Comprehensive Strategies and Recommendations for Optimising Patient Safety Practices in Public Hospitals of Addis Ababa: An Explanatory Sequential Mixed-Methods Study

Comprehensive Strategies and Recommendations for Optimising Patient Safety Practices in Public Hospitals of Addis Ababa: An Explanatory Sequential Mixed-Methods Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comprehensive Strategies and Recommendations for Optimising Patient Safety Practices in Public Hospitals of Addis Ababa: An Explanatory Sequential Mixed-Methods Study Sem Daniel Abreham, S Shakwane This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9209575/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Enhancing patient safety in hospitalised patients is crucial. In Ethiopia, a lack of effective patient safety protocols has led to significant gaps in safety culture. This study aims to develop strategies to enhance patient safety practices in public hospitals in Addis Ababa. Methods A sequential explanatory mixed-methods design was used within a pragmatic worldview framework. Participants were recruited through heterogeneous stratified and purposive sampling. Data collection included a questionnaire, a checklist, and an interview guide. Quantitative data were analysed with descriptive statistics and logistic regression, while qualitative data underwent thematic analysis. The findings informed the development of patient safety strategies. Results Quantitative and qualitative results were integrated to support patient safety practices in public hospitals in Addis Ababa. The integrated findings were used as a foundation for developing the final patient safety strategies. Conclusion Ensuring healthcare workers have a good understanding and implement patient safety principles will improve their adherence to SOPs and guidelines, thereby reducing the risk of errors. Originality Findings from an empirical study informed the development of patient safety strategies, which were then validated through a panel of expert review. Occupational Medicine Addis Ababa Healthcare Quality Optimising Patient Safety Strategies Patient Safety Practices Healthcare Risk Patient Safety Practices Public hospitals Figures Figure 1 Background Patient safety issues are a challenge for public hospitals. Patient safety is the prevention and avoidance of injuries or adverse incidents for patients and healthcare staff during their duties (Asem et al., 2019 :1). More than 400,000 deaths and millions of injuries from preventable medical errors occur every year in the United States of America (Brittain and Carrington, 2021). WHO estimates have shown that 1 in 10 patients in high-income countries suffer an injury during hospital treatment each year, while in low-income countries, 1 in 4 patients suffer an injury during hospitalisation (Cerrone et al., 2023 ). According to the International Institute of Medicine (IOM) report, each year, 2.9% of hospitalised patients encountered adverse events, and 6.6% of them died from patient care-related risks globally, while New York had 3.7% adverse events and 16.6% deaths (Machmud et al., 2017). Therefore, patient safety issues concern every healthcare system worldwide, including Ethiopia (Kati, 2020 ). As a result, preventing harm and proper reporting of adverse events during healthcare provision is crucial for ensuring patient safety (Asem et al., 2019 ). In addition, creating a safe environment within medical facilities is vital for safeguarding both patients and healthcare staff during their duties. To protect patients through ensuring patient safety, healthcare providers must adhere to the established guidelines and report any adverse events (Mistri et al., 2023 ). According to Mortell ( 2019 ), the overall state of patient safety within a hospital is influenced by two fundamental factors. The first issue occurs when there is a lack of proper patient identification for informed decision-making, and the second issue is the theory-practice-ethics gap paradigm, which assumes that all healthcare providers possess the relevant theoretical knowledge and practical skills to provide safe and competent care. Inappropriate communication, insufficient staffing, unreported errors, poor knowledge dissemination, ineffective information systems, personal and work-related conflicts, a lack of comprehensive policies and procedures, and conceptual and technical deficiencies in routine healthcare contribute to patient harm (Kaware et al., 2022 ). Similarly, a field study conducted in Switzerland shows that half of all documented accidents are human errors, followed by organisational settings, infrastructure, and environment, and technical problems (Brittain & Carrington, 2021). In 2005 WHO established guidelines to promote the adoption of policies on reporting and learning from errors to improve the safety of care (Cerrone et al., 2023 ). Therefore, it is important that developing countries establish patient safety measures to promote quality care for their people. In the Ethiopian health system delivery, there is a lack of representative empirical data demonstrating the implementation of a patient safety culture and the related contributing aspects (Kumbi et al., 2020 ). There is also limited evidence regarding patient safety culture and medical errors in Ethiopia's public hospitals, with many errors remaining unreported due to a punitive culture (Garuma et al., 2020 ). As a result, a significant information gap is believed to be a major patient safety problem in Ethiopia (Ahmed Ratan et al., 2023:2). Despite interventions such as training and mentoring, healthcare-related adverse events are increasing significantly (Biresaw et al., 2020 ). Consequently, efforts have been prioritised to improve the capacity of the health workforce through accredited training programmes, defined career paths, staffing standards, health management systems for human resources, and systems for performance evaluation and auditing (Ethiopian Ministry of Health, 2020 ). In 2016, the Ethiopian Ministry of Health introduced the Ethiopian National Health Care Quality Strategy (ENHCQS) to enhance healthcare quality through improvements in clinical outcomes, patient safety, and patient-centred care, focusing on equity and accessibility. It was postulated that by 2020, this strategy was intended to expand patient safety practices nationwide (FMOH, 2016 ). Furthermore, the Health Sector Transformation Plan aligns these objectives with the Sustainable Development Goals (Health Sector Transformation Plan II, 2021). Limited studies in Ethiopia show patient safety culture scores below the 75% benchmark by HSOPSC (Biresaw et al., 2020 ; FMOH, 2016 ; Mekonnen et al., 2017; Tedla, 2019 ). Poor safety practices affect patient care quality and satisfaction (Belay Gizaw et al., 2018 ). These are due to systemic gaps, necessitating alignment in healthcare functions for patient safety and service quality (Elmontsri et al., 2018 ). Therefore, this study suggested comprehensive recommendable strategies to improve patient safety practices in public hospitals of Addis Ababa, Ethiopia. Theoretical Foundations of the Study In this study, the Swiss-Cheese model (SCM) was applied as an illustrative framework to analyse and understand the complex nature of patient safety practices in public hospitals. The Swiss-Cheese Model (SCM) serves as a heuristic tool to explain interactions during catastrophic breakdowns in complex systems (Fukuoka and Furusho, 2016 ). Its success is due to a systemic foundation that broadens the scope of analysis to include the complexity of the organisation and environmental management; therefore, holes and imperfections represent potential weaknesses within the system (Reason, 2017 ). One of the components of SCM is the alignment of the holes, which creates potential risks. This refers to the propensity for system failures that lead to adverse events. As system failures increase, the likelihood of an incident occurring also rises (Shabani et al., 2024 ). In summary, no single layer of defence is without flaws; each has its potential weaknesses or limitations. The SCM conveys that no failure, human or technical, is sufficient to cause an accident. Instead, it involves the unlikely and often unforeseeable conjunction of several contributing human or technical factors arising from different levels of the health system (Fukuoka and Furusho, 2016 ). Reason used the term “active failures” to describe factors at the unsafe acts level , while the term “latent failures” was used to describe unsafe conditions located higher up in the system (Shabani et al., 2024 ). For this study, SCM was used to identify errors and omissions that lead to practical failures in healthcare, specifically misdiagnosis, miscommunication, and medication errors. The findings highlighted that a systems-oriented approach needs to be initiated for better patient safety and cannot be achieved by insisting on individual efforts or blaming individuals. Methods The authors declare that this work is part of a larger study on a sequential explanatory mixed method. In which pragmatism was used to implement multiple research approaches in one study. Pragmatism guides the researcher toward making suitable methodological choices by simplifying different aspects of the research problem during the design phase (Kelly 2020 ). In the quantitative phase, patient safety practices were assessed and measured, followed by qualitative data that explained the quantitative results through focus group interviews. This manuscript outlines the strategies developed based on the integrated results of the empirical research findings. It aimed to develop strategies for improving patient safety practices in public hospitals in Addis Ababa. Summary of Integrated results The findings from both quantitative and qualitative data were integrated to gain a better understanding of patient safety practices. Table 1 presents the findings of the integrated study. Table 1 Integrated study results Findings Discussion Patient care services The study highlighted that while clinicians recognised the existence of standard operating procedures (SOPs) and safety guidelines, instances of non-compliance were prevalent, as 75% acknowledged these measures were in place. However, alarmingly, more than 25% of the respondents reported not having received the necessary training or information about patient safety protocols, which led to a notably high incidence of adverse events occurring in the preceding month. This highlights the urgent need for better training, communication, and resource allocation to create a safer patient care environment. Environmental safety Patient safety management in public hospitals is affected by budget allocation, resource availability, surveillance, research, staffing levels, and the experience and hours worked by healthcare providers. Financial resources are crucial for acquiring supplies, training staff, and enhancing the quality of care. It is essential to balance investments in safety surveillance and research with feedback to address performance gaps. Although over 50% of clinician managers view patient safety management positively, efforts are needed to strengthen this perception among all healthcare professionals, thereby fostering a culture that minimises fear, blame, and silence. The study results indicated that nearly 50% of physician participants believed effective patient safety management is associated with setting reminders and enhancing teamwork, which helps prevent poor practices. Patient safety coordination According to the study findings, effective communication is crucial for ensuring patient safety and maintaining a secure healthcare environment. Many patient porters and receptionists lack clear guidance on policy frameworks and practices needed to provide essential information to patients, leading to confusion and dissatisfaction. The study also revealed that poor communication among healthcare professionals negatively affects the quality of patient care and satisfaction. Patients often feel stressed or overwhelmed, especially while managing their health conditions. The research revealed that 33% of porters and receptionists lacked any established guidelines or methods for delivering compassionate care to patients, highlighting issues surrounding inadequate training and understanding among non-clinical personnel. Furthermore, the poor communication practices, especially in critical areas such as the emergency department, suggest an urgent need for enhancements. Confidentiality of patients stands as a major issue, as evidenced by one-third of study participants, including porters and receptionists, who noted the absence of protective policies. This significant detail highlights potential risks for privacy breaches and highlights the necessity for improved practices. Additionally, the lack of patient advocates and knowledge about standard operating procedures can detract from the quality of care delivered. Focus group participants noted a lack of systematic training for personnel managing medical records, indicating that regular training could enhance their skills and protect patient confidentiality. Adverse events reporting Establish a system for early notification and timely response to adverse events. The average score for patient safety culture was 61.4%, which was evaluated using the Hospital Survey on Patient Safety Culture (HSOPSC) checklist. The evaluated public hospitals exhibited slightly lower patient safety practices compared to similar studies conducted nationwide in comparable settings. To enhance patient care, safety, and the overall quality of healthcare services, it is essential to focus on effective patient safety metrics and encourage the reporting of adverse events by both healthcare professionals and patients. These empirical findings laid a foundation for the development of the strategies. Strategy development The results of the empirical steps were used as input for this phase of developing patient safety strategies. There are seven steps of the strategy development framework that were adopted (Dyson et al., 2015 ; Salman and Mahmoud, 2021 ). This seven-step strategy development approach was employed in this study. Strategy purpose The purpose of the identified strategies and key interventions is to provide high-quality patient care during hospitalisations. Moreover, the developed strategies aimed to enhance patient safety practices by integrating evidence-based principles, enabling patients to make informed choices, aligning safety efforts toward a common objective, and strengthening safety through preventive actions. Scope of developed strategies The proposed strategies are primarily designed for public hospitals with similar setups and socio-demographic peculiarities. Hospitals shall consider the strategies' unique circumstances and tailor them accordingly to achieve the best results. The strategies are robustly designed to focus on key technical and managerial areas that will significantly enhance patient safety practices. Steps to develop patient safety strategies The study followed and adapted the seven-step framework outlined byDyson et al. Salman and Salah Abood Mahmoud (2015: 2021) while developing patient safety strategies as follows. Step 1 The strategic direction-setting step involves focusing on vision, mission, strategic objectives, and goals. A SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis was conducted to establish strategic vision, mission, objectives, and goals. SWOT Analysis for Patient Safety Practice and Management The study highlighted that while clinicians recognised the existence of standard operating procedures (SOPs) and safety guidelines, instances of non-compliance were prevalent, as 75% acknowledged these measures were in place. However, alarmingly, more than 25% of the respondents reported not having received the necessary training or information about patient safety protocols, which led to a notably high incidence of adverse events occurring in the preceding month. Patient safety management in public hospitals is affected by budget allocation, resource availability, surveillance, research, staffing levels, and the experience and hours worked by healthcare providers. Financial resources are crucial for acquiring supplies, training staff, and enhancing the quality of care. It is essential to balance investments in safety surveillance and research with feedback to address performance gaps. Although over 50% of clinician managers view patient safety management positively, efforts are needed to strengthen this perception among all healthcare professionals, thereby fostering a culture that minimises fear, blame, and silence. Table 2 presents the summary of the SWOT analysis for patient safety practice and management. Table 2 SWOT analysis on patient safety practice and management SWOT analysis on patient safety practice and management Strength Weakness - Staff and managerial commitment to foster safer patient care - Presence of transparency among the health workforces - Availability of guiding principles that support the patient safety management process - Staff motivation to notify adverse events. - Presence of a system for patient service audits, including the identification and handling of patient safety malpractices - Available procedures that support easy access to patient services - Inconsistent patient safety practices across service areas - Inadequate advocacy, training, and compliance with the existing patient safety guidelines and procedures - Less compliance with the workforce code of conduct and patient safety standards. - Insufficient staff recognition and managerial support - Presence of a culture of blaming and shaming to report adverse events - Inadequate patient empowerment and communication culture - Long working hours, workload, less teamwork, and a lack of a clear assignment of roles - Critical Shortage of manpower, medical supplies and equipment - Poor managerial feedback on the reported adverse events - Fail to establish an organisational structure to receive and manage reported adverse events. - Fail to use evidence for decision making Opportunity Threat - Presence of managerial commitment to support patient safety implementation - Adequate budget for health service expansion and enhancing patient care quality - Digitisation of patient care services - Presence of health system innovation platforms - Use of technologies for patient care monitoring and error reduction - Lack of patient safety policies, strategies, and guidelines - Presence of weak regulatory functions - Poor staff incentive and recognition mechanism - Weak enforcement of organisational and professional ethics regulations - Sub-optimal health infrastructures and layout - Presence of complex patient safety challenges that require managerial attention - Staff fatigue and burnout due to workload - Lack of in-depth experience in patient safety implementation - Inadequately trained health workforce - Lack of representative studies - Understaffing and high staff attrition SWOT Analysis on patent safety communication and adverse event reporting practice The average score for patient safety culture was 61.4%, which was evaluated using the Hospital Survey on Patient Safety Culture (HSOPSC) checklist. The evaluated public hospitals exhibited slightly lower patient safety practices compared to similar studies conducted nationwide in comparable settings. Based on the study findings, effective communication is crucial for ensuring patient safety and maintaining a secure healthcare environment. Many patient porters and receptionists lack clear guidance on policy frameworks and practices needed to provide essential information to patients, leading to confusion and dissatisfaction. The study also revealed that poor communication among healthcare professionals negatively affects the quality of patient care and satisfaction. Patients often feel stressed or overwhelmed, especially while managing their health conditions. Table 3 provides a summary of patient safety communication and adverse events reporting. Table 3 SWOT analysis on patient safety communication and adverse event reporting practice SWOT analysis on patient safety communication and adverse event reporting practice Strengths Weaknesses - - Presence of professional communication protocols - Presence of labelling of patient service departments - Presence of a system for patient communication and facilitation of the patient flow pattern - Presence of a system for the exchange of patient information across service departments - Presence of verbal and non-verbal (oral) communication channels - Loss of patient information during staff shift hours - Communication breakdown due to poor teamwork and staff workloads - Inadequate training - Lack of a system in place to receive, score, and report adverse events - Less staff communication protocol awareness - Absence of health literacy units for patients attending hospital service outlets - Lack of patient safety advocacy and communication frameworks - Lack of patient empowerment to prevent malpractices - Presence of a non-supportive organisational culture that discourages transparency Opportunities Threats - The availability of advanced technologies and communication platforms improves the culture of professional communication. - Availability of patient service protocols for maintaining proper and continuous staff communication - Availability of financial and technical resources to improve patient safety - Lack of communication policies and - Lack of a regulatory system for patient safety practice scoring and adverse event reporting - Weak legal grounding and enforcement for handling and management of reportable adverse events - Lack of practical experience in patient safety management - Presence of a language barrier that affects patient-to-healthcare provider communication Strategic vision The validated patient safety strategies aim to build a healthcare system where patient safety is essential to quality improvement. This ensures that all interventions are evidence-based, equitable, and sustainable. The vision focuses on immediate safeguards while fostering a lasting culture of safety that promotes resilience, accountability, and continuous learning. Mission statement The strategic mission is to empower public hospitals to bridge the gap between the current state of healthcare and long-term goals through validated strategies that strengthen patient safety. Public hospitals should establish patient safety task forces, utilise checklists and protocols, conduct regular audits, and leverage technology to report and prevent errors. By implementing these key strategies, public hospitals will enhance patient safety and elevate the overall quality of healthcare delivery. Strategic objectives To align key strategies with long-term healthcare objectives to establish a cycle of innovation, evaluation, and adaptation. To foster a safety-oriented culture through ongoing healthcare workers training and awareness to support adherence to patient safety standards. To conduct regular safety audits and risk assessments and use findings to enhance continuous improvement cycles. To establish service points for reporting medical errors and near misses that foster a culture of adverse events reporting. To create a system for providing feedback on safety concerns to improve transparency. Strategic goal The goal of the validated strategies is to enhance safer patient care services by addressing gaps and challenges across service units through the implementation of recommended standard patient safety practices. By adopting these strategies, hospitals will foster a safer environment for patients and significantly improve the overall quality of care. Step 2 Develop the performance measurement step, emphasising the strategic directions Four strategies were developed and presented below. Strategy 1: Standardise patient care service to improve patient safety practices. Strategic goals To ensure the implementation of existing patient safety guidelines and policies to standardise patient care practices by validating practical experiences. To improve the efficient use of healthcare resources to maximise efforts in patient safety practices by making evidence-based decisions and actions. Key interventions Standardise practices and validating experiences. Making evidence-based decisions and actions for the efficient use of healthcare resources Strategy 2: Create a safer healthcare environment through efficient patient safety management. Strategic goals To enhance safer clinical care practices by raising staff awareness, teamwork, effective communication and advocating a positive patient experience. To ensure the existence of functioning structural arrangements that enable enhancing safer patient care practices through continuous monitoring and evaluation. To improve the capacity of healthcare workers to implement safer patient care practices through staff training and advocacy. Key interventions Create smooth communication and advocacy, strengthen teamwork, and conduct training Revitalise existing structural and functional arrangements and carry out monitoring and evaluation. Create collaboration and peer learning among healthcare staff Strategy 3: Patient safety communication and coordination among healthcare providers, patients, and families Strategic goals To enhance stakeholders’ involvement and coordinated efforts in completing essential resources, allowing them to deliver safer patient care practices through improved collaborative partner engagement, capitalising on safer patient care activities. To improve patient empowerment to value decisions and actions over patient care provided through the enhancement of effective patient-to-care provider communication. To improve teamwork and collaboration among the healthcare workforce to prevent medical errors by implementing effective staff engagement and communication techniques. Key interventions Partner mapping and strengthening stallholders’ collaborative action. Create a user-friendly environment and establish a culture of openness. Standardise the mechanism of communication among patient care providers and interdepartmental communication. Strategy 4: Patient care-related adverse event reporting, scoring and management Strategic goals To enhance the implementation of safer patient care practices to elevate the quality of patient care delivery by cultivating a culture of proper patient care data utilisation. To adopt standardised patient safety practices that improve the quality of patient care services by establishing a responsive system for recording and reporting adverse events. To ensure the presence of a mechanism to analyse and manage patient care-related adverse event reporting by designing a system for notification and timely response. Key interventions Standardise patient care data recording, storing and utilisation Establish an effective adverse event reporting, recording and management system Establish a system for early notification and timely response for adverse events Step 3 The sense-making step involves exploring both the internal and external situational context and assessing variations. Data collection was conducted using self-administered questionnaires targeted at healthcare workers and hospital managers. In addition, a review of documents such as SOPs, guidelines and related health sector policy recommendations available at the study public hospitals. A SWOT analysis was conducted using the findings from the qualitative study, particularly the focus group interviews, to explain the results of the quantitative study. This analysis helped identify relevant and feasible considerations that align with the purpose and objectives of the study. Step 4 The strategic initiatives creation step Based on the SWOT analysis of empirical study findings, eleven strategic objectives and key interventions were identified and shaped using integrated study findings. Strategic objectives and key interventions were identified based on their feasibility, achievability, and applicability. The proposed interim strategies were supported by a review of related literature and subsequently validated by a panel of experts as a final strategy. Step 5 Strategic evaluation using organisational models, considering potential uncertainties. The validation of the final patient safety strategy involved subsequent discussions with a group of experts in the field to ensure their insights and expertise were integrated. The strategic goals identified were not focused solely on one aspect; they were well-balanced and measured across multiple dimensions. This made it easier to develop more effective strategies and adjust to shifting situations. Step 6 Review and revise the strategy based on the experiences of experts in similar scenarios. The developed patient safety strategies were reviewed and revised after the validation process by a panel of experts in patient safety and quality assurance. Three rounds of panel discussions were conducted to validate the proposed strategies, and the feedback collected during these sessions played a vital role in shaping the interim strategies. This process enabled a diverse range of perspectives and insights from experts across various institutions. The suggestions and feedback from the panel of experts were thoroughly documented and analysed, then compared against the themes that emerged from the research findings to identify similarities. Step 7 Choosing and approving the strategy in a genuine feedback process that considers performance analysis. The first step in the primary strategy-building process is to create strategic initiatives that can be contextualised within current programmes, projects, and situations to accomplish the mission, vision, and strategic goals. After developing and validating the final patient safety strategies, the strategic goals, key interventions for each goal, and final strategies were identified, as shown in Fig. 1 . Discussion The study aimed to develop and validate strategies that enhance patient safety practices in public hospitals of Addis Ababa. Strategy 1: Standardise patient care service to improve patient safety practices This strategy aims to improve patient safety practices across the health departments in the public hospitals. The need for standard patient safety practices was identified across the healthcare units where the study was conducted. Maintaining high-quality and standardised patient care is crucial in providing the best possible, safest patient care.Cortés-Puch et al. (2020) suggest that the “one-size-fits-all” standardised treatments in some patient care settings may prevent clinicians from meeting individual patients’ needs and decrease care quality. Further,Varpio et al., (2025) warns that adherence to standardisation in healthcare can constrain expert clinical judgment and may not accommodate the unique needs and complexities of individual patients. This is because if the standardised tools are inflexible and poorly supported may result in compromised quality of patient care. Several factors contributed to poor patient safety practices, such as a lack of training for healthcare professionals, poor awareness of existing SOPs, guidelines, and policies, inadequate infrastructure, poor communication, understaffing, and shortages of medical supplies and medications. Furthermore, the scarcity of personnel and other related resources caused a significant barrier to applying standard patient safety measures. To ensure continuous patient safety practices, policies, guidelines, and standard operating procedures (SOPs) should be reviewed so that they can be current and reliable. According to Afework ( 2023 ), the lack of standard operating procedures (SOPs) and policies at the facility level is the main reason for inconsistencies in implementing patient care practices. Without proper guidelines and reliance on evidence, patient care can suffer from inconsistency, decreased efficiency, miscommunication, and insufficient learning from errors. Factors such as a lack of healthcare professionals and support staff negatively impact service quality, resulting in numerous negative experiences for both healthcare workers and patients (Okomo et al., 2024 ). Strategy 2: Create a safer healthcare environment through efficient patient safety management Creating a safer healthcare environment for both patients and healthcare providers through efficient and effective management across public hospitals is critical. Various activities enhance patient safety, but gaps exist between the implementation by patient care providers and the expectations of their supervisors. Similarly, Hibbert et al., (2023) suggested that to enhance safety culture, it's crucial to engage staff and management while ensuring clear communication on patient safety priorities. Prioritising patient safety management approaches and effectively allocating resources to patient safety practices is necessary in developing countries such as Ethiopia. Hospital management should ensure patient safety and support activities that maintain the quality and safety of care provided to patients. According to Abraham et al. ( 2022 ), patient safety management can be realised by hospital administrators ensuring that existing organisational policies and systems are implemented effectively to improve patient safety practices within healthcare institutions. Therefore, they can play an important role in regulating and practising a high standard of care for patients, with administrative actions contributing to the development of a mature safety culture within hospitals. The selected hospitals for the study revealed challenges such as inadequate teamwork, long working hours, poor infrastructure, a lack of early warning systems and risk assessment protocols, non-functional medical equipment, and a significant shortage of medical supplies and medications. Supportive and committed management processes enhance patient safety practices, while poor leadership or frequent leadership turnover is linked to compromised patient safety and organisational integrity (Brittain and Carrington 2021). Despite the challenges in deploying information and communication technology (ICT) infrastructures, it is crucial for improving patient safety practices. ICT helps maintain confidentiality, prevents the loss of patient information, reduces registration errors, and ensures safer patient care. A study by Tegegne and Wubante (2022) identified several barriers to the adoption of ICT in the Ethiopian healthcare system. The most common shortcomings include a lack of ICT training, poor ICT knowledge, inadequate ICT skills, and limited access to computers. Factors that are crucial to implement patient safety management include budget resource availability, surveillance, and research. Additionally, staffing, experience, and working hours of healthcare providers are also important. Thompson et al. (2025) suggest that the role of management in fostering patient safety culture is negligible, as many other factors, such as teamwork, staff communication, organisational learning and adverse event reporting, take a big share in fostering patient safety culture. Thus, Worke (2023) emphasises the importance of systemic interventions, which facilitate open communication, cooperation, and the exchange of ideas among healthcare workers, are essential for enhancing patient safety culture. Similarly, the study also revealed that patient safety practices in the medical records unit frequently resulted in the loss of patient information during the patient registration and recording process. Consequently, this led to patients being misidentified or mistreated. It has also contributed to gaps in interprofessional and interdepartmental communication, exposing patients to avoidable risks. This finding aligns with the study of Kasaye et al. ( 2022 ) which identifies several barriers to effective documentation and patient confidentiality, including a training gap, lack of ICT infrastructure, time constraints, insufficient human resources, unfamiliarity with standard operating procedures (SOPs), and inadequate documentation and record-keeping materials. Hospital managers need to create a supportive working environment that encourages patient safety practices, enabling the fostering of a positive perception among healthcare providers and managers. According to Alshareef (2025), effective hospital management is essential for ensuring patient safety by supporting health professionals, who are crucial in delivering patient care. Therefore, management must provide the necessary resources and support for safer patient care. This helps develop a culture that emphasises transparency while reducing blame, fear, and silence surrounding adverse event reporting and management (Belay Gizaw et al., 2018 ). Therefore, achieving this can be accomplished through an organisational learning culture that improves the quality of patient care and enhances the coordination of patient safety activities across various hospital departments. Strategy 3: Patient safety communication and coordination among healthcare providers, patients, and families Strengthening communication and coordination of patient safety practices by advocating patient safety principles among healthcare providers, patients, and families should be seen as an advocacy role for healthcare professionals and managers. There were many challenges related to communication, teamwork, and coordination between different professionals that challenged patient safety practices. One of these challenges proposed by Chen and Gong (2022) how teamwork is executed in a healthcare setup is largely unknown due to the challenges of measuring team communication in clinical practice. Similarly, a study by Zajac et al. (2021) supported the finding by proposing that combining the expertise needed to address complex healthcare problems is a significant challenge for teams. Additionally, team members’ personalities and communication styles can create barriers, even among passionate and skilled individuals. The proposed solutions focus on managing these challenges at various levels and emphasise the importance of addressing the root causes of team issues rather than just the symptoms. Furthermore, the study revealed significant gaps in the exchange of patient care information during shift changes and challenges in interdepartmental communication. These gaps were attributed to a shortage of personnel, poor communication culture, workload, fostering unfavourable attitudes towards documentation culture, training gaps, and limitations of electronic health recording systems. These findings are consistent with a study by Kasaye et al. ( 2022 ), which indicated that patient record-keeping staff with good knowledge, a favourable attitude, strong motivation, and compliance with standard guidelines tend to have good patient clinical documentation. A study by Alshareef (2025) reaffirms the relationships between overload, burnout, quality of healthcare, and patient safety; thus, overload was related to burnout and decreased patient safety and quality of care. It was found that crucial patient care data was frequently overlooked, deleted, or shared in a manner that compromised patient confidentiality, which may prevent patients from sharing their health status openly with their care providers. Similarly, the study by Tegegne et al. ( 2022 ), indicated that healthcare professionals had a limited attitude towards patient confidentiality but possessed good knowledge of patient information confidentiality. Moreover, the need for healthcare providers to effectively communicate with their patients, using clear and understandable language and ensuring an optimal patient healing process, will improve the practices of reporting adverse events and scoring the patient's safety experience. The study also highlighted various strategies to empower patients and encourage their active participation in their own care. These strategies include providing sufficient time for questions, informing patients about their care plans, and advocating for them to make informed decisions. The study emphasises that regular staff training and skill development programs enhance the efficiency of medical record personnel and improve patient confidentiality. This finding aligns with the result of a study by Kasaye et al. ( 2022 ), which emphasises that targeted training effectively tackles documentation problems in healthcare. It also reduces knowledge gaps, enhances performance among healthcare workers, and fosters a culture of documentation by improving the performance of service providers. This process enhances communication between healthcare providers and patients, resulting in safer, higher-quality care services in healthcare institutions. Therefore, effective communication to implement standardised protocols is crucial for promoting patient safety and enhancing patient outcomes. It is essential to establish clear guidelines and procedures for both clinicians and non-clinical support staff, including cleaners and patient receptionists. This ensures that all employees understand and adhere to existing standard operating procedures (SOPs) and proper work practices. Without proper practices and guidance, communication among support staff and effective cleaning tasks may suffer, negatively impacting the quality of patient care and overall satisfaction. Consequently, the study suggests that communication, collaboration, and teamwork among healthcare professionals and patients are essential for ensuring safe and effective patient care. Strategy 4: Patient care-related adverse event reporting, scoring, and management This strategy aims to enhance the identification of patient safety risks and effectively manage reported adverse events. The study suggests that there is little to no experience in handling adverse event reports, along with insufficient staff awareness regarding the effective management of these events. This situation may be due to a lack of commitment from management in establishing a system for receiving and managing adverse events, as well as an absence of staff training on how to identify and report potential incidents. Additionally, a study byAliberti ( 2023 ) emphasises the importance of staff training on adverse event topics to enhance reporting awareness. Therefore, healthcare managers shall prioritise patient safety and motivate care providers, empowering them to prevent adverse events and promote overall patient safety activities. The research findings revealed that 20.6% of participants confirmed the existence of a system for scoring and reporting adverse events, due to insufficient policies and guidelines. In line with these results, a study by Shemsu et al. ( 2024 ) reported an overall incident reporting behaviour prevalence of 28.7%. This outcome was lower compared to earlier studies in Addis Ababa's public hospitals, which documented an adverse event report of 30.4%. These differences might be initiated by the variations in sociodemographic factors, the study's environment, or its duration. The study also emphasised a gap in awareness concerning the identification of reportable adverse events and the appropriate timing for reporting. This gap may contribute to the absence of patient safety scoring or the underreporting of adverse events. Similarly,Gqaleni and Mkhize ( 2024 ) justified that the existing configuration of the reporting system hinders healthcare professionals from efficiently adhering to the guidelines. The reasons include insufficient consultation, minimal staff involvement, underreporting and assessment of adverse events, limited commitment from healthcare managers, less staff awareness, an unclear framework for handling adverse events, and the absence of comprehensive procedures or guidelines. In this study, the overall score for patient safety culture using an adapted HSOPSC instrument was 61.4%. This result indicated that hospitals still had low patient safety practice scores and areas requiring staff and management commitment to improve, alongside follow-up and progressive quality improvement monitoring. This result was comparable to the study conducted in similar regional public hospitals in Ethiopia using the HSOPSC instrument, such as a study undertaken in Bale zone public hospitals, which scored 66.1% (Kumbi et al., 2020 ), and is a slightly better result than a nationwide study conducted in Ethiopian public hospitals, which scored 46.7% (Mekonnen et al., 2017), as well as a study conducted in public hospitals in Dessie city that scored 44.8% (Mohammed et al., 2021 ). This variation in patient safety scores might be attributed to differences in institutions' locations, infrastructure, professional mix, training, and government attention and support. Conclusions The strategies developed to enhance patient safety have revealed several important insights. Hospital administration should prioritise resource allocation and the integration of technology to improve safety measures effectively. Most importantly, maintaining a sufficient and diverse workforce is essential for reducing errors that arise from excessive workloads and stress. Staff training programs should emphasise both technical skills and critical management elements, such as communication and teamwork. Healthcare personnel must be well-informed about relevant policies and guidelines. Support from hospital leadership is crucial for the successful implementation of these initiatives. Identifying potential weaknesses in patient safety creates opportunities to foster a more secure healthcare environment. Additionally, regular audits and monitoring systems are vital to the continuous improvement of patient safety protocols, as they help identify and properly report risks and develop preventive measures. Recommendations The patient safety culture was not adequately implemented in the clinical settings of public hospitals in Addis Ababa; it is essential to prioritise the adoption and implementation of the validated patient safety strategies. Hospital managers and policymakers should establish clear accountability frameworks, enhance staff training on patient safety protocols, and integrate patient safety indicators into routine monitoring and evaluation systems. Establishing clear guidelines and procedures for both clinical and non-clinical staff is essential for ensuring mutual understanding and adherence to standard operating procedures (SOPs). Furthermore, fostering a culture of safety through ongoing professional development, multidisciplinary collaboration, and clear adverse event reporting mechanisms is essential. By implementing validated strategies, hospitals can reduce preventable harm, enhance the overall quality of patient care, build teamwork, foster effective communication, and ensure compliance with international patient safety standards in public hospitals. Limitations of the study The study acknowledged some limitations, noting that its findings primarily apply to public hospitals in Addis Ababa or similar environments. Adapting the strategies for hospitals in different regions may be challenging and will likely require specific adjustments. Participants may have provided socially acceptable responses to avoid judgment, which could lead to an overreporting of positive behaviours and distort the results. Additionally, reliance on participants' memories may introduce inaccuracies, especially for older or emotionally charged events, which can affect the reliability of self-reported data. Furthermore, the findings may only be relevant to public hospitals in Addis Ababa and similar settings. In other hospitals, implementing these strategies may be more complex and require further customisation. Implications of the study This research proposes strategies aimed at developing practical solutions to address patient safety issues within the national healthcare system. The recommendations aim to improve the standard of patient care and advocate for safer practices in similar healthcare settings. Proven patient safety strategies will guide national health policies and support the progress of the national patient safety strategy. Abbreviations AOR Adjusted Odds Ratios COR Crude Odds Ratios FGD Focus Group Discussions HCAIs Healthcare-associated Infections HSOPSC Hospital Survey on Patient Safety Checklist MOH Ministry of Health SCM Swiss-Cheese Model SOP Standard Operating Procedures SPSS Statistical Software for Social Sciences WHO World Health Organisation Declarations Ethics approval and consent to participate The study obtained ethical approval and consent for data collection. It received an Ethical Clearance Certificate from the Higher Degrees Committee of the College of Human Sciences Research Ethics Committee (CREC) at the University of South Africa (UNISA), with registration number 67120679_CREC_CHS_2021. Ethical clearance certificates were also secured from the Ethiopian Ministry of Health and the ethical clearance committee of the Addis Ababa Health Bureau, MOH-E 30/27/61/450 and AAHB/11968/227, respectively. Permissions to conduct the study were obtained from the research ethics review committees of the participating hospitals. Study participants were informed of the purpose and benefits of the research, and informed consent was obtained. During transcription, personally identifiable information was anonymised or replaced with general descriptions, enabling participants to express their ideas freely. Consent for publication Not applicable. Competing Interests The authors declare that they have no competing interests. Funding There was no funding source for this study. Authors’ contributions Dr Sem Daniel Abreham, and Professor S. Shakwane were instrumental in the conception and design of the study. The first and corresponding author, Dr Sem Daniel Abreham, conducted the collection, examination, and interpretation of the data. Additionally, both Professor S. Shakwane and Dr Sem Daniel Abreham shared equal responsibility for drafting and revising the manuscript, and they endorsed the final draft. Availability of data and materials The datasets used and examined in this research are currently unavailable to the public because they will underpin a forthcoming publication. Nonetheless, interested parties can request access from the corresponding author, provided they sign the necessary documents that align with ethical standards and the Ethics Committee's rulings. A declaration statement for generative AI used Grammarly: Used as an advanced writing and grammar correction tool, it is designed to improve the text's readability and optimise linguistic accuracy throughout the editing phase. Acknowledgments Deepest gratitude goes to all who supported our research. A particular note of appreciation is reserved for the research supervisors, Prof. S. Shakwane and Prof. Sheila Mokoboto-Zwane, for their invaluable guidance and unwavering encouragement. We are grateful to UNISA, especially the College of Human Sciences and the Health Studies Department, for fostering my academic growth. Furthermore, I appreciate the collaboration from the staff at the three public study hospitals in Addis Ababa and the contributions from the UNISA scientific community. Authors Information Sem Daniel Abreham 1 *, S. Shakwane 1** 1 University of South Africa, Pretoria, South Africa, Department of Health Studies 1 * First and corresponding author: Sem Daniel Abreham, University of South Africa Sem Daniel Abreham (Ph.D.) Student Number: 67120679 Department of Health Studies College of Human Sciences, UNISA Email address - [email protected] , [email protected] Tel. (+251) 911 316019/ 906777707, Po. Box -1234 https://orcid.org/0009-0004-9821-2681 Addis Ababa, Ethiopia 1 **Co-author: S. Shakwane, University of South Africa Prof. S Shakwane Associate Professor College of Human Sciences Department of Health Studies WMM 7-183 Tel. 012 429 8450 E-mail: [email protected] https://orcid.org/0000-0002-7228-4183 Pretoria, South Africa References Abraham V, Meyer JC, Godman B, Helberg E (2022) Perceptions of managerial staff on the patient safety culture at a tertiary hospital in South Africa. Int J Qual Stud Health Well-being 17. https://doi.org/10.1080/17482631.2022.2066252 Afework A (2023) Status and Factors Affecting Patient Safety Culture at Dilla University Teaching Hospital: A Mixed-Method Cross-Sectional Study 1157–1169 Ahmad H, Shah SR, Latada F, Wahab MN (2019) Teacher Identity Dev Prof Learning: Overv Theoretical Frameworks 3:1–11 Ahmed Ratan Z, Rashad Massoud M, Fei Huang F, Mohammed T n.d. 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WMU J Maritime Affairs 15:267–292. https://doi.org/10.1007/s13437-015-0099-8 Garuma M, Woldie M, Kebene FG (2020) Areas of potential improvement for hospitals’ patient-safety culture in western Ethiopia. Drug Healthc Patient Saf 12:113–123. https://doi.org/10.2147/DHPS.S254949 Gqaleni TMH, Mkhize SW (2024) Barriers to implementing patient safety incident reporting and learning guidelines in specialised care units, KwaZulu-Natal: A qualitative study. PLoS ONE 19:1–16. https://doi.org/10.1371/journal.pone.0289857 Health (2021) Sector Transformation Plan II Kasaye MD, Beshir MA, Endehabtu BF, Tilahun B, Guadie HA, Awol SM, Kalayou MH, Yilma TM (2022) Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021. BMC Health Serv Res 22:1–13. https://doi.org/10.1186/s12913-022-07809-6 Kati C (2020) Factors Affecting Patient Safety Culture and Medical Error Incidence in Emergency Services Acil Serviste Hasta Güvenliği Kültürünü ve Tıbbi. https://doi.org/10.5222/SHYD.2019.02486 . Hata Görülme Kaware MS, Ibrahim MI, Shafei MN, Hairon SM (2022) Patient Safety Culture and Its Associated Factors: A Situational Analysis among Nurses in Katsina Public Hospitals. Northwest Nigeria Kelly LM (2020) Three principles of pragmatism for research on organizational processes. https://doi.org/10.1177/2059799120937242 Kumbi M, Hussen A, Lette A, Nuriye S, Morka G (2020) Patient safety culture and associated factors among health care providers in bale zone hospitals, southeast ethiopia: An institutional based cross-sectional study. Drug Healthc Patient Saf 12:1–14. https://doi.org/10.2147/DHPS.S198146 Mekonnen AB, McLachlan AJ, Brien JE, Mekonnen D, Abay Z (2017a) Hospital survey on patient safety culture in Ethiopian public hospitals: a cross-sectional study. Saf Health 3:1–11. https://doi.org/10.1186/s40886-017-0062-9 Mekonnen AB, McLachlan AJ, Brien JE, Mekonnen D, Abay Z (2017b) Hospital survey on patient safety culture in Ethiopian public hospitals: a cross-sectional study. Saf Health 3. https://doi.org/10.1186/s40886-017-0062-9 Mistri IU, Badge A, Shahu S, Cureus (2023) https://doi.org/10.7759/cureus.51159 Mohammed F, Taddele M, Gualu T (2021) Patient safety culture and associated factors among health care professionals at public 184. 1–9. https://doi.org/10.1371/journal.pone.0245966 Mortell M (2019) Is there a Theory – Practice – Ethics gap? A Patient Safety Case Study. Int J Afr Nurs Sci 10:38–42. https://doi.org/10.1016/j.ijans.2018.12.002 Okomo U, Gon G, Darboe S, Sey ICM, Nkereuwem O, Leigh L, Camara N, Makalo L, Keita A, Dancer SJ, Graham W, Aiken AM (2024) Assessing the impact of a cleaning programme on environmental hygiene in labour and neonatal wards: an exploratory study in The Gambia. Antimicrob Resist Infect Control 13. https://doi.org/10.1186/s13756-024-01393-6 Quenon JL, Vacher A, Faget M, Faget M, Levif-Lecourt M, Roberts T, Fucks I, Promé-Visinoni M, Cadot C, Bousigue JY, Quintard B, Parneix P, Pourin C (2020) Exploring the role of managers in the development of a safety culture in seven French healthcare facilities: A qualitative study. BMC Health Serv Res 20:1–11. https://doi.org/10.1186/s12913-020-05331-1 Reason J (2017) The contribution of latent human failures to the breakdown of complex systems. Hum Error Aviat 484:5–14. https://doi.org/10.4324/9781315092898-2 salman fadheelah, Mahmoud SA, A (2021) The Role of the Dyson Model for Strategic Development in Achieving Strategic Success / Case Study in Baghdad Municipality. https://doi.org/10.20944/preprints202104.0747.v1 Schoonenboom J, Johnson RB (2017) How to Construct a Mixed Methods Research Design. 107–131. https://doi.org/10.1007/s11577-017-0454-1 Shabani T, Jerie S, Shabani, Takunda (2024) A comprehensive review of the Swiss cheese model in risk management. Saf Extreme Environ. https://doi.org/10.1007/s42797-023-00091-7 Shemsu A, Dechasa A, Ayana M, Robi M (2024) International Journal of Nursing Studies Advances Patient safety incident reporting behavior and its associated factors among healthcare professionals in Hadiya zone, Ethiopia: A facility based cross-sectional study. Int J Nurs Stud Adv 6:100209. https://doi.org/10.1016/j.ijnsa.2024.100209 Skoogh A, Bååth C, Hall-Lord ML (2022) Healthcare professionals’ perceptions of patient safety culture and teamwork in intrapartum care: a cross-sectional study. BMC Health Serv Res 22:1–11. https://doi.org/10.1186/s12913-022-08145-5 Tedla T (2019) Patient Safety Culture among Health Workers in Addis Ababa regional Hospitals. Ethiopia 7. https://doi.org/10.21522/TIJPH.2013.07.02.Art017 Tegegne MD, Melaku MS, Shimie AW, Hunegnaw DD, Legese MG, Ejigu TA, Mengestie ND, Zemene W, Zeleke T, Chanie AF (2022) Health professionals’ knowledge and attitude towards patient confidentiality and associated factors in a resource-limited setting: a cross-sectional study. BMC Med Ethics 23:1–10. https://doi.org/10.1186/s12910-022-00765-0 Worke Yismaw (2023) Annals of Nursing and Practice Factors Affecting Patient Safety Culture among Health Professionals in Ilu Aba-Bora Zone. A Mixed Method Study, South West Ethiopia Additional Declarations The authors declare no competing interests. Supplementary Files ResearchQuestionnaires.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9209575","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":611237637,"identity":"b4146038-ae06-4f62-ac0d-88d19379ec86","order_by":0,"name":"Sem Daniel Abreham","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0004-9821-2681","institution":"University of South Africa (UNISA)","correspondingAuthor":true,"prefix":"","firstName":"Sem","middleName":"Daniel","lastName":"Abreham","suffix":""},{"id":611237638,"identity":"9c34fda6-f7a5-4430-8374-ae3e34d524e8","order_by":1,"name":"S Shakwane","email":"","orcid":"https://orcid.org/0000-0002-7228-4183","institution":"University of South Africa (UNISA)","correspondingAuthor":false,"prefix":"","firstName":"S","middleName":"","lastName":"Shakwane","suffix":""}],"badges":[],"createdAt":"2026-03-24 09:11:49","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9209575/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9209575/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105408611,"identity":"ab6bc170-36d6-4a0b-9a0a-bb46dc4308e0","added_by":"auto","created_at":"2026-03-25 17:04:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":747142,"visible":true,"origin":"","legend":"\u003cp\u003eA schematic diagram showing the goals and final key interventions for the developed final patient safety strategies\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource: Authors’ own work\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9209575/v1/f961c704728e2197e8cdfabb.png"},{"id":105566608,"identity":"6c8f295f-8a08-4c01-99cf-cc67825b3f6e","added_by":"auto","created_at":"2026-03-27 12:56:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1967422,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9209575/v1/d2342eea-7863-47e8-bdf1-776d39c1b842.pdf"},{"id":105408610,"identity":"24ed2e95-7957-4086-a7db-c73688d77a5b","added_by":"auto","created_at":"2026-03-25 17:04:57","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":158085,"visible":true,"origin":"","legend":"","description":"","filename":"ResearchQuestionnaires.docx","url":"https://assets-eu.researchsquare.com/files/rs-9209575/v1/453357dd2a72f068a0d927a2.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eComprehensive Strategies and Recommendations for Optimising Patient Safety Practices in Public Hospitals of Addis Ababa: An Explanatory Sequential Mixed-Methods Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePatient safety issues are a challenge for public hospitals. Patient safety is the prevention and avoidance of injuries or adverse incidents for patients and healthcare staff during their duties (Asem et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e:1). More than 400,000 deaths and millions of injuries from preventable medical errors occur every year in the United States of America (Brittain and Carrington, 2021). WHO estimates have shown that 1 in 10 patients in high-income countries suffer an injury during hospital treatment each year, while in low-income countries, 1 in 4 patients suffer an injury during hospitalisation (Cerrone et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). According to the International Institute of Medicine (IOM) report, each year, 2.9% of hospitalised patients encountered adverse events, and 6.6% of them died from patient care-related risks globally, while New York had 3.7% adverse events and 16.6% deaths (Machmud et al., 2017). Therefore, patient safety issues concern every healthcare system worldwide, including Ethiopia (Kati, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). As a result, preventing harm and proper reporting of adverse events during healthcare provision is crucial for ensuring patient safety (Asem et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). In addition, creating a safe environment within medical facilities is vital for safeguarding both patients and healthcare staff during their duties. To protect patients through ensuring patient safety, healthcare providers must adhere to the established guidelines and report any adverse events (Mistri et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to Mortell (\u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e), the overall state of patient safety within a hospital is influenced by two fundamental factors. The first issue occurs when there is a lack of proper patient identification for informed decision-making, and the second issue is the theory-practice-ethics gap paradigm, which assumes that all healthcare providers possess the relevant theoretical knowledge and practical skills to provide safe and competent care. Inappropriate communication, insufficient staffing, unreported errors, poor knowledge dissemination, ineffective information systems, personal and work-related conflicts, a lack of comprehensive policies and procedures, and conceptual and technical deficiencies in routine healthcare contribute to patient harm (Kaware et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). Similarly, a field study conducted in Switzerland shows that half of all documented accidents are human errors, followed by organisational settings, infrastructure, and environment, and technical problems (Brittain \u0026amp; Carrington, 2021). In 2005 WHO established guidelines to promote the adoption of policies on reporting and learning from errors to improve the safety of care (Cerrone et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). Therefore, it is important that developing countries establish patient safety measures to promote quality care for their people.\u003c/p\u003e \u003cp\u003eIn the Ethiopian health system delivery, there is a lack of representative empirical data demonstrating the implementation of a patient safety culture and the related contributing aspects (Kumbi et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). There is also limited evidence regarding patient safety culture and medical errors in Ethiopia's public hospitals, with many errors remaining unreported due to a punitive culture (Garuma et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). As a result, a significant information gap is believed to be a major patient safety problem in Ethiopia (Ahmed Ratan et al., 2023:2). Despite interventions such as training and mentoring, healthcare-related adverse events are increasing significantly (Biresaw et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Consequently, efforts have been prioritised to improve the capacity of the health workforce through accredited training programmes, defined career paths, staffing standards, health management systems for human resources, and systems for performance evaluation and auditing (Ethiopian Ministry of Health, \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2016, the Ethiopian Ministry of Health introduced the Ethiopian National Health Care Quality Strategy (ENHCQS) to enhance healthcare quality through improvements in clinical outcomes, patient safety, and patient-centred care, focusing on equity and accessibility. It was postulated that by 2020, this strategy was intended to expand patient safety practices nationwide (FMOH, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Furthermore, the Health Sector Transformation Plan aligns these objectives with the Sustainable Development Goals (Health Sector Transformation Plan II, 2021). Limited studies in Ethiopia show patient safety culture scores below the 75% benchmark by HSOPSC (Biresaw et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e; FMOH, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e; Mekonnen et al., 2017; Tedla, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Poor safety practices affect patient care quality and satisfaction (Belay Gizaw et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). These are due to systemic gaps, necessitating alignment in healthcare functions for patient safety and service quality (Elmontsri et al., \u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e). Therefore, this study suggested comprehensive recommendable strategies to improve patient safety practices in public hospitals of Addis Ababa, Ethiopia.\u003c/p\u003e\n\u003ch3\u003eTheoretical Foundations of the Study\u003c/h3\u003e\n\u003cp\u003eIn this study, the Swiss-Cheese model (SCM) was applied as an illustrative framework to analyse and understand the complex nature of patient safety practices in public hospitals. The Swiss-Cheese Model (SCM) serves as a heuristic tool to explain interactions during catastrophic breakdowns in complex systems (Fukuoka and Furusho, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Its success is due to a systemic foundation that broadens the scope of analysis to include the complexity of the organisation and environmental management; therefore, holes and imperfections represent potential weaknesses within the system (Reason, \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the components of SCM is the alignment of the holes, which creates potential risks. This refers to the propensity for system failures that lead to adverse events. As system failures increase, the likelihood of an incident occurring also rises (Shabani et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e). In summary, no single layer of defence is without flaws; each has its potential weaknesses or limitations. The SCM conveys that no failure, human or technical, is sufficient to cause an accident. Instead, it involves the unlikely and often unforeseeable conjunction of several contributing human or technical factors arising from different levels of the health system (Fukuoka and Furusho, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). Reason used the term “active failures” to describe factors at the \u003cem\u003eunsafe acts level\u003c/em\u003e, while the term “latent failures” was used to describe \u003cem\u003eunsafe conditions\u003c/em\u003e located higher up in the system (Shabani et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor this study, SCM was used to identify errors and omissions that lead to practical failures in healthcare, specifically misdiagnosis, miscommunication, and medication errors. The findings highlighted that a systems-oriented approach needs to be initiated for better patient safety and cannot be achieved by insisting on individual efforts or blaming individuals.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eThe authors declare that this work is part of a larger study on a sequential explanatory mixed method. In which pragmatism was used to implement multiple research approaches in one study. Pragmatism guides the researcher toward making suitable methodological choices by simplifying different aspects of the research problem during the design phase (Kelly \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). In the quantitative phase, patient safety practices were assessed and measured, followed by qualitative data that explained the quantitative results through focus group interviews. This manuscript outlines the strategies developed based on the integrated results of the empirical research findings. It aimed to develop strategies for improving patient safety practices in public hospitals in Addis Ababa.\u003c/p\u003e\u003ch3\u003eSummary of Integrated results\u003c/h3\u003e\u003cp\u003eThe findings from both quantitative and qualitative data were integrated to gain a better understanding of patient safety practices. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the findings of the integrated study.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntegrated study results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eFindings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eDiscussion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePatient care services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe study highlighted that while clinicians recognised the existence of standard operating procedures (SOPs) and safety guidelines, instances of non-compliance were prevalent, as 75% acknowledged these measures were in place. However, alarmingly, more than 25% of the respondents reported not having received the necessary training or information about patient safety protocols, which led to a notably high incidence of adverse events occurring in the preceding month. This highlights the urgent need for better training, communication, and resource allocation to create a safer patient care environment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEnvironmental safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePatient safety management in public hospitals is affected by budget allocation, resource availability, surveillance, research, staffing levels, and the experience and hours worked by healthcare providers. Financial resources are crucial for acquiring supplies, training staff, and enhancing the quality of care. It is essential to balance investments in safety surveillance and research with feedback to address performance gaps. Although over 50% of clinician managers view patient safety management positively, efforts are needed to strengthen this perception among all healthcare professionals, thereby fostering a culture that minimises fear, blame, and silence.\u003c/p\u003e \u003cp\u003eThe study results indicated that nearly 50% of physician participants believed effective patient safety management is associated with setting reminders and enhancing teamwork, which helps prevent poor practices.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePatient safety coordination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAccording to the study findings, effective communication is crucial for ensuring patient safety and maintaining a secure healthcare environment. Many patient porters and receptionists lack clear guidance on policy frameworks and practices needed to provide essential information to patients, leading to confusion and dissatisfaction. The study also revealed that poor communication among healthcare professionals negatively affects the quality of patient care and satisfaction. Patients often feel stressed or overwhelmed, especially while managing their health conditions.\u003c/p\u003e \u003cp\u003eThe research revealed that 33% of porters and receptionists lacked any established guidelines or methods for delivering compassionate care to patients, highlighting issues surrounding inadequate training and understanding among non-clinical personnel. Furthermore, the poor communication practices, especially in critical areas such as the emergency department, suggest an urgent need for enhancements.\u003c/p\u003e \u003cp\u003eConfidentiality of patients stands as a major issue, as evidenced by one-third of study participants, including porters and receptionists, who noted the absence of protective policies. This significant detail highlights potential risks for privacy breaches and highlights the necessity for improved practices. Additionally, the lack of patient advocates and knowledge about standard operating procedures can detract from the quality of care delivered. Focus group participants noted a lack of systematic training for personnel managing medical records, indicating that regular training could enhance their skills and protect patient confidentiality.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAdverse events reporting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEstablish a system for early notification and timely response to adverse events. The average score for patient safety culture was 61.4%, which was evaluated using the Hospital Survey on Patient Safety Culture (HSOPSC) checklist. The evaluated public hospitals exhibited slightly lower patient safety practices compared to similar studies conducted nationwide in comparable settings. To enhance patient care, safety, and the overall quality of healthcare services, it is essential to focus on effective patient safety metrics and encourage the reporting of adverse events by both healthcare professionals and patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThese empirical findings laid a foundation for the development of the strategies.\u003c/p\u003e\u003ch3\u003eStrategy development\u003c/h3\u003e\u003cp\u003eThe results of the empirical steps were used as input for this phase of developing patient safety strategies. There are seven steps of the strategy development framework that were adopted (Dyson et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e; Salman and Mahmoud, \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). This seven-step strategy development approach was employed in this study.\u003c/p\u003e\u003cp\u003eStrategy purpose\u003c/p\u003e\u003cp\u003eThe purpose of the identified strategies and key interventions is to provide high-quality patient care during hospitalisations. Moreover, the developed strategies aimed to enhance patient safety practices by integrating evidence-based principles, enabling patients to make informed choices, aligning safety efforts toward a common objective, and strengthening safety through preventive actions.\u003c/p\u003e\u003ch3\u003eScope of developed strategies\u003c/h3\u003e\u003cp\u003eThe proposed strategies are primarily designed for public hospitals with similar setups and socio-demographic peculiarities. Hospitals shall consider the strategies' unique circumstances and tailor them accordingly to achieve the best results. The strategies are robustly designed to focus on key technical and managerial areas that will significantly enhance patient safety practices.\u003c/p\u003e\u003ch3\u003eSteps to develop patient safety strategies\u003c/h3\u003e\u003cp\u003eThe study followed and adapted the seven-step framework outlined byDyson et al. Salman and Salah Abood Mahmoud (2015: 2021) while developing patient safety strategies as follows.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eStep 1\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eThe strategic direction-setting step involves focusing on vision, mission, strategic objectives, and goals.\u003c/p\u003e\u003cp\u003eA SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis was conducted to establish strategic vision, mission, objectives, and goals.\u003c/p\u003e\u003cp\u003eSWOT Analysis for Patient Safety Practice and Management\u003c/p\u003e\u003cp\u003eThe study highlighted that while clinicians recognised the existence of standard operating procedures (SOPs) and safety guidelines, instances of non-compliance were prevalent, as 75% acknowledged these measures were in place. However, alarmingly, more than 25% of the respondents reported not having received the necessary training or information about patient safety protocols, which led to a notably high incidence of adverse events occurring in the preceding month.\u003c/p\u003e\u003cp\u003ePatient safety management in public hospitals is affected by budget allocation, resource availability, surveillance, research, staffing levels, and the experience and hours worked by healthcare providers. Financial resources are crucial for acquiring supplies, training staff, and enhancing the quality of care. It is essential to balance investments in safety surveillance and research with feedback to address performance gaps. Although over 50% of clinician managers view patient safety management positively, efforts are needed to strengthen this perception among all healthcare professionals, thereby fostering a culture that minimises fear, blame, and silence. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the summary of the SWOT analysis for patient safety practice and management.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSWOT analysis on patient safety practice and management\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003c/colgroup\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSWOT analysis on patient safety practice and management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStrength\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eWeakness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Staff and managerial commitment to foster safer patient care\u003c/p\u003e \u003cp\u003e- Presence of transparency among the health workforces\u003c/p\u003e \u003cp\u003e- Availability of guiding principles that support the patient safety management process\u003c/p\u003e \u003cp\u003e- Staff motivation to notify adverse events.\u003c/p\u003e \u003cp\u003e- Presence of a system for patient service audits, including the identification and handling of patient safety malpractices\u003c/p\u003e \u003cp\u003e- Available procedures that support easy access to patient services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Inconsistent patient safety practices across service areas\u003c/p\u003e \u003cp\u003e- Inadequate advocacy, training, and compliance with the existing patient safety guidelines and procedures\u003c/p\u003e \u003cp\u003e- Less compliance with the workforce code of conduct and patient safety standards.\u003c/p\u003e \u003cp\u003e- Insufficient staff recognition and managerial support\u003c/p\u003e \u003cp\u003e- Presence of a culture of blaming and shaming to report adverse events\u003c/p\u003e \u003cp\u003e- Inadequate patient empowerment and communication culture\u003c/p\u003e \u003cp\u003e- Long working hours, workload, less teamwork, and a lack of a clear assignment of roles\u003c/p\u003e \u003cp\u003e- Critical Shortage of manpower, medical supplies and equipment\u003c/p\u003e \u003cp\u003e- Poor managerial feedback on the reported adverse events\u003c/p\u003e \u003cp\u003e- Fail to establish an organisational structure to receive and manage reported adverse events.\u003c/p\u003e \u003cp\u003e- Fail to use evidence for decision making\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eOpportunity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eThreat\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Presence of managerial commitment to support patient safety implementation\u003c/p\u003e \u003cp\u003e- Adequate budget for health service expansion and enhancing patient care quality\u003c/p\u003e\u003cp\u003e- Digitisation of patient care services\u003c/p\u003e\u003cp\u003e- Presence of health system innovation platforms\u003c/p\u003e\u003cp\u003e- Use of technologies for patient care monitoring and error reduction\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Lack of patient safety policies, strategies, and guidelines\u003c/p\u003e \u003cp\u003e- Presence of weak regulatory functions\u003c/p\u003e \u003cp\u003e- Poor staff incentive and recognition mechanism\u003c/p\u003e \u003cp\u003e- Weak enforcement of organisational and professional ethics regulations\u003c/p\u003e \u003cp\u003e- Sub-optimal health infrastructures and layout\u003c/p\u003e \u003cp\u003e- Presence of complex patient safety challenges that require managerial attention\u003c/p\u003e \u003cp\u003e- Staff fatigue and burnout due to workload\u003c/p\u003e \u003cp\u003e- Lack of in-depth experience in patient safety implementation\u003c/p\u003e \u003cp\u003e- Inadequately trained health workforce\u003c/p\u003e \u003cp\u003e- Lack of representative studies\u003c/p\u003e \u003cp\u003e- Understaffing and high staff attrition\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003ch2\u003eSWOT Analysis on patent safety communication and adverse event reporting practice\u003c/h2\u003e\u003cp\u003eThe average score for patient safety culture was 61.4%, which was evaluated using the Hospital Survey on Patient Safety Culture (HSOPSC) checklist. The evaluated public hospitals exhibited slightly lower patient safety practices compared to similar studies conducted nationwide in comparable settings. Based on the study findings, effective communication is crucial for ensuring patient safety and maintaining a secure healthcare environment. Many patient porters and receptionists lack clear guidance on policy frameworks and practices needed to provide essential information to patients, leading to confusion and dissatisfaction. The study also revealed that poor communication among healthcare professionals negatively affects the quality of patient care and satisfaction. Patients often feel stressed or overwhelmed, especially while managing their health conditions. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e provides a summary of patient safety communication and adverse events reporting.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab3\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSWOT analysis on patient safety communication and adverse event reporting practice\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003c/colgroup\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSWOT analysis on patient safety communication and adverse event reporting practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStrengths\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eWeaknesses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" rowspan=\"3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Presence of professional communication protocols\u003c/p\u003e \u003cp\u003e- Presence of labelling of patient service departments\u003c/p\u003e \u003cp\u003e- Presence of a system for patient communication and facilitation of the patient flow pattern\u003c/p\u003e \u003cp\u003e- Presence of a system for the exchange of patient information across service departments\u003c/p\u003e \u003cp\u003e- Presence of verbal and non-verbal (oral) communication channels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Loss of patient information during staff shift hours\u003c/p\u003e \u003cp\u003e- Communication breakdown due to poor teamwork and staff workloads\u003c/p\u003e \u003cp\u003e- Inadequate training\u003c/p\u003e \u003cp\u003e- Lack of a system in place to receive, score, and report adverse events\u003c/p\u003e \u003cp\u003e- Less staff communication protocol awareness\u003c/p\u003e \u003cp\u003e- Absence of health literacy units for patients attending hospital service outlets\u003c/p\u003e \u003cp\u003e- Lack of patient safety advocacy and communication frameworks\u003c/p\u003e \u003cp\u003e- Lack of patient empowerment to prevent malpractices\u003c/p\u003e \u003cp\u003e- Presence of a non-supportive organisational culture that discourages transparency\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eOpportunities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eThreats\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- The availability of advanced technologies and communication platforms improves the culture of professional communication.\u003c/p\u003e \u003cp\u003e- Availability of patient service protocols for maintaining proper and continuous staff communication\u003c/p\u003e \u003cp\u003e- Availability of financial and technical resources to improve patient safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Lack of communication policies and\u003c/p\u003e \u003cp\u003e- Lack of a regulatory system for patient safety practice scoring and adverse event reporting\u003c/p\u003e \u003cp\u003e- Weak legal grounding and enforcement for handling and management of reportable adverse events\u003c/p\u003e \u003cp\u003e- Lack of practical experience in patient safety management\u003c/p\u003e \u003cp\u003e- Presence of a language barrier that affects patient-to-healthcare provider communication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003ch3\u003eStrategic vision\u003c/h3\u003e\u003cp\u003eThe validated patient safety strategies aim to build a healthcare system where patient safety is essential to quality improvement. This ensures that all interventions are evidence-based, equitable, and sustainable. The vision focuses on immediate safeguards while fostering a lasting culture of safety that promotes resilience, accountability, and continuous learning.\u003c/p\u003e\u003ch3\u003eMission statement\u003c/h3\u003e\u003cp\u003eThe strategic mission is to empower public hospitals to bridge the gap between the current state of healthcare and long-term goals through validated strategies that strengthen patient safety. Public hospitals should establish patient safety task forces, utilise checklists and protocols, conduct regular audits, and leverage technology to report and prevent errors. By implementing these key strategies, public hospitals will enhance patient safety and elevate the overall quality of healthcare delivery.\u003c/p\u003e\u003ch2\u003eStrategic objectives\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eTo align key strategies with long-term healthcare objectives to establish a cycle of innovation, evaluation, and adaptation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo foster a safety-oriented culture through ongoing healthcare workers training and awareness to support adherence to patient safety standards.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo conduct regular safety audits and risk assessments and use findings to enhance continuous improvement cycles.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo establish service points for reporting medical errors and near misses that foster a culture of adverse events reporting.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo create a system for providing feedback on safety concerns to improve transparency.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eStrategic goal\u003c/h2\u003e\u003cp\u003eThe goal of the validated strategies is to enhance safer patient care services by addressing gaps and challenges across service units through the implementation of recommended standard patient safety practices. By adopting these strategies, hospitals will foster a safer environment for patients and significantly improve the overall quality of care.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eStep 2\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eDevelop the performance measurement step, emphasising the strategic directions\u003c/p\u003e\u003cp\u003eFour strategies were developed and presented below.\u003c/p\u003e\u003cp\u003e \u003cem\u003eStrategy 1: Standardise patient care service to improve patient safety practices.\u003c/em\u003e \u003c/p\u003e\u003ch2\u003eStrategic goals\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eTo ensure the implementation of existing patient safety guidelines and policies to standardise patient care practices by validating practical experiences.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo improve the efficient use of healthcare resources to maximise efforts in patient safety practices by making evidence-based decisions and actions.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eKey interventions\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eStandardise practices and validating experiences.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMaking evidence-based decisions and actions for the efficient use of healthcare resources\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003cp\u003e \u003cem\u003eStrategy 2: Create a safer healthcare environment through efficient patient safety management.\u003c/em\u003e \u003c/p\u003e\u003ch2\u003eStrategic goals\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eTo enhance safer clinical care practices by raising staff awareness, teamwork, effective communication and advocating a positive patient experience.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo ensure the existence of functioning structural arrangements that enable enhancing safer patient care practices through continuous monitoring and evaluation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo improve the capacity of healthcare workers to implement safer patient care practices through staff training and advocacy.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eKey interventions\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eCreate smooth communication and advocacy, strengthen teamwork, and conduct training\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRevitalise existing structural and functional arrangements and carry out monitoring and evaluation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCreate collaboration and peer learning among healthcare staff\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eStrategy 3: Patient safety communication and coordination among healthcare providers, patients, and families\u003c/h2\u003e\u003ch2\u003eStrategic goals\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eTo enhance stakeholders’ involvement and coordinated efforts in completing essential resources, allowing them to deliver safer patient care practices through improved collaborative partner engagement, capitalising on safer patient care activities.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo improve patient empowerment to value decisions and actions over patient care provided through the enhancement of effective patient-to-care provider communication.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo improve teamwork and collaboration among the healthcare workforce to prevent medical errors by implementing effective staff engagement and communication techniques.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eKey interventions\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003ePartner mapping and strengthening stallholders’ collaborative action.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCreate a user-friendly environment and establish a culture of openness.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStandardise the mechanism of communication among patient care providers and interdepartmental communication.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eStrategy 4: Patient care-related adverse event reporting, scoring and management\u003c/h2\u003e\u003ch2\u003eStrategic goals\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eTo enhance the implementation of safer patient care practices to elevate the quality of patient care delivery by cultivating a culture of proper patient care data utilisation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo adopt standardised patient safety practices that improve the quality of patient care services by establishing a responsive system for recording and reporting adverse events.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo ensure the presence of a mechanism to analyse and manage patient care-related adverse event reporting by designing a system for notification and timely response.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003ch2\u003eKey interventions\u003c/h2\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eStandardise patient care data recording, storing and utilisation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEstablish an effective adverse event reporting, recording and management system\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEstablish a system for early notification and timely response for adverse events\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003cp\u003e \u003cstrong\u003eStep 3\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eThe sense-making step involves exploring both the internal and external situational context and assessing variations.\u003c/p\u003e\u003cp\u003eData collection was conducted using self-administered questionnaires targeted at healthcare workers and hospital managers. In addition, a review of documents such as SOPs, guidelines and related health sector policy recommendations available at the study public hospitals.\u003c/p\u003e\u003cp\u003eA SWOT analysis was conducted using the findings from the qualitative study, particularly the focus group interviews, to explain the results of the quantitative study. This analysis helped identify relevant and feasible considerations that align with the purpose and objectives of the study.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eStep 4\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eThe strategic initiatives creation step\u003c/p\u003e\u003cp\u003eBased on the SWOT analysis of empirical study findings, eleven strategic objectives and key interventions were identified and shaped using integrated study findings. Strategic objectives and key interventions were identified based on their feasibility, achievability, and applicability. The proposed interim strategies were supported by a review of related literature and subsequently validated by a panel of experts as a final strategy.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eStep 5\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eStrategic evaluation using organisational models, considering potential uncertainties.\u003c/p\u003e\u003cp\u003eThe validation of the final patient safety strategy involved subsequent discussions with a group of experts in the field to ensure their insights and expertise were integrated. The strategic goals identified were not focused solely on one aspect; they were well-balanced and measured across multiple dimensions. This made it easier to develop more effective strategies and adjust to shifting situations.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eStep 6\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eReview and revise the strategy based on the experiences of experts in similar scenarios.\u003c/p\u003e\u003cp\u003eThe developed patient safety strategies were reviewed and revised after the validation process by a panel of experts in patient safety and quality assurance. Three rounds of panel discussions were conducted to validate the proposed strategies, and the feedback collected during these sessions played a vital role in shaping the interim strategies. This process enabled a diverse range of perspectives and insights from experts across various institutions. The suggestions and feedback from the panel of experts were thoroughly documented and analysed, then compared against the themes that emerged from the research findings to identify similarities.\u003c/p\u003e\u003cp\u003e \u003cstrong\u003eStep 7\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eChoosing and approving the strategy in a genuine feedback process that considers performance analysis.\u003c/p\u003e\u003cp\u003eThe first step in the primary strategy-building process is to create strategic initiatives that can be contextualised within current programmes, projects, and situations to accomplish the mission, vision, and strategic goals.\u003c/p\u003e\u003cp\u003eAfter developing and validating the final patient safety strategies, the strategic goals, key interventions for each goal, and final strategies were identified, as shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study aimed to develop and validate strategies that enhance patient safety practices in public hospitals of Addis Ababa.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eStrategy 1: Standardise patient care service to improve patient safety practices\u003c/h2\u003e \u003cp\u003eThis strategy aims to improve patient safety practices across the health departments in the public hospitals. The need for standard patient safety practices was identified across the healthcare units where the study was conducted. Maintaining high-quality and standardised patient care is crucial in providing the best possible, safest patient care.Cort\u0026eacute;s-Puch et al. (2020) suggest that the \u0026ldquo;one-size-fits-all\u0026rdquo; standardised treatments in some patient care settings may prevent clinicians from meeting individual patients\u0026rsquo; needs and decrease care quality. Further,Varpio et al., (2025) warns that adherence to standardisation in healthcare can constrain expert clinical judgment and may not accommodate the unique needs and complexities of individual patients. This is because if the standardised tools are inflexible and poorly supported may result in compromised quality of patient care.\u003c/p\u003e \u003cp\u003eSeveral factors contributed to poor patient safety practices, such as a lack of training for healthcare professionals, poor awareness of existing SOPs, guidelines, and policies, inadequate infrastructure, poor communication, understaffing, and shortages of medical supplies and medications. Furthermore, the scarcity of personnel and other related resources caused a significant barrier to applying standard patient safety measures. To ensure continuous patient safety practices, policies, guidelines, and standard operating procedures (SOPs) should be reviewed so that they can be current and reliable. According to Afework (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), the lack of standard operating procedures (SOPs) and policies at the facility level is the main reason for inconsistencies in implementing patient care practices. Without proper guidelines and reliance on evidence, patient care can suffer from inconsistency, decreased efficiency, miscommunication, and insufficient learning from errors. Factors such as a lack of healthcare professionals and support staff negatively impact service quality, resulting in numerous negative experiences for both healthcare workers and patients (Okomo et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eStrategy 2: Create a safer healthcare environment through efficient patient safety management\u003c/h2\u003e \u003cp\u003eCreating a safer healthcare environment for both patients and healthcare providers through efficient and effective management across public hospitals is critical. Various activities enhance patient safety, but gaps exist between the implementation by patient care providers and the expectations of their supervisors. Similarly, Hibbert et al., (2023) suggested that to enhance safety culture, it's crucial to engage staff and management while ensuring clear communication on patient safety priorities.\u003c/p\u003e \u003cp\u003ePrioritising patient safety management approaches and effectively allocating resources to patient safety practices is necessary in developing countries such as Ethiopia. Hospital management should ensure patient safety and support activities that maintain the quality and safety of care provided to patients. According to Abraham et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), patient safety management can be realised by hospital administrators ensuring that existing organisational policies and systems are implemented effectively to improve patient safety practices within healthcare institutions. Therefore, they can play an important role in regulating and practising a high standard of care for patients, with administrative actions contributing to the development of a mature safety culture within hospitals.\u003c/p\u003e \u003cp\u003eThe selected hospitals for the study revealed challenges such as inadequate teamwork, long working hours, poor infrastructure, a lack of early warning systems and risk assessment protocols, non-functional medical equipment, and a significant shortage of medical supplies and medications. Supportive and committed management processes enhance patient safety practices, while poor leadership or frequent leadership turnover is linked to compromised patient safety and organisational integrity (Brittain and Carrington 2021). Despite the challenges in deploying information and communication technology (ICT) infrastructures, it is crucial for improving patient safety practices. ICT helps maintain confidentiality, prevents the loss of patient information, reduces registration errors, and ensures safer patient care. A study by Tegegne and Wubante (2022) identified several barriers to the adoption of ICT in the Ethiopian healthcare system. The most common shortcomings include a lack of ICT training, poor ICT knowledge, inadequate ICT skills, and limited access to computers.\u003c/p\u003e \u003cp\u003eFactors that are crucial to implement patient safety management include budget resource availability, surveillance, and research. Additionally, staffing, experience, and working hours of healthcare providers are also important. Thompson et al. (2025) suggest that the role of management in fostering patient safety culture is negligible, as many other factors, such as teamwork, staff communication, organisational learning and adverse event reporting, take a big share in fostering patient safety culture. Thus, Worke (2023) emphasises the importance of systemic interventions, which facilitate open communication, cooperation, and the exchange of ideas among healthcare workers, are essential for enhancing patient safety culture.\u003c/p\u003e \u003cp\u003eSimilarly, the study also revealed that patient safety practices in the medical records unit frequently resulted in the loss of patient information during the patient registration and recording process. Consequently, this led to patients being misidentified or mistreated. It has also contributed to gaps in interprofessional and interdepartmental communication, exposing patients to avoidable risks. This finding aligns with the study of Kasaye et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) which identifies several barriers to effective documentation and patient confidentiality, including a training gap, lack of ICT infrastructure, time constraints, insufficient human resources, unfamiliarity with standard operating procedures (SOPs), and inadequate documentation and record-keeping materials.\u003c/p\u003e \u003cp\u003eHospital managers need to create a supportive working environment that encourages patient safety practices, enabling the fostering of a positive perception among healthcare providers and managers. According to Alshareef (2025), effective hospital management is essential for ensuring patient safety by supporting health professionals, who are crucial in delivering patient care. Therefore, management must provide the necessary resources and support for safer patient care. This helps develop a culture that emphasises transparency while reducing blame, fear, and silence surrounding adverse event reporting and management (Belay Gizaw et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Therefore, achieving this can be accomplished through an organisational learning culture that improves the quality of patient care and enhances the coordination of patient safety activities across various hospital departments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eStrategy 3: Patient safety communication and coordination among healthcare providers, patients, and families\u003c/h2\u003e \u003cp\u003eStrengthening communication and coordination of patient safety practices by advocating patient safety principles among healthcare providers, patients, and families should be seen as an advocacy role for healthcare professionals and managers. There were many challenges related to communication, teamwork, and coordination between different professionals that challenged patient safety practices. One of these challenges proposed by Chen and Gong (2022) how teamwork is executed in a healthcare setup is largely unknown due to the challenges of measuring team communication in clinical practice.\u003c/p\u003e \u003cp\u003eSimilarly, a study by Zajac et al. (2021) supported the finding by proposing that combining the expertise needed to address complex healthcare problems is a significant challenge for teams. Additionally, team members\u0026rsquo; personalities and communication styles can create barriers, even among passionate and skilled individuals. The proposed solutions focus on managing these challenges at various levels and emphasise the importance of addressing the root causes of team issues rather than just the symptoms.\u003c/p\u003e \u003cp\u003eFurthermore, the study revealed significant gaps in the exchange of patient care information during shift changes and challenges in interdepartmental communication. These gaps were attributed to a shortage of personnel, poor communication culture, workload, fostering unfavourable attitudes towards documentation culture, training gaps, and limitations of electronic health recording systems. These findings are consistent with a study by Kasaye et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), which indicated that patient record-keeping staff with good knowledge, a favourable attitude, strong motivation, and compliance with standard guidelines tend to have good patient clinical documentation. A study by Alshareef (2025) reaffirms the relationships between overload, burnout, quality of healthcare, and patient safety; thus, overload was related to burnout and decreased patient safety and quality of care.\u003c/p\u003e \u003cp\u003eIt was found that crucial patient care data was frequently overlooked, deleted, or shared in a manner that compromised patient confidentiality, which may prevent patients from sharing their health status openly with their care providers. Similarly, the study by Tegegne et al. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), indicated that healthcare professionals had a limited attitude towards patient confidentiality but possessed good knowledge of patient information confidentiality. Moreover, the need for healthcare providers to effectively communicate with their patients, using clear and understandable language and ensuring an optimal patient healing process, will improve the practices of reporting adverse events and scoring the patient's safety experience. The study also highlighted various strategies to empower patients and encourage their active participation in their own care. These strategies include providing sufficient time for questions, informing patients about their care plans, and advocating for them to make informed decisions.\u003c/p\u003e \u003cp\u003eThe study emphasises that regular staff training and skill development programs enhance the efficiency of medical record personnel and improve patient confidentiality. This finding aligns with the result of a study by Kasaye et al. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), which emphasises that targeted training effectively tackles documentation problems in healthcare. It also reduces knowledge gaps, enhances performance among healthcare workers, and fosters a culture of documentation by improving the performance of service providers. This process enhances communication between healthcare providers and patients, resulting in safer, higher-quality care services in healthcare institutions.\u003c/p\u003e \u003cp\u003eTherefore, effective communication to implement standardised protocols is crucial for promoting patient safety and enhancing patient outcomes. It is essential to establish clear guidelines and procedures for both clinicians and non-clinical support staff, including cleaners and patient receptionists. This ensures that all employees understand and adhere to existing standard operating procedures (SOPs) and proper work practices. Without proper practices and guidance, communication among support staff and effective cleaning tasks may suffer, negatively impacting the quality of patient care and overall satisfaction. Consequently, the study suggests that communication, collaboration, and teamwork among healthcare professionals and patients are essential for ensuring safe and effective patient care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eStrategy 4: Patient care-related adverse event reporting, scoring, and management\u003c/h2\u003e \u003cp\u003eThis strategy aims to enhance the identification of patient safety risks and effectively manage reported adverse events. The study suggests that there is little to no experience in handling adverse event reports, along with insufficient staff awareness regarding the effective management of these events. This situation may be due to a lack of commitment from management in establishing a system for receiving and managing adverse events, as well as an absence of staff training on how to identify and report potential incidents. Additionally, a study byAliberti (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) emphasises the importance of staff training on adverse event topics to enhance reporting awareness. Therefore, healthcare managers shall prioritise patient safety and motivate care providers, empowering them to prevent adverse events and promote overall patient safety activities.\u003c/p\u003e \u003cp\u003eThe research findings revealed that 20.6% of participants confirmed the existence of a system for scoring and reporting adverse events, due to insufficient policies and guidelines. In line with these results, a study by Shemsu et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) reported an overall incident reporting behaviour prevalence of 28.7%. This outcome was lower compared to earlier studies in Addis Ababa's public hospitals, which documented an adverse event report of 30.4%. These differences might be initiated by the variations in sociodemographic factors, the study's environment, or its duration.\u003c/p\u003e \u003cp\u003eThe study also emphasised a gap in awareness concerning the identification of reportable adverse events and the appropriate timing for reporting. This gap may contribute to the absence of patient safety scoring or the underreporting of adverse events. Similarly,Gqaleni and Mkhize (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) justified that the existing configuration of the reporting system hinders healthcare professionals from efficiently adhering to the guidelines. The reasons include insufficient consultation, minimal staff involvement, underreporting and assessment of adverse events, limited commitment from healthcare managers, less staff awareness, an unclear framework for handling adverse events, and the absence of comprehensive procedures or guidelines.\u003c/p\u003e \u003cp\u003eIn this study, the overall score for patient safety culture using an adapted HSOPSC instrument was 61.4%. This result indicated that hospitals still had low patient safety practice scores and areas requiring staff and management commitment to improve, alongside follow-up and progressive quality improvement monitoring. This result was comparable to the study conducted in similar regional public hospitals in Ethiopia using the HSOPSC instrument, such as a study undertaken in Bale zone public hospitals, which scored 66.1% (Kumbi et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), and is a slightly better result than a nationwide study conducted in Ethiopian public hospitals, which scored 46.7% (Mekonnen et al., 2017), as well as a study conducted in public hospitals in Dessie city that scored 44.8% (Mohammed et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This variation in patient safety scores might be attributed to differences in institutions' locations, infrastructure, professional mix, training, and government attention and support.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe strategies developed to enhance patient safety have revealed several important insights. Hospital administration should prioritise resource allocation and the integration of technology to improve safety measures effectively. Most importantly, maintaining a sufficient and diverse workforce is essential for reducing errors that arise from excessive workloads and stress. Staff training programs should emphasise both technical skills and critical management elements, such as communication and teamwork. Healthcare personnel must be well-informed about relevant policies and guidelines. Support from hospital leadership is crucial for the successful implementation of these initiatives. Identifying potential weaknesses in patient safety creates opportunities to foster a more secure healthcare environment. Additionally, regular audits and monitoring systems are vital to the continuous improvement of patient safety protocols, as they help identify and properly report risks and develop preventive measures.\u003c/p\u003e\n\u003ch3\u003eRecommendations\u003c/h3\u003e\n\u003cp\u003eThe patient safety culture was not adequately implemented in the clinical settings of public hospitals in Addis Ababa; it is essential to prioritise the adoption and implementation of the validated patient safety strategies. Hospital managers and policymakers should establish clear accountability frameworks, enhance staff training on patient safety protocols, and integrate patient safety indicators into routine monitoring and evaluation systems.\u003c/p\u003e \u003cp\u003eEstablishing clear guidelines and procedures for both clinical and non-clinical staff is essential for ensuring mutual understanding and adherence to standard operating procedures (SOPs). Furthermore, fostering a culture of safety through ongoing professional development, multidisciplinary collaboration, and clear adverse event reporting mechanisms is essential. By implementing validated strategies, hospitals can reduce preventable harm, enhance the overall quality of patient care, build teamwork, foster effective communication, and ensure compliance with international patient safety standards in public hospitals.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003eThe study acknowledged some limitations, noting that its findings primarily apply to public hospitals in Addis Ababa or similar environments. Adapting the strategies for hospitals in different regions may be challenging and will likely require specific adjustments. Participants may have provided socially acceptable responses to avoid judgment, which could lead to an overreporting of positive behaviours and distort the results. Additionally, reliance on participants' memories may introduce inaccuracies, especially for older or emotionally charged events, which can affect the reliability of self-reported data. Furthermore, the findings may only be relevant to public hospitals in Addis Ababa and similar settings. In other hospitals, implementing these strategies may be more complex and require further customisation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eImplications of the study\u003c/h2\u003e \u003cp\u003eThis research proposes strategies aimed at developing practical solutions to address patient safety issues within the national healthcare system. The recommendations aim to improve the standard of patient care and advocate for safer practices in similar healthcare settings. Proven patient safety strategies will guide national health policies and support the progress of the national patient safety strategy.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted Odds Ratios\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrude Odds Ratios\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCAIs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthcare-associated Infections\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHSOPSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHospital Survey on Patient Safety Checklist\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMOH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSwiss-Cheese Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSOP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Operating Procedures\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Software for Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organisation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study obtained ethical approval and consent for data collection. It received an Ethical Clearance Certificate from the Higher Degrees Committee of the College of Human Sciences Research Ethics Committee (CREC) at the University of South Africa (UNISA), with registration number 67120679_CREC_CHS_2021. Ethical clearance certificates were also secured from the Ethiopian Ministry of Health and the ethical clearance committee of the Addis Ababa Health Bureau, MOH-E 30/27/61/450 and AAHB/11968/227, respectively. Permissions to conduct the study were obtained from the research ethics review committees of the participating hospitals. Study participants were informed of the purpose and benefits of the research, and informed consent was obtained. During transcription, personally identifiable information was anonymised or replaced with general descriptions, enabling participants to express their ideas freely.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding source for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr Sem Daniel Abreham, and Professor S. Shakwane were instrumental in the conception and design of the study. The first and corresponding author, Dr Sem Daniel Abreham, conducted the collection, examination, and interpretation of the data. Additionally, both Professor S. Shakwane and Dr Sem Daniel Abreham shared equal responsibility for drafting and revising the manuscript, and they endorsed the final draft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and examined in this research are currently unavailable to the public because they will underpin a forthcoming publication. Nonetheless, interested parties can request access from the corresponding author, provided they sign the necessary documents that align with ethical standards and the Ethics Committee\u0026apos;s rulings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA declaration statement for generative AI used\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGrammarly: Used as an advanced writing and grammar correction tool, it is designed to improve the text\u0026apos;s readability and optimise linguistic accuracy throughout the editing phase.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeepest gratitude goes to all who supported our research. A particular note of appreciation is reserved for the research supervisors, Prof. S. Shakwane and Prof. Sheila Mokoboto-Zwane, for their invaluable guidance and unwavering encouragement. We are grateful to UNISA, especially the College of Human Sciences and the Health Studies Department, for fostering my academic growth. Furthermore, I appreciate the collaboration from the staff at the three public study hospitals in Addis Ababa and the contributions from the UNISA scientific community.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSem Daniel Abreham\u003csup\u003e1\u003c/sup\u003e*, S. Shakwane\u003csup\u003e1**\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eUniversity of South Africa, Pretoria, South Africa, Department of Health Studies\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e* First and corresponding author: Sem Daniel Abreham, University of South Africa\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSem Daniel Abreham (Ph.D.)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudent Number: 67120679\u003c/p\u003e\n\u003cp\u003eDepartment of Health Studies\u003c/p\u003e\n\u003cp\u003eCollege of Human Sciences, UNISA\u003c/p\u003e\n\u003cp\u003eEmail address - [email protected], [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTel. (+251) 911 316019/ 906777707,\u003c/p\u003e\n\u003cp\u003ePo. Box -1234\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ehttps://orcid.org/0009-0004-9821-2681\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAddis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e**Co-author: S. Shakwane, University of South Africa\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Prof. S Shakwane\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAssociate Professor\u003c/p\u003e\n\u003cp\u003eCollege of Human Sciences\u003c/p\u003e\n\u003cp\u003eDepartment of Health Studies\u003c/p\u003e\n\u003cp\u003eWMM 7-183\u003c/p\u003e\n\u003cp\u003eTel. 012 429 8450\u003c/p\u003e\n\u003cp\u003eE-mail: [email protected]\u003c/p\u003e\n\u003cp\u003ehttps://orcid.org/0000-0002-7228-4183\u003c/p\u003e\n\u003cp\u003ePretoria, South Africa\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbraham V, Meyer JC, Godman B, Helberg E (2022) Perceptions of managerial staff on the patient safety culture at a tertiary hospital in South Africa. 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A Mixed Method Study, South West Ethiopia\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of South Africa","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Addis Ababa, Healthcare Quality, Optimising Patient Safety Strategies, Patient Safety Practices, Healthcare Risk, Patient Safety Practices, Public hospitals","lastPublishedDoi":"10.21203/rs.3.rs-9209575/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9209575/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnhancing patient safety in hospitalised patients is crucial. In Ethiopia, a lack of effective patient safety protocols has led to significant gaps in safety culture. This study aims to develop strategies to enhance patient safety practices in public hospitals in Addis Ababa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA sequential explanatory mixed-methods design was used within a pragmatic worldview framework. Participants were recruited through heterogeneous stratified and purposive sampling. Data collection included a questionnaire, a checklist, and an interview guide. Quantitative data were analysed with descriptive statistics and logistic regression, while qualitative data underwent thematic analysis. The findings informed the development of patient safety strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative and qualitative results were integrated to support patient safety practices in public hospitals in Addis Ababa. The integrated findings were used as a foundation for developing the final patient safety strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEnsuring healthcare workers have a good understanding and implement patient safety principles will improve their adherence to SOPs and guidelines, thereby reducing the risk of errors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOriginality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings from an empirical study informed the development of patient safety strategies, which were then validated through a panel of expert review.\u003c/p\u003e","manuscriptTitle":"Comprehensive Strategies and Recommendations for Optimising Patient Safety Practices in Public Hospitals of Addis Ababa: An Explanatory Sequential Mixed-Methods Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 17:04:53","doi":"10.21203/rs.3.rs-9209575/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cea5c72b-8283-413a-9e14-72e95ae44ee3","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":65100155,"name":"Occupational Medicine"}],"tags":[],"updatedAt":"2026-03-25T17:04:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 17:04:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9209575","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9209575","identity":"rs-9209575","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}