) 208–214
Turkey [22] and 60.7% [23] and 70.16% [24] in Iran. Lower scores were
found in Brazil in two different regions (29.62% and 27%) [3,25].
The study showed that 71% of professionals report having security
problems in their services and only 32.7% confirm the effectiveness of
their functioning and their procedures to prevent the occurrence of er-
rors. This is a testament to the existence of real barriers to prevent pro-
fessionals from properly performing their work by prioritizing quality
and patient safety. Indeed, 51.3% found that, it is only by chance that
there have been no more serious errors in the ICU and 47.9% confirm
that the patient safety is never sacrificed to get more work done.
Our results reveal that the dimension of ‘teamwork within units’ had
the highest score (47.9%). However, it was developed in several studies
either in the intensive care setting [21,23,24] or in other fields
[16,26,27]. This reflects a worrying situation, given the importance of
teamwork in the care setting. Indeed, several studies have identified
teamwork as an essential requirement for better quality of care and pa-
tient safety [28,29]. It is important to mention that ICU teams are distin-
guished from other health care teams in that they are low in temporal
stability, which can impede important team dynamics and in that ICU
teams must work in physically and emotionally challenging environ-
ments that affect team performance [30].
In the other hand, the dimension that had the lowest score was ‘non-
punitive response to error’. Indeed, ICUs professionals reported that
they feel like if their mistakes are held against them when an event is
reported, they feel like the person is being written up and not the prob-
lem. This problem of under-reporting must be taken into consideration
and treated with vigilance. It is essential to establish a culture where in-
dividuals are supported to identify and report errors without threat of
punitive action or blame. Indeed, the reporting of errors is an integral
part of a continuous cycle of improving patient safety and quality of
care that includes error identification, reporting, analysis and corrective
actions [31].
This punitive environment can explain the under-reporting shown
by D2 (frequency of events reported) which had a very low score
(19.2%). This under-reporting can be explained by the fact that the com-
mission of error is always considered as a lack of skills and rarely seen as
a learning opportunity. Actually, this problem in the current study oc-
curs despite the voluntary and anonymous nature of the adverse events
reporting systems. Reporting anonymity refers to whether the identity
of the reporter is hidden or cut off from the reporting form during the
analysis. Indeed, a number of barriers to reporting exist in literature, in-
cluding insufficient time to report, lack of feedback, fear of blame, and
damage to reputations and patient confidence in such an actual compet-
itive environment [16,32].
4.2. Factors associated with PSC
The results of this survey revealed that 7 dimensions, out of 10, were
significantly more developed in the private sector compared to the pub-
lic sector. These results are similar to the results of Mallouli et al.'s study
[33] where 8 of the 10 dimensions were significantly more developed in
private hospitals than in public ones. Indeed, having a competitive
profit-making goal, private hospitals seek to maintain a “brand image”
and a good reputation to attract a maximum of customers, which ex-
plains the importance and interest they dedicate to the quality of care
and patient safety. On the other hand, the dimension «frequency events
reported» was significantly higher in the public sector than in the pri-
vate sector (p = .04). This reflects the presence of several barriers ham-
pering private sector's professionals from reporting errors despite
having developed PSC. A possible explanation is that management and
supervisors in private hospitals are more intolerant to error since it is
their brand and reputation that will be challenged and therefore profes-
sionals do not report the error for fear of sanctions and problems they
will face.
As for workload, it has been shown that when the ratio staff per pa-
tient is higher (ie workload is reduced) the PSC was significantly more
213
developed when it came to overall perceptions of safety, teamwork
within units, communication openness and staffing. Actually, it is ad-
mitted that workload may have severe consequences and negative out-
comes on patient safety and the quality of care. In fact, Linda O'Brien-
Pallas et al. [34] conducted a study to examine the relationship of
staffing and workload, they found that fewer number of professionals
increased workload, and unstable staff unit environments was linked
to negative patient outcomes including falls and medication errors.
They also reported that when staff demand/supply levels exceeded
80%, the number of negative outcomes increased not only for patients
but also for workers and hospitals [34].
In the current study, only one establishment was ISO 9001 certified.
PSC was significantly more developed in this institution when it came to
overall perception of safety (p = .1 × 10−5), staffing (0.042) and man-
agement support for patient safety (p = .044). This is not surprising
since the certification of the establishment means that its functioning
and its procedures are conform to the standards of the required quality.
Moreover, these results are supported by the results of an international
review on the impact of health facility certification [35]. The results
showed a positive impact of the certification of health facilities on the
improvement of organizations, management and professional practices
[35]. Thus, decision makers of healthcare facilities should be aware of
the importance of the institutions' certification and invest on it to en-
sure safer care.
On the other hand, PSC was significantly more developed in small
units, having b10 beds, when it came to overall perception of safety
(p = .026), organizational learning and continuous improvement
(p = .04), Teamwork within units (p = .021), communication
openness (p = .047) and staffing (p = .03). In this regard, Vifladt
et al. [36] carried out a study to explore the impact of the restructuring
of the ICUs, with the aim of their extension, on PSC. They found that PSC
was significantly and negatively affected by this extension [36].
Similarly, El-Jardali et al. [16] found that professionals working in
small hospitals (b100 beds) had a more developed PSC and this con-
cerned all dimensions except for the dimension “staffing”. Actually
larger units may face greater challenges and difficulties that prevent
them from paying more attention to the quality of care compared to
smaller units.
5. Conclusions
Aiming to assess PSC in ICUs and to determine its associated factors,
this study highlighted the poor level of PSC and that all the dimensions
have to be improved. Such low results reflect a critical and alarming sit-
uation of quality and security in the intensive care units included in this
study.
The study showed also several factors associated with PSC in ICUs
that must be focused on to build a well-developed safety culture such
as workload or unit size. It highlighted also some areas of concern
such as the need of training in patient safety, especially among para-
medical professionals who had a lower PSC than physicians and the
huge difference in term of PSC between private and public sector.
Thus, patient safety culture should be a strategic priority of policy
makers, managers, leaders and especially health professionals by put-
ting in place consistent approaches with specific objectives aiming at
improving patient safety and healthcare quality.
The problem of underreporting can be a research track that can be
explored by studying in depth the barriers that hinder professionals
from reporting, allowing a revision of the current reporting systems
and a better adherence of professionals.
Mohamed Ayoub Tlili was the lead researcher responsible for the de-
sign of the study and contributed to the study design, and drafting of the
protocol and manuscript, Wiem Aouicha and Mohamed Ben Rejeb con-
tributed to study design, drafting of the protocol and data collection.
Jihene Sahli and Mohamed Ben Dhiab were responsible for data analysis
and revision of the manuscript and its submission. Souad Chelbi, Ali
214 M.A. Tlili et al. / Journal of Critical Care 56 (2020) 208–214

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