PERCEPTION OF PATIENT SAFETY CULTURE AMONG HOSPITAL STAFF 
Rumyana STOYANOVA
1*
, Rositsa DIMOVA
1
, Bianka TORNYOVA
2
, Momchil MAVROV
2
, Harieta ELKOVA
3
1
Medical University – Plovdiv, Health management and health economics, 15a Vassil Aprilov blvd, 4002 Plovdiv, Bulgaria
2
Medical University – Plovdiv, Healthcare management, 15a Vassil Aprilov blvd, 4002 Plovdiv, Bulgaria
3
Hospital “St. Panteleymon”, Physical and Rehabilitation Medicine, 4004 Plovdiv, Bulgaria
Received: May 20, 2020
Accepted: Feb 1, 2021 
 *Corresponding author: Tel. + 359 89-9936 048; E-mail: rumi_stoqnova@abv.bg
10.2478/sjph-2021-0015 Zdr Varst. 2021;60(2):97-104
97
 Stoyanova R, Dimova R, Tornyova B, Mavrov M, Elkova H. Perception of patient safety culture among hospital staff.  
Zdr Varst. 2021;60(2):97-104. doi: 10.2478/sjph-2021-0015.
ABSTRACT
Keywords: 
healthcare 
professionals, safety 
patient culture, 
e-platforms, HSOPSC
 zdravstveni 
delavci, kultura 
varnosti pacientov, 
e-platforme, HSOPSC Introduction: A patient safety culture (PSC) is a complex phenomenon, representing an essential part of 
the organizational culture and refers to the shared values, conceptions and beliefs which contribute to the 
formation and encouragement of safe behavioural models in a health organization. With this study, the authors 
wanted to delineate the attitude of hospital staff in Bulgaria regarding PSC and to document to whether 
attitudes differ between physicians and other healthcare professionals (HCPs).
Methods: A national cross-sectional survey among 384 HCPs was conducted using an online version of the 
Bulgarian version of Hospital Survey on Patient Safety Culture (B-HSOPSC). The data was analysed with 
descriptive statistics, non-parametric Mann-Whitney U and x 2 tests.
Results: The physicians represented 37.50% (144) of the sample and other HCPs 62.50% (240). Respondents from 
 error” were most problematic, as their percentage of positive response rates (PRRs) were lowest. However, 
“Handoffs and transitions” and “Supervisor/manager expectations and actions promoting safety“ showed the 
highest mean values in both physicians and other HCPs. From all participants, 76.0% have never reported an 
adverse event or error.
Conclusion: The results of the study show that all respondents demonstrate a positive attitude regarding 
PSC. A comparison of the mean values and that of PRRs in the dimensions did not show any group differences, 
according to the type of staff position, i.e. physicians or other HCPs.
 Kultura varnosti pacientov je kompleksen pojav, ki je bistven del organizacijske kulture in se nanaša 
 delavcev


1 INTRODUCTION
Errors in medical practice have been a topic of concern 
since ancient times, and still remain a focus of attention, 
particularly after the publishing of the Institute of 
Medicine (IOM) report “To Error is Human: Building a 
Safer Health System” (1, 2). Initially, the term “safety” 
was mainly used in other spheres, such as the nuclear and 
chemical industries, as well as in aviation, however over 
 risk of unnecessary harm associated with healthcare to an 
acceptable minimum” (1, 6). In fact, patient safety culture 
(PSC) is a term that differs from patient safety, although 
the former might be considered as a prerequisite for the 
latter (7). PSC is a complex phenomenon, representing 
an essential part of an organizational culture and refers 
to the shared values, conceptions and beliefs which 
contribute to the formation and encouragement of safe 
behavioural models in any health organization (8, 9). 
PSC is, in fact, a set of actions taken by the healthcare 
organization in order to achieve safe delivery of care. It 
includes effective leadership, a spirit of teamwork and co-
operation, application of standardized procedures, open 
 (a culture, that predominantly recognizes system errors 
and failures, rather than individual errors, and assumes 
responsibility for them) and patient centred care (10). 
In fact, PSC directly impacts safe medical care through 
the adoption of high quality and successful practices and 
models that encourage patient safety, and thus, indirectly 
prevents the delivery of low quality medical care. 
Generally, a lower quality of care and higher number of 
medical errors are associated with poor PSC. In fact, the 
 competence and skills of all HCPs. There is undeniable 
evidence that medical errors and adverse events can be 
 nurses, are more focused on the safety of patients (11).
In practice, physicians and nurses may face different tasks 
and challenges even in the same medical environment 
(e.g. divisions, operating rooms, and laboratories), and 
their attitudes towards patient safety varies depending 
 it is critically important to understand the opinions and 
attitudes towards patient safety from various hospital staff 
viewpoints. Assessment of PSC is thus often performed, 
using surveys with validated questionnaires (12, 13). 
The Hospital Survey on Patient Safety Culture (HSOPSC) 
developed by the United States Agency for Healthcare 
Research and Quality (AHRQ) in 2004, has been translated 
and validated for use in a number of languages (14). In 
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our country, Bulgaria, regardless of the keen interest in 
PSC, limited research has been done to clearly identify 
the difference of perceptions among physicians and other 
HCPs towards hospital PCS based on the internationally 
validated questionnaires. Moreover, regulations about 
implementation of reporting systems of patient safety 
are still lacking in Bulgaria. Therefore, implementing the 
Bulgarian version of the Hospital Survey on Patient Safety 
Culture (B-HSOPSC) could contribute to the improvement 
of healthcare quality by increasing hospital staff awareness 
on issues related to safety (15).
The aim of this study is to delineate the attitudes of 
hospital staff in Bulgaria regarding PCS and to document 
whether such attitudes differ between physicians and 
other HCPs. The survey was performed online using the 
B-HSOPC. 
2 METHODS
2.1 Study design and context A national cross-sectional survey was conducted using 
an internet-based software platform for registration and 
evaluation of hospital PCS through B-HSOPSC. The present 
 University. Linguistic validation and cultural adaptation of 
the B-HSOPSC questionnaire was performed, and the results 
showed acceptable psychometric characteristics (15). 
2.2 Participants 
The participants included a diverse group of professionals, 
either physicians or other HCPs, directly involved in patient 
care at their respective hospitals, regardless of the length 
of experience at the institution. All of them were eligible 
for participation in this study. It is important to note that 
for the purposes of the current research the term other 
HCPs stand for nurses, midwives, clinical and radiology 
technicians and rehabilitators. After obtaining written 
consent, the hospital staff were asked to complete the 
B-HSOPSC questionnaire on the e-based platform. 
2.3 Data collection and questionnaire 
The survey was organized as a multistep process, 
initially 50 out of a total of 346 multispecialty private 
or public hospitals (representing 14.0% of all healthcare 
facilities in the country) were randomly selected from 
all 28 administrative areas in the country. Around 5,300 
medical staff were working in the selected units. A 
snowball sampling method was used for sample selection. 
This method relies on referrals from initially sampled 
respondents to other persons believed to have the 
characteristics of interest (16). 
During step 1, hospital executives and managers were 
provided by post and email with information brochures 

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2.4 Data analysis methods Data was collected in the period from July to October 
2018. The data was exported to SPSS 17.0 statistical 
software and analysed with descriptive statistics and non-
parametric Mann-Whitney U and Chi-square tests. The 
 3 RESULTS 
A total of 384 valid questionnaires were collected from 
the respondents from 15 administrative areas in Bulgaria. 
The percentage of other HCPs was the highest 62.50% 
(240), while physicians represented 37.50% (144) of the 
sample. Respondents from governmental or municipal 
hospitals prevailed (53.6%). About 61.4% of the study 
participants had more than 5 years’ work experience, and 
89.6% had direct contact with patients at the workplace. 
Other work-related characteristics of the respondents are 
shown in Table 1. 
In our study a comparison of the mean values and that of 
positive response rates (PRRs) in the dimensions did not 
show any group differences according to the type of staff 
position, i.e. physicians or other health professionals. 
 difference found between physicians’ responses and 
those of other HCPs, the latter giving higher mean values 
(P=0.017) (Table 2).  
including a link to the web-based platform allowing access 
to the online questionnaire (www.rsps.bg). A cover letter 
introducing the purpose and expected outcomes of the 
 letters an attempt was made to obtain managers’ co-
operation and their encouragement of hospital staff to 
participate in the survey. The next stage included follow-
up reminder phone calls to the hospital managers. The 
snowball sampling method allowed us much less control 
over potential respondents than otherwise, and so we had 
no information on how many respondents received the 
hyperlink to information about the study’s aims, making it 
impossible to calculate the response rate. 
The B-HSOPSC includes 42 questions, grouped in 12 
different dimensions measuring patient safety culture. 
The questionnaire also measures two outcome variables 
(patient safety grade and number of adverse events 
reported). In three of the dimensions, the frequency of 
response option was used (“Feedback and communication 
about error”, “Communication openness” and “Frequency 
of events reported”). The other nine dimensions were 
 responses ranging from 1 (“strongly disagree” or “never”) 
to 5 (“strongly agree” or “always”). To avoid staff anxiety 
regarding any negative consequences (penalties, negative 
image impact, etc.) of participation, and thus encourage 
respondents to participate, no questions about the hospital 
name or brand and demographic details such as gender, 
age and educational level were included. The participants 
were asked only to indicate the areas of the administrative 
county where the hospital is located, hospital ownership 
(private or public) and its teaching status. 

10.2478/sjph-2021-0015 Zdr Varst. 2021;60(2):97-104
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Working units
Internal medicine
Surgery 
Other units
Total 
Years in hospital
 1-5
6-10
 Total Years in department
 1-5
6-10
 Total Ownership 
 Governmental/municipal 
Private 
Total Teaching hospitals
 Yes 
 Total Contact with patient directly
 Yes, often 
 Total Number of events reported
 1–2 events
3–5 events
6–10 events
11–20 events
Total Table 1. Work-related characteristic of the study participants, (n=380).
143 (37.24)
113 (29.43)
128 (33.33)
384 (100.0)
28 (7.30)
124 (32.30)
98 (25.50)
134 (34.90)
384 (100.0)
29 (7.55)
119 (30.99)
90 (23.44)
146 (38.02)
384 (100.0)
26 (6.77)
206 (53.65)
152 (39.58)
384 (100.0)
28 (7.29)
275 (71.61)
81 (21.10)
384 (100.0)
9 (2.35)
344 (89.58)
31 (8.07)
384 (100.0)
292 (76.04)
63 (16.41)
17 (4.43)
8 (2.08)
 4 (1.04)
384 (100.0)
79 (32.92)
81 (33.75)
80 (33.33)
240 (100.0)
19 (7.92)
80 (33.33)
55 (22.92)
86 (35.83)
240 (100.0)
20 (8.33)
73 (30.42)
52 (21.67)
95 (39.58)
240 (100.0)
8 (3.33)
131 (54.58)
101 (42.09)
240 (100.0)
6 (2.50)
171 (71.25)
63 (26.25)
240 (100.0)
6 (2.50)
210 (87.50)
24 (10.00)
240 (100.0)
190 (79.17)
33 (13.75)
8 (3.33)
6 (2.50)
3 (1.25)
240 (100.0)
64 (44.44)
32 (22.22)
48 (33.34)
144 (100.0)
9 (6.25)
44 (30.56)
43 (29.86)
48 (33.33)
144 (100.0)
9 (6.25)
46 (31.94)
38 (26.39)
51 (35.42)
144 (100.0)
18 (12.50)
75 (52.08)
51 (35.42)
144 (100.0)
22 (15.28)
104 (72.22)
18 (12.50)
144 (100.0)
3 (2.08)
134 (93.06)
7 (4.86)
144 (100.0)
102 (70.83)
30 (20.83)
9 (6.25)
2 (1.39)
1 (0.7)
144 (100.0)
Work-related
Details
Total n (%)
Other health professionals
n (%)
Physicians
n (%)

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The dimensions D10, D5 and D1 had the highest mean 
values from both physicians and other HCPs, whereas D7, 
D6 and D9 received the lowest mean values (Table 2).  
The percentage of positive response rates were the 
highest in both respondents’ groups in the dimensions 
D10, D1 and D2. On the other hand, the least valued 
 positive response rates) were found for D6, D7 and D11, 
and thus these seem to negatively affect the overall level 
of patient safety culture. As such, the results indicate that 
these areas are problematic in terms of patient safety in 
hospitals across the country. 
The mean positive values in the dimensions in descending 
order among all respondents are presented in Table.3. 
D1_Supervisor/manager expectations 
and actions promoting safety 
D2_Organizational learning-
continuous improvement  
D3_Teamwork within hospital units
D4_Communication openness  
D5_Feedback and 
communication about errors  
 D8_Hospital management 
support for patient safety  
D9_Teamwork across hospital units  
D10_Handoffs and transitions  
D11_Frequency of event reporting  
D12_Overall perceptions of safety 
Table 2. A comparison of the means and percentage of positive response rates (PRRs) regarding “patient safety culture” in the items 
and dimensions of the B-HSOPSC among study participants.
 3.61±0.859 
3.65±0.881 
3.52±0.916
3.63±0.981
3.64±1.018 
2.92±0.932
2.85±0.625
3.43±1.033 
3.39±0.996
3.64±0.904
3.47±1.170
3.56±0.881
  93 (64.6) 
100 (69.4) 
82 (56.9)
84 (58.3)
84 (58.3) 
58 (40.3)
60 (41.7)
84 (58.3) 
75 (52.1)
95 (66.0)
77 (53.5)
92 (63.9)
3.63±0.779 
3.57±0.926 
3.59±0.814
3.49±0.992
3.65±1.003 
3.07±0.833
2.75±0.595
3.63±0.865 
3.60±0.796
3.87±0.730
3.63±1.175
3.71±0.724
156 (65.0) 
154 (64.2) 
146 (60.8)
128 (53.3)
138 (57.5) 
102 (42.5)
103 (42.9)
153 (63.8) 
149 (62.1)
174 (72.5)
143 (59.6)
167 (69.6)
0.811 
0.386 
0.514
0.169
0.897 
0.225
0.072
0.075 
0.064
0.017*
0.196
0.232
0.934 
0.344 
0.520
0.397
0.957 
0.748
0.894
0.343 
0.069
0.216
0.287
0.298
Dimensions (D) Physicians 
mean±SD
Physicians’ 
PRR
Other health 
professionals 
mean±SD
Other health 
professionals ’ PRR 
P P
D10_Handoffs and transitions  
D12_Overall perceptions 
of safety 
D2_Organizational learning-
continuous improvement  
D1_Supervisor/manager 
expectations and actions 
promoting safety 
D8_Hospital management 
support for patient safety  
D3_Teamwork within 
hospital units 
D9_Teamwork across 
hospital units  
D5_Feedback and 
communication about errors  
D11_Frequency of 
event reporting  
D4_Communication openness  
 response to errors  
Total Table 3. The overall percentage of positive responses to each 
dimension.
*PRRs - Positive response rates 
4
4 
3 
4 
 
3 
4 
4 
3 
3 
3
4
3 
42
70.1
67.4 
66.1 
64.8 
 
61.7 
59.4 
58.3 
57.8 
57.3 
55.2
42.4
41.7 
58.5
Number of items 
in the dimension
PRRs*
(%)

The results of this study showed an average composite 
positive response rate among physicians of 56.9±9.03, 
 (59.4±9.33). The total composite perception of PSC among 
both physicians and other HCPs in the study was found to 
be 58.52%±8.93.
It is worth noting that among all the participants as many 
as 76.0% have never reported an adverse event or error. 
 found between the number of reported adverse events 
and medical errors based on the staff positions of the 
participants (Table 1).
4 DISCUSSION 
The results of the study show that PSC is generally well 
accepted by HCPs, who show a positive attitude towards 
it, varying from 41.7% to 70.1%. The total positive response 
rate of the current work is similar to that reported in an 
Indian (58.0%) study, although lower than that given in a 
study from the US (63-64%) and higher compared to the 
results reported in Slovenian research (53%) (17-20). This 
is likely due to differences in both cultural and healthcare 
systems.
This study showed an average composite positive response 
rate among physicians of 56.9%, and this was higher among 
other health professionals, mostly nurses (59.4%). This 
 doctors and 60.0% for nurses) (17), although the opposite 
 ratings among physicians (21). The tendency of more 
positive response rates among the nursing staff found in 
the current study could be explained by their direct access 
to the inbuilt organizational system, which facilitates day-
 are controlled by the nursing staff (17).
In the present study ten of the 12 dimensions showed 
positive response rates of over 50%. The dimensions D10, 
D12 and D2 showed the highest positive response rates of 
70.1%, 67.4% and 66.1%, respectively. Similarly to in the 
Slovenian studies, in our work none of the dimensions 
reached the set threshold of 75%, as was reported in the 
original AHRQ study (20, 22).
In most studies, the highest positive response rate was 
reported for dimension D3 (18, 23-26). In contrast, the 
 response rate for dimension D9 (24, 25). The present 
 response rates for D3 (59.4%) compared to D9 (58.3%). 
These two dimensions had an average rate of positive 
responses in the current study.
The positive score for the dimension D3 in Bulgarian 
hospitals was lower compared to that found in some 
 for Bulgarian culture, which emphasizes an individualistic 
mindset and behaviour. On the other hand, the domain D10, 
which requires cooperation between health professionals 
both inside their units and among them, showed a lower 
positive response rate in a number of other international 
 study (18, 21, 23, 24). In the current work, this dimension 
had the highest positive response rate (70.1%). These high 
 communist countries: the persisting authoritarian and 
hierarchical management style, as well the presence of 
well-established co-ordination structures and mutual trust 
among healthcare specialists (27, 28).
The lowest positive response rate results in the present 
study were for dimension D6 (41.7%), which has also been 
found in other studies (29-32). It seems likely that not 
reporting adverse events is predominantly due to fear 
of being blamed, legally prosecuted and fear of licence 
suspension (20, 22). 
The second lowest scored dimension is D7. The likely 
 in Bulgaria. Unfortunately, there has been a downward 
trend in the number of doctors and nurses over the last 
decades, and this results in work overload during shifts 
and increases the risk of not providing safe healthcare 
(33). On the one hand, the number of working hours is 
related to the quality of performance, as being tired and 
less alert increase the incidence of medical errors (34). 
On the other hand, recruitment agencies for locum work 
are not used in Bulgaria.
The dimension D4 also indicates that there is a need to 
set priorities in this area. The unsatisfactory outcome 
with regard to this dimension could be attributed to 
the communication barriers within the healthcare 
team caused by cultural and national differences (17). 
Ineffective communication increases the risk of adverse 
events or errors occurring, and is directly related to 
declining quality of care (32, 35-37). 
The negative results in the three dimensions are consistent 
with those from a Brazilian study, as well as those in a 
systematic review involving 18 studies from Arab countries 
in which various dimensions, including D4, D6 and D7, also 
require further improvement (5, 32).
El-Jardali et al. found that the number of reported events 
 questions measuring communication openness and non-
punitive response to errors (38). Moreover, the dimension 
D5 is most closely related to the event reporting dimension 
(39). Our results showed a comparatively low positive 
scores in this dimension, which highlights the critical role 
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of D5 as a tool to ensure patient safety and the quality of 
healthcare provided. In the present study, 76.1% of the 
participants responded that they had never reported a 
 that seen in studies conducted in India (56.0%) and Brazil 
(65.0%), and lower than that in research carried out in the 
 Our study showed that most of the hospital staff fear 
asking questions in cases when they feel something went 
wrong. They also are worried that their mistakes are kept 
 the a of punishment and loss of good reputation, as well 
as the fear of the widely used individual approach in the 
hospital management style and the preference for blaming 
individuals for mistakes, rather than systems. Other 
studies have also documented similar results (42), and 
Leape claims that adverse event-reporting systems will 
 a non-punitive culture should be promoted to prevent 
mistakes and reduce the incidence of such events for 
patients in hospital settings.
 by the two groups in our study, unlike in other works. 
Other studies found differences between the groups and 
explained them using the existing model that nurses, 
doctors, and supervisors/managers usually have different 
views in certain situations (43 ,44). In our study, the 
physicians were more likely to report adverse events and 
errors compared to other health professionals, which 
again contradicts the results of other research (45). The 
likely explanation is that physicians in most cases assume 
greater responsibility for events compared to other HCPs. 
On the other hand, this phenomenon could be explained 
by the presence of greater distance and sub-ordination 
among nurse and midwives from their managers. This 
makes them more dependent, and less free to report 
adverse events and errors.
 not report any adverse events over the last 12 months. 
This could be an indicator that potential safety problems 
may go unrecognized, or are not addressed properly in 
Bulgarian hospitals. 
The dimensions D4, D6 and D7 which had negative response 
ratings by the hospital staff should be addressed in order 
to optimize patient safety in Bulgaria. Subsequently, 
hospital managers, should undertake differentiated 
 in order to achieve positive changes in this regard. 
4.1 Strengths and limitations 
 conducted using the self-administered online B-HSOPSC 
questionnaire, and thus avoiding the likelihood of 
interviewer bias. The study was part of a university 
 of the participants was secured through the anonymity 
of the responses. A web survey in general allows better 
 their responses, especially when the survey topic is 
very sensitive, as in the current case.  Additionally, the 
respondents were assured that their responses would 
not result in any penalty actions, and thus the responses 
obtained are believed to be highly reliable.  
The present study has some limitations that should 
be noted. First, the small sample size could affect the 
results, and does not allow generalizations to the whole 
country.  Secondly, the   snowball sampling method was 
used for two reasons – the sensitivity of the topic (which 
requires the cooperation of the hospital management) 
and the regulations on personal data protection. Thus 
the researchers had no control of respondent selection 
and were unaware of how many of potential respondents 
received the hyperlink in order to participate and chose 
not to. Regardless of the random sampling of the hospitals 
in the country, respondents were selected not randomly 
but based on their availability. 
Another limitation is that in order to secure anonymity and 
a good response rate questions regarding demographic 
characteristics such as sex and age were excluded, as 
 (such as name, brand and address). However, regardless 
of the measures used to maintain the anonymity of the 
respondents, the level of participation was less than 
expected. This limitation does not allow us to monitor PSC 
in all hospitals or to make comparisons between hospitals 
in Bulgaria and learn how things change over time. 
5 CONCLUSION 
In general, the present study showed positive ratings of 
PSC in Bulgarian hospitals, regardless of the work position 
of respondents. Based on the evidence presented in this 
work, hospital management should focus on introducing 
a positive PSC and improving the problematic areas. 
Undoubtedly, large-scale research and more detailed 
analysis could encourage and help health authorities 
and hospitals to develop proper patient safety policies 
and strategies. It would also facilitate the adoption of a 
non-punitive approach and analyses of systematic errors, 
rather than focusing on individuals to blame and punish. 
CONFLICT OF INTEREST
 study.
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FUNDING
 
 ETHICAL APPROVAL
The study was approved by the Medical University’s 
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