Perception of Patient Safety Culture Among Healthcare Practitioners in Dammam and Jeddah, Saudi Arabia

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to read this manuscript. Evaluating patient safety culture (PSC) is an important topic as PSC provides a foundation for augmenting patient safety. However, I have a number of questions about the study itself, and concerns about the analysis and conclusions drawn from the reported findings.

Background:

• Page 2, Line 88-89: while I agree that there has been limited research on patient safety and patient safety culture emanating from Saudi Arabia, I question your statement that there has been minimal research on patient safety culture. A quick search on “patient safety culture” in journal titles yielded almost 400 articles published between 2020 and 2025.
• Was there a reason for focusing on, and comparing results, for Dammam and Jeddah? It would be helpful for a naïve reader to know a little about these two cities and how they are similar/different.
• On Page 3, L 133-134 you state: “The study closely examined the extent of HCWs’ awareness and under-standing of patient safety in both cities.”. The Hospital Survey on Patient Safety Culture that I am familiar with does not measure this. Lines 147-149 on page 4 also seems to misrepresent the purpose of the study.

Methods:

• Please provide a brief description/comparison of the 4 hospitals, e.g., level of acuity/number of beds/size of staff. Were there 2 hospitals in each city?
• Participants: Abstract and Page 4, L 149-150: The abstract claims a 49% response rate for the 357 participants who completed the survey, but if the target population was 5,000, this suggests a much lower response rate. I would consider 51% to be an attrition rate of the 737 who started the survey but apparently did not complete it. Did you do an attrition analysis to determine who completed vs did not complete the survey after beginning it?
• You were fortunate to obtain complete surveys for 357 participants which is exactly what your sample size calculations showed was necessary.
• Did you measure Saudi/non-Saudi status of the participants? I seem to recall having seen studies in the past indicating some differences in perceptions of the health care environment depending on ex-pat status, but I don’t have any citations for this.

Instrumentation/Measures:

The abstract and lines 162-167 on page 4 indicate that you used the Saudi Hospital Survey on Patient Safety Culture (HSPSC), with 10 composite measures and 32 items. This sounds like the HSOPSC developed by the US Agency for Healthcare Research and Quality. If so, you should reference them as the source, and indicate the version (1.0 or 2.0). You should also explain why this is called the “Saudi” HSPSC. Was a Saudi adaptation and validation conducted on the original US instrument? And if so, please provide these details. If not, please provide more details of the tool you are using and how it compares with the US HSOPSC. Somewhere in the manuscript, please list the 10 composites/dimensions. Also – please clarify in section 2.2 that the survey was administered in English (as you indicate only on page 17).

 

Results:

• I found that the level of detail in Table 1 distracted from an overall understanding of participant characteristics. You might consider grouping some of the job categories, e.g., all nurses, all physicians/residents/interns, other health care professionals, paraprofessionals, technical staff, etc.
• Also, if you are going to compare results for the two cities, in Table 1 please report separate statistics for the demographic characteristics of the samples in the 2 cities.

 

•  There is nowhere in the manuscript where I see results for all 10 composites. Figure 1 puzzles me in particular, because it is labelled “Staff perceptions of Pt Safety Teamwork’ and yet the US HSOPSC includes only 3 variables (i.e., survey items) in this composite (not 14). Figure 1 includes several items from other composites that the US HSOPSC categorizes as Staffing and Work Pace, and Organizational Learning-Continuous Improvement, and Response to Error. Did you do a factor analysis to revise the number of factors represented by your data or why are these combined? Also, why present this as a figure and the results for other composites in tabular format (Table 2)?
• I would prefer to see just the composite scores (Means and % Positive Responses), rather than the scores for each item, but other reviewers may disagree.
• Table 4 presents a comparison for 6 scores. Four of these represent pt safety culture, but patient events reporting and safety rating are better considered pt safety outcome Please explain and justify why you have only reported 4 of the 10 pt safety culture composite scores in Table 4.
• Later in the Discussion, P 13, L 387-388, you state “The results of the present study also support the notion that teamwork helps reduce medical errors”. Was medical error another pt safety outcome measure? And if so, please clarify that in your description of the HSPSC in section 2.2, and provide descriptive statistics for this measure, and the analysis you did that showed an inverse association between teamwork and medical areas. Similarly, on P 15, L 454-455, you state that “PSC is more valued in health units that follow a comprehensive reporting strategy” – but I do not see that “valuing of PSC” was measured; at least it is not reported in this manuscript.

Discussion:

As noted above, I have concerns that you have drawn some conclusions that go beyond the reported data and findings. This may be a matter of English language, or perhaps you collected additional data and did further analyses that is not represented in this manuscript.

Writing/organization:

I encourage you to review and reorganize the Introduction and Discussion sections for a more logical flow of content. Also, there are numerous sentences/phrases that are vague/ambiguous, some of which I have identified above, or below.

Minor issues/recommendations:

• Page 2, L 49-50: please indicate the period of time for the 64 million years of lost life/disability
• Page 2, L59-64: I would delete this paragraph on healthcare worker safety as your study is focused on patient safety.
• Page 3, L 117-119. This comment should go in the Discussion, rather than the Introduction.
• The subheading “Experience vs number of events reported” in Table 1 does not make sense, because you have provided only univariate (not bivariate) descriptive stats here.
• Page 13, L 384/385 “indicate a moderate response level”. Please try to be more explicit.
• Page 14, L 428: I believe you made a mistake in writing, in saying that “a lack of non-punitive procedures” was a problem associated with an absence of a strong PSC.
• Page 16, L 540-543: Unclear meaning.
• Page 17, L 594-596: Unclear meaning

Comments on the Quality of English Language

The quality of the English language could be improved to more clearly describe the study, and perhaps alleviate some of my concerns regarding interpretation/conclusions that go beyond the data and reported findings.

Author Response

Dear Sir, Please find attached file with detailed point-by-point response to all your comments.

Also, please consider that: 

Some modifications and additions were made according to the comments of the second reviewer e.g. Figure 3: PSC benchmarking between Dammam (DM) and Jeddah (JD) hospitals and Agency for Healthcare Research and Quality (AHRQ) (Separation of data of the two cities), with related data presentation and discussion. We think that those changes will improve the quality of the manuscript.

Moreover, regarding English language proofreading:

Sure, the manuscript will be subjected to further English Language Proofreading after all these modifications, additions and deletions (responses to Rev 1 and Rev 2). Although, it was subjected to proofreading in early stages before submission (evidence provided). 

 

Finally, we are sure that your comments will greatly improve the quality of the manuscript

 

Kind Regards

 

Dr Mahmoud Berekaa

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The study highlights the importance of understanding healthcare workers' perceptions of patient safety culture to identify strengths and areas for improvement. I appreciate the authors' efforts; however, I invite them to address the comments below to enhance the manuscript’s quality.

Abstract

Line 26: “Of 737 participants, 357 completed the survey, yielding a response rate of 49.39%.” 49.39% is incorrect as it should be 357/737*100 = 48.43%.

As I understand, 49 nurses (13.72%) from Table 1 participated in the study; however, the authors misreport that 56 (15.8%) nurses participated. Also, correct this error in line 208.

The authors are inconsistent in their reporting: they mention the Position in the hospital (Table 1) and the transporter, but refer to the transporter as 'transport staff' in the text. This might cause serious confusion among the readers. Please check that all the positions in the hospital mentioned in the tables are consistent throughout the manuscript.

Introduction

Include more specific statistics or data from global studies to emphasize the importance of PSC. For example, how does Saudi Arabia compare to other countries in terms of PSC? What are the international benchmarks for PSC, and how does this study aim to align with or improve upon them?

Clearly define key terms, such as "patient safety culture" and "error reporting," to ensure readers understand the study's scope and focus.

The authors should address why they chose Dammam and Jeddah among the major cities in Saudi Arabia. Please specify the reason with relevant literature citations.

Method

Line 150: Please cite the reference for “the target population 5000…”

Line 151: “the proportion estimate is 71.4%” Please cite the reference for this.

Lines 170 and 171: “Major communication channels including E-mail, WhatsApp, and Google Form.” The authors should include the resources available for the healthcare workers' email addresses and WhatsApp numbers.

Line 172: “...groups in pursued healthcare facilities within Dammam and Jeddah regions.” The target groups in this survey are from the government, the private sector, or both. The authors should add more details in this regard, as there was a difference in healthcare services between the private and government sectors. Although the authors consider this a form of participation bias, it should still be clarified in the method section for the readers' understanding.

Line 178: “For some questions worded negatively, the scoring was reversed before analysis.” The author should clarify which questions those are, as not all readers are familiar with the instrument used in this survey.

Lines 188 and 189: “…’Poor’ and ‘Fair’ combined into a single category labelled ‘Poor’…” I believe that the fair cannot be poor. If the authors acknowledge, please cite the references in this regard.

The survey was conducted in English, which may have posed a challenge for some participants and affected the accuracy of responses.

Results

Line 245 and Figure 1: “mean scores of 3.85 ± 1.27 and 3.82 ± 1.3...” The provided data are reported as mean ± SD in the text, but only the mean in Figure 1. Please be consistent between the figure and the text regarding the data.

If the "Don't Know" responses were excluded from the mean score calculation, this should be clarified in the table or accompanying text in the method section. If they were included, it should also be explicitly stated.

Why have basic demographic characteristics, including age and sex, not been reported? These variables are influencing factors for any healthcare survey. Consider this a potential limitation and address it in the limitations section.

Figure 3: I recommend that the authors compare the Dammam and Jeddah data separately with AHRQ, as these items show significant variation (Table 4) and cannot be combined. Also, it will be helpful for the readers.

Discussion

The discussion section of the document provides a comprehensive analysis of the findings, but there are areas where improvement could enhance clarity and depth:

While the discussion highlights areas for improvement, it could more explicitly connect these findings to actionable recommendations. For example, the discussion mentions the need for training and non-punitive environments but does not elaborate on specific strategies or examples.

The discussion could include a dedicated section on future research directions, highlighting areas that warrant further investigation, such as the impact of cultural differences across cities on PSC or the role of specific interventions in improving safety culture.

Conclusion

The conclusion mentions differences between Dammam and Jeddah but does not delve into the underlying factors that might explain these differences, such as cultural, organizational, or resource-related disparities.

The conclusion does not adequately address the benchmarking comparison with the Agency for Healthcare Research and Quality (AHRQ). ​ The results show that teamwork, supervisor support, and hospital management commitment were below AHRQ benchmarks, but this is not explicitly discussed in the conclusions.

 

 

Author Response

Dear Sir, Please find attached file with detailed point-by-point response to all your comments.

Also, please consider that: 

 

• Some modifications and additions were made according to the comments of the second reviewer e.g. Table 1: Demographic characteristics: Separation of the two cities Dammam and Jeddah- Categorization of some jobs, with detailed description and discussion. Also, e.g. Figure 3: PSC benchmarking between Dammam (DM) and Jeddah (JD) hospitals and Agency for Healthcare Research and Quality (AHRQ) (Separation of data of the two cities), with related data presentation and discussion. Overall, we think that those changes will improve the quality of the manuscript.

 

• We would like to reveal that, the manuscript will be subjected to further English Language Proofreading after all these modifications, additions and deletions (responses to Rev 1 and Rev 2). Although, it was subjected to proofreading in early stages before submission (evidence provided).Finally, we are sure that your comments and suggestions will greatly improve the manuscript

Best Regards

 

Dr Mahmoud Berekaa

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to read the revised manuscript. It seems that you have addressed some of my concerns, but not all. I suspect that some of my concerns may be related to the use of language, but these will also need to be addressed. The two most critical of my concerns pertaining to results were not addressed:

1.  Figure 1. Staff perceptions of Patient Safety Teamwork: Figure 1 puzzles me beause it is labelled “Staff perceptions of Pt Safety Teamwork’ and yet the US HSOPSC includes only 3 variables (i.e., survey items) in this composite (not 14, which you have included). Figure 1 includes several items from other composites that the US HSOPSC categorizes as Staffing and Work Pace, and Organizational Learning-Continuous Improvement, and Response to Error. Did you do a factor analysis to revise the number of factors represented by your data or why are these combined? Also, why present this as a figure and the results for other composites in tabular format (Table 2)? It is confusing that you are not reporting results for all 10 dimensions in one table with a consistent level of detail.
2. Table 4. PSC in Dammam and Jeddah cities. Table 4 presents a comparison for 6 scores that you refer to as patient safety culture scores – but patient safety rating is better considered pt safety outcome measure as it is not one of the 10 dimensions of PSC. Please explain and justify why you have not reported all 10 pt safety culture composite scores in Table 4. Please do the same for Figure 3.2.5 where you only report on 5 of the 10 PSC composite scores.

 Abstract

• Methods L26: Please indicate the sampling strategy used. Re: the statement: “Of 737 participants, 357 completed survey, yielding a response rate of 48.43%.”. I suspect you meant that complete data was obtained from 357 of the 737 respondents who began the survey – which is not a response rate.
• Results L29: Please clarify the meaning of this statement: “Only two domains were statistically significant (p < 0.05)” What was being tested?

Background:

• This section should be reviewed and rewritten with better organization of content; this would help you to reduce the redundancies and provide more logical argumentation. Also, try to stay focused on patient safety and patient safety culture, e.g., delete mention of clinical efficiency and healthcare worker safety.
• L49-50. It is important that you acknowledge the source of the HSOPSC (i.e, the AHRQ) here and on L188.
• L133-134 “The study closely examined the extent of HCWs’ awareness and under-standing of patient safety in both cities.” I did not see how this was examined in the study. Please, either explain how these data were collected, or delete this sentence.

Materials and Methods

• 1 Study Location: I see that you have added some description of the cities and hospital, but what you have written would be strengthened if you provided a comparison of the 4 hospitals as previously asked rather than just providing total number of beds/employees (and reduced the description of cities if not considered relevant to PSC). For example, did all 4 hospitals provide the same level of care (e.g., tertiary?)

Results:

• 2.2 Patient Safety Rating It would have been more informative if you provided the results for patient safety ratings for each city (if not each hospital), and also tested for differences with a chi-square test.

 Discussion:

• As commented previously, I do not understand the basis for making the statement on L434-435,“The results of the present study also support the notion that teamwork helps reduce medical errors” if there was no analysis of a relationship between this PSC dimension and an outcome variable measuring medical errors.

Writing/organization:

I encourage you to review and reorganize the Introduction and Discussion/Conclusion sections for a more logical flow of content. 

Comments on the Quality of English Language

The quality of the English language could be improved - but I have more concerns with how the paper is written in terms of organization and logical flow. 

Author Response

Dear Sir

Kindly find response letter to the provided comments. 

Note that all changes highlighted in Yellow and all deletions highlighted in Red.

 

Thank you very much for your time and cooperation

 

Best Regards

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The author's efforts are commendable, as they extensively revised the manuscript in response to the comments. I hope the manuscript has improved in quality, and I have noticed some errors in the references that need correction. References [18] and [75] lack volume, issue, and page numbers. Please ensure that all references are formatted according to the Journal's style.

Author Response

Dear Sir

Kindly find response letter to the provided comments. 

Note that all changes highlighted in Yellow and all deletions highlighted in Red.

 

Thank you very much for your time and cooperation

 

Best Regards

Author Response File: Author Response.pdf

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

1. Abstract: L29 Please remove the statement about response rate as 48.43% was the completion rate, not a response rate.
2. Abstract: L33 is inconsistent with L39. 
3. L165-167 states that you are benchmarking against the findings of the AHRQ for the HSOPSC. Therefore, you should be reporting results for all 10 composites as is done by the AHRQ. 
4. Moreover, according to your text (P16 L457), you have cited results for version 1.0 of the HSOPSC in your benchmarking statistics for the AHRQ (presented in Table 3), but you used version 2.0 of the HSOPSC for data collection. Therefore, you should be benchmarking against the AHRQ database for version 2. 
5. I remain concerned with Figure 1 as the figure title does not indicate that these variables are selected items from a number of composites. This will be confusing to readers familiar with the HSOPSC. 
6. Please report results for all 10 composites in Table 4 and Figure 3. 
7. Discussion, P17: The revisions in L480-481 do not adequately address my prior comments regarding L434-435 in the first revision of the manuscript. 
8. Overall, the tables and figures could be more comprehensive but succinctly designed.

Author Response

Dear Sir

Fist, thank you very much for your valuable comments and suggestion.

Kindly find the attached file will point-by-point comment to all comments and suggestions.

Also, please note that we made great modification through reconstruction of the benchmarking section as well as using the 10 composites measures for comparison between the two cities. We are sure that those changes enrich the manuscript, especially regarding the assessment of the PSC in the two cities.

Again, many thanks for your efforts

 

Best Regards

 

Dr Mahmoud Berekaa

Author Response File: Author Response.pdf