Introduction

Patient safety and quality improvement have gained momentum in the last decade and are becoming more integrated into the culture of healthcare organisations and the practice improvement initiatives of healthcare professionals. According to what is defined by the 1999 Institute of Medicine (IOM) report "To Err is Human: Building a Safer Health System", the pillars of healthcare are safety, timeliness, effectiveness, efficiency, equity, and person-centred care. Implementing a safety culture depends on all levels of the healthcare system (^{Al-Jabri et al., 2021}; Marsch et al., 2022).

Before proceeding, it is necessary to clarify key concepts related to the topic of patient safety.

Healthcare literacy refers to the capacity of individuals to obtain, process, and understand basic health information needed to make appropriate health decisions. Patient safety literacy is a subset of this, focusing specifically on the ability to comprehend and apply information related to preventing harm to patients during healthcare delivery. Patient safety itself is defined as the prevention of errors and adverse effects to patients associated with healthcare. It involves the implementation of practices and systems aimed at minimizing the occurrence of incidents that can cause harm. Finally, a safety culture in healthcare refers to the shared values, attitudes, beliefs, and norms that influence organizational behavior and promote patient safety, as adopted by the DGS in their biennial national evaluations (^{DGS, 2022}).

Patient safety is globally perceived as an area with significant knowledge gaps among healthcare professionals. In 2009, the World Health Organization expressed the need for enhanced knowledge to improve patient safety and reduce harm. An error, as defined by the Directorate-General for Health (^{DGS, 2011}), is the "failure in the execution of a planned action as intended or the incorrect development of a plan." Errors can manifest as the "practice of a wrong action (commission) or the failure to practice the right action (omission), whether in the planning phase or the execution phase." The context in which incidents occur is categorized by the same entity into four classes: "patient characteristics, incident characteristics, contributing hazards/factors, and organizational consequences"(^{DGS, 2011}). These organizational consequences showcase the direct outcomes both at the level of the healthcare organization and the increased rates of resource utilization for patient care, among others. In this regard, the presence of a patient safety culture in any healthcare institution is essential as a key element of care quality. It should be a priority in health systems worldwide. Kosydar-Bochenek et al. state that the objective of patient safety programs is to prevent errors, incidents, and reduce potential harm to patients (Kosydar-Bochenek et al., 2022). A patient safety culture should be deeply rooted in healthcare institutions to also ensure a safe working environment for healthcare professionals. Achieving a safety culture requires an understanding of the values, attitudes, beliefs, and norms that are vital for the organization of healthcare and determining which attitudes and behaviors are appropriate and expected for patient safety (^{Marsch et al., 2022}).

Achieving a culture of safety requires an understanding of the values, attitudes, beliefs and norms that are important to the healthcare organisation and what attitudes and behaviours are appropriate and expected for patient safety (^{Marsch et al., 2022}).

The quality of care and patient safety have been acknowledged as pivotal issues in the establishment and provision of accessible, effective, and responsive health systems. Unsafe healthcare practices are linked to significant rates of morbidity and mortality globally, many of which might be amenable to timely intervention (^{Kumbi et al., 2020}). Globally it is estimated that an average of 10% of all hospital admissions result in a degree of accidental patient harm and it is estimated that up to 75% of these gaps in healthcare delivery are preventable (^{Kumbi et al., 2020}).

The general objective of this study was to assess the level of healthcare professionals' literacy about patient safety. The specific objectives were to analyse which socio-demographic and professional variables interfere with the literacy of healthcare professionals on patient safety, considering the following dimensions: "Patient Error and Safety", "Health System Safety", "Personal Influence on Safety", and "Personal Attitudes towards Patient Safety".

1. Methods

A quantitative, descriptive-correlational, and cross-sectional study was conducted, with data collection carried out during 2021, utilizing a non probabilistic sample of 300 professionals from a Hospital Center in the central region of Portugal. Inclusion criteria considered healthcare professionals who were working during the period from january to december of 2021.

The World Health Organization's "Questionnaire to Assess the Implementation of the Multi-professional Guide" was used. It is an assessment instrument composed of two sections.

The first section includes sociodemographic and professional questions. The second section comprises the "KIT TOOL-S2 TEXT", whose translation and validation was authorized by the World Health Organization (WHO) on 12/03/2019, with the number 275563, having been validated by Amaral and Sequeira in 2021. This questionnaire contains four sections: Section 1 - Error and Patient Safety, which includes 7 items, assessed according to a 5-point scale (1 = low level of knowledge; 3 - moderate level of knowledge; 5 - high level of knowledge); Section 2 - Health System Safety, which contains 5 items, assessed on a 5-point Likert-type scale, where 1 corresponds to "Strongly Disagree" and 5 to "Strongly Agree"; Section 3 - Personal Influence on Safety, consisting of 7 items, each assessed on a 5-point Likert scale, where 1 corresponds to "Strongly Disagree" and 5 to "Strongly Agree"; Section 4 - Personal Attitudes towards Patient Safety, comprising 4 items, assessed on a 5-point Likert-type scale, where 1 corresponds to "Strongly disagree" and 5 to "Strongly agree". The scale was tested through apparent and content validity. The psychometric properties were assessed using Cronbach's Alpha coefficient (α) for internal consistency and construct validity through exploratory and confirmatory factor analysis, convergent validity, and discriminant validity. The exploratory factor analysis resulted in a tetra factor structure that explained 43.0% of the variance in total and with an overall Cronbach's alpha coefficient of 0.759.

To determine the level of health professionals' literacy in patient safety, cohort groups are established based on the statistical technique that uses the mean +/- 1/4 of the standard deviation, namely (^{Pestana & Gageiro, 2014}):

Low literacy: minimum to the mean of the items minus 0.25 of the standard deviation;

Moderate literacy: between the mean minus 0.25 of the standard deviation and the mean + 0.25 of the standard deviation;

High literacy: from the mean + 0.25 of the standard deviation to the maximum.

2. Results

3. Discussion

The sociodemographic and professional profile of a sample of 300 healthcare professionals working in a Hospital Center in the central region of the country reveals a majority of female participants, with a minimum and maximum age ranging between 26 and 66 years, yielding an average age of 43.86±9.38 years. The predominant age range among the health professionals was 36-50 years. In the entire sample, the healthcare professionals had an average of 20.48±8.95 years of professional experience. Nurses are predominantly represented, among whom those in general care roles are most prevalent. The vast majority of healthcare professionals worked 35 hours per week, and a significant percentage worked in shift rotations. Almost all of the sample did not hold managerial or leadership roles. Similarly, Brasaite et al. in their quantitative study at three multidisciplinary hospitals in Western Lithuania, with a sample of 1,082 healthcare professionals, found a predominance of nurses (70%, including 54 head nurses) with an average age of 46.7± 10.9 years (Brasaite et al., 2016). Nearly all were female (91.4%) and had an average professional experience of 23.9 years, working an average of 39.9 hours per week. Most of the healthcare professionals worked in shifts (60.9%).

In the studied sample, a low level of patient safety literacy prevailed across nearly all dimensions: "Error and Patient Safety", "Health System Safety", and "Personal Attitudes towards Patient Safety". Only in the dimension "Personal Influence on Safety" did slightly more than half of the healthcare professionals exhibit high literacy. These findings align with the evidence from the study by Kim et al., whose aim, involving pre- and post-tests, was to assess the effectiveness of a patient safety training program developed for the Comprehensive Plans for Patient Safety (2018-2022) in Korea (Kim et al., 2020). The authors observed that, before the training, there was a low level of patient safety literacy among healthcare professionals. However, there was a significant increase in high literacy post-training, with the majority of healthcare professionals reporting that the training contributed to "safe hospitalization". Given these findings, the authors suggest that, to improve healthcare professionals' patient safety literacy, it is essential to provide further training both in foundational curricula and in-service. This would optimize communication, knowledge, skills, and attitudes of healthcare professionals to uphold and foster a culture of patient safety in a hospital setting. In this context, the current study found that the vast majority of healthcare professionals indicated that patient safety was not taught at their university/school, reinforcing the suggestions made by Kim et al.(Kim et al., 2020). This is also in agreement with Morrison et al., who advocate that patient safety should be content included in foundational courses, forming a standalone course unit, which would result in a reduction of errors, greater Health System Safety, more positive Personal Attitudes towards Patient Safety, and more positive Personal Influence on Patient Safety (Morrison et al., 2021). Kosydar-Bochenek et al., in their study conducted in five European countries (Poland, Spain, France, Turkey, and Greece), assessed the patient safety literacy of 1,061 healthcare professionals (doctors, nurses, and paramedics) using the short version of the Safety Attitude Questionnaire (SAQ). They too observed a low level of literacy. Paramedics scored significantly lower compared to nurses and doctors. The participants' perceptions of the patient safety climate were not at a particularly satisfactory level, suggesting a need to develop a patient safety culture in European healthcare settings (Kosydar-Bochenek et al., 2022).

Brasaite et al., among doctors, nurses, and operational assistants, recorded a notably low level of patient safety literacy, particularly concerning general patient safety knowledge (^{Brasaite et al., 2016}). The foundational factors of healthcare professionals, such as professional category, educational qualifications, patient safety information provided during their professional and ongoing training, and their experience in their field, correlated with various areas of patient safety literacy. Despite significant variation in foundational factors, the respondents' literacy level was generally considered low, especially concerning specific issues like medication, healthcare-associated infections, falls, and pressure injury prevention. It was noted that 62.2% of Lithuania's healthcare professionals had not received any patient safety training during their foundational education, yet slightly over half (54.4%) had participated in ongoing training after professional education. 80% of respondents did not report any patient safety incidents in the year leading up to the study.

Healthcare professionals can enhance their patient safety literacy through ongoing training and in-service education. It's crucial to emphasize the importance of foundational education, which includes training that allows them to distinguish between errors, incidents, near-misses, non-harmful events, harm, how to report patient safety incidents and errors, best practices for patient care, and how to strive for effective collaboration and improve communication within a multi-professional team (^{Kosydar-Bochenek et al., 2022}). Health literacy affects both individuals' perceptions and management of their health state and their healthcare activities. Studies have shown that poor safety care literacy jeopardizes patient safety, leading to incidents, both harmful and non-harmful. Thus, patient safety largely depends on accurate healthcare information provided to patients and understood by them. The safety literacy of healthcare provided by professionals is central to planning and patient safety activities (^{Kim et al., 2020}; ^{Morrison et al., 2021}).

In the current study, variables of statistically significant relevance were age, profession, professional practice duration, weekly working hours, type of schedule, holding multiple roles, and job satisfaction (p<0.05). Therefore, it was inferred that nurses aged 36-50 years, with longer professional tenure, those working 35 hours a week, with a fixed schedule, not holding multiple roles, and those highly satisfied with their profession had higher patient safety literacy. These results align with Tocco et al., who also found that nurses are the healthcare professionals with the highest patient safety literacy, as well as professionals with more professional experience and fewer weekly working hours (^{Tocco Tussardi et al., 2021}). Konlan and Shin's study's evidence associated patient safety with academic qualifications, professional category, weekly working hours, participation in a patient safety training program, adverse event reporting, open communication among multi-professional team members, organizational learning, teamwork, the physical environment, error feedback exchange, and support from hospital management (Konlan & Shin, 2022).

Given these findings, it's crucial to establish a culture of safety in healthcare organizations, recognized as a pivotal strategy to ensure patient safety, reduce errors, and improve care quality. A safety culture is essential for delivering safe and high-quality care and the well-being of healthcare professionals (^{Konlan & Shin, 2022}; ^{Tocco Tussardi et al., 2021}).

It's worth noting that the WHO, in its Global Patient Safety Action Plan 2021-2030, emphasizes the need for all countries to strive to achieve universal health coverage and the Sustainable Development Goals, yielding benefits in better health service access without compromising patient safety (^{OMS, 2021}). This concern's expression in recent years culminated in the Seventy-second World Health Assembly's 2019 adoption of resolution WHA72.6 on "Global action on patient safety". This is mirrored in the five pillars of Portugal's National Patient Safety Plan 2021/2026 (Order No. 9390/2021, dated September 24), namely: Safety Culture, Leadership and Governance, Communication, Prevention and Management of Patient Safety Incidents, and Safe Practices in Safe Environments.

Conclusion

Although there is considerable research on patient safety, there still exists a gap in the literature regarding the assessment of health professionals' literacy levels on this topic. Understanding health professionals' knowledge and attitudes towards patient safety is crucial, as it has a direct impact on the quality of care provided to patients. This study aims to fill this gap by evaluating health professionals' literacy levels in different dimensions of patient safety, such as "Patient error and safety," "Health System Safety," "Personal Influence on Safety," and "Personal Attitudes towards Patient Safety."

By addressing this gap in the literature, the study can help identify areas where healthcare professionals may need further training or support to improve patient safety. Additionally, the findings can contribute to the development of targeted educational interventions and policies, ultimately leading to a safer healthcare environment and better patient outcomes.

This study reveals that, in a sample of Portuguese health care professionals, low literacy levels prevailed in the dimensions "Patient Error and Safety", "Health System Safety" and "Personal Attitudes towards Patient Safety". Only in the dimension "Personal Influence on Safety" a little more than half of the health professionals revealed high literacy. In view of these results, it is important that health professionals have more training in the area to ensure citizens' trust in their professional practices and confidence in the health system.

The COVID-19 pandemic placed important limitations on this study, including the limited sample size and diversity of health professionals, as the study was done only in services without COVID-19 hospitalizations. Also, using a non-probabilistic and accidental sample may have introduced a selection bias, making it harder to apply the findings to the whole health professional population.

The present study was intended to be transversal in nature, as it was intended to be representative of the entire population under study. However, no such representation was obtained, so its results cannot be generalised. Thus, we suggest the replication of the same study with a larger sample and in a wider timeframe. Despite this limitation, it is considered that the results obtained show that patient safety literacy is an area that requires more investment, and these results serve as a diagnosis of the situation. Thus, considering that this study contributed to a greater visibility of the topic of patient safety literacy, presenting data based on scientific evidence, we propose, as implications for practice, the implementation of a training programme in the Hospital where the study was conducted, so as to carry out a pre- and post-assessment study on patient safety literacy (before and after the training).

Acknowledgments

We would like to express our deepest appreciation to both the Universitat Rovira i Virgili, Tarragona, and NursID - Inovação e Desenvolvimento em Enfermagem, for their exceptional support throughout our research project. The Universitat Rovira i Virgili has been instrumental in providing us with outstanding facilities and the invaluable expertise of its academic and support staff, which significantly contributed to the progression of our research. Equally, our collaboration with NursID - Inovação e Desenvolvimento em Enfermagem, has been paramount, granting us access to pioneering research resources and a collaborative environment that has greatly enhanced the quality and impact of our study.

Author contributions

Conceptualization, C.A.; data curation, C.A.; formal analysis, C.A.; investigation, C.A.; methodology, C.A., C.S., N.A.R.,and C.F.G.; project administration, C.A.; supervision, C.S., N.A.R, L.P. and C.F.G.; validation, C.A., C.S., N.A.R, L.P. and C.F.G.; writing-original draft, C.A.; writing-review and editing, C.A., C.S., N.A.R, L.P. and C.F.G.

Conflicts of interest

The authors declare no conflict of interest.