Abstract
Background
Patient safety in operating rooms has globally improved through interventions such as the World Health Organization (WHO) Surgical Safety Checklist and multidisciplinary team training. However, while evidence from high-income countries is well documented, there remains limited consolidated knowledge on the understanding, application, and effectiveness of safety culture interventions in African surgical settings, which this review seeks to address.
Methods
This systematic review examined factors and protocols affecting surgical safety in African operating rooms. We hypothesized that persistent systemic barriers undermine safety culture despite adoption of global measures. Following PRISMA 2020, we searched eight databases (Medline, Embase, Cochrane, Africa-Wide, CINAHL, Global Health, Global Index Medicus, Web of Science) from inception to 5 December 2024, using variations of text words present in the title, abstract, or keyword fields, alongside relevant subject headings, to identify articles addressing surgical safety and culture throughout Africa. Included studies involved operating room professionals in African countries and used quantitative, qualitative, or mixed-methods designs. We excluded non-operating room settings, patient-only studies, inaccessible full texts, reviews, editorials, letters, conference abstracts, and duplicates. Two reviewers independently screened and appraised studies using the Mixed Methods Appraisal Tool. Findings were synthesized narratively with subgroup analysis by study type and theme.
Results
Out of 9,875 identified records, 22 studies from 12 African countries (2014–2024) met inclusion criteria, with Ethiopia contributing the highest number (n = 4). Various assessment tools, including the Hospital Survey on Patient Safety Culture, the Safety Attitudes Questionnaire, and the National Surgical, Obstetric, and Anaesthesia Plans interview manual, revealed recurring challenges: inadequate non-punitive responses to errors, communication barriers, hierarchical structures, and resource constraints. Four interventions showed promise: implementation and training on the WHO Surgical Safety Checklist, Safe Surgery 2020 initiatives, Non-Technical Skills for Surgeons training, and multidisciplinary training.
Conclusion
The heterogeneity of study designs, sample sizes, and outcome measures limited direct comparisons and precluded meta-analysis. Nonetheless, the review highlights persistent barriers and emerging opportunities to strengthen patient safety culture in African operating rooms. While the WHO Surgical Safety Checklist remains valuable, sustainable progress requires multi-level strategies that address systemic constraints and incorporate context-sensitive adaptations.
Registration
PROSPERO, CRD42024627076.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13037-025-00461-z.
Keywords: Patient safety culture, Operating room, Africa, Surgical safety, Quality improvement, Global surgery
Background
Since its publication in 1999, the Institute of Medicine’s landmark report, To Err is Human, has catalyzed global efforts to improve patient safety by revealing the widespread prevalence of medical errors and advocating for systemic healthcare reforms focused on error prevention [1]. Despite two decades of concerted efforts by healthcare organizations, regulatory bodies, and policymakers to address these issues, the persistence of quality problems remains a pressing concern [2]. Alarmingly, many surgical patients continue to experience preventable harm during their care, underscoring the need for ongoing vigilance and innovation in safety practices [2, 3].
The World Health Organization (WHO) emphasizes that ensuring access to safe medical services is a global imperative, particularly in light of the disparities that exist between high-income countries and low- and middle-income countries (LMICs) [4]. In LMICs, including many countries in Africa, the challenges to maintaining and improving patient safety are exacerbated by a confluence of factors such as limited resources, inadequate infrastructure, workforce shortages, and varying cultural norms that influence healthcare delivery practices [5, 6]. These challenges create an environment where the risk of adverse events is heightened, making it imperative to develop targeted strategies to improve patient safety outcomes [7].
Operating rooms (OR) are among the most critical and high-risk settings in healthcare, where the complexity of surgery and the unpredictability of patient responses make preventable errors more likely [8]. Research indicates that approximately 10% of avoidable patient injuries occur in surgical settings, with a significant proportion of adverse events transpiring before or after surgical interventions [9, 10]. The implications of these statistics are profound, highlighting the urgent need for robust patient safety measures within operating rooms to protect vulnerable patients undergoing surgery [11].
The advancement of patient safety is contingent upon the precise measurement and evaluation of safety culture within healthcare organizations, a process rendered challenging by the inherently multidimensional nature of safety [12, 13]. The Hospital Survey on Patient Safety Culture (HSOPSC) and the Safety Attitudes Questionnaire (SAQ) are widely used tools to assess hospital safety culture, offering insights into healthcare professionals’ views on practices, communication, teamwork, and leadership support [14, 15].
In recent years, interventions to improve patient safety in operating rooms have shown promise, with the World Health Organization’s Surgical Safety Checklist emerging as a transformative tool for enhancing surgical outcomes [16]. This checklist has been rigorously evaluated and proven effective in reducing morbidity and mortality associated with surgical procedures across diverse healthcare settings [16–18].
Despite global progress in patient safety, understanding how safety culture emerges and persists in African operating rooms remains limited, as context-specific factors—such as hierarchical dynamics, resource scarcity, informal task-shifting, and uneven protocol adherence—interact in ways not adequately captured by prevailing international frameworks [19]. These characteristics necessitate a tailored approach that accounts for both structural limitations and culturally embedded practices. This systematic review aims to identify and synthesize the key factors influencing PSC (patient safety culture) in African operating rooms and to critically evaluate the contextual relevance and effectiveness of interventions designed to strengthen safety culture within this unique healthcare landscape. By consolidating existing evidence, the review seeks to support the development of targeted, context-specific strategies that improve patient safety and reduce preventable harm in surgical settings.
Methods
Information sources and search strategy
A senior medical librarian conducted a comprehensive search across several databases from their inception until December 5, 2024. The databases included Medline (Ovid), Embase (Ovid), Cochrane Library (Wiley), Africa-Wide (EBSCO), CINAHL (EBSCO), Global Health (Ovid), Global Index Medicus (WHO), and Web of Science Core Collection (Clarivate).
The search strategy employed variations of text words present in the title, abstract, or keyword fields, alongside relevant subject headings, to identify articles addressing surgical safety and culture throughout Africa. For a detailed account of the search strategy, refer to the supplementary files 1 and 1A.
This study adhered to the PRISMA 2020 guidelines, the updated version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, along with PRISMA-S, an extension specifically designed to enhance the reporting of search strategies in systematic reviews [20, 21], refer to the supplementary file 2 and 3.
Selection process
At the conclusion of the reference search, duplicate entries were identified and removed using EndNote’s Author/Title/Year duplicate checker, followed by a manual verification process to ensure accuracy. The Covidence software platform (https://www.covidence.org/) was utilized to organize the references and facilitate the identification of any additional duplicates. Two independent reviewers (JFB & NG) screened the titles and abstracts of the identified papers, with those selected progressing to the subsequent phase involving a full-text review. During this phase, any conflicts regarding the inclusion or exclusion of articles were documented in Covidence; in such instances, the two reviewers engaged in discussions to reach a consensus on whether to include the study for full-text assessment and a third arbitrator addressed conflicts (DP). This same process was applied during the full-text assessment phase, with no automated tools employed throughout this process.
Eligibility criteria
This review included English or French studies (no year restrictions) involving African OR healthcare professionals. Quantitative studies (cross-sectional, cohort, pre-post) assessing PSC factors or interventions were included, alongside qualitative studies (interviews, focus groups) exploring staff experiences. Mixed-methods studies were also considered.
Excluded: Non-operating room studies, patient-centric research, inaccessible full texts, book chapters, editorials, letters, conference abstracts, reviews, or duplicates.
Data collection process and data items
Two reviewers independently summarized the data using a data extraction Excel sheet that was collaboratively developed and discussed to serve as a template for data collection. The following information was extracted from each paper: country of study, authors, publication year, journal, study objectives, study design, population and sample size, interventions or strategies employed to enhance patient safety, and tools utilized to assess PSC. Additionally, the results of the interventions—such as improvements in teamwork, communication, or measurable shifts in culture—were documented, along with the main findings of the assessment, study limitations, and the level of evidence. The level of evidence was evaluated according to the Joanna Briggs Institute (JBI) classification [22].
Quality appraisal
The Mixed Methods Appraisal Tool (MMAT) was used to assess the methodological quality of the studies included in the review, covering qualitative, quantitative, and mixed-methods research. Reviewers independently applied the MMAT to evaluate the studies and then compared their findings to identify similarities and discrepancies. In cases of disagreement, discussions were held to reach a consensus on the final evaluations, ensuring a thorough and unbiased assessment. No automated tools were used in this process, allowing for a detailed examination of each study’s strengths and weaknesses. The MMAT provides specific criteria for various study designs, enabling adequate evaluation of the diverse methodologies. Each study received an overall quality score ranging from 20% (*) to 100% (****) based on these methodological quality criteria [23].
Synthesis methods
This review encompasses a heterogeneity of studies, including qualitative, quantitative, and mixed-methods research, which makes statistical meta-analysis unfeasible. Consequently, we adopted two approaches for data synthesis. The narrative synthesis with subgroup analysis approach enabled us to qualitatively summarize and interpret the studies [24, 25].
Results
A total of 9,875 references were identified from the searched databases. After removing duplicates and screening titles/abstracts, 22 studies met inclusion criteria (see Fig. 1).
Fig. 1.
PRISMA Flowchart for Study Selection (https://www.prisma-statement.org/prisma-2020-flow-diagram). OR: Operating Room, PSC: Patient safety culture. *: During the records screening (title and abstract screening) phase, studies were excluded if they did not address patient safety culture, were conducted outside African surgical settings, lacked empirical data, or did not meet the eligibility criteria for peer-reviewed primary research
The included studies were published between 2014 and 2024, with nine studies (41%) published in the last five years. These studies were conducted across twelve African countries, with Ethiopia contributing the highest number of articles (four), followed by Tunisia and Tanzania, each with three articles (see Fig. 2).
Fig. 2.
The geographical distribution of studies and participants
The characteristics of the studies, along with their results, limitations or risk of bias, and levels of evidence are detailed in supplementary file 4. Among the included studies, eight assessed PSC in the OR, while fourteen evaluated interventions or strategies aimed at improving patient safety in this setting.
Regarding the quality appraisal of these studies using the MMAT, all qualitative studies [26–30], and most quantitative descriptive studies [31–34] achieved 100% scores. One quantitative descriptive study [35] and the non-randomized qualitative studies [36–38] scored 80%. Of nine mixed-methods studies, three [39–41] scored 100%, while the remaining six [42–47] scored 80%. See Supplementary File 5 for details.
Factors associated with patient safety culture in African operating rooms
A range of tools was used to assess PSC in the included studies; for a detailed overview of factors affecting patient safety culture, see Table 1 and Supplementary File 4.
Table 1.
Patient safety culture in African operating rooms
| Author, country, year | Study design | Population, sample size | Tools used to assess PSC | Main result | Level of evidence↟ |
|---|---|---|---|---|---|
| Mallouli et al. 2017, Tunisia [31] | Cross-sectional study | Surgeons, anaesthesiologists, techs, nurses, caregivers (n = 368) | French validated version of HSOPSC | All PSC dimensions are low; teamwork and supervisor support highest; non-punitive response and staffing lowest. | IV |
| Fajemilehin and Faronbi 2016, Nigeria [32] | Cross-sectional study | Perioperative nurses (n = 211) | Non-validated tool | Good safety knowledge; 57% used WHO checklist. | IV |
| Labat and Sharma 2016, DRC [26] | Qualitative study | Surgeons, nurses, anaesthetists, orderlies (n = 16) | Non-validated tool | Positive safety views; barriers: resources, hierarchy, blame culture, management support. | IV |
| Mulugeta et al. 2024, Ethiopia [27] | Qualitative study | Nurses, surgeons, anaesthetists (n = 20) | NSOAP interview manual | Challenges: infrastructure, morale, hierarchy, communication, socio political issues. | IV |
| Berhe et al. 2024, Ethiopia [33] | Cross-sectional study | Anaesthetists, nurses, surgical staff (n = 260) | SAQ | Most had unfavourable safety attitudes; age, work hours, OR assignment influenced attitudes | IV |
| Aouicha et al. 2022, Tunisia [39] | Mixed-methods design | Surgeons, nurses, anaesthesiologists, caregivers (n = 297) | HSOPSC | Low PSC scores; non-punitive response and communication openness major issues. | III |
| Smiley et al. 2019, Ghana [40] | Cross-sectional study | Surgeons, nurses, anaesthesiologists, staff (n = 46) | SAQ and HCAHPS | High teamwork and safety culture; strong patient satisfaction; some gaps remain. | IV |
| Nwosu et al. 2022, Nigeria [34] | Cross-sectional study | Surgeons, nurse anaesthetists, nurses (n = 132) | HSOPSC | Weak PSC; teamwork strong; non-punitive response poor. | IV |
↟: Level of evidence evaluated according to the Joanna Briggs Institute classification. DRC: Democratic Republic of Congo, HSOPSC: Hospital Survey on Patient Safety Culture, HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems Survey, NSOAP: National Surgical, Obstetric and Anesthesia Planning, PSC: Patient Safety Culture, SAQ: the Safety Attitudes Questionnaire, WHO: World Health Organization, ORs: Operating Rooms
Overall patient safety
Six studies evaluated the overall state of PSC. Three reported consistently low scores across all PSC dimensions [31, 34, 39], with Berhe et al. [33] noting negative clinician attitudes toward perioperative safety. In contrast, Smiley et al. [40] described a hospital with strong perioperative safety standards, and Labat and Sharma [26] found the surgical team held a positive view of overall surgical patient safety.
Non-punitive response to error
Multiple studies revealed inadequate responses to errors, dominated by a blame culture. Mallouli et al., Aouicha et al., and Nwosu et al. reported insufficient non-punitive responses [31, 34, 39]. Labat and Sharma highlighted punitive measures and blame culture [26]. Similarly, Aouicha et al. identified a blame culture within ORs in their qualitative analysis [39].
Communication barriers
Using the HSOPSC tool, studies consistently showed poor communication openness. Mallouli et al., Aouicha et al., and Nwosu et al. reported low positive responses (26.3%–27.9%) for communication openness [31, 34, 39]. Mulugeta et al. identified communication barriers as systemic challenges in perioperative care [27].
Hierarchical structures
Labat and Sharma noted paternalistic management and physician dominance over nurses, fostering a culture of authority [26]. Mulugeta et al. also recognized hierarchical barriers as key systemic challenges [27].
Resource constraints
Staffing shortages were common, with low positive response rates (21.2%–28.6%) reported [31, 34, 39]. Financial constraints also impacted safety, as reported by Mulugeta et al. [27]. Furthermore, Labat et al. highlighted severe human resource shortages in conflict-affected Eastern DRC, worsened by economic crisis linked to armed conflict, detrimentally affecting patient safety [26].
Strategy and intervention implemented to improve patient safety culture in African operating rooms
For a detailed overview of strategies and interventions used to improve patient safety culture in African operating rooms, refer to Fig. 3 and Supplementary File 4.
Fig. 3.
Intervention pathways in African operating rooms. ORs: Operating rooms, SS2020: Safe Surgery 2020 initiative, WHO: World Health Organization, SSC: Surgical Safety Checklist, mod: modified, NOTSS: Non-Technical Skills for Surgeons, DRC: Democratic Republic of the Congo
WHO surgical safety checklist
Eight studies explored the impact of the WHO Surgical Safety Checklist on PSC in African OR. Tlili et al. [35] found that WHO Surgical Safety Checklist use significantly improved safety culture perceptions. Michel et al.‘s study [42], showed that a 4-day WHO Surgical Safety Checklist training program led to consistent adherence to six basic safety processes in over 50% of participants at 15 months, with improvements in teamwork, organization, and safe anaesthesia practices, though hierarchical culture remained a challenge.
Close et al. [44] demonstrated a 3-day multidisciplinary SSC training in 21 Madagascar hospitals improved checklist use, teamwork, communication, and safety protocol adherence. Bashford et [43]. detailed a successful WHO Surgical Safety Checklist implementation strategy in a low-resource setting (n = 20), resulting in enhanced staff communication, patient safety, and overall care.
Dirie et al. [38] implemented a week-long WHO checklist training in Mogadishu, improving adherence, safety practices, team dynamics, and communication. El-Shafei et al. [36] expanded the WHO Surgical Safety Checklist to include infection control, which improved knowledge and practices related to patient safety and infection prevention. M.C. White et al. [46] evaluated a nationwide WHO Surgical Safety Checklist program in Benin, showing sustained improvements in teamwork, communication, safety culture, and checklist adherence over time. Finally, Michelle C. White et al. [47] evaluated sustained WHO Surgical Safety Checklist use in Madagascar, finding lasting improvements in teamwork, communication, hospital culture, job satisfaction, and safety protocol adherence.
Safe surgery 2020 intervention
In ten Tanzanian facilities, the Safe Surgery 2020 initiative improved teamwork, communication, checklist use, and safety protocol adherence [29]. Comparing high- and low-performing sites revealed that strong teamwork, integrated safety practices, and leadership engagement distinguished high performers. Lower-performing sites improved but showed less cultural integration [28]. A related mentorship program enhanced teamwork, communication, standardized practices, and mentee confidence [45].
Non-technical skills for surgeons
Lin et al. [37] implemented NOTSS (Non-Technical Skills for Surgeons) for variable-resource contexts in Rwanda, increasing understanding from 55.6% pre-course to 80.9% post-course, with gains in situation awareness, communication, teamwork, decision-making, and leadership. Abahuje et al. [41] identified barriers (workload, hierarchy, poor communication) and facilitators (preparation, trained staff) to NOTSS implementation. Training improved team dynamics, empowerment, and safety practices.
Multidisciplinary training and quality improvement project
Negash et al. [30] studied the Lifebox McCaskey Safe Surgery Fellowship, a multidisciplinary program enhancing teamwork, leadership, and safe surgical practices. Interviews with fellows revealed positive shifts in attitudes toward teamwork and increased adherence to the WHO Surgical Safety Checklist.
Discussion
This systematic review analyses the key factors shaping PSC in African ORs and evaluates strategies to enhance PSC, underscoring the urgent need for improved surgical and patient safety initiatives across the continent.
Factors influencing patient safety culture
Consistently low PSC scores are reported in African ORs, reflecting broader global concerns about surgical safety and care quality. Assessing current safety culture is the essential first step in improving patient safety [12]. Our analysis revealed various tools used to assess the PSC, including the HSOPSC, SAQ, NSAOP (National Surgical, Obstetric and Anesthesia Planning) interview manual and non-validated assessment. The HSOPSC and SAQ have been identified in multiple reviews as the most widely used instruments [48, 49], with HSOPSC favoured for its benchmarking capabilities [50, 51].
This review shows poor PSC in African ORs across all dimensions in several studies [31, 34, 39]. Vikan et al. indicate that low PSC scores are associated with higher rates of adverse events [52]. Berhe et al. highlighted negative attitudes toward perioperative safety among clinicians, which further erodes the safety culture [33]. However, Smiley et al. documented a hospital with robust perioperative care standards and a strong commitment to safety [40], while Labat and Sharma found positive perceptions of surgical safety among teams in specific contexts [26]. This highlights the need for both individual engagement and systemic organizational change to foster a positive safety culture [53].
Non-punitive responses to errors remain critically underdeveloped in African ORs [31, 34, 39]. Blame-oriented practices obstruct error reporting and learning, perpetuating a cycle where mistakes are concealed rather than addressed [26, 39]. This not only endangers patients but also creates “second victim” scenarios for staff involved in errors [26, 54–56]. Transitioning to a non-punitive approach is vital for fostering reporting and learning, supported by voluntary error-reporting systems that enhance transparency and drive improvement [55, 57]. Establishing a just culture-advocated by the WHO-is essential for advancing patient safety and continuous quality improvement [58, 59].
Communication openness is low in many African ORs [31, 34, 39], hindering effective teamwork. Barriers to communication are critical challenges in perioperative care [27]. The WHO Surgical Safety Checklist demonstrates that structured communication protocols can reduce adverse events and improve outcomes [18, 60].
Hierarchical structures in African ORs [26, 27], exacerbate communication barriers, fostering a culture of silence where lower-ranking staff hesitate to voice concerns. This communication gap risks misunderstandings and adverse outcomes [61–63]. Flattening hierarchies and promoting interprofessional collaboration are associated with better patient safety [64].
This review highlighted low staffing levels, financial constraints, and inadequate infrastructure as major challenges [27, 31, 34, 39]. In conflict-affected regions like Eastern DRC, severe shortages of human resources and economic crises further exacerbate these issues [26]. Such constraints increase workloads and reduce vigilance, compromising safety [65, 66]. The WHO has highlighted that adequate staffing and resources are essential for safe care [58].
Strategies to enhance patient safety culture
To address the challenges faced in African operating rooms, hospitals have implemented several effective interventions to enhance PSC. Foremost among these is the adoption of the WHO Surgical Safety Checklist, which has been extensively validated in reducing surgical complications and mortality by improving teamwork and communication [18]. Successful implementation often requires structured training programs, as highlighted by recent evidence [67]. Systematic reviews, including that by Aquino et al., reinforce the importance of the checklist alongside ongoing education, structured handovers, and knowledge translation efforts [68]. Innovations such as digital checklists offer additional advantages by dynamically adapting to procedure types and patient-specific risk factors, providing real-time prompts to ensure compliance—addressing limitations of traditional paper checklists which risk being overlooked [69]. Because each item contributes directly to patient safety, just as an actor cannot skip lines without breaking the coherence of a play, a surgical team must not omit any step of the safety checklist [70].
Beyond the Surgical Safety Checklist, programs such as Safe Surgery 2020 (SS2020) in Tanzania and the Non-Technical Skills for Surgeons (NOTSS) training in Rwanda have shown measurable improvements in teamwork, communication, and adherence to safety protocols [29, 41, 71]. These findings align with the WHO Global Patient Safety Report 2024, which emphasizes embedding safety interventions within local sociocultural and systemic realities [72]. To ensure sustainability, periodic training should be integrated into both undergraduate curricula and professional re-training courses [73]. Together, these strategies—structured Surgical Safety Checklist implementation, digital innovations, and context-specific training—form a coherent pathway for strengthening patient safety culture in African operating rooms.
Strengths and limitations
This PROSPERO-registered systematic review followed PRISMA guidelines, ensuring a transparent approach to examining factors influencing and interventions enhancing PSC in ORs. Including qualitative and quantitative studies provided diverse perspectives but introduced methodological heterogeneity, hindering direct comparisons and meta-analysis. Variations in study design, sample size, and outcomes further complicate analysis.
Publication bias is a potential limitation, alongside possible exclusion of grey literature. Study quality variations could affect reliability. Differing OR contexts (hospital type, specialty, country) might limit generalizability.
Implications of the results for practice, policy, and future research
Practice: Standardized checklists (e.g., WHO Surgical Safety Checklist) enhance OR safety through consistent practices. Addressing hierarchical barriers via open communication and multidisciplinary training fosters sustainable safety culture improvements.
Policy: Prioritize systemic interventions dismantling punitive cultures and integrating teamwork-driven programs into national safety frameworks.
Research: Focus on context-specific adaptations across Africa’s diverse healthcare systems and comparative studies to identify cost-effective strategies targeting hierarchies, reporting systems, and resource allocation.
Conclusion
This review reveals key challenges to PSC in African ORs, including communication gaps, hierarchy, and limited resources. Interventions like the WHO Surgical Safety Checklist, SS2020, and NOTSS improve safety by standardizing practices and training teams. Progress requires fostering a culture of transparency, addressing staffing shortages, and securing leadership commitment with continuous education. Importantly, a tailored PSC bundle that reflects the specific context of African ORs is needed. Collaborative efforts are essential to enhance patient safety and surgical care worldwide.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We thank Quan Nha Hong for invaluable assistance with the critical appraisal, especially in applying the MMAT and supporting data synthesis. Their expertise strengthened this study.
Abbreviations
- HCAHPS
Hospital Consumer Assessment of Healthcare Providers and Systems Survey
- HSOPSC
Hospital Survey on Patient Safety Culture
- LMICs
Middle-income countries
- MMAT
Mixed Methods Appraisal Tool
- NOTSS
Non-Technical Skills for Surgeons
- NSAOP
National Surgical, Obstetric and Anesthesia Planning
- OR
Operating rooms
- PRISMA
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- PSC
Patient safety culture
- SAQ
Safety Attitudes Questionnaire
- WHO
World Health Organization
Author contributions
Conceptualization: JFB, KMC, TKZ, DP, Literature Search and Strategy: EG, Screening and Study Selection: JFB, NG, DP, Data Extraction and Curation: JFB, NG, EG, Methodology and analysis: JFB, NG, EG, Writing – Original Draft: JFB, Writing – Review and Editing: JFB, NG, EG, DP, KMC, TKZ.
Funding
None.
Data availability
All data analysed during this study are included in this published article and its supplementary information files.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Authors information
JFB is a general surgeon and a Fellow of the College of Surgeons of East, Central and Southern Africa (COSECSA). He is currently pursuing a PhD, with research focusing on patient safety culture in operating rooms across hospitals in his region.
Registration and protocol
The protocol for this review was developed in advance and registered with the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024627076 (https://www.crd.york.ac.uk/PROSPERO/view/CRD42024627076).
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Kohn LT, Corrigan JM, Molla S. To Err is Human: Building a Safer Health System. Vol. 52. Regulatory Toxicology and Pharmacology; 2008.
- 2.Bates DW, Singh H. Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety. Qual Care [Internet]. 2018;11(11):1736–43. Available from: https://www.healthaffairs.org/doi/epdf/10.1377/hlthaff.2018.0738. [DOI] [PubMed]
- 3.Pellegrini CA. Revisiting To Err Is Human 20 years later. 2020;11–4. Available from: https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2020/02/revisiting-to-err-is-human-20-years-later/.
- 4.WHO. Global action on patient safety. WHO Dir Gen Rep to 72nd World Health Assembly. 2019;(May 2019):2–4.
- 5.Wilson RM, Michel P, Olsen S, Gibberd RW, Vincent C, El-Assady R, et al. Patient safety in developing countries: retrospective Estimation of scale and nature of harm to patients in hospital. BMJ. 2012;344(7850):20. [DOI] [PubMed] [Google Scholar]
- 6.Basukala S, Bohara S, Thapa A, Shah A, Pahari S, Khand Y, et al. Patient safety and organizational safety culture in surgery: A need of an hour in the developing countries. J Soc Surg Nepal. 2022;25(2):63–8. [Google Scholar]
- 7.Alabdullah H, Karwowski W. Patient safety culture in hospital settings across continents. Appl Sci [Internet]. 2024;14(18):1–26. Available from: 10.3390/app14188496.
- 8.Finstad A, Tipney B, Lamb T, Rahman A, Devenny K, Abou Khalil J, et al. Exploring human factors in the operating room: scoping review of training offerings for healthcare professionals. BJS Open. 2022;6(2). [DOI] [PMC free article] [PubMed]
- 9.Satriyanto MD, Sayidah N, Ady SU. Patient safety determinants in surgical settings: A literature review. Dinasti Int J Manag Sci. 2024;5(3):570–6. [Google Scholar]
- 10.World Health Organization. Patient safety. 2023 Sep;2–7. Available from: https://www.who.int/news-room/fact-sheets/detail/patient-safety.
- 11.Chee D, Tan TK. Patient safety in the operating theatre: an ongoing endeavour. Proc Singap Healthc. 2025;34:1–11. [Google Scholar]
- 12.Nieva VF, Sorra J. Safety culture assessment: A tool for improving patient safety in healthcare organizations. Qual Saf Heal Care. 2003;12(SUPPL 2):17–24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.England NHS, Improvement NHS. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients [Internet]. 2019 Jul. Available from: https://www.england.nhs.uk/wp-content/uploads/2020/08/190708_Patient_Safety_Strategy_for_website_v4.pdf.
- 14.Sorra J, Yount N, Famolaro T, Laura G. Hospital Survey on Patient Safety Culture Version 2.0: User’s Guide. Rockville (MD): Agency for Healthcare Research and Quality; 2019. AHRQ Publication No. 19–0076; 41 p. Available from: https://www.ahrq.gov/sops/surveys/hospital/index.html.
- 15.Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The safety attitudes questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.World Health Organization. Implementation Manual: WHO Surgical Safety Checklist 2009. 2009.
- 17.Jain D, Sharma R, Reddy S. Review Article WHO safe surgery checklist: barriers to universal acceptance. J Anesthesiol Clin Pharmacol. 2018;34(1):7–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med [Internet]. 2009;491–9. Available from: https://www.nejm.org/doi/full/10.1056/NEJMsa0810119. [DOI] [PubMed]
- 19.Konlan KD, Shin J. The status and the factors that influence patient safety in health care institutions in Africa: a systematic review. PLOS Glob Public Heal [Internet]. 2022;2(12):e0001085. Available from: 10.1371/journal.pgph.0001085. [DOI] [PMC free article] [PubMed]
- 20.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372. [DOI] [PMC free article] [PubMed]
- 21.Rethlefsen ML, Kirtley S, Waffenschmidt S, Ayala AP, Moher D, Page MJ, et al. PRISMA-S: an extension to the PRISMA Statement for reporting literature searches in systematic reviews. 2020. Available from: https://osf.io/y765x. [DOI] [PMC free article] [PubMed]
- 22.The Joanna Briggs Institute (JBI). JBI Levels of Evidence. JBI approach [Internet]. 2013 Oct;2–6. Available from: https://joannabriggs.org/sites/default/files/2019-05/JBI-Levels-of-evidence_2014_0.pdf.
- 23.Nha Q, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Mixed Methods Appraisal Tool (MMAT) Version 2018: User guide. 2018.
- 24.Centre for Reviews and Dissemination. Systematic Reviews CRD’s guidance for undertaking reviews in health care [Internet]. 2009. 294 p. Available from: https://www.york.ac.uk/media/crd/Systematic_Reviews.pdf#page=228.
- 25.Ryan R. Cochrane Consumers and Communication Review Group: data synthesis and analysis. 2013;1–5. Available from: http://cccrg.cochrane.org.
- 26.Labat F, Sharma A. Qualitative study exploring surgical team members’ perception of patient safety in conflict-ridden Eastern Democratic Republic of congo. BMJ Open. 2016;6(4):1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Mulugeta H, Zemedkun A, Mergia G, Abate SM, Gebremariam M, Nenko G, et al. Voices from the frontline: a reflexive thematic analysis illuminating perioperative practice realities in Southern Ethiopian teaching hospitals. Qual Health Res. 2024. [DOI] [PubMed]
- 28.Alidina S, Chatterjee P, Zanial N, Alreja SS, Balira R, Barash D, et al. Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others? BMJ Qual Saf. 2021;30(12):937–49. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Alidina S, Zanial N, Meara JG, Barash D, Buberwa L, Chirangi B, et al. Applying the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to Safe Surgery 2020 Implementation in Tanzania’s Lake Zone. J Am Coll Surg [Internet]. 2021;233(2):177–191.e5. Available from: 10.1016/j.jamcollsurg.2021.04.006. [DOI] [PubMed]
- 30.Negash S, Starr N, Mesfin S, Weiser G, Negussie T. A novel global safe surgery mentorship program using a multidisciplinary team approach. World J Surg. 2024;48(7):1609–15. [DOI] [PubMed] [Google Scholar]
- 31.Mallouli M, Tlili MA, Aouicha W, Rejeb M, Ben, Zedini C, Salwa A, et al. Assessing patient safety culture in Tunisian operating rooms: a multicenter study. Int J Qual Heal Care. 2017;29(2):176–82. [DOI] [PubMed] [Google Scholar]
- 32.Fajemilehin BR, Faronbi JO. Safety practices employed by perioperative nurses in selected tertiary health institutions in South Western Nigeria. J Egypt Public Health Assoc. 2016;9(2):579–95. [Google Scholar]
- 33.Berhe YW, Ferede YA, Ayen B, Melkie TB, Yiheyis A, Arefayne NR, et al. Attitude toward perioperative safety among operation room clinicians at Ethiopian University hospital. Int J Qual Heal Care. 2024;36(3). [DOI] [PubMed]
- 34.Nwosu ADG, Ossai E, Ahaotu F, Onwuasoigwe O, Amucheazi A, Akhideno I. Patient safety culture in the operating room: a cross-sectional study using the hospital survey on patient safety culture (HSOPSC) instrument. BMC Health Serv Res. 2022;22(1):1–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Tlili MA, Mallouli M, Aouicha W, Guedhami F, Dhiab M, Ben. La check-list aux blocs opératoires, Telle Que perçue par les soignants Tunisiens. Tunis Med. 2017;95(2):115–9. [PubMed] [Google Scholar]
- 36.El-Shafei AMH, Ibrahim SY, Tawfik AM, Abd El Fatah SAM. World health organization surgical safety checklist with addition of infection control items: intervention study in Egypt. Open Access Maced J Med Sci. 2019;7(21):3691–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Lin Y, Scott JW, Yi S, Taylor KK, Ntakiyiruta G, Ntirenganya F, et al. Improving surgical safety and nontechnical skills in variable-resource contexts: a novel educational curriculum. J Surg Educ [Internet]. 2018;75(4):1014–21. Available from: 10.1016/j.jsurg.2017.09.014. [DOI] [PubMed]
- 38.Dirie NI, Elmi AH, Ahmed AM, Ahmed MM, Omar MA, Hassan MM, et al. Implementation of the WHO surgical safety checklist in resource-limited Somalia: a new standard in surgical safety. Patient Saf Surg. 2024;18(1). [DOI] [PMC free article] [PubMed]
- 39.Aouicha W, Tlili MA, Sahli J, Mtiraoui A, Ajmi T, Said Latiri H, et al. Patient safety culture as perceived by operating room professionals: a mixed-methods study. BMC Health Serv Res [Internet]. 2022;22(1):1–12. Available from: 10.1186/s12913-022-08175-z. [DOI] [PMC free article] [PubMed]
- 40.Smiley K, Ofori L, Spangler C, Acquaah-Arhin R, Deh D, Enos J, et al. Safety culture and perioperative quality at the Volta river authority hospital in Akosombo, Ghana. World J Surg. 2019;43(1):16–23. [DOI] [PubMed] [Google Scholar]
- 41.Abahuje E, Bartuska A, Koch R, Youngson G, Ntakiyiruta G, Williams W, et al. Understanding barriers and facilitators to behavior change after implementation of an interdisciplinary surgical non-technical skills training program in rwanda. J Surg Educ [Internet]. 2021;78(5):1618–28. Available from: 10.1016/j.jsurg.2021.01.011. [DOI] [PubMed]
- 42.White MC, Peterschmidt J, Callahan J, Fitzgerald JE, Close KL. Interval follow up of a 4-day pilot program to implement the WHO surgical safety checklist at a Congolese hospital. 2017;1–9. [DOI] [PMC free article] [PubMed]
- 43.Bashford T, Reshamwalla S, McAuley J, Allen NH, McNatt Z, Gebremedhen YD. Implementation of the WHO surgical safety checklist in an Ethiopian referral hospital. Patient Saf Surg. 2014;8(1). [DOI] [PMC free article] [PubMed]
- 44.Close KL, Baxter LS, Ravelojaona VA, Rakotoarison HN, Bruno E, Herbert A, et al. Overcoming challenges in implementing the WHO surgical safety checklist: lessons learnt from using a checklist training course to facilitate rapid scale up in Madagascar. BMJ Glob Heal. 2017;2:6–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Alidina S, Tibyehabwa L, Alreja SS, Barash D, Bien-Aime D, Cainer M, et al. A multimodal mentorship intervention to improve surgical quality in Tanzania’s Lake Zone: a convergent, mixed methods assessment. Hum Resour Health [Internet]. 2021;19(1):1–14. Available from: 10.1186/s12960-021-00652-6. [DOI] [PMC free article] [PubMed]
- 46.White MC, Randall K, Capo-Chichi NFE, Sodogas F, Quenum S, Wright K, et al. Implementation and evaluation of nationwide scale-up of the surgical safety checklist. Br J Surg. 2019;106(2):e91–102. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.White MC, Randall K, Ravelojaona VA, Andriamanjato HH, Andean V, Callahan J, et al. Sustainability of using the WHO surgical safety checklist: A mixed-methods longitudinal evaluation following a nationwide blended educational implementation strategy in Madagascar. BMJ Glob Heal. 2018;3(6):1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Ramos Azevedo Fernandes AR, Silva Fassarella C, Giron Camerini F, De Mendonça Henrique D, De Mendonça Nepomuceno R. Abreu da Silva R. Safety culture in the operating room: an integrative review. Rev Eletrônica Enferm REE [Internet]. 2021;23:1–9. Available from: https://revistas.ufg.br/fen/article/view/65437/36812.
- 49.Hanifa YNM, Dhamanti I. Instrument for measuring patient safety culture: literature review. JMMR (Jurnal Medicoeticolegal dan Manaj Rumah Sakit). 2021;10(2):158–76.
- 50.Hare R, Tapia A, Tyler ER, Fan L, Ji S, Yount ND, et al. Surveys on Patient Safety CultureTM (SOPS®) Hospital Survey 2.0: 2022 User Database Report. [Internet]. 2022. Available from: www.ahrq.gov.
- 51.De Bienassis K, Klazinga N. Comparative assessment of patient safety culture performance in OECD countries: findings based on the Hospital Survey on Patient Safety Culture versions 1 and 2. 2024;(168). Available from: https://www.oecd.org/health/health-working-papers.htm.
- 52.Vikan M, Haugen AS, Bjørnnes AK, Valeberg BT, Deilkås ECT, Danielsen SO. The association between patient safety culture and adverse events – a scoping review. BMC Health Serv Res [Internet]. 2023;23(1):1–27. Available from: 10.1186/s12913-023-09332-8. [DOI] [PMC free article] [PubMed]
- 53.Clark G. Organisational culture and safety: an interdependent relationship. Aust Health Rev. 2002;25(6):181–9. [DOI] [PubMed] [Google Scholar]
- 54.Feeser VR, Jackson AK, Savage NM, Layng TA, Senn RK, Dhindsa HS, et al. When safety event reporting is seen as punitive: I’ve been PSN-ed! Ann Emerg Med [Internet]. 2021;77(4):449–58. Available from: 10.1016/j.annemergmed.2020.06.048. [DOI] [PubMed]
- 55.Paradiso L, Sweeney N. Just culture is more than a policy. Nurs Manage [Internet]. 2019;50(6):38–45. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6716556/pdf/numa-50-38.pdf. [DOI] [PMC free article] [PubMed]
- 56.Quillivan RR, Burlison JD, Browne EK, Scott SD, Hoffman JM. Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses. Jt Comm J Qual Patient Saf [Internet]. 2017;42(8):377–86. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC5333492/. [DOI] [PMC free article] [PubMed]
- 57.Mauti G, Githae M. Medical error reporting among physicians and nurses in Uganda. Afr Health Sci [Internet]. 2019;19(4):3107–17. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7040326/pdf/AFHS1904-3107.pdf. [DOI] [PMC free article] [PubMed]
- 58.World Health Organization. Towards eliminating avoidable harm health care: Global patient safety action plan 2021–2030[Internet]. 2021. p. 1689–1699. Available from: https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan.
- 59.Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture in health care. Heal Care Manag Rev. 2009;34(December):312–22. [DOI] [PubMed] [Google Scholar]
- 60.Weiser TG, Haynes AB. Ten years of the Surgical Safety Checklist. BJS [Internet]. 2018;927–9. Available from: https://pubmed.ncbi.nlm.nih.gov/29770959/. [DOI] [PMC free article] [PubMed]
- 61.Ndirangu-Mugo E. Psychological safety: nurses’ experiences and leadership roles in Sub-Saharan Africa. Nurse Lead [Internet]. 2024;23(1):82–6. Available from: 10.1016/j.mnl.2024.10.012.
- 62.Anicich EM, Swaab RI, Galinsky AD, Ndirangu-Mugo E. Hierarchical cultural values predict success and mortality in high-stakes teams. Proc Natl Acad Sci U S A [Internet]. 2015;112(5):1338–43. Available from: 10.1016/j.mnl.2024.10.012. [DOI] [PMC free article] [PubMed]
- 63.Fernandopulle N. To what extent does hierarchical leadership affect health care outcomes? Med J Islam Repub Iran [Internet]. 2021;35:1–4. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8683790/pdf/mjiri-35-117.pdf. [DOI] [PMC free article] [PubMed]
- 64.Reeves S, Pelone F, Harrison R, Goldman J, Zwarenstein M. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev [Internet]. 2017;2017(6). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6481564/pdf/CD000072.pdf. [DOI] [PMC free article] [PubMed]
- 65.Azevedo MJ. The state of health system(s) in Africa: challenges and opportunities [Internet]. Vol. II, African Histories and Modernities. 2017. p. 1–73. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7123888/pdf/978-3-319-32564-4_Chapter_1.pdf.
- 66.Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. [DOI] [PubMed] [Google Scholar]
- 67.Elmi AH, Abdi AO, Hassan RA. Surgical safety checklist implementation in a post-armed conflict country with limited resources: the Somali experience. Patient Saf Surg. 2025;19(22):1–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 68.Aquino L, Araújo D, Cunha Y, Santos V, Saraiva C, Martins Q. Strategies for promoting a culture of patient safety in the operating room: systematic review. J Nurs UFPE Online [Internet]. 2024; Available from: https://periodicos.ufpe.br/revistas/index.php/revistaenfermagem/article/view/257173.
- 69.Rarani SA. Smart technologies and digital innovations for improving perioperative patient safety: a review. Patient Saf Surg. 2025;19(31):1–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 70.Rarani SA. Viewing patient safety in surgery through the lens of a theatrical performance: a narrative review. Patient Saf Surg. 2025;19(23):1–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 71.Alidina S, Menon G, Staffa SJ, Alreja S, Barash D, Barringer E, et al. Outcomes of a multicomponent safe surgery intervention in tanzania’s lake zone: A prospective, longitudinal study. Int J Qual Heal Care. 2021;33(2):1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 72.World Health Organization. Global Patient Safety Report 2024 [Internet]. 2024. Available from: https://iris.who.int/bitstream/handle/10665/376928/9789240095458-eng.pdf.
- 73.Pourzamani M, Beigom M, Shamloo B, Rashidi N. Barriers to implementing the surgical safety checklist in operating rooms of educational hospitals of Dezful university of medical sciences: A qualitative study. Evid Based Care J. 2025;15(1):67–75. [Google Scholar]
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Data Availability Statement
All data analysed during this study are included in this published article and its supplementary information files.