Introduction

Patient safety (PS) awareness among healthcare providers is a critical concern worldwide, including in Saudi Arabia. It is now a key factor in ensuring high-quality healthcare services for patients. PS is defined as “preventing errors and adverse effects associated with healthcare provision for all types of patients”. A good PS culture is imperative for better healthcare delivery and patient safety.¹ All healthcare professionals who are actively involved in patient care have equal responsibility for ensuring PS during patients’ stays in the hospital.²

The Kingdom of Saudi Arabia (KSA) provides free, excellent healthcare services in public hospitals. All hospitals are equipped with state-of-the-art technologies and advanced equipment. PS awareness and its implementation in clinical practice have become paramount in such an environment. Negligence in any aspect of patient care may have grave consequences for patients’ health outcomes.^3,4 Literature indicates the involvement of many contributing factors in hospitals’ failure to provide up-to-date healthcare services. The most common issue is the unavailability of well-written standard operating procedures for various medical procedures and investigative processes, which expose patients to unnecessary risks. In such circumstances, the probability of healthcare providers making inconsistent decisions increases the risk of medical errors and adverse events.⁵

Understaffing could be another factor increasing the workload for all healthcare professionals, leading to fatigue and burnout and raising the chances of overlooking critical details or failing to respond promptly to patient needs.⁶ Allowing many visitors and maintaining unhygienic environments in hospital units can also be a source of disturbance and a potential threat to other patients.⁷ A comprehensive approach is needed to address PS issues, including improved communication, enhanced training, standardized protocols, and fostering a safety culture within healthcare organizations. Such an approach will improve PS and the overall quality of care.¹

A hospital’s clear PS policies could significantly affect patient care. In a good PS culture, patients should be the priority. A lack of emphasis on PS policies may also discourage hospital staff from reporting incidents, thus preventing learning and improvement opportunities. Supporting a culture of incident reporting is essential for avoiding future harmful events. Every effort should be made to encourage reporting without fear of being penalized.^4,8 In Saudi Arabia, authorities are making serious efforts to update the curriculum on PS training for medical students attending clinics and hospital wards. Almost all medical colleges have incorporated PS modules into the curriculum for senior medical students exposed to hospital patient care settings.^9,10

Assessing PS attitudes among medical students and interns is critical because they are future physicians, and their positive attitudes are essential for improving the healthcare system. The current study employed the “Attitudes to Patient Safety Questionnaire III (APSQ-III)” to evaluate medical students’ and interns’ attitudes, as it is a valid and reliable tool that has been used multiple times for this purpose. Several studies have reported medical students’ attitudes regarding PS.^11–13 However, inconclusive results have been reported. Moreover, there is a lack of such studies that have involved interns and compared medical students’ and interns’ attitudes. The present study assessed and compared medical students’ and interns’ attitudes regarding PS at the Faculty of Medicine (Rabigh and Jeddah) and King Abdulaziz University Hospital (KAUH) in Jeddah, KSA. The present study’s findings provide valuable information about medical students’ and interns’ attitudes toward PS, which is tremendously important in the healthcare system. This information can help policymakers and educators modify teaching and learning strategies to optimize the effectiveness of the PS module.

Materials and Methods

The current investigation was conducted in the Faculty of Medicine, Rabigh, KAU, Jeddah, KSA. Data were collected from medical students and interns at the Rabigh and Jeddah campuses from November 2021 to February 2023. The study was conducted following the Declaration of Helsinki and approved by the Unit of Biomedical Ethics Research Committee of King Abdulaziz University, Jeddah (Ref No. 357–19). Informed consent was obtained from all participants. A brief statement at the beginning of the questionnaire outlined the study’s objectives, and participants were notified that completing the questionnaire would be considered as providing their voluntary consent. Participants were ensured that their confidentiality would be preserved, and the results would be published anonymously.

At KAU, the medical curriculum includes a two-credit-hour PS module for sixth-year medical students. The Faculty of Medicine at KAU and KAUH has about 3000 students and interns. The sample size was calculated using a Raosoft calculator (Raosoft Inc., USA) with a 5% margin of error, a 95% confidence level, and a 50% expected response rate. The calculated sample size was 341 participants. However, the calculated sample size in the present study was 341, but the questionnaire was sent to 1000 students, and 493 students were included in the final analysis.

A validated and modified version of the “Attitudes to Patient Safety Questionnaire III (APSQ-III)” was used to collect data.¹⁴ Several studies have previously utilized this questionnaire.^13,15,16 The questionnaire’s reliability and comprehensibility were not measured in the present study because it has been used on medical and dental students in KSA in multiple studies.^17,18 The questionnaire was validated, and its reliability coefficient ranged from 0.64-0.82 across nine domains.¹⁴ The questionnaire comprises 26 items covering various PS issues across nine domains. The main reason for choosing the APSQ-III among several questionnaires was its validity, reliability, and widespread use in several studies within and outside KSA.^13,15–18 Additionally, the questionnaire’s main domains and items were perfectly aligned with the objectives of the present study.

The questionnaire used a seven-point Likert scale, where 7 represented “strongly agree”, 4 represented “unsure”, and 1 represented “strongly disagree”. Eight items (11, 13–18, 25) were reverse-scored, where 1 represented “strongly agree” and 7 represented “strongly disagree”. For positively phrased items, responses of “strongly agree”, “agree”, or “somewhat agree” were considered positive. For reverse-coded items, responses of “strongly disagree”, “disagree”, or “somewhat disagree” were considered positive. Conversely, responses of “strongly disagree”, “disagree”, or “somewhat disagree” in positively phrased questions and “strongly agree”, “agree”, or “somewhat agree” in reverse-coded questions were considered negative.^13,19 The mean scores of the study participants for each individual item were classified as follows: a positive attitude (score > 4), a neutral attitude (score = 4), and a negative attitude (score < 4).¹⁹

The inclusion criteria for this study required participation from medical students of both genders at two KAU-affiliated medical colleges and interns from KAUH. Incomplete questionnaires and preparatory year students were ruled out from the study. The online questionnaire (Google Form) was distributed to 1000 students via Email and social media platforms, including WhatsApp, Instagram, Telegram, and Facebook. All the participants were KAU medical students, and all the researchers were from the same university, making it easy to approach and contact them. A total of 708 responses were collected, yielding a response rate of 70.8%. However, the 215 responses from second- and third-year students were excluded from the final analysis because these students had not yet been exposed to clinical rotations and, therefore, lacked sufficient exposure to medical errors and PS-related issues. Including their responses would have produced erroneous results. Thus, their comments were removed from the analysis. At KAU, clinical rotations begin in the fourth year, so only responses from fourth-, fifth-, and sixth-year students, as well as interns, were included in the final analysis. The Bachelor in Medicine and Bachelor in Surgery (MBBS) program at KAU consists of six years of study and one year of internship. The first year is preparatory, and formal medical education begins in the second year. A few steps were taken to minimize biases, such as using a valid and reliable questionnaire, maintaining the anonymity of participants, and employing closed-ended questions (Likert scales).

Statistical Analysis

SPSS version 24 was employed to analyze data. Frequencies and percentages were used for qualitative data and mean and standard deviation were used for quantitative data. Differences in attitudes between genders and between medical students and interns were assessed using an independent sample t-test. A p-value of < 0.05 was set as significant. All missing and incomplete data were not included in the final analysis.

Results

A total of 493 students and interns participated in the study, including 233 females (47.3%) and 260 males (52.7%). The participants were distributed as follows: 114 (23.1%) from the fourth year, 102 (20.7%) from the fifth year, 145 (29.4%) from the sixth year, and 132 (26.8%) interns (not shown in the table). The participants’ mean score on most domain items was less than four, indicating a generally negative attitude toward PS. However, in two out of three items within the “disclosure responsibility” domain, participants scored higher than four, reflecting a more positive attitude in this area (Table 1). The mean scores of the study participants across the nine key PS domains are presented in Table 2.

Table 1 Mean Scores of the Study Participants in the Individual Items of “Attitudes to Patient Safety Questionnaire III (N=493)”

Table 2 Mean Scores of the Study Participants in the Key Nine Domains of “Attitudes to Patient Safety Questionnaire III (N=493)”

In several items, males had higher mean scores compared to females. For example: “my training is preparing me to prevent medical errors” (males: 2.66±1.82 vs females: 1.88±1.23, p < 0.001), “by not taking regular breaks during shifts, doctors are at an increased risk of making errors” (males: 2.32±1.51 vs females: 1.87±1.15, p < 0.001), “the number of hours doctors work increases the likelihood of making medical errors” (males: 2.43±1.59 vs females: 2.02±1.29, p = 0.002), “even the most experienced and competent doctors make errors” (males: 2.15±1.43 vs females: 1.85±1.09, p = 0.011), “all medical errors should be reported” (males: 1.98±1.36 vs females: 1.70±1.01, p = 0.013). In contrast, females scored better on a few items, such as “most medical errors result from careless doctors” (females: 4.06±1.88 vs males: 3.45±1.84, p < 0.001), “medical errors are a sign of incompetence” (females: 3.65±1.77 vs males: 3.15±1.79, p = 0.002), and “doctors have a responsibility to disclose errors to patients only if the errors result in patient harm” (females: 4.68±2.04 vs males: 3.93±2.20, p < 0.001) (Table 3).

Table 3 Gender-Wise Comparison of Mean Scores of the Study Participants in the Individual Items of “Attitudes to Patient Safety Questionnaire III (N=493)”

A gender-wise comparison revealed that males mean scores across several domains were significantly higher than females, including “PS training received” (p = 0.001), “working hours as a cause of error” (p = 0.002), “team functioning” (p< 0.001), “patient involvement in reducing errors” (p = 0.002), and “importance of PS in the curriculum” (p < 0.001) (Table 4).

Table 4 Gender-Wise Comparison of the Mean Scores of the Study Participants in the Key Nine Domains of “Attitudes to Patient Safety Questionnaire III (N=493)”

There was no significant difference found between the mean scores of interns and medical students across the nine key domains, except in the domain of “professional incompetence as an error cause”, where medical students scored higher than interns (12.9±4.46 vs 11.3±4.75, p = 0.001) (Table 5).

Table 5 Comparison Between Interns’ and Medical Students’ Mean Scores in the Key Nine Domains of “Attitudes to Patient Safety Questionnaire III (N=493)”

Discussion

Globally, it is a significant concern that negligence in patient care and adverse events caused by medical errors endanger the lives of hospitalized patients. Awareness of PS among all healthcare students and practitioners is crucial for delivering high-quality healthcare to the community. The Saudi healthcare system’s unique characteristics include its cultural dynamics and medical education framework. In Saudi culture, there is a strong religious influence and an emphasis on family-centered care. The Kingdom provides free healthcare services to all Saudi nationals. Medical educational institutes follow a structured curriculum, and cultural awareness has been incorporated into training programs. Additionally, there is a greater focus on public health and preventive care in KSA. Within this context, the present study holds significant importance.

The study cohort included male and female medical students receiving clinical training in hospital settings and young doctors undergoing internships in various hospital units. The responses in the present study were not positive for most items. A similar survey conducted in Dammam, KSA, showed only one-tenth of the participants among dental students and interns reported positive attitudes toward patient safety culture.¹⁸ Contrary to the present study’s findings, studies from Palestine, India, Lebanon, China, and Pakistan have shown more positive attitudes among medical students.^{11,13,19–21} A systematic review reported mixed attitudes among healthcare students.²²

The negative results in the study could be attributed to a common psychological phenomenon among students, where they avoid taking responsibility due to fear of consequences, such as being penalized or receiving poor evaluations from teachers.^13,23 This unwillingness to “speak up” requires greater attention, as overcoming the fear of revealing shortcomings is crucial to fostering a culture of safety.¹³ Other potential factors contributing to these results include educational gaps in PS training, cultural influences, personal reservations, or liability concerns. The present system clearly needs more focused, practical PS-based training, which currently emphasizes theoretical knowledge over hands-on skills. Furthermore, improving students’ communication skills to discuss medical errors with colleagues and patients, supporting their PS concerns, correcting their misconceptions, and providing full moral and legal support could help shift these negative attitudes toward more positive engagement with PS practices.

Interestingly, the current study found positive attitudes in two items within the “disclosure responsibility” domain. These results are similar to an Indian study²¹ and dissimilar to a Pakistani study.¹⁹ The positive attitude in these two reversely coded items suggests that students recognize the significance of reporting all errors, even those that do not result in harm, to improve healthcare systems, maintain professional integrity, and build patient trust. They may also understand that even non-significant errors could have cumulative or delayed effects on PS. Moreover, reporting errors is ethical and can protect physicians from future litigation. This indicates that students have some awareness of the legal and ethical consequences of concealing medical errors. With the growing global emphasis on patient-centered care, where patients actively participate in healthcare decisions, students with such mindsets may help promote greater openness and transparency in the Saudi healthcare system.

In contrast to the present study findings, a few studies have reported positive attitudes in other domains such as “PS training received”, “patient involvement in reducing errors”, “working hours as a cause of error”, “error inevitability”, and “importance of PS in the curriculum”.^13,15 Differences in attitudes could be attributed to differences in PS training, cultural norms, implementation of PS rules, the impact of regulatory authorities, and the extent to which patients and their families are involved in diagnosis and management processes.

In the present study, medical students demonstrated lower scores in the domains of “working hours as an error cause”, “patient involvement in reducing error”, and “error inevitability”. Several other studies have also reported lower mean scores for the domain “professional incompetence as an error cause”.^11–13,19 These findings suggest that respondents may not fully understand the causes of some medical errors. An American study also found that students had difficulty comprehending medical errors and their underlying factors.²⁴ The current study results suggest that medical students may view long working hours as a cultural norm in medicine, seeing them as a sign of commitment and dedication rather than recognizing their potential negative impact on PS. Students may also underestimate the effects of sleep deprivation and cognitive fatigue. The low mean score in the domain “patient involvement in reducing error” reflects respondents’ belief that patients lack the knowledge to contribute significantly to error prevention. Additionally, the low score in “error inevitability” may indicate that students have not yet fully grasped the complexities of the hospital environment and may mistakenly believe that errors are solely a result of incompetence.

The present study also identified gender differences in attitudes toward PS, with males scoring significantly higher than females in several domains. These findings are similar to those of a Saudi study that found males had higher mean scores than females in a few PS domains among healthcare practitioners.¹⁷ A few studies reported no significant gender variances in mean scores,^16,19,21 while a Lebanese study reported that males scored significantly higher in a few domains of PS.¹¹ A survey from Ghana also showed that male participants had clearer perspectives than females regarding PS.²⁵ A systematic review found that female healthcare professional students generally tended to have more positive PS attitudes.²² In our study, males’ mean scores on PS issues were better than females, even though both groups received the same training. This suggests that individual assessments of their capabilities and training differ. Male participants showed greater confidence in their knowledge, regardless of the actual training they received.

The current study observed no statistically significant difference in PS knowledge and attitudes between interns and medical students. This is surprising, as it was expected that interns would have a better understanding and attitude due to their increased clinical exposure. A recent study reported that fewer than half of the interns exhibited better knowledge of medication errors than students.²⁶ Other studies have suggested that interns may not possess optimal awareness of PS protocols if they did not receive dedicated PS training during their studies.^26,27 The present result is unexpected because our institution has included a two-credit-hour PS module in the sixth-year curriculum for many years. Therefore, interns were expected to show better attitudes than medical students. One explanation could be that interns prioritize clinical tasks and practical knowledge over safety concepts during their one-year internship. Another possibility is a gap between their academic training and clinical experience, which may result in an inconsistent application of PS principles. Additionally, inadequacies in PS assessment during medical studies and internships may be reflected in their attitudes.

Unlike this study’s findings, a study from Saudi Arabia described a significant increase in PS attitudes from fourth-year dental students to interns.¹⁸ Another study showed mixed responses across different PS domains based on students’ ages,¹¹ indirectly reflecting their academic years. Previous research has indicated that students and healthcare workers need proper PS training to improve their knowledge and attitudes.²⁸ The present study scores indicate both groups appear to have been exposed to inadequate PS training and are less familiar with the practical application of PS principles. Additionally, it is likely that interns at the early stage of their clinical careers may not have had enough exposure to the clinical environment to develop more positive attitudes compared to medical students. Since both groups were trained within similar educational and clinical environments with the same curricula, teachers, and supervisors, their attitudes were not significantly different. The institutional policies and culture likely had a uniform effect on both groups.

The lower mean score on PS attitudes in a few domains among interns indicates inadequate attention to PS initiatives in clinical practice. The literature suggests that the PS curriculum should be taught spirally, with standard competencies, regular assessments, and a focus on practical, real-world applications to better prepare students for the realities of clinical practice.²⁹ Alsahli et al suggested that continuous training, effective policies, the use of technology, and dedicated management within institutions are beneficial for promoting a PS culture.³⁰

In practice, medical education often focuses more on clinical knowledge and technical skills than communication, teamwork, and PS. These skills should be given more attention during medical training. The overall negative attitudes may also result from numerous factors, including cultural influences, systemic issues, educational gaps, and a lack of appropriate role models.

Recommendations

PS is of tremendous importance in medical education curricula. According to the results of this investigation, it is recommended that PS education should not be confined to a two-credit-hour module in the sixth year. Instead, PS education should be incorporated from the beginning of medical classes to establish a strong foundation for a PS culture among future physicians. When students are introduced to PS concepts early in their medical education and receive reinforcement during their clinical years, it establishes a strong foundation for their perceptions of PS. To accomplish this, utilizing standardized content, like real-life case studies of medical errors and adverse events, is crucial as it promotes contextual learning and engages and inspires students. Furthermore, simulation-based training should be integrated into the curriculum. Following each session, discussions and constructive feedback should be offered, as this can positively influence students’ attitudes toward PS.

In some domains, males scored better than females, highlighting the need to address gender disparities in PS education. While both genders had negative attitudes in most domains, institutions should provide additional support and resources to all students, especially female students, to ensure equal training and understanding of PS practices. It is also recommended that PS principles be emphasized during internships. Hospital administrations should regularly assess the application of PS principles in clinical settings. In the context of overall negative attitudes observed in this study, awareness campaigns, seminars, and motivational workshops should be arranged to promote a more positive attitude toward PS. These efforts would help improve medical students’ competency in PS and enable them to become more professional, ethical physicians, enhancing the PS culture within institutions and improving patient outcomes.

Limitations

Like other cross-sectional studies, this study has some limitations. First, it presents the attitudes of a sample of medical students and interns at KAU. As a single-center study, the results cannot be generalized to other institutions. Medical students at other universities in KSA or other regions may score differently. There may be variances among students of different institutes in clinical exposure, internship opportunities, and socio-demographic characteristics. Additionally, differences in PS curriculum, instructional methods, faculty competence, or institutional culture limit the generalizability of the present study. Second, the study depended on self-reported data, which has inherent limitations. Participants may have under- or overestimated their knowledge and attitudes. Third, while the study found gender differences in some PS domains, it could not explore the reasons behind these differences. Fourth, the study did not address potential confounding variables, such as prior patient safety training, clinical exposure beyond curriculum, or cultural factors influencing responses. Future research using focus group discussions and in-depth interviews could offer a more inclusive understanding.

Conclusion

The findings of this study demonstrate that most participants’ PS attitudes require a shift toward more positive engagement. Gender disparities were found in PS attitudes among Saudi medical students and interns, with males demonstrating significantly better mean scores than females in several key PS domains. However, no significant variance was noted between the intern and medical student groups in the key PS domains. There is a clear need to address this issue to provide safe and better patient care. Integrating interactive learning methods, creating mentorship programs, addressing systemic barriers to reporting errors, and adding PS education early and longitudinally may help to improve knowledge and shift towards a positive attitude. Educators can reform the PS curriculum by emphasizing PS as a core competency.

Additionally, there is a strong need for international collaboration to share evidence-based practices in PS education. By introducing PS training in the early years, students would understand its importance early on. Interactive learning methods, such as simulations, case studies, and hands-on workshops, should be implemented to create more engaging PS training. Such methods would help students better comprehend real-life PS scenarios and prevention strategies.

Regular awareness campaigns, workshops, and seminars should be organized to improve PS competencies among medical students and interns. This would foster a more robust PS culture within healthcare institutions that would positively impact the healthcare system. Further, mixed-method studies are suggested to better and broadly explore students’ attitudes.