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†