According to the World Health Organization (WHO), “patient safety is defined as the absence of preventable harm to a patient during the process of health care” (Brasaite, Kaunonen, & Suominen, 2015; Muftawu, & Aldogan, 2020). Health care is one of the most complex activities in which human beings are involved (Izadi, Drikvand, & Ebrazeh, 2013). Treatment is not always safe, and possibilities for medical errors threaten patient safety (Wachter, 2012; Moghaddasi, Sheikhtaheri, & Hashemi, 2007; Marin, 2004). Providing care without harming the patient is one of the most important criteria for healthcare delivery systems (Muftawu, & Aldogan, 2020; Poorcheraghi, Hekmatpou, & Mehrabi, 2019). Several studies have shown a high incidence of medical errors, and there are many gaps in the quality of global standards of health care (Stratton et al., 2004; Muftawu, & Aldogan, 2020). In the United States, 250000 patient deaths are reported annually due to medical errors (Karande, Marraro, & Spada, 2021). In 2008, Saudi Arabia reported 1356 deaths due to medical errors (Al-Ahmadi, 2009). 
According to the studies in Iran, medication errors are the most common error threatening patient safety. One-third of patients referring to medical centers to get services have been involved with this issue. Also, 87.7% of medical staff in a study confirmed at least one or more medical errors during the previous year (Vaziri et al., 2019; Askarian et al., 2020). In a study examining the rate of medical errors through the investigation of public complaints, the proven rate of staff medical errors has been estimated at 42%-53% (Sadoughi et al., 2011). To improve the quality of hospital services, health care organizations must pay attention to the culture of patient safety (Chen and Li, 2010; Bodur, & Filiz, 2010). Patient safety culture is defined as the beliefs, values, and norms of an organization that supports and promotes patient safety (Simsekler et al., 2020). These beliefs extend to all levels of an organization (e.g. system, department, unit) and influence the actions and behaviors of staff throughout the organization so that the staff and organization viewpoints demonstrate the priority of patient safety culture (Schutz, Counte, & Meurer, 2007; Farokhzadian, Nayeri, & Borhani, 2018). Studies have shown that hospitals with better patient safety standards have better performance and fewer errors (Mardon et al., 2010). Positive safety culture directs the behaviors of healthcare providers. Accordingly, patient safety becomes one of their highest priorities, requiring an emphasis on organizational learning, teamwork, open communication, feedback, non-punitive responses to errors, and a common perception in all medical staff, which leads to defined standards (Zwart et al., 2011; Castle, & Sonon, 2006; El-Jardali et al., 2010). Positive safety culture can encourage error reporting by health care providers, which will be an effective tool for improving safety (Salavati et al., 2013). The first step in creating a positive safety culture in hospitals is determining its condition. The occurrence of adverse events due to unsafe care is probably one of the 10 leading causes of death and disability in the world. It is estimated that 4 in every 10 patients is harmed while receiving hospital care which can be caused by a range of adverse events, with nearly 50% of them being preventable (Lawati et al., 2018; Huang, Wu, & Lee, 2018). Patient safety culture has been reported as undesirable (Smits et al., 2008). Also, in a study in Iran, only 37% of staff reported their unit safety culture to be excellent (Yaghobi far et al., 2013). Assessing the safety culture of hospitals while identifying problem wards to improve their performance helps increase manager awareness of staff attitudes and behaviors about patient safety (Nieva, & Sorra, 2003). Patient safety culture is one of the components of health services’ quality that is very important and also an essential element in monitoring the accreditation of medical centers (Gutberg and Berta, 2017). Evaluation of patient safety culture in hospitals is the first step toward building such a culture (Alquwez et al., 2018). This study aimed to investigate the patient safety culture from the viewpoints of medical staff in two teaching hospitals in Saveh City, Iran.

A cross-sectional descriptive study was conducted in selected teaching hospitals of Saveh City in 2019. Saveh, with a population of 238000 over an area of 10279 km2, is situated in the central part of Iran near Tehran City (Karimy et al., 2016). The study population included medical staff (nurses, midwives, operating room technicians, anesthesiologists, radiologists, laboratory experts, and general physicians) in Saveh teaching hospitals. The sample size was estimated to be 196, using the limited population calculation formula (Cochran’s formula) as below, and the samples were selected by proportional stratified sampling method.


, where α=0.05, d=0.05, p=0.5; q=0.5, Z=1.96, and N=196. 
The inclusion criterion was having a professional experience of at least six months. The subjects were excluded from the study if they did not want to participate or had an incomplete answer to the questionnaire. Before starting the study, the necessary correspondence was made to the Ethics Committee of Saveh University of Medical Sciences and executive officials of the centers under investigation (Shahid Modarres and Shohadaye Hefdah Shahrivar). The study data were collected using the standard questionnaire of the Hospital Survey on Patient Safety Culture (HSOPSC), designed by the US Agency for Health Research and Quality in 2004 (Vifladt et al., 2016). In Iran, Moghry et al. used this tool for the first time at Tehran University of Medical Sciences (Moghri et al., 2012). The reliability of the questionnaire has been confirmed with a Cronbach α of 0.90 (Shamsadini Lori et al., 2016). 
The first part of the questionnaire examines demographic information such as sex, age, marital status, and professional experience of the staff. The second part has 42 questions and assesses 12 different aspects of patient safety: frequency of events reported (3 items), overall perceptions of patient safety (4 items), manager/supervisor expectations and actions promoting safety (4 items), organizational learning/continuous improvement (3 items), teamwork across units (4 items), communication openness (3 items), feedback and communication about error (3 items), non-punitive response to error (3 items), staffing (4 items), management support for patient safety (3 items), teamwork within units (4 items), and hospital handoffs and transitions (4 items). 
The questions are scored on a 5-point Likert scale from “completely agree” to “completely disagree”. The average total score of the questionnaire groups into three categories: less than 40% of the total score of the questionnaire is considered an unfavorable situation, a score between 40% to 60% is regarded as an average situation, and a score between 60% to 100% a desirable situation. In the final analysis and according to the guideline for using the questionnaire, the dimensions with an average response of at least 70% of the total score of that dimension were considered as the strengths of safety culture (good group); dimensions with an average response between 50% and 70% of the total score of the dimension are considered neutral (average group), and less than 50%, is considered weak (weak group). At the end of the questionnaire, the participants were asked about patient safety in their units and the number of errors reported over the past 12 months. These questions were scored on a 5-point Likert scale (from “excellent” to “unacceptable” in the first question, and from no report to 21 or more” in the second question). The obtained data were presented as mean, standard deviation, and percentage and analyzed by the independent t-test and Mann-Whitney test in SPSS software v. 16. 

Table 1 presents the demographic characteristics of the samples. The Mean±SD score of patient safety culture was 3.45±0.21 out of 5.



Among the 12 dimensions of the questionnaire, the highest and lowest Mean±SD belonged to the “teamwork within units” and “teamwork across units”, respectively (Table 2).



The findings showed that “intra-organizational teamwork”, “overall perceptions of patient safety”, and “hospital handoffs and transitions” with 76%, 72.3%, and 71.7% of the relevant score, respectively, were in a desirable condition. Dimensions of “teamwork among organizational units” and “feedback and communication about error” with scores of 36.6% and 38.5%, respectively, were in poor condition.
The independent t-test results showed a significant relationship between gender and patient safety culture, and women were more responsive to patient safety than men (P<0.05). However, there was no significant difference between patient safety culture and other demographic characteristics of the subjects, such as education level, marital status, and professional experience (P>0.05) (Table 3).

This study investigated the dimensions of patient safety culture among Saveh teaching hospital staff. The total Mean±SD of patient safety culture was 3.45±0.21, indicating a moderate level of patient safety culture. Some other studies show that the status of patient safety culture is moderate among teaching hospitals (Nekoei-Moghadam, Raadabadi, & Heidarijamebozorgi, 2020; Almasi et al., 2015) which is consistent with our findings. These findings emphasize that the safety culture regarding different aspects of patient care in the studied hospitals needs improvement. In the present study, the “teamwork within units” dimension was favorable, consistent with other studies (Bodur and Filiz, 2010; Yaghobi far et al., 2013; Westat et al., 2010; Amarapathy et al., 2013). However, Faryabi et al. found that the “teamwork within units” is at a moderate level (Faryabi et al., 2015). Based on our study results, the “teamwork across units” was poor, consistent with some other studies (Faryabi et al., 2015; Ravaghi et al., 2012). Some studies have found that “teamwork across units” is moderate (Bodur, & Filiz, 2010; Yaghobi far et al., 2013; Westat et al., 2010;Mozafari et al., 2013), while Tabrizchi et al. found that the “teamwork across units” is favorable (Tabrizchi and Sedaghat, 2012). One of the reasons for the poor condition of teamwork across units in the present study may be inadequate training of personnel in this field and their high workload. 
The “hospital handoffs and transitions” dimension was weak, which is consistent with the study of Nekoei-Moghadam et al. (2015), while in other studies, it was average (Sabouri et al., 2017; Kiaei et al., 2016). The high workload may lead to the poor condition of “hospital handoffs and transitions”. Moderate level of patient safety culture could be due to punitive culture, which dominates the hospitals, unjust distribution of nurses in the units, and lack of support for patient safety by head nurses and managers (Nekoei-Moghadam, Raadabadi, & Heidarijamebozorgi, 2015). 
The results showed that female staff was more responsive to patient safety culture than male staff. Other studies also found the most significant relationship between patient safety culture and gender (Shamsadini Lori et al.; 2016; Kabir et al., 2013; Moghri et al., 2012). Two important factors that may have led to this significant relationship are giving importance to the assigned work and responsibilities, as well as women’s sharpness and sensitivity (Galvão et al., 2018). It has been shown that women are more sensitive than men in adherence to safety, quality of patient care, and ethics (Dehghani and Mohammadkhan Kermanshahi, 2012). 
Creating a safe atmosphere in the hospitals where the employees can report errors without fear of being blamed and determining the number of nursing staff in different units based on each department’s workload could help enhance patient safety culture among the staff. Regarding the limitations of the research, this study is descriptive and limited to a specific region of Iran. Also, self-reporting always has its limits.

One of the important factors contributing to patient safety in hospitals and medical centers is patient safety culture. The present study’s findings showed a moderate level of patient safety culture among the staff of Saveh teaching hospitals. Also, the “intra-organizational teamwork” dimension was in the best position, and “teamwork among organizational units” was in the poorest condition. 
Educational workshops focused on patient safety to enhance patient safety culture, as well as the use of social networks to keep staff information up to date about patient safety, could help improve the patient safety culture. Adequate staffing and error reporting are essential and necessary in enhancing patient safety. Considering the weak condition of teamwork across hospital units and less observance of safety culture among male staff, healthcare managers and hospital policymakers should design policies and plans by examining the relevant causes in this field. Further studies with larger sample sizes and qualitative studies on this subject are recommended, too. 

Compliance with ethical guidelines
This study was approved by the Medical Ethics Committee of Saveh University of Medical Sciences (Code: IR.SAVEHUMS.REC.1396.27). The study participants were assured of the confidentiality of their information, and they provided written consent to participate in the study.

Funding
This project was financially supported by the Vice-Chancellor of the Research Department of Saveh University of Medical Sciences.
Authors' contributions
All authors contributed to this article and read and approved the final manuscript for submission.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors appreciate the Research Council of Saveh University of Medical Sciences for the financial support and all study participants for their time and energy spent on this study.
 

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