Received: 11 March 2020 | Revised: 8 July 2020 | Accepted: 4 August 2020

DOI: 10.1111/eje.12588

ORIGINAL ARTICLE

Patient safety culture amongst dental students and interns in

Dammam, Saudi Arabia

Reem AlOlayan1 | Albandri Alahmad1 | Danah Buali1 | Faisal Alonaizan2 |

Muhanad Alhareky3 | Jehan Alhumaid3 | Muhammad Ashraf Nazir3

1
College of Dentistry, Imam Abdulrahman
Bin Faisal University, Dammam, Saudi Arabia
2
Department of Restorative Dental Sciences,
College of Dentistry, Imam Abdulrahman Bin
Faisal University, Dammam, Saudi Arabia
3
Department of Preventive Dental Sciences,
College of Dentistry, Imam Abdulrahman Bin
Faisal University, Dammam, Saudi Arabia
Correspondence
Muhammad Ashraf Nazir, Department of
Preventive Dental Sciences, College of
Dentistry, Imam Abdulrahman Bin Faisal
University, P. O. Box 1982 Dammam 31441,
Saudi Arabia.
Email: manazir@iau.edu.sa
Abstract
Objective: To evaluate awareness and attitudes of dental students and interns about
patient safety culture in Dammam, Saudi Arabia.
Materials and methods: This cross-sectional study was conducted on 272 under-
graduate dental students and interns using the Safety Attitudes Questionnaire (SAQ)
from November 2019 to January 2020. The SAQ consists of six domains: teamwork
climate, safety climate, job satisfaction, stress recognition, perception of manage-
ment and work conditions. The score of SAQ ranges from 0 to 100, and a cut-off ≥75
is considered a positive attitude of patient safety.
Results: The study included 47.1% of males and 52.9% of females with a mean age
of 22.58 ± 1.3 years. Few participants (9.9%) showed a positive attitude of patient
safety culture. Nearly one-third of participants (35.7%) attended a course on patient
safety and 31.6% reported experiencing adverse events by them or their families. Out
of six domains, job satisfaction showed the highest mean score (70.25) and 75.4% of
participants felt proud to practise in the dental clinic. Female students demonstrated
a significantly higher mean score of stress recognition (64.28 ± 18.98) than male
students (56.98 ± 22.53) (P 0.004). The mean SAQ score increased significantly from
fourth year students to interns (P < .001).
Conclusions: A small percentage of students demonstrated a positive attitude of pa-
tient safety and only one-third attended a patient safety course. The job satisfaction
domain was highly rated and patient safety culture significantly improved from junior
to senior students. Dental curricula should include patient safety courses to improve
the quality and safety of patient care.

KEYWORDS

dental students, dentistry, medical errors, patient safety

1 | I NTRO D U C TI O N environment is a public health problem as it presents adverse events

to the patients and staff. 2 The adverse events are situations where
The healthcare environment predisposes patients and healthcare harm is caused to patients unintentionally during treatment and
teams to considerable risk factors and hazards.1 An unsafe health are associated with different factors at the level of individual tasks,

© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Eur J Dent Educ. 2020;00:1–8.  wileyonlinelibrary.com/journal/eje | 1

2 |
teamwork, work environment or the organisation.3 A retrospective
analysis of medical records of hospital admission from eight coun-
tries showed that the prevalence of adverse events was 8.2%, and
83% of these events were preventable. 2 The adverse events are also
common in dental practice as shown in a study of 270 cases of ad-
verse events where 24.4% of cases resulted in permanent harm and
11.1% in patient mortality.4 The understanding of the nature and
extent of the adverse events can help prevent or minimise their oc-
currence in dentistry.3
Providing a safe healthcare environment is as important as
any other aspect of healthcare because it shows the care, com-
passion and attentiveness that healthcare providers have towards
their patients. 5 The Institute of Medicine defines patient safety as
“the prevention of harm to patients from the care that is intended
to help them.”6 Patient safety culture is viewed as shared values,
perceptions, and competencies which create behavioural norms or
practices amongst the members of a healthcare organisation for
the promotion of safety.7,8 Positive patient safety culture can help
reduce preventable adverse events such as medical errors, compli-
cations and accidents in addition to minimising unavoidable events
in health care.1,7 The culture of patient safety is not only related
to the safe provision of care and patient protection by healthcare
teams, but it also has financial, cultural, social and organisational
implications.1
Lately, the concept of patient safety skills has raised the inter-
9
ests of healthcare researchers. Workplace safety culture can be
improved by assessing the current safety culture of healthcare or-
ganisations. This assessment can help organisations identify the
areas that need improvement and recognise the strengths and weak-
10
nesses of their patient safety culture. It is therefore emphasised
that the patient safety culture should be developed in a way that
healthcare providers should share their positive and negative expe-
riences to enhance the understanding of the issues and improve the
11
provision of safer healthcare services.
Evidence suggests that the inclusion of patient safety pro-
grammes in curricula enables students to recognise the impor-
tance of patient safety culture which has positive effects on their
healthcare attitudes and behaviours, thus making them safer
healthcare providers in the future.12 Myung et al13 analysed data
of medical students before and after incorporating patient safety
course into the curriculum and observed a significant increase
in students' awareness about patient safety. In another study,
Aboumatar et al14 showed a significant increase in the knowledge,
self-efficacy and system-based thinking about patient safety
amongst medical students after completing a three-day patient
safety course.
The burden of human errors in dentistry is less than in the med-
ical profession. That is why the healthcare system does not give
much needed importance to patients' safety in dentistry.15 However,
11
the impact of dental errors should not be underestimated. For in-
stance, patient safety culture from seven dental schools was com-
pared with twenty general hospitals in the United States and it was
found the participants in dental schools demonstrated higher overall
ALOLAYAN et al.
patient safety culture scores than their counterparts in hospitals.15 In
Riyadh, a study of female students from two dental colleges showed
that the students of the dentistry programme were more likely to
have a positive perception of patient safety culture than dental hy-
giene students.12 However, another study in Riyadh reported a more
positive score about patient safety culture by dental assistants than
dental students.16 Recently, the researchers in the United States
observed improvement in patient safety over time; however, there
were variations in dental institutions.17
There is a growing emphasis on patient safety in dental educa-
tion. However, there is insufficient data about patient safety culture
in dental colleges. Therefore, the aim of this study was to evalu-
ate dental students' awareness and attitudes of the patient safety
culture in the College of Dentistry, Imam Abdulrahman Bin Faisal
University in Dammam, Saudi Arabia.
2 | M ATE R I A L S A N D M E TH O DS
This cross-sectional study was carried out in the College of Dentistry,
Imam Abdulrahman Bin Faisal University, Dammam, Eastern prov-
ince of Saudi Arabia. The data for the study were collected between
November 2019 and January 2020. The study employed a census
sample of students and interns. It is known that the census sam-
ple provides accurate information as study results are not subject to
sampling errors. Therefore, undergraduate students in their fourth,
fifth and sixth year classes and interns were invited to participate
in the study. The participants in their clinical years and those who
agree to voluntary participation met eligibility criteria. Second year
students in both semesters and third year students in the first se-
mester were excluded from the study as they are not exposed to the
clinical environment/patient treatment.
The Safety Attitude Questionnaire (SAQ) is one of the most
widely used tools for the evaluation of patient safety culture.18 The
SAQ was developed by the Agency for Healthcare Research and
Quality in the US19 The patient safety culture in our study was as-
sessed by using SAQ because it is one of the most commonly ad-
opted and rigorously validated tools for patient safety culture in
healthcare settings. 20
The SAQ is composed of 36 questions about patient safety
perception and is divided into six domains: teamwork climate,
job satisfaction, perception of management, stress recognition,
safety climate and working conditions. The teamwork climate do-
main appraises teamwork between healthcare personnel using six
statements. The job satisfaction domain measures the satisfac-
tion of work experience using five statements. The approval of
management actions is assessed in the perception of management
domain using six statements. The stress recognition domain rec-
ognises how performance is affected by stress using four state-
ments. The safety climate domain determines the commitment
to safety by using eight statements. The last domain, work con-
ditions, assesses the quality of the work environment by using
seven statements.
ALOLAYAN et al.
A Likert scale with five levels (strongly disagree, disagree, neu-
tral, agree and strongly agree) is used for SAQ items. The score of
the instrument ranges from 0 to 100, with 0 representing the worst
perception and 100 corresponding to the best perception of patient
safety. A cut-off ≥ 75 is considered a positive attitude of patient
safety. The scores of SAQ and its domains were calculated by giv-
ing 0 to strongly disagree, 25 to disagree, 50 to neural, 75 to agree
and 100 to strongly agree options. The responses of all items were
added and then divided by the total number of items to give over-
all score of SAQ. The score in each domain was also calculated in a
similar way. 21,22 In addition, the study collected information about
participant's age, gender, academic year, previous year's grade point
average (GPA) and parent's education.
It is known that a previously validated questionnaire may not
be valid in another culture. 23 Therefore, the questionnaire was re-
viewed comprehensively from a cultural point of view and the items
in the SAQ were evaluated for relevance and acceptance in dental
24
students and interns in Saudi Arabian culture. A recent study in
the country used SAQ to assess the underlying concept of patient
safety culture amongst dental students.12 This also supported our
cross-cultural adaptation process. 24 Moreover, the questionnaire
was pilot tested amongst 30 male and female students for clarity
and appropriateness of the items. However, no modifications were
indicated because of the review process and pilot testing of the
questionnaire.
The reliability analysis of SAQ was performed, and Cronbach's
alpha (α) was 0.88. Data were collected from the participants in per-
son using self-administered questionnaires. The questionnaire was
distributed amongst interns in the teaching clinics, and they were
contacted twice if they were unable to provide their responses in the
first visit due to their busy schedules. Amongst dental students, the
questionnaire was administered in their classrooms. The participants
were informed about the purpose of the study. Participation in the
survey was voluntary, and participants were assured about the pri-
vacy and confidentiality of their responses. The questionnaire was
provided to nearly all fourth, fifth and six year students and interns
(N = 398), but those who were willing to participate in the study pro-
vided their responses (N = 272). They were free to withdraw from
the study at any time without a negative impact. Ethical approval
was obtained from the Scientific Research Unit (ethics committee) at
the College. The study was conducted per the ethical guidelines of
the Declaration of Helsinki.
SPSS software (IBM SPSS Statistics for Windows, version 22.0;
IBM Corp) was used for data entry and analysis. Descriptive statis-
tics such as percentages, means and standard deviations of different
variables were calculated. The participants’ responses to each item
of the SAQ were combined into three categories: agree, neutral and
disagree for improved clarity and interpretation of results. Agree
and strongly agree options were combined to create the “agree” cat-
egory, and disagree and strongly disagree options were combined
to make the “disagree” category. Independent t test and one-way
ANOVA were performed in the study. A P < .05 was used for statis-
tical significance.
| 3
3 | R E S U LT S
The response rate of study was 68.3% (272/398). There were 47.1%
of males and 52.9% of females in the study with a mean age of
22.58 ± 1.3 years. Twenty-seven participants (9.9%) demonstrated
a positive score of patient safety culture (SAQ ≥ 75). A course on
patient safety culture was attended by 35.7% of the participants.
Adverse medical/dental event or “medical error” was experienced by
31.6% of participants or their family members.
Table 1 shows students' responses about three domains of SAQ
(teamwork climate, safety climate and job satisfaction). For the team-
work climate domain, most participants agreed (67.3%) that it was
easy for them to ask questions when there was something that they
did not understand. This was followed by 66.5% of the participants
who agreed that they had the support they needed from other per-
sonnel for patient care. In the safety climate domain, more than 60%
of participants agreed that they would feel safe being treated here
as a patient and medical errors were handled appropriately in this
clinical area. The most commonly agreed statement (75.4%) in the job
satisfaction domain was “I am proud to practice in this dental clinic”.
The answers of participants for questions in stress recognition,
perception of management and working conditions are presented
in Table 2. Regarding stress recognition statements, 62.1% of the
participants reported being less effective when fatigued. Amongst
items in the perception of management, most participants (61%)
stated that the levels of the students in the dental clinic were suffi-
cient to handle the number of patients. In the work conditions do-
main, the majority agreed (67.3%) that the dental clinic does a good
job of training new personnel.
Figure 1 presents the mean scores of six domains of SAQ in den-
tal students. The job satisfaction domain showed the highest mean
score (70.25 ± 21.22) and this was followed by the work condition
domain (64.74 ± 20.11). Mean scores of SAQ and its domains were
compared between male and female students and students with low
and high GPA. The median GPA was 4.4 which was dichotomised
into low (up to 4.4 GPA) and high (more than 4.4 GPA). Female stu-
dents demonstrated a significantly higher mean score of stress rec-
ognition (64.28 ± 18.98) than male students (56.98 ± 22.53) (P =
.004). No significant differences in the mean scores of SAQ and its
domains were observed between male and female students and stu-
dents with low and high GPA (Table 3).
The comparison of mean scores of SAQ and its domains in stu-
dents with low and high parental education is presented in Table 4.
The analysis showed no statistically significant differences in the
mean scores of SAQ and its domain. In Table 5, mean scores of SAQ
and its domains are shown in fourth, fifth and sixth year students
and interns. The teamwork climate improved from the fourth year
(55.93 ± 17.82) to the internship (64.02 ± 10.61), and the difference
in the mean score was statistically significant (P < .001). Similarly,
safety climate (P = .002), perception of management (P = .002) and
work condition (P < .001) significantly improve from the fourth year
to the internship. Overall, the mean SAQ score also increased signifi-
cantly from junior classes to the internship (P < .001).
4 | ALOLAYAN et al.

TA B L E 1 Descriptive analysis of each question of SAQ in three domains teamwork atmosphere, safety atmosphere and job satisfaction of
dental students

Strongly disagree/ Agree/Strongly

Disagree Neutral Agree
Safety attitude statement N (%) N (%) N (%)

Teamwork climate
1. Students input is well received in this clinical area 28 (10.3) 92 (33.8) 152 (55.9)
2. In this dental clinic, it is difficult to speak up if I perceive a problem with patient care 156 (57.4) 75 (27.6) 41 (15.1)
3. Disagreements in this clinical area are resolved appropriately (ie not who is right, 34 (12.5) 90 (33.1) 148 (54.4)
but what is best for the patient)
4. I have the support I need from other personnel to care for patients 25 (9.2) 66 (24.3) 181 (66.5)
5. It is easy for students here to ask questions when there is something that they do 38 (14) 51 (18.8) 183 (67.3)
not understand
6. The supervisors and students here work together as a well-coordinated team 33 (12.1) 66 (24.3) 173 (63.6)
Safety climate
7. I would feel safe being treated here as a patient 31 (11.4) 71 (26.1) 170 (62.5)
8. Medical errors are handled appropriately in this clinical area 21 (7.7) 80 (29.4) 171 (62.9)
9. I know the proper channels to direct questions regarding patient safety in this 52 (19.1) 84 (30.9) 136 (50)
clinical area
10. I receive appropriate feedback about my performance 55 (20.2) 76 (27.9) 141 (51.8)
11. In this dental clinic, it is difficult to discuss errors 147 (54) 84 (30.9) 41 (15.1)
12. I am encouraged by my colleagues to report any patient safety concerns I may 38 (14) 91 (33.5) 143 (52.6)
have
13. The environment in this dental clinic makes it easy to learn from the errors of 40 (14.7) 73 (26.8) 159 (58.5)
others
Job satisfaction
15. I like my specialty 23 (8.5) 61 (22.4) 188 (69.1)
16. Practicing here is like being part of a large family 37 (13.7) 70 (25.7) 165 (60.7)
17. This is a good place to practise 25 (9.2) 56 (20.6) 191 (70.2)
18. I am proud to practise in this dental clinic 21 (7.7) 46 (16.9) 205 (75.4)
19. Ethics in this dental clinic is high 32 (11.8) 65 (23.9) 175 (64.3)

4 | D I S CU S S I O N Patient Safety Culture” (MOSOPS). 26 Recently, MOSOPS instru-

This cross-sectional study evaluated patient safety culture amongst
dental students and interns in a dental institution in Saudi Arabia. The
study used the SAQ instrument the validity and reliability of which
20,25
were confirmed in previous studies. In Northern China, a study
was conducted to validate the reliability and validity of the SAQ in
27 public hospitals in five cities across Heilongjiang Province. In this
study, Cronbach's alpha (α) for the total scale was high (0.91) indi-
cating good internal consistency reliability and confirmatory factor
analysis showed satisfactory validity of the instrument. 25 Similarly,
another study of Albanian hospitals which included 341 healthcare
providers showed that SAQ had acceptable validity and reliability. 20
Literature indicates the use of different instruments for the
evaluation of patient safety culture in dentistry.12,15,17,26 Leong
et al used “Hospital Survey on Patient Safety Culture” amongst
dental students, staff, faculty and administrators in seven dental
schools in the United States.15 Romani et al evaluated patient safety
culture in three US dental schools using “Medical Office Survey on
ment was utilised by Yansane et al17 to observe patient safety cul-
ture in three dental institutions in the United States. Both Romani
et al and Yansane et al used MOSOPS amongst dental faculty, den-
tal hygienists, dental students and dental staff.17,26 In Saudi Arabia,
female dental students from two dental colleges provided their
responses about patient safety culture by responding to “Safety
Attitude Questionnaire” (SAQ).12 Given similar cultural and aca-
demic context and homogeneity of study population, the present
study also used SAQ instrument in dental students and interns.
Many researchers used SAQ for the evaluation of patient
safety amongst medical, nursing and other healthcare profession-
als. 20,22,25,27 Similarly, MOSOPS is a widely used tool in medical
office settings involving physicians, nurses, and clinical and admin-
istrative staff. The instrument consists of 38 items that evaluate pa-
tient safety in 10 dimensions such as “Communication About Error”,
“Communication Openness”, “Office Processes and Standardization”,
“Organizational Learning”, “Overall Perceptions of Patient Safety
and Quality”, “Owner/Managing Partner/Leadership Support for
ALOLAYAN et al. | 5

TA B L E 2 Descriptive analysis of each question of SAQ in three domains stress, perception of management and working conditions of
dental students

Strongly disagree/ Agree/

Disagree Neutral Strongly Agree
Safety attitude statement N (%) N (%) N (%)

Stress recognition
20. When my workload becomes excessive, my performance is impaired. 46 (16.9) 88 (32.4) 138 (50.7)
21. I am less effective at work when fatigued. 44 (16.2) 59 (21.7) 169 (62.1)
22. I am more likely to make errors in tense or hostile situations 59 (21.7) 84 (30.9) 129 (47.4)
23. Fatigue impairs my performance during emergency situations (eg emergency 58 (21.3) 107 (39.3) 107 (39.3)
resuscitation, seizure).
Perception of management
24. Clinical management supports my daily efforts 19 (7) 122 (44.9) 131 (48.2)
25. Clinical management doesn't knowingly compromise patient safety 63 (23.2) 123 (45.2) 86 (31.6)
26. Clinical supervisor is doing a good job 33 (12.1) 81 (29.8) 158 (58.1)
27. Problem personnel are dealt with constructively by our clinical units 31 (11.4) 127 (46.7) 114 (41.9)
28. I get adequate, timely info about events that might affect my work 45 (16.5) 105 (38.6) 122 (44.9)
29. The levels of students in this dental clinic are sufficient to handle the number of 37 (13.6) 69 (25.4) 166 (61)
patients.
Work conditions
30. This dental clinic does a good job of training new personnel.(eg students or staff) 21 (7.7) 68 (25) 183 (67.3)
31. All the necessary information for diagnostic and therapeutic decisions is routinely 37 (13.6) 89 (32.7) 146 (53.7)
available to me.
32. Trainees in my discipline are adequately supervised 36 (13.2) 86 (31.6) 150 (55.1)

avoidance of medical errors and effective management of care.16

Mean score of domains of SAQ
However, only 9.9% of the participants demonstrated a positive pa-
70.25
tient safety culture in our study. Therefore, equipping students and
healthcare providers with knowledge and skills of patient safety is
64.74
mandatory to ensure the quality and safety of care. The effective-
61.18 60.85 61.25 ness of patient safety courses in curricula and continuing education
59.73
programmes is well documented.13,14
Dental students, as the future dentists and leaders in the dental
profession, must learn the concepts and principles of patient safety
Teamwork Safety Climate Job Stress Perception of Work culture. Although, dental curricula are constantly changing to adapt
Climate Satisfaction Recognition Management Conditions
to the latest advancements in dental sciences, technologies and

FIGURE 1 Mean score of domains of SAQ in dental students
Patient Safety”, “Patient Care Tracking/Follow-up”, “Staff Training”,
28
“Teamwork” and “Work Pressure and Pace”. Although items of
SAQ and MOSOPS instruments differ, however, both instruments
broadly assess teamwork, communication, patient safety, training/
learning, work pressure/stress, and management/leadership sup-
port and demonstrate ability to draw comparable inferences of pa-
tient safety culture.
A positive patient safety culture prevents harm to patients by
involving providers, patients and healthcare organisations through
shared values, perceptions, behaviours, and competencies of indi-
viduals and groups.8,12,19 Patient safety helps ensure high quality
patient care by providing proper diagnosis, prevention of infections,
equipment, and changes in the delivery of oral care. 29,30 However,
patient safety is not a stand-alone subject, but it pertains to all areas
of dental practice and its understanding amongst dental students
will them help evaluate its effects on the quality and safety of dental
care in their future career. Therefore, the World Health Organization
in the Patient Safety Curriculum Guide recommends the integration
of patient safety in health sciences education to prepare students
for the safe practice of their disciplines.30
Several factors influence patient safety culture and clinical prac-
tice which include organisational factors, work environment factors,
team factors and staff factors.12,19 The students in this study gave
the highest score to the job satisfaction domain. A study of female
dental students in Riyadh based on the SAQ instrument also indi-
cated the highest score for the job satisfaction domain.12 Similarly,
three studies of nursing professionals in Brazil used the same
6 | ALOLAYAN et al.

TA B L E 3 Relationship between domains of SAQ and gender and GPA of dental students

Domains Males Females P-value Low GPA High GPA P-value

Teamwork climate 61 ± 16.37 61.34 ± 13.6 .852 62.5 ± 14.44 59.99 ± 15.32 .168
Safety climate 60.38 ± 15.11 59.15 ± 12.58 .466 60.82 ± 14.37 58.74 ± 13.27 .215
Job satisfaction 70.7 ± 21.81 69.85 ± 20.74 .742 72.09 ± 20.22 68.59 ± 22.02 .175
Stress recognition 56.98 ± 22.53 64.28 ± 18.98 .004 61.29 ± 20.31 60.44 ± 21.68 .742
Perception of 61.05 ± 17.48 61.43 ± 14.37 .842 62.82 ± 14.35 59.84 ± 17.07 .123
management
Work conditions 65.3 ± 20.67 64.23 ± 19.66 .664 67.18 ± 19.34 62.53 ± 20.6 .057
Total SAQ score 62.33 ± 13.78 62.51 ± 10.51 .907 63.92 ± 11.53 61.08 ± 12.54 .054

Note: Independent t test was performed to compare mean score of SAQ and mean scores of its six domains.

TA B L E 4 Relationship between domains of SAQ and parental education of dental students

Low education of High education of Low education of High education of

Domains fathers fathers P-value mothers mothers P-value

Teamwork climate 61.38 ± 15.07 61.61 ± 13.86 .899 59.64 ± 16.32 62.66 ± 13.33 .101
Safety climate 60.86 ± 14.37 58.42 ± 12.32 .154 60.27 ± 15.08 59.52 ± 12.33 .660
Job satisfaction 71.07 ± 20.59 70.1 ± 20.79 .707 70.03 ± 22.7 70.04 ± 19.6 .997
Stress recognition 60.48 ± 22.16 61.65 ± 17.94 .651 60.95 ± 22.59 60.56 ± 19.49 .882
Perception of 62.27 ± 16.02 60.33 ± 14.52 .317 61.68 ± 16.42 60.52 ± 15.53 .556
management
Work conditions 66.07 ± 20.3 63.43 ± 18.79 .287 65.69 ± 20.59 63.44 ± 19.99 .366
Total SAQ score 63.08 ± 12.01 62.08 ± 11.07 .495 62.47 ± 13.56 62.23 ± 10.67 .876

Note: Independent t test was performed to compare mean score of SAQ and mean scores of its six domains.

TA B L E 5 Relationship between domains of SAQ and class years and internship

Domains Fourth year Fifth year Sixth year Internship P-value

Teamwork climate 55.93 ± 17.82 62.89 ± 14.07 64.02 ± 12.62 64.02 ± 10.61 <.001
Safety climate 55.08 ± 16.73 61.43 ± 12.54 61.42 ± 11.82 63.33 ± 10.07 .002
Job satisfaction 65.53 ± 24.76 73.18 ± 20.25 72.82 ± 16.73 70.24 ± 20.97 .082
Stress recognition 59.7 ± 22.25 58.58 ± 19.43 64.96 ± 19.35 60.21 ± 23.54 .275
Perception of management 55.84 ± 19.36 63.71 ± 14.46 62.93 ± 12.06 65.07 ± 13.63 .002
Work conditions 57.55 ± 23.42 70.22 ± 17.45 64.08 ± 17.85 70.73 ± 16.26 <.001
Total SAQ score 57.49 ± 15.64 64.37 ± 9.93 64.7 ± 9.09 65.16 ± 9.02 <.001

Note: One-way ANOVA was performed to compare mean score of SAQ and mean scores of its six domains.

instrument and reported the highest score for the job satisfaction
21,22,27
domain. Positive responses about job satisfaction in our study
is because students believed that they practised in a family like en-
vironment, liked the discipline of dentistry, enjoyed the workplace,
felt proud about practicing in the clinics, and recognised high morale
in the clinics. In our study, 75.4% of participants reported that they
were proud to practise in the dental clinic and 70.2% mentioned that
it was a good place to practise and these were the most agreed/
strongly agreed responses in the job satisfaction domain. High job
satisfaction in our study is encouraging because it is associated with
improved quality of care, better clinical outcomes and enhanced pa-
tient satisfaction. 22
Similar to the findings of a previous study by Al-Surimi et al,12
who used SAQ, the present study showed a low score for the safety
climate domain. Al Sweleh et al16 also conducted a study on den-
tal students, interns, dental assistants and general dentists using a
questionnaire of the modified version of Hospital Survey on Patient
Safety Culture. The authors reported a negative score in most do-
mains of patient safety amongst dental students.16 The low score of
the safety climate domain is possibly related to low attendance of our
participants (35.7%) in a patient safety course. In addition, 31.6% of
the participants and their families experienced adverse events in our
study which may contribute to a low score of patient safety climate
due to their better recall of such events. Nevertheless, responding to
ALOLAYAN et al.
the items in the patient safety climate domain, most students (>62%)
reported that they would feel safe being treated here as a patient
and medical errors were handled appropriately in this clinical area.
The results of the patient safety climate domain show that students
have opportunities to learn from medical errors; however, this area
in particular calls for further improvement. The prevention of ad-
verse events in dental practice should be the top priority because
these events can result in morbidity and mortality.8
Parental education has a positive influence on academic achieve-
ment, and university students with higher educational levels of their
parents were shown to perform better on tests than the students
of parents with lower educational attainment.31 Similarly, academic
performance (GPA) also affects the learning styles of dental stu-
32
dents. Hence, it was assumed that parental educational level and
academic performance of students have a role in the learning pro-
cesses and consequently in patient safety culture. The present study
was the first to investigate the influence of parental education and
GPA on the score of patient safety culture. However, no significant
differences in patient safety scores were observed between the par-
ticipants with low and high parental education and GPA.
Except for stress recognition, the gender comparison of individ-
ual domains showed no significant differences in the patient safety
scores in our study. Female students demonstrated a significantly
higher score of stress recognition domain than male students. Factors
such as increased workload, fatigue and being tense or in hostile sit-
uations possibly contributed to increased stress recognition amongst
female students in our study. Higher stress recognition amongst fe-
male participants underscores the importance of the factors that can
negatively affect patient safety culture; hence, this area needs to be
strengthened. Generally, female students demonstrate more stress
than male students. For instance, a recent multicountry study of 14
different dental schools reported that female students compared
with male students revealed higher stress scores on most domains
33
of the dental environmental stress (DES) questionnaire. Another
research showed that the workload and performance pressures most
highly contributed to higher stress in female than male dental stu-
dents in addition to the stressors related to clinical training and pa-
34
tient treatment. The excessive workload can lead to stress, burnout
and depression, all of which compromise patient safety environment
and the quality of care, thus increasing the risk of medical errors.35
In the present study, the patient safety score significantly in-
creased from the fourth year class to the internship. This trend was
consistent in all domains of SAQ except job satisfaction and stress
recognition domains which also showed improvement; however, it
was not significant. Junior students (fourth year students) than se-
nior students (fifth and six years students) and interns have more
didactic learning, lower clinical requirements, lesser clinical train-
ing and patient treatment, and reduced familiarity with delivery of
care and organisational policies and procedures. This may explain
why junior students demonstrated lower patient safety score than
senior students and interns in the present study. Similar trends were
observed in another study where stress related to clinical training,
| 7
performance, patient treatment and workload increased significantly
from 2nd through 6th year dental students.34 However, a previous
study of female dental students showed no significant differences
in the domains of SAQ with class years (junior classes 1-2 years vs
senior classes 3-4 years) except for teamwork climate.12
4.1 | Study limitations
The findings of the present study add an important component to
research on patient safety culture in dental students and interns.
However, the study has several limitations that should be considered
during the interpretation of its results. The students were enrolled
from a public dental college which limited the possibility to gener-
alise study findings to students in other private and public dental
colleges. A census sample of students and interns was used to mini-
mise sampling error, but 68.3% of students and interns actually par-
ticipated in the study. The questionnaire-based study is subjected to
over and under-reporting of responses. Also, a cross-sectional study
design does not demonstrate temporality between patient safety
culture and the potential factors. However, given the significance of
patient safety and limited studies in dentistry, large cross-sectional
and longitudinal studies should be conducted in dentistry nationally
and internationally to provide a strong knowledge base on the topic
for safer dental care.
5 | CO N C LU S I O N S
The study revealed that only a few students and interns showed a
positive attitude of patient safety. Adverse events were experienced
by a considerable proportion of students and interns and their fami-
lies. A course on patient safety was attended by nearly one-third of
participants. The job satisfaction domain received the highest score
followed by the work conditions domain. The study found no signifi-
cant gender differences in the mean score of SAQ and its domains
except for stress recognition. Similarly, no significant influences of
parental education and academic performance of students and in-
terns on the patient safety culture were observed. The students in
the junior classes demonstrated lower patient safety scores than
the students in senior classes and internship. Patient safety courses
should be integrated into dental curricula to reduce adverse events
and improve the quality of patient care.
DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request from the corresponding author.
ORCID
Muhanad Alhareky https://orcid.org/0000-0001-5731-6434
Jehan Alhumaid https://orcid.org/0000-0002-8263-6285
Muhammad Ashraf Nazir https://orcid.
org/0000-0003-2259-6602
8 | ALOLAYAN et al.

REFERENCES 20. Gabrani A, Hoxha A, Simaku A, Gabrani JC. Application of the

Safety Attitudes Questionnaire (SAQ) in Albanian hospitals: a
1. Yamalik N, Perea PB. Patient safety and dentistry: what do we need
cross-sectional study. BMJ Open. 2015;5:e006528.
to know? Fundamentals of patient safety, the safety culture and im-
21. Godinho Rigobello MC, Fontenele Lima de Carvalho RE, De Bortoli
plementation of patient safety measures in dental practice. Int Dent
Cassiani SH, et al. The climate of patient safety: perception of nurs-
J. 2012;62:189-196.
ing professionals. Acta Paulista de Enfermagem. 2012;25:728-735.
2. Wilson RM, Michel P, Olsen S, et al. Patient safety in developing
22. Toso GL, Golle L, Magnago TS, et al. Patient safety culture in hospitals
countries: retrospective estimation of scale and nature of harm to
within the nursing perspective. Rev Gaucha Enferm. 2016;37:e58662.
patients in hospital. BMJ. 2012;344:e832.
23. Herdman M, Fox-Rushby J, Badia X. A model of equivalence in the
3. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing
cultural adaptation of HRQoL instruments: the universalist ap-
risk and safety in clinical medicine. BMJ. 1998;316:1154-1157.
proach. Qual Life Res. 1998;7:323-335.
4. Obadan EM, Ramoni RB, Kalenderian E. Lessons learned from den-
24. Gjersing L, Caplehorn JR, Clausen T. Cross-cultural adaptation of
tal patient safety case reports. J Am Dent Assoc. 2015;146(5):318-
research instruments: language, setting, time and statistical consid-
326.e2.
erations. BMC Med Res Methodol. 2010;10:13.
5. Hughes R. Patient Safety and Quality: An Evidence-Based Handbook
25. Li Y, Zhao X, Zhang X, et al. Validation study of the safety attitudes
for Nurses. Rockville, MD: Agency for Healthcare Research and
questionnaire (SAQ) in public hospitals of Heilongjiang province,
Quality; 2008.
China. PLoS One. 2017;12:e0179486.
6. Hincapie AL, Slack M, Malone DC, MacKinnon NJ, Warholak TL.
26. Ramoni R, Walji MF, Tavares A, et al. Open wide: looking into the
Relationship between patients' perceptions of care quality and
safety culture of dental school clinics. J Dent Educ. 2014;78:745-756.
health care errors in 11 countries: a secondary data analysis. Qual
27. Matiello RDC, Lima EdFA, Coelho MCR, et al. Patient safety culture
Manag Health Care. 2016;25:13.
from the perspective of nurses. Cogitare Enferm. 2016;21(Spe).
7. Singer S, Lin S, Falwell A, Gaba D, Baker L. Relationship of safety
28. Famolaro T, Yount ND, Hare R, Thornton S, Sorra J, Agency for
climate and safety performance in hospitals. Health Serv Res.
Healthcare Research and Quality. Medical office survey on patient
2009;44:399-421.
safety culture 2016 user comparative database report. Rockville, MD:
8. Lawati MHA, Dennis S, Short SD, Abdulhadi NN. Patient safety and
Agency for Healthcare Research and Quality; 2016.
safety culture in primary health care: a systematic review. BMC Fam
29. Dragan IF, Dalessandri D, Johnson LA, Tucker A, Walmsley AD.
Pract. 2018;19:104.
Impact of scientific and technological advances. Eur J Dent Educ.
9. Brasaitė I, Kaunonen M, Martinkėnas A, Mockienė V, Suominen T.
2018;22:17-20.
Health care professionals' skills regarding patient safety. Medicina.
30. World Health Organization. Patient safety curriculum guide: Multi-
2016;52:250-256.
professional edition. 2011. https://www.who.int/patie​ ntsaf​
ety/
10. Stavrianopoulos T. The development of patient safety culture.
educa​tion/mp_curri​culum_guide/​en/. Accessed January 6, 2020.
Health Sci J. 2012;6:201.
31. Gooding Y.The relationship between parental educational level and
11. Pemberton MN. Developing patient safety in dentistry. Br Dent J.
academic success of college freshmen. 2001. https://lib.dr.iasta​
2014;217:335-337.
te.edu/cgi/viewc​ontent.cgi?artic​le=1428&conte​x t=rtd. Accessed
12. Al-Surimi K, AlAyadi H, Salam M. Female dental students' percep-
January 6, 2020.
tions of patient safety culture: a cross sectional study at a middle
32. Al-Saud LM. Learning style preferences of first-year dental stu-
eastern setting. BMC Med Educ. 2018;18:301.
dents at King Saud University in Riyadh, Saudi Arabia: influence of
13. Myung SJ, Shin JS, Kim JH, et al. The patient safety curriculum for
gender and GPA. J Dent Educ. 2013;77:1371-2138.
undergraduate medical students as a first step toward improving
33. Alhajj MN, Khader Y, Murad AH, et al. Perceived sources of stress
patient safety. J Surg Educ. 2012;69:659-664.
amongst dental students: a multicountry study. Eur J Dent Educ.
14. Aboumatar HJ, Thompson D, Wu A, et al. Republished: develop-
2018;22:258-271.
ment and evaluation of a 3-day patient safety curriculum to ad-
34. Halboub E, Alhajj MN, AlKhairat AM, Sahaqi AM, Quadri MFA.
vance knowledge, self-efficacy and system thinking among medical
Perceived stress among undergraduate dental students in rela-
students. Postgrad Med J. 2012;88:545-551.
tion to gender, clinical training and academic performance. Acta
15. Leong P, Afrow J, Weber HP, Howell H. Attitudes toward patient
Stomatol Croat. 2018;52:37-45.
safety standards in U.S. dental schools: a pilot study. J Dent Educ.
35. Hall LH, Johnson J, Watt I, Tsipa A, O'Connor DB. Healthcare staff
2008;72:431-437.
wellbeing, burnout, and patient safety: a systematic review. PLoS
16. Al Sweleh FS, Al Saedan AM, Al Dayel OA. Patient safety cul-
One. 2016;11:e0159015.
ture perceptions in the college of dentistry. Medicine (Baltimore).
2018;97:e9570.
17. Yansane A, Lee JH, Hebballi N, et al. Assessing the patient safety
culture in dentistry. JDR Clin Trans Res. 2020:2380084419897614. How to cite this article: AlOlayan R, Alahmad A, Buali D,
18. Pronovost P, Sexton B. Assessing safety culture: guidelines and rec- et al. Patient safety culture amongst dental students and
ommendations. Qual Saf Health Care. 2005;14:231-233.
interns in Dammam, Saudi Arabia. Eur J Dent Educ.
19. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes
Questionnaire: psychometric properties, benchmarking data, and 2020;00:1–8. https://doi.org/10.1111/eje.12588
emerging research. BMC Health Serv Res. 2006;6:44.