International Emergency Nursing 54 (2021) 100941

Contents lists available at ScienceDirect

International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

Exploring patient safety culture in emergency departments: A

Tunisian perspective
Wiem Aouicha a, b, c, *, Mohamed Ayoub Tlili a, b, c, Jihene Sahli b, c, Mohamed Ben Dhiab b,
Souad Chelbi a, b, Ali Mtiraoui b, c, Houyem Said Latiri b, d, Thouraya Ajmi b, c, Chekib Zedini b, c,
Mohamed Ben Rejeb b, d, Manel Mallouli b, c
a
University of Sousse, Higher School of Health Sciences and Techniques of Sousse, Tunisia
b
University of Sousse, Faculty of Medicine Ibn El Jazzar, Sousse, Tunisia
c
Laboratory of research « Qaulité des soins et management des services de santé maternelle LR12ES03 », Tunisia
d
Sahloul University Hospital, Department of Prevention and Care Safety, Tunisia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Emergency departments (EDs) are considered a high-risk environment because of the high frequency
Patient safety of adverse events that occur within. Measuring patient safety culture is an important step that assists healthcare
Patient safety culture facilities in planning actions to improve the quality of care provided to patients. This study aims to assess patient
Emergency departments
safety culture within EDs and to determine its associated factors.
Associated factors
Methods: A cross-sectional study conducted among professionals from all the EDs of public and private healthcare
institutions in Tunisia. It spread from June to September 2017. We used the validated French version of the
Hospital Survey on Patient Safety Culture questionnaire.
Results: In total, 11 EDs were included in the study, with 442 participants and a participation rate of 80.35%. All
the ten dimensions of patient safety culture were in need of improvement. ‘Teamwork within units’ scored the
highest with 46%, however, the lowest score was attributed to ’the frequency of adverse events reporting’
(19.6%). Several factors have been found significantly related to safety culture. Private EDs have shown
significantly higher scores regarding nine patient safety culture dimensions.
Conclusion: This study showed a concerning perception held by participants about the lack of a patient safety
culture in their EDs. Also, it provided baseline results giving a clearer vision of the aspects of safety that need
improvement.

1. Background nurses and emergency technicians (nurses with specific additional

Every day, emergency departments (EDs) professionals must inter­
vene in unstable contexts that are potentially hazardous to patients [1],
especially with an increasing admissions rate worldwide [2].
Although the main mission of caregivers in EDs is to assess patients’
need for urgent interventions and provide treatment and care [3], the
different patient characteristics, as well as the severity of their illnesses
make the process of care in these units more complex [4]. Additionally,
patients often come to the ED with incomplete or non-existent medical
records, or they can be in a state that does not allow them to commu­
nicate information about their medical conditions [4].
Furthermore, care delivery in the ED often involves collaboration
between the different EDs staff composed by physicians, registered
training on emergency and resuscitation care). It also requires collabo­
ration between different medical and surgical hospital departments and
pre-hospital emergency units. In fact, the implication of numerous
caregivers and different departments, added to the uncontrollable
workload and the unpredictable numbers of patients may compromise
patient safety and induce patient risk involving any undesirable situa­
tion related to health-care environment and can have negative conse­
quences for the patient (adverse events) [3,5,6].
According to a study conducted in 92 United States hospitals, one of
the key findings was that ED professionals perceived a much lower level
of patient safety climate compared to other specialties [7]. The study
also showed that these units require more patient safety improvement
efforts than other areas in the hospital [7]. Furthermore, a Spanish study

* Corresponding author.
E-mail addresses: wifi.waouma@gmail.com (W. Aouicha), medtlili@yahoo.fr (M.A. Tlili).

https://doi.org/10.1016/j.ienj.2020.100941
Received 2 December 2019; Received in revised form 17 September 2020; Accepted 14 October 2020
Available online 17 December 2020
1755-599X/© 2020 Elsevier Ltd. All rights reserved.
W. Aouicha et al.
conducted in 62 urban EDs, revealed that at least 7% of patients arriving
in a serious state have suffered adverse events [8]. In addition, it has
been shown that 12% of all emergency returns, within 7 days of the first
visit, were related to adverse events [9]. In a systematic review, Stang
et al. revealed that the most common types of adverse events occurring
in EDs involved errors related to management, diagnostic, medication
and procedures [10]. It is important to note that 36 to 71% of these
occurring adverse events in EDs were deemed preventable [10].
In the Tunisian context, a retrospective study, conducted in a Uni­
versity Hospital in 2005, showed 10% adverse events incidence, of
which 60% were considered avoidable [11]. In addition, Bouafia et al.’s
study, aiming to determine the extent and nature of adverse events in a
Tunisian hospital, reported that emergency admissions increased the
risk of adverse events occurrence compared to non-urgent ones (AOR =
1.64, CI:1.07–2.52, p = 0.023) [12].
According to the High Authority of Health, the root causes of these
adverse events are rarely related to a lack of technical skills but mainly
to a lack of patient safety culture among caregivers [13]. In healthcare
institutions, Nieva and Sorra defined patient safety culture as the
product of individual and group values, attitudes, perceptions, compe­
tencies and patterns of behaviour that determine the commitment to the
style and proficiency of an organization’s safety management [14].
Many experts in the safety field have pointed the importance of assessing
patient safety culture and shared the belief that developing patient
safety culture improves patient safety outcomes [15]. Indeed, patient
safety culture encourages teamwork, reporting of adverse events,
freedom of expression, transparency, feedback and learning from mis­
takes. Also, it involves collaboration and support from the management
of the health facility to ensure patient safety [16]. Particularly within
EDs, Camargo et al. revealed that a more developed patient safety cul­
ture was associated with a lower rate of near-miss events [8].
Many studies have focused on the assessment of patient safety cul­
ture in different care settings, such as intensive care units, operating
rooms and primary healthcare centres [17–19]. However, the lack of
research on patient safety attitudes in EDs has been addressed in liter­
ature, pointing out that few studies have focused solely on EDs [20,21].
The aim of the study was to assess patient safety culture in public and
private EDs in the Centre of Tunisia and to determine its associated
factors.
2. Methods
2.1. Study design and setting
A descriptive cross-sectional and multicentre study was conducted
over a period of 4 months (June to September 2017) in all the EDs of
public and private health institutions in the Tunisian Centre (6 gover­
norates: Sousse, Monastir, Mahdia, Kairouan, Sidi Bouzid and Kasserine)
which accepted to be part of the study.
2.2. Population and sampling
In order to have a sample of optimal size, to guarantee reliable results
and to minimize the biases related to sampling, the survey targeted all
healthcare professionals (n = 565) that were employed in the afore­
mentioned settings. The participants were divided into medical and
paramedical staff (nurses, emergency technicians and assistant care­
givers). The inclusion criteria were established based on the recom­
mendations of the Hospital Survey On Patient Safety Culture (HSOPSC)
questionnaire user’s guide [22].
2.3. Measures
To measure the level of patient safety culture in the ED, the HSOPSC
was used, which was, originally, developed by the Agency for Health­
care Research and Quality for a better understanding of the patient
2
International Emergency Nursing 54 (2021) 100941
safety culture in health care settings [23]. In this study, we used the
French version which was provided by the Coordinating Committee for
Clinical Evaluation and Quality in Aquitaine in France [23], allowing to
measure 10 dimensions related to patient safety culture, presented in
Table 1.
The French version of the HSOPSC was validated in acute care set­
tings (medical and surgical) among medical and paramedical caregivers
[23] and has acceptable psychometric properties; the Cronbach’s alpha
is 0.88 for the questionnaire and varies from 0.46 to 0.84 for the di­
mensions [23].
In total, the questionnaire counted 49 items: 40 were used to mea­
sure the 10 dimensions related to patient safety culture; 2 items exam­
ined the overall perception of patient safety and the number of events
reported during the last 12 months and 7 items for demographic and
professional characteristics of participants (as seen in Table 2). To rate
professionals’ agreement or disagreement, a Likert scale of 5-points was
used (from 1 = don’t agree at all to 5 = strongly agree), also to estimate
frequency (from 1 = never to 5 = always) [23].
2.4. Data collection and analysis
The researcher distributed the HSOPSC to the participants and fol­
lowed up to retrieve the filled questionnaires. This follow-up consisted
of visits to the study sites to search for professionals who were absent
during the last visit or for redistribution of the questionnaire to the ones
who declared that they had lost it. In each setting, the investigator
handed out the questionnaires to participants, one at a time, and they
were all asked to give him the filled form. This way each investigator
kept track of whom answered and handed him the questionnaire, which
was immediately put in a locked box.
Once the questionnaires were collected, their eligibility has been
verified according to the user’s guide criteria [22]. Afterwards, for each
dimension, a score that represents the average percentage of positive
responses to items was calculated. Dimensions that obtain a score of
Table 1
Definitions of patient safety culture dimensions.
Dimension Definition
Overall perceptions of patient Procedures and systems are good at preventing
safety (D1) errors and there is a lack of patient safety
problems.
Frequency of adverse events Mistakes of the following types are reported: (1)
reporting (D2) mistakes caught and corrected before affecting
the patient, (2) mistakes with no potential to
harm the patient, and (3) mistakes that could
harm the patient but do not.
Supervisor/Manager expectations Supervisors/managers consider staff
(D3) suggestions for Actions Promoting Patient
Safety improving patient safety, praise staff for
following patient safety procedures, and do not
overlook patient safety problems.
Organizational learning- Mistakes have led to positive changes and
continuous improvement (D4) changes are evaluated for effectiveness.
Teamwork within units (D5) Staff supports each other, treat each other with
respect, and work together as a team.
Communication openness (D6) Staff freely speaks up if they see something that
may negatively affect a patient and feel free to
question those with more authority.
Non-punitive response to error Staff feels that their mistakes and event reports
(D7) are not held against them and that mistakes are
not kept in their personnel file.
Staffing (D8) There are enough staff to handle the workload
and work hours are appropriate to provide the
best care for patients.
Management support for patient Hospital management provides a work climate
safety (D9) that promotes patient safety and shows that
patient safety is a top priority
Teamwork across units (D10) Hospital units cooperate and coordinate with
one another to provide the best care for
patients.
W. Aouicha et al. International Emergency Nursing 54 (2021) 100941

Table 2 (n = 78) belonged to in the process of having the certification EDs (that
Sociodemographic and professional characteristics of the participants. were going through certification process during the data collection).
Characteristics n %
3.2. Patient safety culture dimensions
Gender Male 205 46.4
Female 237 53.6
Professional title Physicians 165 37.2 Results revealed that all ten dimensions of the patient safety culture
Emergency 43 9.7 were rated as < 50% by the ED healthcare employees and thus, all were
Technician in need of improvement. The dimension of “teamwork within units” had
Nurses 181 40.9
Assistant caregivers 27 6.1
the highest score 46%. Whereas, “Non-punitive response to error” and
Ambulance Drivers 23 5.2 “frequency of adverse events reporting” had the lowest scores, respec­
Not Indicated 04 0.9 tively (19.8% and 19.6%) (Table 3).
Work experience <10 years 305 69 The level of patient safety in EDs was deemed ‘Acceptable’ in 41.4%
>10 years 137 31
(n = 183) of cases and ‘Poor’ in 32.8% (n = 145). As for the number of
Nature of the healthcare facility Public 386 87.2
Private 56 12.8 reported adverse events, 86.6% (n = 383) of participants said that no
Certification Certified 70 15.8 form of reporting was completed during the last 12 months (Table 4).
Amid certification 78 17.6
Not Certified 294 66.5 3.3. Factors associated with patient safety culture
Involvement in risk management Yes 345 78.2
committees No 96 21.8
Receiving patient safety training Yes 192 43.4 After the statistical analysis, data from this study showed that age,
No 250 56.6 gender and work experience, were not associated with any patient safety
culture dimension.
Regarding the professional title, the “overall perception of safety”
50% or below are considered as “in need of improvement” and those
(D1) was significantly higher among paramedical staff (p = 0.02). In
with a score of 75% or above are considered as “developed”, following
addition, the participants working in private EDs rated significantly
the definitions provided by the questionnaire’s user guide [22].
higher the patient safety culture and this was demonstrated in nine di­
The collected data were managed and analysed using IBM SPSS
mensions (D1, p = 2.10-6; D2, p = 0.01; D3, p = 0.04; D4, p = 2.10-6; D5,
Statistics for Windows, version 20 (IBM Corp., Armonk, N.Y., USA) and
p = 5.10-4; D6, p = 1.6.10-4; D8, p = 0.03; D9, p = 4.10-4 and D10, p =
Epi info 6.04d (CDC, Atlanta, GA, USA)”. A bi-varied analysis was car­
0.003), however, the “non-punitive response to error” (D7, p = 0.74)
ried out to highlight the potential associations between participants’
was the only dimension that wasn’t rated significantly higher in the
characteristics with the different dimensions of patient safety culture.
private sector (Table 5).
For this, comparisons of percentages were made by the Pearson chi-
square test and the statistical significance was defined at P ≤ 0.05.
4. Discussion

2.5. Ethical considerations
This study was approved by the local ethics committee (reference:
CEFMS02/2017) and administrative authorizations were granted by the
heads of the different EDs and administrations of the health facilities in
which the study took place.
Additionally, as the study poses no risk or threats to participants, we
opted for an informed verbal consent that was obtained from the tar­
geted caregivers after giving them a participant information sheet that
was attached on the first page of the questionnaire, on which the aim
and all the necessary information about the study were listed. Also, it
highlighted that the participation was completely voluntary, anonymity
and confidentiality are respected and they can refuse or withdraw from
the study without punitive repercussions.
3. Results
Nineteen health facilities, equipped with EDs, were contacted to
participate in the survey, only eleven accepted to take part. A total of
454 professionals agreed to participate in the study; 12 questionnaires
were ineligible and were systematically excluded from the analysis.
Therefore, the response rate was 80.35% (n = 442).
3.1. Characteristics of the participants
Among 442 participants, the average age was 34.5 ± 9.1 years old.
Also, the female gender was predominant with 53.6% (n = 237). As for
professional title, the participants were divided into five categories;
most of them were nurses (40.9%, n = 181) followed by physicians
(37.2%, n = 165).
Most participants (87.2%, n = 386), were employed in six public
healthcare institutions and the remainder in five private ones (Table 2).
Also, 15.8% (n = 70) of participants belonged to certified EDs and 17.6%
All the ten dimensions of patient safety culture were in need of
improvement (scores below 50%). Participants attributed the highest
score to ‘teamwork within units’ (46%) and the lowest score to ’fre­
quency of reported adverse events’ (19.6%). Several factors were found
to be significantly related to patient safety culture, such as the profes­
sional title and the nature (private/public) of the healthcare facility.
These findings could be explained by the professionals’ lack of infor­
mation and awareness regarding the different domains of patient safety
culture [24].
4.1. Patient safety culture dimensions
4.1.1. Overall perception of safety
Our findings showed that participants perceived a low level of safety
in their EDs (D1). According to Verbeek-van Noord et al., the percep­
tions of caregivers regarding patient safety in their units could be rele­
vant and revealing, as they might be the first to notice safety issues [16].
The HSOPSC benchmarking study (2016) conducted by the AHRQ,
which reported results from 680 hospitals in the USA, revealed that
safety perception has been the lowest in EDs compared to other units
(ICUs and rehabilitation services) [25]. In fact, EDs are often recognized
as particularly stressful environments with high pressure and high-
volume workloads [26]. This might explain why EDs caregivers
remain challenged by patient safety [27]. A recently published sys­
tematic review (2020) revealed that the lack of safety-related education
and training is a contributing factor to patient safety incidents that occur
in EDs and impact negatively on staff’s perception of safety [27].
4.1.2. Teamwork within units
As for teamwork, two studies exploring patient safety climate in
Sweden [28] and Brazil [29] have found that teamwork was scored low
by the professionals working in EDs. Also, a recent systematic review,
that explored patient safety attitudes among EDs caregivers, found that

3
W. Aouicha et al. International Emergency Nursing 54 (2021) 100941

Table 3 Table 3 (continued )

Scores and items of the 10 dimensions of patient safety culture. Items of patient safety culture dimensions Absolute Average positive
Items of patient safety culture dimensions Absolute Average positive frequency (n) response (%)
frequency (n) response (%)
D9: Management support for patient 36.87
D1: Overall perceptions of safety 40.82 safety
Patient safety is never sacrificed to get more 200 47.3 Management provides a work climate that 155 35.4
work done promotes patient safety
Our procedures and systems are good at 188 42.7 The actions of management show that 149 34.3
preventing errors from happening patient safety is a top priority
It is just by chance that more serious mistakes 188 42.4 Management seems interested in patient 146 33.3
do not happen around here safety only after an adverse event happens
We have patient safety problems in this 136 30.9 Units work well together to provide the best 195 44.5
facility care for patients
D2: Frequency of adverse events 19.6 D10: Teamwork across units 30.31
reporting There is good cooperation among units that 146 33.3
When a mistake is made, but is caught and 97 22 need to work together
corrected before affecting the patient, it is Units do not coordinate well with each other 140 32
reported It is often unpleasant to work with staff from 117 26.5
When a mistake is made, but has no potential 61 13.8 other units
to harm the patient, it is reported Things ‘fall between the cracks’ when 125 28.3
When a mistake is made that could harm the 98 23 transferring patients from oneunit to
patient, but does not, it is reported another
D3: Supervisor/manager expectations 38.37 Important patient care information is often 140 32.2
and actions promoting patient safety lost during shift changes
Manager says a good word when he/she sees 181 41.2 Problems often occur in the exchange of 130 29.6
a job done according to establishedpatient information across units
safety procedures
Manager seriously considers staff suggestions 172 39.1
for improving patient safety
Whenever pressure builds up, my manager 123 28 Table 4
wants us to work faster, even if it means The level of patient safety perceived by participants and the number of reported
taking shortcuts adverse events during the last 12 months.
My manager overlooks patient safety 199 45.3
Level of perceived patient safety n %
problems that happen over and over
D4: Organizational learning and 38.85 Excellent 25 5.7
continuous improvement Very good 49 11
We are actively doing things to improve 210 48.2 Good 183 41.1
patient safety Poor 145 32.8
Mistakes have led to positive changes here 181 41 Failing 40 9
After we make changes to improve patient 214 48.9 Number of adverse events reported in the past 12 months n %
safety, we evaluate their effectiveness No event reported 383 86.6
We are given feedback about changes put 84 19.2 1–2 34 7.9
into place based on event reports 3–5 15 3.4
We are informed about errors that happen in 164 37.4 6–10 7 1.6
the facility 11–20 2 0.5
In this facility, we discuss ways to prevent 169 38.4
errors from happening again
D5: Teamwork within units 46 they were generally low, especially on teamwork [21]. Admittedly, an
People support one another in this facility 154 36.1
effective teamwork in health systems has been identified as a crucial
When a lot of work needs to be done quickly, 231 52.6
we work together as a team to get the work component for effective and efficient care, better time management and
done staff and patient satisfaction [30]. A retrospective study conducted in
In facility, people treat each other with 208 47.3 EDs in the USA identified 54 cases of errors that could have been avoided
respect
if there was better teamwork [31].
When one area in this unit gets really busy, 214 48.1
others help out
D6: Communication openness 29.5 4.1.3. Frequency of adverse events reported
Staff will freely speak up if they see 173 39.3 Concerning the dimension related to ‘Frequency of adverse events
something that may negatively affect reported’, it had the lowest score. In fact, compared to other medical
patient care
specialties, the density of decision-making that EDs caregivers encounter
Staff feel free to question the decisions or 71 16.2
actions of those with more authority is much greater, which may lead to the occurrence of errors [32]. These
Staff are afraid to ask questions when 145 33 errors must be subsequently reported, thus allowing to understand their
something does not seem right root causes, learn from them and avoid their resurgence [16]. Indeed, A
D7: Nonpunitive response to error 19.8 study conducted in 33 EDs in the Netherlands found that the frequency
Staff feel like their mistakes are held against 100 23.3
them
of error reporting was positively associated with the reported level of
When an event is reported, it feels like the 60 13.8 patient safety [16].
person is being written up, not the problem The low score reported in our results, is corroborated by other studies
Staff worry that mistakes they make are kept 98 22.3 exploring patient safety culture in EDs internationally [16,33,34] and
in their personnel file
also in Tunisia [24,35,36]. This under-reporting can be explained by the
D8: Staffing 22.83
We have enough staff to handle the workload 122 27.7 fact that the commission of error is still always considered as a lack of
Staff in this facility work longer hours than is 93 21 skills and rarely seen as a learning opportunity [24]. In fact, a study
best for patient care conducted in Brazil to explore the consequences of reporting adverse
We work in crisis mode trying to do too 87 19.8 events on professionals found that 74.3% confirmed to be punished after
much, too quickly
committing an error of which 49% were punished by oral warnings and
33% by written warnings [37]. Also, 11% of professionals stated that

4
W. Aouicha et al. International Emergency Nursing 54 (2021) 100941

Table 5
Factors associated with Patient Safety Culture.
Factors Dimensions Subgroups p value

Medical (n ¼ 165) Paramedical (n ¼ 274)

Professional title D1 35.99% 47.14% 0.02

D2 19.99% 19.21% 0.86
D3 36.05% 33.84% 0.69
D4 45.69% 46.62% 0.79
D5 46.05% 49.81% 0.46
D6 31.71% 28.69% 0.55
D7 17.77% 20.43% 0.46
D8 19.79% 24.20% 0.32
D9 33.47% 38.40% 0.29
D10 27.36% 31.79% 0.32

Public (n ¼ 386) Private (n ¼ 56)

Nature of the healthcare facility D1 36.91% 62.49% 2.10-6

D2 18.56% 31.54% 0.01
D3 36.33% 50.88% 0.04
D4 34.94% 67.34% 2.10-6
D5 41.35% 66.06% 5.10-4
D6 28.40% 53.71% 1.6.10-4
D7 19.59% 18.45% 0.74
D8 21.52% 34.54% 0.03
D9 32.89% 58.02% 4.10-4
D10 27.5% 47.02% 0.003

Certified (n ¼ 70) Amid certification (n ¼ 78) Uncertified (n ¼ 294)

Certification D1 47.78% 31.18% 18.21% 2.10-6

D2 20.97% 20.50% 15.70% 0.37
D3 43.61% 32.36% 21.78% 4.10-4
D4 43.75% 27.13% 32.61% 0.07
D5 48.12% 44.34% 36.42% 0.1
D6 30.26% 28.62% 19.04% 0.05
D7 19.83% 20.51% 16.66% 0.64
D8 25.71% 20.08% 22.78% 0.75
D9 43.27% 27.56% 17.85% 3.10-5
D10 36.10% 20.58% 15.47% 5.10-4

Yes (n ¼ 96) No (n ¼ 345)

Participation into risk management committees D1 44.26% 39.12% 0.41

D2 30.21% 18.93% 0.01
D3 41.40% 37.38% 0.44
D4 45.59% 36.13% 0.08
D5 57.54% 42.16% 0.007
D6 45.41% 27.72% 8.10-4
D7 33.69% 19.99% 0.005
D8 27.42% 21.53% 0.2
D9 34.89% 33.33% 0.84
D10 33.50% 29.22% 0.44

Yes (n ¼ 192) No (n ¼ 250)

Follow-up of training on patient safety D1 42.70% 38.20% 0.35

D2 22.04% 17.73% 0.26
D3 36.32% 39.6% 0.5
D4 41.40% 27.66% 0.002
D5 52.91% 43.6% 0.04
D6 38.37% 28.53% 0.02
D7 17.88% 20.40% 0.47
D8 22.04% 23.33% 0.7
D9 36.45% 36.50% 0.9
D10 32.28% 28.40% 0.3

*Dimensions in bold character have been significantly associated to patient safety culture.
*p ≤ 0.05.
Amid certification: EDs that were going through certification process during the data collection.
D1: Overall perceptions of safety, D2: Frequency of adverse events reporting, D3: Supervisor/manager expectations and actions promoting patient safety, D4:
Organizational learning and continuous improvement, D5: Teamwork within units, D6: Communication openness, D7: Nonpunitive response to error, D8: Staffing, D9:
Management support for patient safety, D10: Teamwork across units.

they were temporarily removed from work, 5% were permanently dis­
missed and 2% of professionals experienced psychological harassment
following the reporting of errors [37].
4.2. Factors associated with patient safety culture
4.2.1. Professional title
Our results revealed that the paramedical staff rated significantly
higher the “overall perception of safety”. For instance, it has been shown
that the nursing professionals are the most influential members of

5
W. Aouicha et al.
healthcare teams in providing safe care and play a pivotal role in
improving patient safety [38,39]. A literature review stated also that
nursing professionals are considered a key to safety improvement and
have a crucial role in enhancing the quality of care given the nature of
their work that provide them with opportunities to reduce adverse
events and intercept healthcare errors before they occur [40].
4.2.2. Nature of the healthcare facility
Our findings also show that the nature of the healthcare facility had
an influence on the perception of patient safety culture, where 9 di­
mensions were significantly more developed in private hospitals. Simi­
larly, a national study conducted among nurses in South Africa found
that public sector caregivers were significantly more dissatisfied with
their work than those in the private sector [41]. The main differences
between the two sectors were related to the lack of safety conditions and
the available resources, the crowdedness and workload and the absence
of a good relationship with management in the public sector [41,42].
Indeed, private hospitals seek to maintain a “brand image” and a good
reputation to attract a maximum of customers, which explains the
importance and interest they dedicate to the quality of care and patient
safety.
4.3. Recommendations
In light of our findings, we recommend systematic improvement of
staff qualifications by providing training opportunities and educational
interventions on the principles of patient safety, teamwork and effective
communication strategies. A systematic review about interventions to
improve team effectiveness within healthcare settings, revealed that
training is the most frequently explored intervention and is most likely
to be effective in acute care settings, such as the ED [43]. To this end,
TeamSTEPPS, which is a standardized training that received consider­
able attention in the past decade, was recently evaluated in an ED setting
and proved its effectiveness to promote teamwork and patient safety
attitudes [43]. Furthermore, it is essential for the ED to foster a working
environment that encourages open dialogue about adverse events and
provide protection to caregivers to report errors. Thus, it is mandatory to
introduce an anonymous reporting system to create a non-punitive
environment in the ED.
4.4. Limitations
This study is among limited research which has focused on patient
safety culture in Tunisian hospitals and to our knowledge, it is the first
study in Tunisia to explore this concept in EDs. However, the results
remain specific to Tunisia and are therefore not generalisable to other
ED settings internationally. Another limitation was related to the self-
administered questionnaire used in the study that may have led to a
self-reporting bias. Also, we report the possibility of a self-selection bias
as part of the nature of data collection.
Finally, it is important to note that eight out of thirteen private
healthcare facilities did not respond with approval to take part in this
study which may have affected the representativity of the private sector.
5. Conclusion
The findings of this study showed a concerning perception held by
participants about the lack of a patient safety culture in their EDs. We
highlighted different areas of concern, such as teamwork, frequency of
adverse events reported and non-punitive response to error. Results
showed that several factors have been found significantly related to
patient safety culture such as the involvement in risk management
committees, training in patient safety and ED certification. These factors
must be focused on to guide future interventions.
It is suggested that patient safety culture should be a strategic pri­
ority of policy makers, managers, leaders and especially health
6
International Emergency Nursing 54 (2021) 100941
professionals by establishing consistent approaches with specific ob­
jectives aiming to improve continuously patient safety and healthcare
quality.
Ethical statement
All ethical recommendations listed in the duties for authors in the
publishing ethics have been read and respected.
CRediT authorship contribution statement
Wiem Aouicha: Conceptualization, Methodology, Writing - original
draft. Mohamed Ayoub Tlili: Writing - original draft. Jihene Sahli: .
Mohamed Ben Dhiab: Supervision. Souad Chelbi: Writing - review &
editing. Ali Mtiraoui: Writing - review & editing. Houyem Said Latiri:
Project administration. Thouraya Ajmi: Writing - review & editing.
Chekib Zedini: Writing - review & editing. Mohamed Ben Rejeb:
Conceptualization, Methodology, Writing - original draft. Manel Mal­
louli: Conceptualization, Methodology, Writing - review & editing,
Supervision.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
Authors would like to express special thanks and gratitude to
healthcare practitioners that took the effort to be part of this study, and
also the administrative teams of all the EDs in which the study was
conducted for their collaboration and support attitudes.
References
[1] Bigham BL, Maher J, Morrison LJ. Canadian Patient Safety Institute. Patient safety
in emergency medical services: advancing and aligning the culture of patient safety
in EMS. Edmonton, Alta: Canadian Patient Safety Institute; 2010.
[2] Bion J. Patient safety: Needs and initiatives 2008.
[3] Durgun H, Kaya H. The attitudes of emergency department nurses towards patient
safety. Int Emerg Nurs 2018;40:29–32. https://doi.org/10.1016/j.
ienj.2017.11.001.
[4] Farmer B. Patient Safety in the Emergency Department. Emerg Med 2016;48:
396–404. https://doi.org/10.12788/emed.2016.0052.
[5] Hesselink G, Berben S, Beune T, Schoonhoven L. Improving the governance of
patient safety in emergency care: a systematic review of interventions. BMJ Open
2016;6:e009837.
[6] Jiménez-Rodríguez E, Feria-Domínguez J, Sebastián-Lacave A. Assessing the
Health-Care Risk: The Clinical-VaR, a Key Indicator for Sound Management. Int J
Environ Res Public Health 2018;15:639. https://doi.org/10.3390/ijerph15040639.
[7] Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L. Patient safety climate in 92
US hospitals: differences by work area and discipline. Med Care 2009;47:23–31.
[8] Camargo CA, Tsai C-L, Sullivan AF, Cleary PD, Gordon JA, Guadagnoli E, et al.
Safety Climate and Medical Errors in 62 US Emergency Departments. Ann Emerg
Med 2012;60(555–563):e20. https://doi.org/10.1016/j.
annemergmed.2012.02.018.
[9] Calder LA, Forster A, Nelson M, Leclair J, Perry J, Vaillancourt C, et al. Adverse
events among patients registered in high-acuity areas of the emergency
department: a prospective cohort study. CJEM 2010;12:421–30. https://doi.org/
10.1017/S1481803500012574.
[10] Stang AS, Wingert AS, Hartling L, Plint AC. Adverse Events Related to Emergency
Department Care: A Systematic Review. PLoS ONE 2013;8:e74214. https://doi.
org/10.1371/journal.pone.0074214.
[11] Letaief M, El Mhamdi S, El-Asady R, Siddiqi S, Abdullatif A. Adverse events in a
Tunisian hospital: results of a retrospective cohort study. Int J Qual Health Care
2010;22:380–5. https://doi.org/10.1093/intqhc/mzq040.
[12] Bouafia N, Bougmiza I, Bahri F, Letaief M, Astagneau P, Njah M. Ampleur et impact
des évènements indésirables graves liés aux soins: étude d’incidence dans un
hôpital du Centre-Est tunisien. Pan Afr Med J 2014;16.
[13] Haute Autorité de Santé. La sécurité des patients mettre en œuvre la gestion des
risques associés aux soins en établissement de santé. 2012.
[14] Nieva VF. Safety culture assessment: a tool for improving patient safety in
healthcare organizations. Qual Saf Health Care 2003;12:17ii–23. https://doi.org/
10.1136/qhc.12.suppl_2.ii17.
W. Aouicha et al.
[15] Feng X, Bobay K, Weiss M. Patient safety culture in nursing: a dimensional concept
analysis. J Adv Nurs 2008;63:310–9. https://doi.org/10.1111/j.1365-
2648.2008.04728.x.
[16] Verbeek-Van Noord I, Wagner C, Van Dyck C, Twisk JWR, De Bruijne MC. Is
culture associated with patient safety in the emergency department? A study of
staff perspectives. Int J Qual Health Care 2014;26:64–70. https://doi.org/
10.1093/intqhc/mzt087.
[17] Dunstan E, Cook J-L, Coyer F. Safety culture in intensive care internationally and in
Australia: A narrative review of the literature. Aust Crit Care 2019;32:524–39.
https://doi.org/10.1016/j.aucc.2018.11.003.
[18] Zhao P, Li Y, Li Z, Jia P, Zhang L, Zhang M. Use of patient safety culture
instruments in operating rooms: A systematic literature review: Zhao et al. J Evid-
Based Med 2017;10:145–51. https://doi.org/10.1111/jebm.12255.
[19] AL Lawati MH, Short SD, Abdulhadi NN, Panchatcharam SM, Dennis S. Assessment
of patient safety culture in primary health care in Muscat, Oman: a questionnaire
-based survey. BMC Fam Pract 2019;20:50. https://doi.org/10.1186/s12875-019-
0937-4.
[20] Egea FR, Vecina ST, Borras MRC. Patient safety culture in 30 Spanish hospital
emergency departments: results of the Agency for Healthcare Research and
Quality’s Hospital Survey on Patient Safety Culture. Emergencias 2011;23:356–64.
[21] Alzahrani N, Jones R, Rizwan A, Abdel-Latif ME. Safety attitudes in hospital
emergency departments: a systematic review. Int J Health Care Qual Assur 2019;
32:1042–54. https://doi.org/10.1108/IJHCQA-07-2018-0164.
[22] Comité de coordination de l’évaluation clinique et de la qualité en Aquitaine.
Mesure de la culture de sécurité des soins dans les établissements de santé Guide
d’utilisation version octobre 2015. 2015.
[23] Occelli P, Quenon J-L, Kret M, Domecq S, Delaperche F, Claverie O, et al.
Validation of the French version of the Hospital Survey on Patient Safety Culture
questionnaire. Int J Qual Health Care 2013;25:459–68. https://doi.org/10.1093/
intqhc/mzt047.
[24] Tlili MA, Aouicha W, Ben Rejeb M, Sahli J, Ben Dhiab M, Chelbi S, et al. Assessing
patient safety culture in 18 Tunisian adult intensive care units and determination
of its associated factors: A multi-center study. J Crit Care 2020;56:208–14. https://
doi.org/10.1016/j.jcrc.2020.01.001.
[25] The Agency for Healthcare Research and Quality. Hospital survey on patient safety
culture: 2016 User Comparative Database Report. 2016.
[26] Johnston A, Abraham L, Greenslade J, Thom O, Carlstrom E, Wallis M, et al.
Review article: Staff perception of the emergency department working
environment: Integrative review of the literature: ED Staff Perception of Working
Environment. Emerg Med Australas 2016;28:7–26. https://doi.org/10.1111/1742-
6723.12522.
[27] Amaniyan S, Faldaas BO, Logan PA, Vaismoradi M. Learning from Patient Safety
Incidents in the Emergency Department: A Systematic Review. J Emerg Med 2020;
58:234–44. https://doi.org/10.1016/j.jemermed.2019.11.015.
[28] Milton J, Chaboyer W, Åberg ND, Erichsen Andersson A, Oxelmark L. Safety
attitudes and working climate after organizational change in a major emergency
department in Sweden. Int Emerg Nurs 2020:100830. https://doi.org/10.1016/j.
ienj.2020.100830.
International Emergency Nursing 54 (2021) 100941
[29] Rigobello MCG, de Carvalho REFL, Guerreiro JM, Motta APG, Atila E,
Gimenes FRE. The perception of the patient safety climate by professionals of the
emergency department. Int Emerg Nurs 2017;33:1–6. https://doi.org/10.1016/j.
ienj.2017.03.003.
[30] Kilner E, Sheppard LA. The role of teamwork and communication in the emergency
department: A systematic review. Int Emerg Nurs 2010;18:127–37. https://doi.
org/10.1016/j.ienj.2009.05.006.
[31] Dhingra KR, Elms A, Hobgood C. Reducing Error in the Emergency Department: A
Call for Standardization of the Sign-out Process. Ann Emerg Med 2010;56:637–42.
https://doi.org/10.1016/j.annemergmed.2010.02.004.
[32] Hobgood C. Error Identification, Disclosure, and Reporting: Practice Patterns of
Three Emergency Medicine Provider Types. Acad Emerg Med 2004;11:196–9.
https://doi.org/10.1197/j.aem.2003.08.020.
[33] Burström L, Letterst\a al A, Engström M-L, Berglund A, Enlund M. The patient
safety culture as perceived by staff at two different emergency departments before
and after introducing a flow-oriented working model with team triage and lean
principles: a repeated cross-sectional study. BMC Health Serv Res 2014;14:296.
[34] Wang X, Liu K, You L, Xiang J, Hu H, Zhang L, et al. The relationship between
patient safety culture and adverse events: A questionnaire survey. Int J Nurs Stud
2014;51:1114–22. https://doi.org/10.1016/j.ijnurstu.2013.12.007.
[35] Tlili MA, Aouicha W, Ben Dhiab M, Mallouli M. Assessment of nurses’ patient
safety culture in 30 primary health care centres in Tunisia. East Mediterr Health J
2020. https://doi.org/10.26719/emhj.20.026.
[36] Mallouli M, Tlili MA, Aouicha W, Ben Rejeb M, Zedini C, Salwa A, et al. Assessing
patient safety culture in Tunisian operating rooms: A multicenter study. Int J Qual
Health Care 2017. https://doi.org/10.1093/intqhc/mzw157.
[37] Claro CM, Krocockz DVC, Toffolleto MC, Padilha KG. [Adverse events at the
Intensive Care Unit: nurses’ perception about the culture of no-punishment]. Rev
Esc Enferm U P 2011;45:167–72.
[38] Tomazoni A, Rocha PK, de Souza S, Anders JC, de Malfussi HFC. Patient safety
culture at neonatal intensive care units: perspectives of the nursing and medical
team. Rev Lat Am Enfermagem 2014;22:755–63. https://doi.org/10.1590/0104-
1169.3624.2477.
[39] Ammouri AA, Tailakh AK, Muliira JK, Geethakrishnan R, Al Kindi SN. Patient
safety culture among nurses. Int Nurs Rev 2015;62:102–10.
[40] Richardson A, Storr J. Patient safety: a literative review on the impact of nursing
empowerment, leadership and collaboration. Int Nurs Rev 2010;57:12–21. https://
doi.org/10.1111/j.1466-7657.2009.00757.x.
[41] Pillay R. Retention strategies for professional nurses in South Africa. Leadersh
Health Serv 2009;22:39–57. https://doi.org/10.1108/17511870910928010.
[42] Khoshakhlagh AH, Khatooni E, Akbarzadeh I, Yazdanirad S, Sheidaei A. Analysis of
Affecting Factors on Patient Safety Culture in Public and Private Hospitals in Iran.
In Review; 2019. https://doi.org/10.21203/rs.2.10737/v1.
[43] Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve
team effectiveness within health care: a systematic review of the past decade. Hum
Resour Health 2020;18:2. https://doi.org/10.1186/s12960-019-0411-3.