PERCEPTION OF PATIENT SAFETY CULTURE AT THE PRIMARY CARE LEVEL: 
THE CASE OF THE COMMUNITY HEALTH CENTRE LJUBLJANA 
Tina VIRTIČ POTOČNIK
 1, 2*
   , Zalika KLEMENC-KETIŠ
 1,2, 3
 
1 
Community Health Centre Ljubljana, Primary Healthcare Research and 
Development Institute, Metelkova 9, 1000 Ljubljana, Slovenia 
2 
University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska 8, 2000 Maribor, Slovenia 
3 
University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana, Slovenia 
Received: Oct 16, 2023
Accepted: Nov 27, 2023
Original scientific article
*Correspondence: tina.virtic@gmail.com
10.2478/sjph-2024-0004 Zdr Varst. 2024;63(1):21-29
21
ZAZNAVANJE KULTURE VARNOSTI PACIENTOV NA PRIMARNI RAVNI 
ZDRAVSTVENEGA VARSTVA: RAZISKAVA V ZDRAVSTVENEM DOMU LJUBLJANA
© National Institute of Public Health, Slovenia. 
Virtič Potočnik T, Klemenc-Ketiš Z. Perception of patient safety culture at the primary care level: The case of the Community Health Centre Ljubljana. 
Zdr Varst. 2024;63(1):21-29. doi: 10.2478/Sjph-2024-0004.
ABSTRACT
Keywords: 
Safety culture
Patient safety
Quality healthcare
Primary healthcare
Health promotion
IZVLEČEK
Ključne besede: 
kultura varnosti 
varnost bolnikov
kakovostno 
zdravstveno varstvo
primarno zdravstveno 
varstvo
promocija zdravja
Background: Patient safety is a crucial element of quality healthcare, and endeavours to enhance it are vital for 
attaining universal health coverage and improving patient outcomes. This study aimed to evaluate the perception 
of patient safety culture among staff at the Community Health Centre Ljubljana (CHCL).
Methods: A cross-sectional study was conducted in December 2022. All CHCL staff (N=1,564) from different 
professional groups were invited to participate in an anonymous electronic survey using the validated Slovenian 
version of the “Medical Office Survey on Patient Safety Culture” (MOSPSC). Mean percent positive scores for all 
items in each composite were calculated. 
Results: The final sample included 377 participants (response rate, 24.1%), most of whom were women (91.5%, 
N=345) with different professional profiles. The mean age of the participants was 44.5 years (SD 11.1) with a mean 
work experience of 20.1 years (SD 12.1). The percentage of positive overall MOSPSC composite scores was 59.6%. 
A strong patient safety culture perception was identified in the following dimensions: Information exchange with 
other settings (93.5%), Organisational learning (90.2%), List of patient safety and quality issues (88.1%), Patient care 
tracking/follow-up (76.2 %) and Teamwork (75.0%). Weak patient safety culture was identified in the dimensions of 
Work pressure and pace (10.7%), Leadership support for patient safety (27.1%), Communication openness (40.9%), 
Office processes and standardisation (48.2%) and Overall ratings on quality and patient safety (49.4%).
Conclusions: CHCL leadership should address weaknesses, redesign processes, and implement strategies to 
reduce patient safety incidents. Establishing a just culture that encourages employees to report errors fosters 
transparency and facilitates learning from errors. 
Izhodišča: Za kakovostno zdravstveno varstvo je ključna varnost pacientov in prizadevanja za njeno izboljšanje so 
bistvenega pomena za doseganje splošnega zdravja in izboljšanje izidov za paciente. V Sloveniji kultura varnosti 
pacientov še ni sistemsko urejena. Redno ocenjevanje kulture varnosti je pomembno za opredelitev področij, kjer 
so potrebne izboljšave in za zagotovitev najboljše možne oskrbe pacientom. Namen raziskave je bil oceniti kulturo 
varnosti pacientov med zaposlenimi v Zdravstvenem domu Ljubljana (ZDL).
Metode: V decembru 2022 je bila izvedena presečna raziskava, v katero so bili povabljeni vsi zaposleni v ZDL (n 
= 1564) iz različnih poklicnih skupin. V anonimni elektronski anketi so izpolnili slovensko različico “Medical Office 
Survey on Patient Safety Culture” (MOSPSC). Za vsako dimenzijo varnosti je bil v skladu z navodili izračunan 
povprečni odstotek pozitivnih ocen.
Rezultati: Končni vzorec je vključeval 377 udeležencev (24,1 % odzivnost) različnih poklicnih profilov, med katerimi 
je bilo 345 (91,5 %) žensk. Njihova povprečna starost je bila 44,5 leta (SD 11,1), s povprečno delovno dobo 20,1 
leta (SD 12,1). Delež pozitivnih ocen vseh MOSPSC dimenzij je znašal 59,6 %. Kultura varnosti je bila identificirana 
kot močna v 5 dimenzijah: Izmenjava informacij z drugimi okolji (93,5 %), Organizacijsko učenje (90,2 %), Seznam 
težav glede varnosti in kakovosti bolnikov (88,1 %), Sledenje/nadaljnja oskrba bolnikov (76,2 %) in Timsko delo 
(75,0 %). Šibka kultura varnosti je bila prepoznana v naslednjih dimenzijah: Delovni pritisk in tempo (10,7 %), 
Podpora vodstva za varnost bolnikov (27,1 %), Odprtost komunikacije (40,9 %), Pisarniški procesi in standardizacija 
(48,2 %) ter Skupna ocena kakovosti in varnosti bolnikov (49,4 %). Ugotovljene so bile razlike med dimenzijami 
MOSPSC in posameznimi enotami ZDL, starostjo zaposlenih, različnimi poklicnimi profili in trajanjem zaposlitve.
Zaključek: Zaznava kulture varnosti pacientov v ZDL je bila ocenjena kot pozitivna v petih dimenzijah MOSPSC 
lestvice, vendar so bila prepoznana tudi šibka področja, ki potrebujejo izboljšave. Pomembno je, da vodstvo ZDL 
obravnava ta vprašanja, preoblikuje procese in izvaja strategije za zmanjšanje števila incidentov, povezanih z 
varnostjo pacientov. Potrebno je spodbujati pravično kulturo in ustvariti okolje, kjer bodo zaposleni brez zadržkov 
poročali o potrebnih izboljšavah, storjenih napakah in se iz njih učili. Nenehno prizadevanje, spremljanje in 
izboljševanje prispevajo k zagotavljanju varne, učinkovite in kakovostne oskrbe pacientov.
This article was presented at the 2nd ISCPC conference, which took place in Cankarjev dom, Ljubljana, Slovenia, on 23 and 24 November, 2023. The conference was organised by the Community Health Centre 
Ljubljana and Medical Faculty, University of Ljubljana, Slovenia.

1 INTRODUCTION
Patient safety is a critical component of quality 
healthcare, and efforts to improve it are essential for 
achieving universal health coverage and improving patient 
outcomes. The World Health Organization defines patient 
safety as a “framework of organised activities that creates 
cultures, processes, procedures, behaviours, technologies 
and environments in healthcare that consistently and 
sustainably lower risks, reduce the occurrence of avoidable 
harm, make errors less likely and reduce impact of harm 
when it does occur” (1).
Prioritising patient safety in healthcare settings has gained 
greater recognition in recent years (2). Achieving optimal 
patient safety requires a safety culture that promotes open 
communication, transparency, and continuous learning 
(1). It entails a shared understanding that safety is a top 
priority and everyone’s responsibility (3), necessitating 
systems that encourage error reporting, root cause 
analysis, and effective preventive strategies (1, 3). 
Patient safety in primary healthcare in Slovenia varies 
significantly from secondary to tertiary levels. Acting as 
a gatekeeper to hospital care, primary care is accessible 
and involves frequent patient contact (4, 5) with diverse 
health issues. Health providers are often required to make 
complex decisions with limited information (6). Hence, 
it is crucial to be comfortable with uncertainty, explore 
probabilities, and minimise risks (7).
Patient safety culture remains unregulated in Slovenia, 
and thus there is a need for more quality assessment 
with regard to enhancing the quality of work in this 
sector. Unfortunately, punitive measures and fault-based 
liability persist (8). As Slovenia increasingly focuses on 
“value-based healthcare” to optimise patient treatment 
outcomes, a stakeholder expert panel has been formed to 
develop a roadmap for its implementation (9). 
The safety culture in Slovenian out-of-hours primary 
healthcare settings was recently assessed, with the results 
showing the need to standardise working conditions 
(10, 11). While leaders in Slovenian primary healthcare 
organisations generally express positive perceptions of 
safety culture, there remains room for improvement in 
communication and stress recognition (12). The only study 
evaluating the perception of patient safety culture among 
employees at the Community Health Centre Ljubljana 
(CHCL) was conducted in 2017 , and this revealed an overall 
good patient safety culture. However, variations between 
professions were noted, and certain areas require further 
evaluation (4).
Regularly assessing patient safety culture is crucial for 
identifying areas of improvement and ensuring optimal 
patient care (13, 14). This study thus aimed to evaluate 
employee perceptions of patient safety culture at the 
10.2478/sjph-2024-0004 Zdr Varst. 2024;63(1):21-29
22
CHCL and explore the relationships among different 
dimensions of patient safety and the sociodemographic 
characteristics of the study participants.
2 MATERIALS AND METHODS
2.1 Research design and setting
We conducted a cross-sectional study at CHCL, the largest 
community healthcare centre in Slovenia, which provides 
health services for the Municipality of Ljubljana with over 
450,000 registered patients. The CHCL consists of eight 
units, located in various parts of Ljubljana. In 2022, there 
were 1,564 employees from different areas of healthcare.
The study was approved by the Slovenian National Medical 
Ethics Committee (No. 107/07/16).
2.2 Participants
We invited all employees (N=1,564) of the CHCL to 
participate in the study (physicians, dentists, healthcare 
assistants, registered nurses, management, administrative 
or clerical staff, clinical support staff and employees 
working at other positions).
2.3 Tool
We utilised the validated Slovenian version of MOSPSC 
(15), developed by the Agency for Healthcare Research 
and Quality (16). This tool facilitates the assessment of 
patient safety culture at the primary healthcare level, the 
detection of possible differences, better understanding 
with regard to the safety of a particular organisation, 
and evaluating the impact of specific interventions for 
improving patient safety culture (13, 16, 17). 
The structure of MOSPSC is outlined in Table 1. Domains 
A and B were answered according to a 6-point frequency 
scale from “daily” to “not in the past 12 months”. 
Domain C consists of four dimensions and domain D 
of three dimensions, both answered according to a 
5-point Likert scale. Domain E included four items on 
leadership support, answered only by individuals without 
a leadership function, using a 5-point Likert scale. Those 
with a leadership function were required to respond 
to Domain F. Domain G describes overall ratings in five 
areas of healthcare quality (patient-centred, effective, 
timely, efficient, and equitable) and an overall rating on 
patient safety, using a 5-point Likert scale. All 52 items 
also included the response option “Does not apply” or “I 
don’t know” (16, 18). Finally, data on sociodemographic 
characteristics (gender, age, function, work experience, 
working hours, and location of work) were collected.

10.2478/sjph-2024-0004 Zdr Varst. 2024;63(1):21-29
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A
B
C
D
E
F
G
Age (years), mean (SD)
Age group (years), n (%)
<25
26-40
41-55
>56
Male
Female
Profile, n (%)
Physician, dentist
Registered nurse
Management
Administrative or clerical staff
Healthcare assistants
Other clinical staff
Other position
Health centre unit, n (%)
Center
Moste-Polje
List of patient safety and quality issues 
Information exchange with other settings 
Teamwork 
Work pressure and pace 
Staff training 
Office processes and standardisation 
Communication openness 
Patient care tracking/follow-up 
Communication about error
Leadership support for patient safety 
Organisational learning 
Overall perceptions of patient safety and quality 
Overall ratings on quality 
Overall rating on patient safety
44.5 (11.1)
14 (1.8)
135 (17.8)
142 (18.7)
86 (11.3)
32 (8.5)
345 (91.5)
84 (21.8)
102 (26.5)
12 (3.1)
12 (3.1)
97 (25.2)
47 (12.2)
31 (8.1)
79 (21.0)
85 (22.5)
DIMENSION
DESCRIPTIVES
DOMAIN
CHARACTERISTIC
Table 1.
Table 2.
Structure of the MOSPSC tool (16).
Sociodemographic characteristics of the participants.
2.4 Data collection
The survey was completed electronically, and the link was 
sent to the participants’ email addresses in December 
2022. A reminder was sent after two weeks. Participation 
was anonymous, as possible identifiers such as email and 
IP address were removed by the administrative coordinator 
of the project. It was not possible for the researchers to 
link the participants to their responses.
2.5 Data analysis
We performed a univariate analysis with frequency 
distributions and descriptive statistics. The MOSPSC 
analysis was performed according to the AHRQ 
recommendations. Responses with the highest scores on 
the Likert scale indicate a more positive patient safety 
culture evaluation at each item level. Negatively worded 
items (C3, C6, C8, C10, C12, C14, D4, D7, D10, E1, E2, E4, 
F3, F4, and F6) were reversed so that higher scores always 
indicated a more positive evaluation of the safety culture. 
“Does not apply” or “I don’t know” responses were treated 
as missing data. A positive response was considered when 
the response score was equal to or above 4 on any 5-point 
or 6-point Likert scale (16). We calculated a percent 
positive score for each of the composites and the overall 
MOSPSC composite percent positive score using the mean 
percent score of positive responses of all dimensions. 
A positive patient safety culture was considered when 
the composite percent positive score was above 60%. 
The patient safety culture was considered strong when 
composite percent positive score was equal to or greater 
than 75% and identified as weak when composite percent 
positive score was less than 50%, suggesting the need for 
improvements (16). 
For the statistical analysis, the composite percent positive 
scores are expressed as the mean ± standard deviation (SD) 
and median and interquartile range (25–75%). According 
to the Kolmogorov-Smirnov test with Lilliefors correction, 
the overall MOSPSC composite percent positive score 
had a normal distribution, and all composite percent 
positive scores of MOSPSC dimensions had a non-normal 
distribution. The association between the composite 
percent positive scores of the MOSPSC dimensions and the 
participants’ gender or professional profile was evaluated 
using the Mann-Whitney U test, resulting in the calculation 
of the U value. Additionally, the Kruskal-Wallis test was 
employed to compare the medians of the composite 
percent positive scores of the MOSPSC dimensions 
across various sociodemographic characteristics of the 
employees, yielding the H value. A p-value of <0.05 was 
considered statistically significant.
3 RESULTS 
3.1 Demographic characteristics 
The final sample comprised 377 participants who returned 
eligible and complete surveys, resulting in a response 
rate of 24.1%. The majority were women (91.5%, N=345). 
Participants had a mean age of 44.5 years (SD 11.1) and a 
mean work experience of 20.1 years (SD 12.1), with 78.5% 
having more than 16 years of experience. On average, the 
participants worked 37.1 hours per week (SD 10.1) and 
the average length of work in the current medical office 
location was 12.4 years (SD 10.9).

List of patient safety and quality issues, %
Information exchange with other settings, % 
Teamwork, % 
Work pressure and pace, % 
Staff training, % 
Office processes and standardisation, % 
Communication openness, % 
Patient care tracking/follow-up, % 
Communication about error, %
Leadership support for patient safety, % 
Organisational learning, %
Overall perceptions of patient safety and quality, %
Overall ratings on quality and patient safety, %
Overall MOSPSC composite percent positive score, %
 
G1: Overall ratings on quality
G2: Overall rating on patient safety
Overall ratings on quality and patient safety, %
88.1 (18.9)
93.5 (18.8)
75.0 (29.7)
10.7 (20.3)
51.6 (36.7)
48.2 (28.2)
40.9 (33.7)
76.2 (28.6)
58.3 (31.6)
27.1 (31.2)
90.2 (22.9)
70.1 (24.2)
49.4 (38.3)
59.6 (15.7)
48.4 (50.0)
51.7 (50.0)
47.1 (50.0)
47.1 (50.0)
69.8 (46.0)
52.8 (40.3)
32.6 (46.9)
49.4 (38.3)
G1A: Patient-centred, %
G1B: Effective, %
G1C: Timely, %
G1D: Efficient, %
G1E: Equitable, %
G1: Average overall rating on quality, %
G2, %
100.0 (77.8-100.0)
100.0 (100.0-100.0)
75.0 (50.0-100.0)
0.0 (0.0-25.0)
66.7 (33.3-66.7)
50.0 (25.0-72.0)
25.0 (0.0-75.0)
75.0 (50.0-100.0)
75.0 (25.0-75.0)
25.0 (0.0-50.0)
100.0 (100.0-100.0)
75.0 (50.0-100.)
50.0 (16.7-83.3)
75.0 (50.0-100.0)
0.0 (0.0-100.)
100.0 (0.0-100.0)
0.0 (0.0-100.0)
0.0 (0.0-100.0)
100.0 (0.0-100.0)
60.0 (0.0-100.0)
0.0 (0.0-100.0)
50.0 (16.7-83.3)
Mean (SD)
Mean (SD) ITEMS
Median (IQ 25-75)
Median (IQ 25-75)
MOSPSC DIMENSIONS
DOMAIN G
Table 3.
Table 4.
Composite percent positive scores of the Medical Office Survey on Patient Safety Control (MOSPSC) and its dimensions. 
Percentage of positive responses on Overall ratings on quality and patient safety.
Legend: SD – standard deviation; IQ 25–75 – 25%–75% interquartile range
Legend: SD – standard deviation; IQ 25–75 – 25%–75% interquartile range
Legend: SD – standard deviation
10.2478/sjph-2024-0004 Zdr Varst. 2024;63(1):21-29
24
Management
Šentvid
Vič-Rudnik
Bežigrad
Emergency Care Unit
Šiška
Work experience 
(years), n (%) 
<4
4-7
8-15
>16
5 (1.3)
12 (3.2)
82 (21.8)
56 (14.9)
6 (1.6)
52 (13.8)
 
13 (3.4)
25 (6.6)
43 (11.4)
296 (78.5)
DESCRIPTIVES CHARACTERISTIC
3.2 Attitudes to patient safety culture
Table 3 shows the composite percent positive scores of the 
MOSPSC and its dimensions. Strong patient safety culture 
was detected in five dimensions: Information exchange 
with other settings (93.5%), Organisational learning 
(90.2%), List of patient safety and quality issues (88.1%), 
Patient care tracking/follow-up (76.2 %) and Teamwork 
(75.0%). Weak patient safety culture was identified in 
the following five dimensions: Work pressure and pace 
(10.7%), Leadership support for patient safety (27.1%), 
Communication openness (40.9%), Office processes and 
standardisation (48.2%) and Overall ratings on quality and 
patient safety (49.4%). The overall MOSPSC composite 
percent positive score was 59.6%.
Table 4 shows the percentage of positive scores for items 
of Domain G. The percentage of positive responses on 
Overall ratings on quality was 52.8% and that for Overall 
rating on patient safety was 32.6%, with the composite 
percent positive score of 49.4%. Regarding the items of 
the G1 sub-domain, only Equitable showed a positive 
safety culture, with 69.8%.

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List of patient safety  
and quality issues, %
Mean (SD)
Median (IQ 25-75) 
Information exchange  
with other settings, %
Mean (SD)
Median (IQ 25-75) 
Teamwork, %
Mean (SD)
Median (IQ 25-75)
Work pressure and pace, %
Mean (SD)
Median (IQ 25-75)
Staff training, %
Mean (SD)
Median (IQ 25-75),  
U value if p-value <0.05 
 
 
85.6 (24.7)
80.0  
(70.0-100.0)
 
94.2 (17.4)
95.0  
(90.0-100.0)
76.8 (29.3)
70.0 (60.0-87.5)
8.1 (18.8)
0.0 (0.0-33.3)
43.8 (40.0) 
50.0 (0.0–75.0), 
(U=9362.0; 
p=0.019)
  
88.9 (17.0)
85.0  
(80.0.-100.0)
 
95.0 (16.8)
95.0  
(90.0-100.0)
75.8 (29.2)
70.0 (60.082.5)
11.2 (19.0)
15.0 (0.0-25.0)
50.5 (36.7)
50.0 (25.0-75.0)
 
 
  
96.3 (6.4)
100.0  
(90.0-100.0)
 
100 (0.0)
100.0  
(100.0-100.0)
85 (24.1)
100.0 (75.0-100.0
12.5 (13.4)
0.0 (0.0- 33.3)
77.8 (29.6) 
75.0 (60–100.0), 
(U=2870.5; 
p=0.014)
  
/
/ 
 
100 (0.0)
100.0  
(100.0-100.0)
87.5 (25.0)
100.0 (75.0-100.0
37.5 (53.0)
30.0 (25.0-47.5)
38.1 (35.6)
25.0 (25.0-75.0)
 
 
 
 
90.8 (13.8)
90.0  
(90.0-100.0)
 
92.6 (20.4)
100. (80.0-100.0)
 
70.7 (32.7)
70.0 (50.0-87.5)
8.3 (16.8)
0.0 (0.0-33.3)
50.2 (36.0)
50.0 (25.0-87.5)
 
 
  
100 (0.0)
100.0  
(100.0-100.0)
 
91.1 (20.3)
100.0 (75.0-
100.0)
68.6 (31.2)
75.0 (50.0-100.0
18.1 (29.0)
25.0 (25.0-25.0)
48.8 (30.0)
50.0 (25.0-80.0)
 
 
Physician, 
dentist (n=84)
Registered 
nurse (n=102)
Management 
(n=12) 
Administrative 
or clerical 
staff (n=12)
Healthcare 
assistants 
(n=97)
Other clinical 
staff (n=47)
MOSPSC dimensions
Table 5. Analysis of composite percent positive score of the MOSPSC dimensions based on different professional profiles.
3.3 Associations between the MOSPSC dimensions and 
the employees’ characteristics
Bivariate analyses revealed relationships among the 
various sociodemographic characteristics of participants 
and MOSPSC dimensions. No differences were found 
between gender and the assessment of MOSPSC 
dimensions. However, significant variations were observed 
among different age groups in their perception of patient 
safety culture dimensions. 
Employees aged 55 and older rated Staff training 
(H=13.801; p=0.003), Office processes and standardisation 
(H=12.287; p=0.006) and Patient care tracking/follow-
up (H=10.451; p=0.015) higher than their younger co-
workers. Management workers aged over 41 evaluated 
Organisational learning (H=7.944; p=0.019) more positively 
than their younger colleagues. Participants with less 
than three years of employment rated Staff training 
(H=13.455; p=0.004) and Patient care tracking/follow-up 
(H=19.333; p<0.001) significantly lower than others. Those 
employed more than 16 years of employment assessed 
Office processes and standardisation better than their co-
workers (H=9.963; p=0.019). Leadership support received 
a higher assessment from those with more than eight years 
of work experience (H=8.440; p=0.038). No significant 
differences were found between the number of weekly 
working hours and the employees’ evaluation of MOSPSC 
dimensions. Teamwork was the only dimension assessed 
differently across CHCL units, with the Emergency care 
unit and management personnel providing the highest 
scores (H=15.441, p=0.031).
Table 5 illustrates the relationship between the composite 
percent positive score of the MOSPSC dimensions and 
professional profiles. Physicians rated Office processes and 
standardisation lower than employees in other positions 
(U=8942.0; p=0.037), whereas management staff rated 
this dimension higher than their co-workers (U=2963.0; 
p=0.004). Physicians also evaluated Patient care tracking/
follow-up with lower score compared to others (U=9362.0; 
p=0.049). Management personnel evaluated Staff training 
(U=2870.5; p=0.014), Office processes and standardisation 
(U=2963.0; p=0.003), Communication openness (U=1715.5; 
p=0.043) and Communication about error (U=1592.0; 
p=0.043) higher than other employees. Other clinical 
staff (e.g. physiotherapist, laboratory assistant, etc.) 
rated Communication openness (U=2269.5; p=0.011) and 
Leadership support for patient safety (U=2074.5; p=0.002) 
lower than employees in other positions.

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Physician, 
dentist (n=84)
Registered 
nurse (n=102)
Management 
(n=12) 
Administrative 
or clerical 
staff (n=12)
Healthcare 
assistants 
(n=97)
Other clinical 
staff (n=47)
MOSPSC dimensions
Office processes and 
standardisation, %
Mean (SD)
Median (IQ 25-75), U 
value if p-value <0.05
 
 
Communication openness, %
Mean (SD)
Median (IQ 25-75),  
U value if p-value <0.05 
 
Patient care tracking/
follow-up, %
Mean (SD)
Median (IQ 25-75),  
U value if p-value <0.05 
 
Communication 
about error, %
Mean (SD)
Median (IQ 25-75),  
U value if p-value <0.05 
 
Leadership support for 
patient safety, %
Mean (SD)
Median (IQ 25-75),  
U value if p-value <0.05 
Organisational learning, %
Mean (SD)
Median (IQ 25-75), U 
value if p-value <0.05
/Overall perceptions of 
patient safety and quality, %
Mean (SD)
Median (IQ 25-75), U 
value if p-value <0.05
/Overall ratings on quality 
and patient safety, %
Mean (SD)
Median (IQ 25-75), U 
value if p-value <0.05
 
43.4 (26.1)   
37.5 (20.0–80.0), 
(U=8942.0; 
p=0.037)
 
52.9 (31.0) 
62.5 (25.0-75.0), 
(U=9542.5; 
p<0.01)
 
 
70.8 (31.1) 
75.0 (75.0-100.0), 
(U=3937.5; 
p=0.049)
 
 
56.2 (32.2)
50.0 (50.0-75.0)
 
 
 
 
31.5 (32.6)
25.0 (0.0-50.0)
 
 
66.7 (38.4) 
75.0 (50.0-100.0)
 
 
62.5 (32.2)
66.7 (33.3-100.0)
 
 
53.4 (36.3)
66.7 (33.3-100.0)
 
49.7 (28.9)
50.0 (33.3-80.0)
 
 
 
34.1 (33.3) 
25.0 (0.0-50.0)
 
 
 
 
77.7 (27.7)
75.0 (75.0-100.0)
 
 
 
 
56.9 (32.0)
50.0 (50.0-75.0)
 
 
 
 
28.7 (28.9)
33.3 (0.0-33.3)
 
 
/
/
 
 
/
/
 
 
46.4 (39.8)
50.0 (33.3-66.7)
 
72.9 (24.9)    
75.0  
(80.0–100.0), 
(U=2963.0; 
p=0.003)
63.9 (35.6)    
75.0 (50.0–
100.0), 
(U=1715.5; 
p=0.043)
 
68.8 (23.9)
75.0 (50.0-100.0)
 
 
 
 
87.5 (18.9)  
100.0  
(75.0-100.0), 
(U=1592.0; 
p=0.043)
 
50.0 (25.0)
50.0 (25.0-75.0)
 
 
100 (0.0)
100.0 (100.0-
100.0)
 
75.0 (25.0)
66.7 (33.3-100.0)
 
 
52.8 (33.2)
50.0 (33.3- 100.0)
  
55.0 (41.1)
75.0 (50.0–75.0)
 
 
 
33.3 (28.9)
25.0 (0.0-50.0)
 
 
 
 
/
/
 
 
 
 
75.0 (0.0)
80.0 (75.0-100.0)
 
 
 
 
58.3 (52.0)
50.0 (50.0-100.0)
 
 
/
/
 
 
/
/
 
 
20.8 (34.9) 
20.0 (0.0-50.0), 
(U=1260.5; 
p=0.009)
Legend: SD – standard deviation; IQ 25–75 – 25%–75% interquartile range; U – value in the Mann-Whitney U test if p-value <0.05
 
47.8 (25.9)
50.0 (25.0-75.0)
 
 
 
37.3 (31.6)
25.0 (0.0-50.0)
 
 
 
 
80.3 (26.9)
75.0 (75.0–100.0)
 
 
 
 
58.6 (28.0)
50.0 (25.0-75.0)
 
 
 
 
27.9 (32.8)
25.0 (0.0–50.0)
 
 
87.2 (25.6)
100.0 (75.0- 
100.0
 
58.3 (14.4)
50.0 (50.0-75.0)
 
 
47.6 (40.4)
50.0 (33.3- 66.7)
  
50.0 (27.1)
50.0 (33.3-66.7)
 
 
 
25.0 (32.3) 
25.0(10.0-50.0), 
(U=2269.5; 
p=0.011)
 
 
70.5 (36.8)
70.0 (60.0-82.5)
 
 
 
 
58.8 (30.6)
50.0 (25.0-75.0)
 
 
 
 
12.5 (24.7) 
0.0 (0.0–33.3), 
(U=2074.5; 
p=0.002)
/
/
 
 
/
/
 
 
56.0 (34.3)
66.7 (33.3-66.7)

4 DISCUSSION
This study provides valuable insights into the perception 
of safety culture at CHCL, highlighting areas that require 
attention to enhance patient safety. While five dimensions 
of MOSPSC are identified as strong (Information exchange 
with other settings, Organisational learning, List of 
patient safety and quality issues, Patient care tracking/
follow-up, and Teamwork), there are still areas in need 
of improvement, namely Work pressure and pace, 
Leadership support for patient safety, Communication 
openness, Office processes and standardisation, and 
Overall ratings on quality and patient safety. Additionally, 
the research indicates variations in the MOSPSC domains 
based on CHCL’s individual units, employee age, different 
professional profiles, and length of employment.
The present study found no significant relationship 
between any of the safety culture composites and gender, 
similar to a study in Greece (19). In contrast, Polish (20), 
Spanish (21) and Slovenian (4) studies revealed that 
women rated certain domains higher than men. Our 
study showed a positive relation between seniority and 
responses referring to Staff training, Office processes and 
standardisation and Patient care tracking/follow-up. A 
study in Spain also showed the best perception of safety 
culture was among respondents 56 to 69 years old (21). We 
found differences in the patient safety culture among the 
professional profiles and so did other studies (4, 21–23).
Information exchange with other settings (93.5%) received 
the highest score, indicating effective communication and 
collaboration. This is an essential component of a strong 
patient culture in healthcare, as it enables healthcare 
providers to share important patient information and 
coordinate care across different settings (16). Teamwork 
(75.0%) and Organisational learning (90.2%) were also 
among the highest rated MOSPSC dimensions which 
is consistent with studies from Spain (21), Brazil (24), 
Yemen (25), Iran (26), and Poland (20). These findings 
highlight the importance of comprehensive primary 
care in promoting and strengthening teamwork, as 
multi-professional healthcare stakeholders are involved 
in managing patients (10). Moreover, this dimension is 
essential because it influences the health professionals’ 
satisfaction and participation, and promotes personal and 
professional well-being (24). In addition, the emphasis 
on organisational learning is also an important aspect of 
promoting quality and safety. Through ongoing evaluation 
and improvement of healthcare practices, healthcare 
professionals can continuously learn and adapt to changing 
patients’ needs and healthcare environments (21).
The dimension List of patient safety and quality issues 
considers daily tasks such as access to care, patient 
identification, accessibility of medical records, medical 
equipment, medication and diagnostics (16), and these 
were assessed as having a strong safety culture (88.1%). 
This dimension was the highest scoring for all professional 
categories in the Spanish study (21). A strong safety 
culture was also evident in the Patient care tracking/
follow-up dimension (76.2%), especially when compared 
to two Brazilian studies (56.1%) (23) and (60.1%) (24) and 
a Yemeni study (52%) (26). This dimension ensures that 
patients receive timely and appropriate care (17). In our 
study, doctors assessed it worse (p=0.049) than registered 
nurses and healthcare assistants, and it is essential to 
identify the reasons for this discrepancy, which may 
involve a lack of communication and coordination among 
healthcare providers.
We identified a weak safety culture in Work pressure and 
pace (10.7%) and Leadership support for patients’ safety 
(27.1%), with the lowest scores. Notably, the dimension of 
Work pressure and pace is a significant concern for patient 
safety in primary care, consistently associated with low 
scores across various studies (4, 20, 21, 24, 25, 27). Research 
highlights challenges in primary care settings, emphasising 
issues such as inadequate staffing levels to manage 
patient loads (4, 14, 26, 27). Healthcare professionals in 
CHCL gave the lowest scores for this dimension, aligning 
with the shortage of personnel and high workload among 
family medicine doctors (8) and nurses in Slovenia, 
with negative impacts on healthcare quality and safety 
(28). Understanding and addressing factors influencing 
workload is crucial for developing interventions to improve 
efficiency, reduce work pace, and prevent burnout (17, 
27). For the sustainability of the Slovenian healthcare 
system it is essential to transfer health competences and 
responsibility from healthcare professionals to empowered 
patients (8, 29). To this end, CHCL recently introduced a 
model of peer support with trained lay individuals who 
are CHCL’s volunteers and ambassadors, with the aim 
of empowering patients, family members and informal 
caregivers in the local community (29).
In the Overall ratings on quality and patient safety 
dimension (49.4%), administrative staff scored significantly 
lower than employees in other profiles, aligning with 
Hickner’s et al. study (17). Continuous education and 
training are instrumental in improving the skills and 
knowledge of all employees (14). Regarding the overall 
quality assessment, Equitability (69.8%) obtained the 
highest score. This can be attributed to the CHCL’s 
pivotal role as Slovenia’s largest primary health centre, 
in promoting health equity and reducing disparities. By 
addressing social determinants, it can enhance the health 
and well-being of its diverse population. 
While the overall MOSPSC composite percent positive 
score of 59.6% falls below the threshold for a positive 
assessment, it surpasses the observed scores in other 
primary healthcare settings (23, 24). In contrast, studies 
in Poland (20), Yemen (25), Iran (26), and Greece (19) 
10.2478/sjph-2024-0004 Zdr Varst. 2024;63(1):21-29
27

reported positive overall MOSPSC composite percent 
positive scores. Nonetheless, CHCL has demonstrated 
ongoing efforts over the years to enhance patient safety 
culture and care quality. This commitment is further 
underscored by its recent participation in the OECD 
initiative, focusing on the outcomes and experiences of 
patients receiving care in family medicine practices (30). 
A notable strength of this article could be in its chronological 
consistency, employing the same methodology to assess 
the environment at CHCL over time. In contrast with 
the one prior study at CHCL in 2017, where 37.3% of the 
respondents reported a positive score for the Overall 
ratings on quality and patient safety dimension (4), the 
current result of 49.4% is promising. However, it must be 
interpreted carefully, given our study’s low response rate 
of only 24.1%, compared to 67.8% in the 2017 study (4).
However, several limitations of this study should 
be acknowledged. The CHCL represents just one of 
numerous health centres in Slovenia, and the sample 
may not accurately reflect the diversity of Slovenian 
primary healthcare. Additionally, the findings may not be 
generalisable to the entire CHCL, given the study’s low 
response rate of 24.1%, possibly indicating organisational 
or leadership culture issues. The participants might not 
have felt entirely comfortable expressing safety concerns, 
despite confidentiality assurances. Those who chose to 
participate may also have had a heightened interest or 
knowledge about the topic, introducing potential bias. 
Encouraging healthcare professionals to identify and 
report errors without fear or blame is crucial, fostering a 
shift from an accountability to a just culture, focused on 
learning to prevent errors (21, 31). As most respondents 
were registered nurses, healthcare assistants and 
physicians, the results did not adequately reflect the 
perceptions of management and administrative staff. 
This aligns with the common misconception that only 
healthcare staff bear responsibility for patient safety and 
incidents. As such, delving into the reasons for the limited 
participation of other professional groups is crucial. A 
thorough understanding of the barriers these groups 
face in this regard can guide the development of more 
effective strategies to engage them in research. 
Additionally, it is important to note a limitation related 
to the MOSPSC’s validation, which originally focused 
on participants in leadership positions (15). Further 
psychometric evaluation is necessary, considering the 
diverse roles within our participant population. Moreover, 
not using open-ended questions may limit understanding 
healthcare professionals’ perceptions of safety culture 
(24), emphasising the need for a combined quantitative 
and qualitative approach. Given these limitations, it is 
crucial to interpret the study results carefully. 
5 CONCLUSIONS
This study offers insights into the perception of the safety 
culture at CHCL, pinpointing areas for attention to further 
enhance patient safety. Although five dimensions of the 
MOSPSC were identified as strong, there are still areas 
needing improvement. It is crucial for CHCL leadership to 
address these issues, redesign processes, and implement 
improvement strategies that reduce patient safety 
incidents. Fostering a just culture within the organisation 
is imperative with regard to enhancing future participation 
rates, where employees are comfortable reporting 
errors, learning from them, and promoting transparency. 
Continuous effort, monitoring and improvement can 
ultimately contribute to the delivery of safe, effective, 
and high-quality patient care.
ACKNOWLEDGMENT 
We would like to acknowledge and thank all the subjects 
who participated in the survey.
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist. 
FUNDING 
The study received no funding.
ETHICAL APPROVAL 
The study was approved by the National Ethics Committee 
of the Republic of Slovenia (No. 107/07/16).
AVAILABILITY OF DATA AND MATERIALS 
All data and materials used in this study are available 
upon reasonable request.
ORCID
Tina Virtič Potočnik: 
https:/ /orcid.org/0000-0003-4925-3706
Zalika Klemenc-Ketiš: 
https:/ /orcid.org/0000-0002-0270-1754
10.2478/sjph-2024-0004 Zdr Varst. 2024;63(1):21-29
28

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