The Impact of a Patient Participating in Evaluating Patient Safety by Using the Patient Measure of Safety in Saudi Arabia: A Cross-Sectional Study

Abstract

Background 

Patient safety is an essential element for delivering quality of healthcare. Many studies focus on measuring patient safety from the healthcare provider’s perspective to improve patient safety in healthcare facilities. However, patient participation may reduce medical errors and improve patient safety by providing information regarding the safety of their care. This study aimed to evaluate patient safety from the inpatients’ perspective and the extent of the influence of the sociodemographic factors on their assessment.

Methods 

A cross-sectional study was conducted at hospitals in different Saudi Arabian regions with 1569 inpatient adults 18 years of older who voluntarily completed an online questionnaire using the Patient Measure of Safety tool (Arabic translated). Two questions were added to assess patient feedback about the overall perception of safety and witnessing patient safety events. COVID-19 patients and those with a mental disorder or incapable of providing informed consent were excluded.

Result 

The total number of participants was 1569 inpatients from 17 hospitals. Sixty-one percent of the participants were female, and 41.62% were from the 18- to 35-year age group. Less than half (38.69%) of patients stayed at the hospital between 3 and 5 days. Percentages of positive responses were more than 90% observed in dignity and respect, communication and teamworking, and organization and care planning domains. Percentages of negative responses were more than 20% found in organization and care planning, access to resources, and ward type and layout domains. Among the respondents, 57.3% (n = 899) rated the safety of their wards as excellent as opposed to 2.9% (n = 46) who rated it as poor. Approximately 5% (n = 79) have noticed 1 event, and 2.3% (n = 36) have noticed 2 or 3 events. Unemployed participants had a significantly lower rate of positive responses in domains of communication, access to resources, and ward type. In contrast, the no-schooling group had a significantly greater rate of negative responses in care planning and ward-type domains.

Conclusions 

The patient plays a key role in enhancing the quality of care and has the potential to detect adverse events. The study highlighted the need to focus on better communication processes for patients with low education levels to enhance their engagement in their care. Further steps should be taken to understand the extent of the patient’s involvement in the improvement that could be tackled from feedback on the safety of care.

Patient safety is defined as the prevention or reduction of harm to patients during the treatment journey.^1,2 The safety of patients has always been a priority for most healthcare organizations worldwide. Lack of safe care causes 2.6 million deaths annually in low- and middle-income countries.³ Moreover, 1 of 10 patients in high-income countries is harmed while receiving hospital care, and 50% of these harms are caused by preventable adverse events.⁴ Accordingly, Saudi Arabia’s health system is mandating accreditation for all healthcare facilities, which includes patient safety standards. Developing and improving patient safety culture is urged by many entities in Saudi such as the Saudi patient Safety Center, the Saudi Central Board for Accreditation of Healthcare Institutions, and the Saudi Commission for Health Specialties.⁵

Thus, many studies investigated the factors of adverse events in Saudi Arabia to enhance patient safety. A study conducted in Saudi Arabia aimed to measure the pattern of sentinel events from 2012 to 2015 and recommended that efforts should focus on enhancing the National Sentinel Events Reporting System to increase the reporting culture among healthcare facilities.⁶ Another study revealed that 44% of 727 adverse events were reported from 2016 to 2019 and considered avoidable.⁷

One of the several factors contributing to enhancing patient safety is measuring the patient’s perception of safety in collaboration with healthcare organizations and providers.⁸ Moreover, effective patient and family engagement plays an important role in improving patient safety and preventing adverse events.⁹

Numerous studies emphasized that the role of patients is prioritized internationally; accordingly, healthcare is shifting to be more patient centric by empowering and involving patients in many aspects of their treatment journey.¹⁰

There are several movements to improve patient safety from different aspects by promoting partnerships with patients, families, and healthcare providers and by encouraging reporting and learning from errors.¹¹ World Health Organization’s World Alliance for Patient Safety cites mobilization and empowerment of patients as 1 of the 6 action areas that will be taken forward in its “Patients for Patient Safety” program.¹²

In many countries, parallel mechanisms have been established for incorporating patients’ experiences into quality improvement.¹³ Therefore, the measurement of patient experience is an indicator to assess the safety culture and the level of patient involvement to identify areas of improvement at the service or unit level and for quality reporting.¹⁴

The importance of patient perspective in patient safety has been studied in different countries to prove that patients could predict harm and could play an active role in promoting safety. Patients’ feedback was investigated by Lawton et al¹⁵ found that feedback provided by patients about the safety of their care can be used to improve the patient’s safety outcomes. According to a UK study conducted by Lawton et al¹² to evaluate the efficacy of the Patient Reporting and Action for a Safe Environment intervention, the authors highlighted that patients are willing to provide feedback about the safety of their care.

Although patient safety measurement remains a global challenge, patients can provide insight and a source of learning about safety that complements existing patient safety measurements.¹⁶ A systematic review published by Albalawi et al¹⁷ identified the contributing factors to the patient safety culture; 14 articles were included and provided a comprehensive insight into the strengths and weaknesses of the contributing factors. Despite the results, all factors identified in the review were based on the healthcare professionals’ perspectives, and factors from patients’ perspectives remain unknown.

Patients and families observe directly and indirectly many aspects of safety culture; therefore, they play an essential role in providing a comprehensive assessment of safety culture.¹⁸ A study by Taylor et al¹⁹ reported that patients could provide a unique perspective on the safety of care in hospitals and be necessary for the direction of targeted interventions across healthcare systems.

There are several tools developed to measure patient safety from a patient perspective. The Patient Measure of Safety (PMOS) was developed and validated to assess 8 domains of ward safety from the patient’s perspective and has been used in many studies.

An Australian study aimed to test the psychometric properties of PMOS-Australia among a large cohort of hospitalized patients concluded that PMOS was a sufficiently reliable and valid tool for patient perceptions of safety.¹⁹

A study by Schiavone et al²⁰ examined an Italian version of the PMOS-30 questionnaire to improve healthcare quality in an Italian hospital. The study was conducted with 435 inpatients, and the results were presented to the hospital decision-makers suggesting appropriate interventions. The experience showed that the use of the PMOS-30 questionnaire improves safety and healthcare quality in hospital settings through patient feedback.

There are many studies in Saudi Arabia measuring the patient experience in primary healthcare using the Clinician & Group Consumer Assessment of Healthcare Providers and Systems tool, which is a survey that asks patients to report on their experiences with providers and staff in primary care and specialty care.²¹ However, there is a lack of studies that focus on the patient’s perspective to improve patient safety in Saudi Arabia.²² Accordingly, a further step should be taken to understand the extent of the patient’s involvement in the improvement that can be tackled because of their feedback on the safety of care.

Thus, this study aims to evaluate patient safety from inpatients’ experience and the extent of the influence of the sociodemographic factors on their assessment.

METHODS

Study Setting

A multicenter cross-sectional study was conducted among inpatients. A total of 1569 participants were invited from different ward types. The self-administrated survey was sent through SMS or scan QR to all patients to access the Web-based questionnaire, including the aim of the study and informed consent.

Study Populations

All inpatients who are admitted into the hospital and 18 years and older in Saudi hospitals were included in the study. Patients who had COVID-19 infections, those with a mental disorder, those younger than 18 years, and those who were unable to provide informed consent were excluded from the study population.

Diverse sociocharacteristics, such as sexes, age groups, education levels, and employment statuses, were included. The total number of recruited hospitals was 17, with different bed capacities. Hospitals were classified as 50 to 100, 101 to 200, 201 to 300, 301 to 500, and more than 500 beds.

The participating hospitals were selected based on their type (governmental, semigovernmental, and private hospitals) and geographical location (Riyadh region, Western region, and Eastern region) for each hospital.

Ethical Considerations

Informed consent was obtained on the first page of the Web-based questionnaire before they could participate and proceed to questionnaire items. Voluntary participation ensures maintaining the confidentiality of the respondent’s information. Institutional review boards were issued by the King Abdulaziz City for Science and Technology (22-092E) and King Saud University (E-21-6527).

Sample Size

The sample size was determined for each hospital based on its bed capacity and volume of inpatients. The Joint Commission Sampling Manual was used to determine the sample size and refer to bed capacity as the population (Sampling Chapter TJC, 2016).²³

Data Collection and Study Procedure

Between April 25 and June 30, 2022, hospitals were invited to participate by engaging their patients to complete the Web-based questionnaire. During the data collection phase, the research team monitored the hospital participation weekly. Progress reports were provided to the recruited hospitals to avoid gender imbalance, to ensure the representativeness of the sample size, and to collect the required sample from each hospital. Each hospital distributed the questionnaire to eligible admitted patients.

Study Tool

In this study, the PMOS-30 questionnaire Arabic version was used that developed by National Health Service originally. Previous translation work was conducted by using the forward-backward translation method and validated through a pilot study. The Arabic PMOS-30 was reviewed with our stakeholders (quality, patient safety, and patient experience officers) through virtual meetings.

The tool was established as a Web-based questionnaire and contained 30 items and 8 domains known to contribute to hospital safety: (1) communication and teamwork, (2) organization and care planning, (3) access to resources, (4) ward type and layout, (5) information flow, (6) staff roles and responsibilities, (7) staff training, and (8) delays. All items were measured using a 5-point Likert scale (1, strongly disagree; 2, disagree; 3, neither disagree nor agree; 4, agree; 5, strongly agree). There was also the option of “not applicable.”

Statistical Analysis

Data analysis was performed using SPSS Statistics 26.0 for Windows by showing descriptive statistics, including frequencies and percentages. Response percentage was calculated by the score of positive responses as agree/strongly agree and negative responses as disagree/strongly disagree. Negatively worded questions marked with R, which are Reversed Scores, were considered by calculating the percentage of positive responses as disagree/strongly disagree and the percentage of negative responses from agree to strongly agree. Mean, median, and SD were calculated for each item.

Analysis of variance test was performed to check the differences between sociodemographic characteristics for the positive mean response by each domain. The significance level was set at P < 0.05, and Tukey post-hoc analysis was performed for the difference between groups.

RESULTS

A total of 1569 patients responded, and 61% were female (Table 1). Participants aged 18 to 35 years were 41.62%, whereas patients older than 70 years were the lowest group by 7.27%.

TABLE 1 - Sociodemographic Characteristics of Participants

Sociodemographic Characteristics		Count	%
Sex
Male		612	39
Female		957	61
Age, y
18–35		653	41.62
36–55		538	34.29
56–70		264	16.83
>70		114	7.27
Educational level
Bachelor and higher		691	44.04
High school		451	28.74
No schooling completed		188	11.98
Intermediate school		136	8.67
Primary school		103	6.56
Employment
Housewife		547	34.86
Employed		522	33.27
Retired		224	14.28
Unemployed		170	10.83
Student		106	6.76
Ward type
Medical		405	25.81
Surgical		453	28.87
Oncology		115	7.33
Other		171	10.9
Obstetrics and gynecology		425	27.09
Days of dospitalization
1–2		575	36.65
3–5		607	38.69
>5		387	24.67

The participants had different educational levels: 44% had a bachelor’s degree or higher, and the patients with a primary school degree were the lowest, with 6.56%. In regard to employment status, housewives and employed were at the top at 34.86% and 33.27%, respectively. It has been noticed that the surgical ward was the highest proportion of participating patients: 28.87% and 38.69% of patients stayed at the hospital between 3 and 5 days (Table 1).

The percentages of responses for 30 items considering questions marked with R, as the negative answer (disagrees/strongly disagree) on a negatively worded question reflecting a positive response, are presented in Table 2.

TABLE 2 - Patient Measure of Safety

Items	Positive, %	Negative, %	Mean	Median	SD
Dignity and respect
1. I was always treated with dignity and respect.	92.67	4.27	4.38	5.00	0.819
Communication and teamworking (domain 1)
3. I got answers to all the questions I had about my care.	90	4.78	4.30	4.00	0.855
28. I always felt staff listened to me about my concerns.	84.13	7.90	4.14	4.00	0.928
13. There was always someone available to deal with every aspect of my care.	86.04	6.50	4.16	4.00	0.888
19. I felt that the attitude of staff towards me was poor. (R)	74.51	14.98	2.02	2.00	1.210
24. Staff worked together as a team here.	88.91	4.65	4.24	4.00	0.844
Organization and care planning (domain 2)
2. My medicines were always available.	91.08	4.53	4.33	4.00	0.837
4. Staff didn’t always know when a doctor changed my plan of care. (R)	59.78	27.15	2.51	2.00	1.346
22. Staff gave me conflicting information about my care. (R)	68.26	21.10	2.29	2.00	1.296
25. When I needed treatment there was always someone available who was trained to do it.	89.10	4.84	4.22	4.00	0.823
Access to resources (domain 3)
23. Staff/patients waited a long time for porters to arrive. (R)	58.51	22.05	2.46	2.00	1.265
29. Staff seemed to struggle to get help when they needed it. (R)	54.11	24.47	2.55	2.00	1.266
27. Equipment and supplies were always available when needed (e.g., hoists, bed pans, walking aids, dressings).	86.49	7.84	4.17	4.00	0.942
Ward type and layout (domain 4)
11. Staff were prompt in answering my buzzer.	78.84	10.83	4.03	4.00	1.063
10. The ward was able to deal with all my treatment needs.	88.78	6.05	4.23	4.00	0.886
9. Lack of space made it difficult for staff to do their jobs. (R)	58.89	21.73	2.45	2.00	1.294
The following aspects of the ward made it uncomfortable for me:	54.37	31.6	2.66	2.00	1.414
15. Noise levels (R)
16. Lighting levels (R)
17. Temperature (R)
18. Poor cleanliness (R)
Information flow (domain 5)
30. Information about me that my health care team needed was always available (eg, drug charts, medical notes, test results).	92.35	3.31	4.32	4.00	0.765
5. After shift changes staff knew important information about my care.	84.38	7.20	4.18	4.00	0.916
Staff roles and responsibilities (domain 6)
6. I knew what the different roles of the people caring for me were.	86.23	6.12	4.17	4.00	0.871
12. It was clear who was in charge of the ward staff.	69.09	16.44	3.80	4.00	1.140
20. I knew which consultant was in charge of my care.	87.25	7.65	4.22	4.00	0.929
26. I always knew which nurse or nurses were responsible for my care.	85.15	7.20	4.15	4.00	0.907
Staff training (domain 7)
7. Staff were always able to use the necessary equipment.	92.16	3.31	4.30	4.00	0.755
14. Staff were always able to carry out tasks that they should be able to do.	89.80	4.02	4.24	4.00	0.793
Delays (domain 8)
21. There were enough staff on the ward to get things done on time.	79.22	9.62	4.01	4.00	1.002
8. My treatment/procedure/operation always happened on time.	87.57	6.31	4.21	4.00	0.895

R, Reversed Scores, which are the negatively worded questions. A negative answer (strongly disagree/disagree) to R question indicates a positive response.

Only 5 items in different domains showed more than 90% of positive responses among respondents. The highest item was about “dignity and respect” with 92.67% (mean, 4.38), then D5 (item 30), D7 (item 7), D2 (item 2), and D1 (item 2), respectively. The least positive responses among respondents, with less than 60%, were found in 5 items, and the lowest item was D3 (item 29), with 54.11% (mean, 2.55) in the “access to resources” domain, and then items D4 (items 9, 16, and 17), which is about “ward type and layout,” and D3 (item 23). Most of the other items had more than 60% positive response percentages (Table 2).

Six items showed a percentage of negative among respondents greater than 20%, which were items D2 (items 4 and 22), D3 (items 23 and 29), and D4 (item 9). The highest negative percentage was found in D9 (item 15), with 31.6% (mean, 2.66) being about “ward type and layout” (Table 2). Moreover, 5% of the respondents reported having noticed one event that caused harm to the patient, and 2.3% (n = 36) have noticed 2 or 3 events, whereas 8 of them reported that they had noticed more than 5 times events (Table 3).

TABLE 3 - Overall Patient Perception of Safety

	Count	%
How do you rate the safety of this ward?
Poor	46	2.9
Fair	105	6.7
Good	203	12.9
Very good	316	20.1
Excellent	899	57.3
How many events have you noticed that could have caused harm to patients?
None	1440	91.8
Once	79	5
2–3 times	36	2.3
4–5 times	6	0.4
>5 times	8	0.5

There is a significant difference among respondents according to employment characteristics for communication and teamwork, organization and care planning, access to resources, and ward type and layout domains (D1, D2, D3, and D4).

To identify the differences between groups, the post-hoc test was performed and showed the difference between unemployed and housewives under the communication and teamwork domain (P = 0.048; Table 4), whereas for the organization and care planning domain, the difference seems between retired and housewives (P = 0.013). In the access to resources domain, the difference was between unemployed and housewives (P = 0.001). Among all the comparisons, the housewives had the higher positive response percentage (Table 4).

TABLE 4 - Sociodemographic Characteristics Versus Domains Positive and Negative Responses

		D1		D2		D3		D4		D5		D6		D7		D8
		Mean ± SD, %
		+	−	+	−	+	−	+	−	+	−	+	−	+	−	+	−
Employment	Unemployed	81 ± 0.25a	10 ± 0.18	75 ± 0.27	17 ± 0.22	59 ± 0.33a,c	21 ± 0.28	63 ± 0.28a,b	20 ± 0.24	83 ± 0.31	7 ± 0.21	81 ± 0.29	10 ± 0.22	87 ± 0.28	6 ± 0.18	81 ± 0.31	7 ± 0.20
	Retired	84 ± 0.24	8 ± 0.16	74 ± 0.27a	17 ± 0.21a	62 ± 0.32b	22 ± 0.29a	68 ± 0.29	20 ± 0.23	84 ± 0.30	7 ± 0.19	82 ± 0.30	8 ± 0.20	90 ± 0.26	6 ± 0.19	80 ± 0.34	10 ± 0.27
	Student	87 ± 0.19	6 ± 0.14	77 ± 0.26	15 ± 0.21	65 ± 0.32	20 ± 0.28	71 ± 0.27	16 ± 0.22	89 ± 0.24	6 ± 0.16	85 ± 0.22	5 ± 0.13	93 ± 0.20	1 ± 0.07	83 ± 0.30	8 ± 0.22
	Employed	83 ± 0.25	8 ± 0.18	76 ± 0.28	14 ± 0.21	67 ± 0.33a	18 ± 0.26	70 ± 0.29a	17 ± 0.23	83 ± 0.31	8 ± 0.21	82 ± 0.28	9 ± 0.21	91 ± 0.25	3 ± 0.15	83 ± 0.31	8 ± 0.24
	Housewife	87 ± 0.23a	7 ± 0.16	80 ± 0.25a	12 ± 0.20a	70 ± 0.32b,c	16 ± 0.24a	73 ± 0.28b	16 ± 0.23	85 ± 0.29	8 ± 0.21	81 ± 0.27	10 ± 0.21	93 ± 0.23	3 ± 0.16	86 ± 0.28	7 ± 0.20
P		0.027*	0.127	0.007†	0.021*	0.001†	0.018*	0.002†	0.153	0.321	0.717	0.785	0.105	0.073	0.049*	0.073	0.367
	Bachelor and higher	84 ± 0.25	8 ± 0.18	79 ± 0.27a	12 ± 0.20a	69 ± 0.33a	16 ± 0.26a	72 ± 0.28	170.23a	83 ± 0.30	9 ± 0.22	80 ± 0.29	11 ± 0.23a	91 ± 0.25	4 ± 0.17	83 ± 0.31	9 ± 0.24
Education	High school	85 ± 0.22	6 ± 0.14	77 ± 0.0.25	14 ± 20b	67 ± 0.32b	18 ± 0.25	70 ± 0.29	17 ± 0.23b	84 ± 0.30	7 ± 0.19	84 ± 0.26	7 ± 0.17a	90 ± 0.25	3 ± 0.15	83 ± 0.30	8 ± 0.21
	Intermediate school	85 ± 0.23	8 ± 0.16	77 ± 0.28	15 ± 0.22	62 ± 0.33	22 ± 0.27	67 ± 0.29	19 ± 0.24	35 ± 0.30	6 ± 0.18	83 ± 0.25	8 ± 0.19	90 ± 0.24	3 ± 0.12	86 ± 0.30	7 ± 0.21
	Primary school	87 ± 0.22	7 ± 0.13	75 ± 0.27	17 ± 0.21	65 ± 0.31	20 ± 0.27	73 ± 0.27	15 ± 0.21c	89 ± 0.24	4 ± 0.14	84 ± 0.25	8 ± 0.17	91 ± 0.26	4 ± 0.18	87 ± 0.29	5 ± 0.17
	No schooling	84 ± 0.24	10 ± 0.16	72 ± 0.27a	21 ± 0.22a,b	59 ± 0.31a,b	24 ± 0.29a	66 ± 0.29	22 ± 0.25a,b,c	85 ± 0.29	7 ± 0.21	83 ± 0.29	10 ± 0.23	93 ± 0.23	4 ± 0.15	83 ± 0.32	8 ± 0.24
P		0.741	0.107	0.024*	0.000‡	0.001†	0.001†	0.044*	0.017*	0.472	0.052	0.203	0.012*	0.733	0.843	0.588	0.702
Ward type	Surgical	85 ± 0.22a	8 ± 0.16	76 ± 0.25a,b	16%,0. ±21a	64 ± 0.33a	21 ± 0.28a	68 ± 0.29a	21 ± 0.24a	87 ± 0.27a	7 ± 0.20	83 ± 0.27a	8 ± 0.19a,b	91 ± 0.25	4 ± 0.16	82 ± 0.32	9 ± 0.24
	Medical	84 ± 0.25	8 ± 0.17	75 ± 0.27c	18 ± 0.22b	68 ± 0.31b	20 ± 0.27b	70 ± 0.30	17 ± 0.23	84 ± 0.30	7 ± 0.18	83 ± 0.28b	8 ± 0.19c	91 ± 0.24	4 ± 0.16	84 ± 0.31	8 ± 0.22
	Ob-gyn	87 ± 0.22b	7 ± 0.16	83 ± 0.25a,c,d	9 ± 0.18a,b,c	72 ± 0.32a,c,d	13 ± 0.23a,b,c	75 ± 0.27a,b	14 ± 0.21a,b	86 ± 0.27b	9 ± 0.21	82 ± 0.27c	12 ± 0.22a	93 ± 0.23a	3 ± 0.14	87 ± 0.26a	6 ± 0.19
	Oncology	86 ± 0.22	5 ± 0.14	77 ± 0.28	12 ± 0.17	57 ± 0.32b,c	14 ± 0.25	70 ± 0.27	15 ± 0.21	82 ± 0.33	8 ± 0.22	85 ± 0.24d	7 ± 0.14d	92 ± 0.23	3 ± 0.16	80 ± 0.32	6 ± 0.21
	Others	79 ± 0.30a,b	10 ± 0.19	69 ± 0.30b,d	17 ± 0.21c	61 ± 0.33d	20 ± 0.26c	64 ± 0.29b	22 ± 0.23 (b)	78 ± 0.36a,b	8 ± 0.22	74 ± 0.32a,b,c,d	14 ± 0.26b,c,d	85 ± 0.29a	6 ± 0.19	78 ± 0.34a	11 ± 0.26
P		0.004†	0.165	0.000‡	0.000 ‡	0.000‡	0.000‡	0.000‡	0.000‡	0.018*	0.342	0.003†	0.000‡	0.013*	0.274	0.005†	0.041*

^a,b,c Tukey post hoc test: means with the same letter indicate significant difference.

*P < 0.05.

^†P < 0.01.

^‡P < 0.001.

D1, communication and teamwork; D2, organization and care planning; D3, access to resources; D4, ward type and layout; D5, information flow; D6, staff roles and responsibilities; D7, staff training; D8, delays; Mean, mean of response percentage.

In regard to the ward type and layout domain, the housewives reported a significantly higher positive response percentage (0.73) than the unemployed groups (P = 0.001), and the employed group had a higher positive response percentage (0.70) with a P value of 0.047.

However, there are significant differences among the negative respondents for 3 domains (D2, D3, D7) according to their employment status. Post-hoc tests showed that the retired group had a higher negative response than the housewives in domains 2 and 3 (P = 0.021 and 0.018, respectively; Table 4).

Moreover, Table 4 shows that there is a significant difference among respondents in positive responses according to educational level for “organization and care planning,” “access to resources,” and “ward type and layout” domains (D2, D3, D4). According to the post-hoc test, the bachelor groups had higher positive response percentages than the no-schooling groups in both D2 and D3 (P = 0.009 and 0.025, respectively).

The result from Table 4 shows that there is a significant difference among respondents in negative responses according to educational level for “organization and care planning,” “access to resources,” “ward type and layout,” and “staff roles and responsibilities” domains (D2, D3, D4, and D6). The no-schooling group had the highest negative response percentage among all 4 domains.

Table 4 demonstrates that there is a significant difference among respondents in positive responses in all of the 8 domains. The highest mean in positive responses in these 3 domains (D2, D3, and D4) was found in the ob-gyn ward.

However, the result in Table 4 shows that there is a significant difference among respondents in negative responses in 5 of 8 domains, which are “organization and care planning,” “access to resources,” “ward type and layout,” “staff roles and responsibilities,” and “delays” domains (D2, D3, D4, D6, and D8).

For the organization and care planning and access to resources domains, there was a significant difference in the negative responses between the ob-gyn ward and the following ward types: “surgical,” “medical,” and “others.”

DISCUSSION

This study offered a unique opportunity to evaluate the safety experiences of patients during their recent hospitalization periods of care. The majority of the patients responded positively toward the dignity and respect domain, which is reflected in their average scores (92.67%). Similar findings from Australian and Italian studies showed that patients reported positively in the domain pertaining to dignity and respect (89.2%).^19,20

This study showed that patients feel positive toward safety in hospitals, with more than 90% agreement on answering the questions about their care, availability of medications, availability of information for their healthcare team, and the use of the necessary equipment. However, 54.5% to 59% of the patients indicated that they had to wait long for porters to arrive, there was a lack of space for staff to do their jobs, and the staff struggled for resources. More than half felt that their ward was uncomfortable. Forty percent of respondents indicated that the staff did not always know when a doctor changed a patient’s care plan, and almost 68% of respondents stated that staff gave them conflicting information. Ten percent of respondents felt that there was inadequate staffing, which inhibited getting things done on time. Thus, these items are indicative of the need for improvement because they directly affect patient safety; similarly, it was evident in many studies the role of space in delivering safer care to patients.^24,25 Deficits in communication were identified with patient reports of conflicting information given to patients, and more than half of the staff did not always know about changes in care plans. Lack of communication is a major factor in unsafe care and a risk factor for adverse events, and this issue was noted by the patient, which emphasized the importance of the patient role in detecting safety.²⁶

The latest Saudi Arabian Ministry of Health (MOH) patient satisfaction and experience survey showed similar results to this study in terms of communication.²⁷ Around 90% of positive respondents in this study compared with the MOH results scoring 86.27%. One of the MOH improvement priority plans in the report was informing the patient about the medical team, which is one of the patients’ bills of rights issued by the MOH.

The results of this study suggested areas for improvement, as greater than 30% of participants reported they did not know who was in charge of ward staff, and around 15% did not know which nurse was responsible for their care. Another MOH improvement priority area is related to improving the environment of patients’ wards and rooms, which was reinforced in this study as one of the lowest scores, as 54.37% of participants found their rooms to be uncomfortable.²⁷

According to our results, 8.2% of participants have noticed at least one safety event that could have harmed patients, in agreement with a similar result that was found in another study measuring patient safety from patient perception using the same tool; 7.1% of the participants noticed an adverse event.¹⁹ Therefore, the latter percentage is an important indicator of patients’ ability to identify adverse events.

The effect of sociostatus, such as employment, education, and ward type, on patients’ perspective was investigated and showed that housewives and ob-gyn wards were significantly associated with a higher mean positive response compared with unemployed and retired in many domains. The employment level has an impact on access to good care, as well as their well-being, self-confidence, uncertainty, and loneliness, which has been aligned with the results of this study, where the unemployment group had the lowest positive rate among domains focusing on communication and access to resources.²⁸ Although few studies found no gender differences in the perceptions of patient participants, female healthcare professionals were more likely to view patient safety positively.^29,30 Interestingly, female patients were more likely to experience more adverse events than male patients.³¹ In our study, the proportion of female participants was higher, which could be due to the inclusion of ob-gyn ward.

The education level was investigated in a study about patient safety in the Eastern Region of Saudi Arabia and found a relationship between the education level and the negative view and lower trust.^20,29 In our study, patients with no schooling had the significantly highest negative and lowest rate of positive responses. Studies suggested that those with low education status potentially perceive themselves as less involved in the health decision-making process or not empowered enough.^31,32 Therefore, multicommunication strategies considering the patient’s sociodeterminants, including adequate explanations and clarity of the language, would improve patient engagement and enhance the patient’s experience.

The measurement of patient safety was always investigated based on healthcare providers’ perspectives.¹⁷ However, this study focused on patients’ perspectives, as one study has found that differences exist in the interpretation and perceptions of patient safety between patients and healthcare professionals.³³

One limitation of using the PMOS-30 tool is that it measures if the patients have noticed safety issues. Still, it does not count if patients have reported any safety issues whenever they notice them. However, a couple of questions were added to catch the ability of the patient to report the safety event.

The aforementioned points underlined the importance for hospitals to survey patients about harm experienced or witnessed to take action accordingly. Although the Saudi MOH developed the measuring of the patient experience program to understand the priorities and factors for improving the patient experience at the MOH facilities and services level, there is a need to establish a process or a system for patients to report adverse events at the hospital level during or after receiving their care, so they can target the defects that affect the safety. This study revealed the need for hospitals to focus on better communication processes to help the low-education group to engage and feel more comfortable with their care. Therefore, more strategic communication plans for marginalized patients should be addressed to eliminate communication barriers that limiting their engagement on their health needs and treatment. It is also vital to ensure that ward and patient rooms are designed comfortably and efficiently for patients and healthcare workers.

Future studies should apply qualitative methods to explore the reasons behind patients’ perspectives and the differences between being in certain wards and having different levels of education or employment status. Future research should also focus on sex and other sociodemographic differences in reporting and experiencing adverse events.

CONCLUSIONS

Patient safety is one of the priorities for healthcare systems that need the triangulation roles integrating patients, healthcare providers, and the system. This study highlighted the importance of patients’ participation in enhancing healthcare services and reducing adverse events. This study illustrated that patients’ perception of safety is significantly influenced by their level of education and employment status and other sociodemographic factors. Patients proved the ability to detect events; however, more studies from different angles need to conduct to improve the perception on patient safety.