Patient safety culture and reporting barriers among healthcare professionals in the United Arab Emirates: A cross-sectional study

Abstract

BACKGROUND:

To assess patient safety culture using the Hospital Survey on Patient Safety Culture (HSOPSC) and to examine associations between occupational characteristics, perceived incident-reporting barriers, and overall safety culture scores among healthcare professionals in the United Arab Emirates.

MATERIALS AND METHODS:

A cross-sectional survey was conducted between January and March 2023 among 629 healthcare professionals in the United Arab Emirates, including physicians, nurses, and allied health professionals, using convenience sampling. Participants completed a sociodemographic and work characteristics questionnaire alongside the HSOPSC. Item-level positive response rates were calculated, and overall HSOPSC mean scores were compared across occupational characteristics and reporting-barrier frequency categories using t-tests and analysis of variance (two-sided; P < 0.05).

RESULTS:

Reporting of near-miss events was limited (40.1%), despite high levels of perceived interpersonal respect (84.2%). Respondents reporting barriers seldom demonstrated significantly higher patient safety culture scores across the majority of barrier domains (P < 0.05).

CONCLUSION:

Targeted system-level interventions, including simplification of reporting processes, strengthening nonpunitive culture, and improving feedback mechanisms, are recommended to enhance reporting and patient safety outcomes.

Introduction

Patient safety remains a fundamental component of healthcare quality and a major global concern. The landmark report by the Institute of Medicine in 1999 highlighted the scale of the problem, estimating that between 44,000 and 98,000 deaths occur annually in the United States as a result of preventable medical errors.[1] Subsequent evidence has reinforced the magnitude of this issue. The World Health Organization has reported that approximately 10% of hospitalized patients in Europe experience avoidable harm related to medical care,[2,3] while other studies have estimated that around 7.5% of healthcare encounters involve medical errors, the majority of which are preventable.[3,4] The challenges of achieving safe health care have been recognized over the past few decades after repeated reports of adverse events for patient safety.[5,6,7] The necessity of forming a patient safety culture has been taken into consideration because the examination of the weakness in patient safety has shown that the patient safety culture is an important factor in unpleasant events.[8] Safety culture is a subset of organizational culture and refers to how patient safety is viewed and implemented by members of an organization.[9]

Patient safety culture refers to shared values, attitudes, perceptions, and behaviors that determine how safety is prioritized and operationalized within an organization.[4,10] Another definition has defined patient safety culture as “as the product of individual and grouP values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s safety management.[11]” The results of the studies have shown that when there is a positive patient safety culture, it leads to an increase in patient safety and helps to improve patient safety standards.[12,13,14]

The evaluation of hospital safety culture started to be used as a measurement tool and was encouraged by health professionals and health policy makers in the world.[15] In 2000, assessment tools were developed to measure organizational safety culture.[15] The Hospital Survey on Patient Safety Culture (HSOPSC) developed by Agency for Healthcare Research and Quality (AHRQ).[15] It measures patient safety culture among hospital staff whose work directly or indirectly influences patient care.[16] This tool has been translated and used in many languages.[17,18,19,20,21] This tool for measuring patient safety culture has been used in extensive studies and has a satisfactorily in psychometric analyses.[22,23,24] This tool has been used by hundreds of hospitals, and until 2015, more than 60 countries have published studies using this tool.[15,25,26,27] However, safety culture scores can be misleading when interpreted without understanding the organizational frictions that shape incident reporting behavior. High interpersonal respect and teamwork may coexist with under-reporting of near-miss and no-harm events if reporting is perceived as time-consuming, punitive, futile, or hierarchically unsafe. Quantifying reporting barriers alongside HSOPSC outcomes provides a more actionable systems-level diagnosis for policy and quality improvement than culture measurement alone.

Patient safety culture is a critical determinant of healthcare quality, with safer organizational cultures associated with reduced clinical risk and improved patient outcomes.[28,29] Evidence from systematic reviews indicates that deficiencies in patient safety are often rooted in organizational culture rather than individual performance, highlighting the need for system-level interventions.[30] In particular, fostering a culture that encourages transparent reporting of errors and learning from adverse events has been identified as a key priority for healthcare institutions.[30]

While the HSOPSC has been widely applied across diverse healthcare settings globally, including in parts of the Middle East, evidence from the United Arab Emirates remains limited and largely descriptive, with little attention to the underlying factors influencing reporting behavior. In particular, few studies have examined how organizational and psychological barriers interact with safety culture domains to shape incident reporting practices. This relationship can be understood within organizational safety and psychological safety frameworks, where individual reporting behavior is influenced by leadership practices, hierarchical structures, and perceived consequences of speaking up.[31] In such contexts, reporting barriers are not merely operational constraints but reflect deeper features of organizational climate and trust.

Building on this conceptual perspective, the present study aimed to (i) describe HSOPSC item-level strengths and vulnerabilities among healthcare professionals in the UAE, and (ii) examine the association between occupational characteristics, perceived incident-reporting barriers, and overall patient safety culture scores. By integrating a validated safety culture instrument with a structured assessment of reporting barriers across multiple professional groups, this study moves beyond descriptive evaluation to provide a more comprehensive analysis of the organizational determinants of patient safety culture in the UAE healthcare context.

Materials and Method

Study design and setting

The study was reported in accordance with strengthening the reporting of observational studies in epidemiology guidelines for cross-sectional studies.[32]

Study participants and sampling

The study involved 629 healthcare professionals from the United Arab Emirates, selected through convenience sampling. Data were collected between January and March 2023. Participants included physicians, nurses, and allied health professionals working or training in UAE healthcare settings, including interns and residents where applicable. Administrative and nonclinical staff were excluded.

Data collection tools and technique

The survey utilized a two-part questionnaire. The first part captured sociodemographic and work-related characteristics. The second part employed the HSOPSC, developed by the AHRQ, which assesses multiple dimensions of patient safety culture among healthcare professionals whose work directly or indirectly influences patient care.

Ethical considerations

This study was conducted in accordance with the ethical guidelines outlined in the Declaration of Helsinki, receiving approval from the Social Sciences Research Ethics Committee of the United Arab Emirates University (Approval number ERS_2020_7224). Informed consent was obtained from all participants, who were assured of their anonymity and informed of the study’s objectives and procedures before participation. Participants were informed of their right to withdraw at any time. Data were anonymized and stored securely with restricted access. No financial or nonfinancial incentives were offered for participation in the study.

Statistical analysis

Data analysis began with assessing the normal distribution of data. Using SPSS 21 (IBM, USA), we conducted descriptive statistics to summarize the demographic characteristics and employment status of the participants. Inferential statistical methods, including t-tests and ANOVA, were applied to examine differences in HSOPSC patient safety culture scores, focusing on demographic variables and perceived barriers to reporting safety events. A significant level of P < 0.05 was adopted for all statistical tests.

Results

Participant characteristics

A total of 629 healthcare professionals participated in the study. Demographic and work-related characteristics are shown in Table 1. Most respondents were female (72.5%, n = 456) and aged between 20 and 30 years (93.8%, n = 590), indicating a predominantly early-career workforce. Over half of participants had less than one year of professional experience (53.9%, n = 339), while 66.9% (n = 421) reported 1–5 years of hospital experience. The majority had been working in their current unit for less than one year (69.6%, n = 438). Most respondents reported working 40–59 hours per week (50.2%, n = 316).

Table 1.

Demographic and work-related characteristics of the participants

Variable		Frequency		%
Gender
Female		451		72.50%
Male		175		27.80%
Age (years)
20–25		331		52.60%
26–30		259		41.20%
31–35		30		4.80%
36–40		6		1.00%
>40		3		0.50%
Professional work experience (years)
<1		339		53.90%
1–5		266		42.30%
6–20		24		3.8
Hospital experience (years)
<1		186		29.60%
1–5		421		66.90%
≥6		22		3.50%
Work in the same unit experience (years)
<1		438		69.60%
1–5		178		28.30%
6–20		13		2.10%
Working hours per week
<20		66		10.50%
20–39		178		28.30%
40–59		316		50.20%
60–79		51		8.10%
≥80 hours		18		2.90%

Item-level patient safety culture

Item-level results from the HSOPSC are shown in Table 2. Overall, a clear divergence was observed between interpersonal aspects of safety culture and reporting-related dimensions. Items reflecting teamwork and mutual respect within units received the highest positive response rates, including “people treat each other with respect” (84.2%) and “we work together as a team when work needs to be done quickly” (81.3%). In contrast, several items related to staffing, workload, and nonpunitive response to error demonstrated low positive response rates. Only 45.0% of respondents agreed that there were enough staff to handle the workload, while 28.4% reported that staff felt their mistakes were held against them. In summary, interpersonal and teamwork dimensions demonstrated consistently high positive response rates, whereas domains related to staffing adequacy, workload, and nonpunitive response to error scored substantially lower. This divergence indicates a safety culture characterized by strong relational cohesion but weaker structural support for safe practice and learning.

Table 2.

Means, standard deviation, and the percentage of positive responses to hospital survey on patient safety culture**

Survey questions/statements				Mean (±SD)		% of positive
Your work area/unit (continued)
1		People support one another in this unit		4.19 (±0.86)		79.5%
2		We have enough staff to handle the workload		3.31 (±1.16)		45.0%
3		When a lot of work needs to be done quickly, we work together as a team to get the work done		4.18 (±0.87)		81.3%
4		In this unit, people treat each other with respect		4.28 (±0.81)		84.2%
5		Staff in this unit work longer hours than is best for patient care*		2.27 (±1)		10.0%
6		We are actively doing things to improve patient safety		4.14 (±0.86)		77.8%
7		We use more temporary staff than is best for patient care*		2.91 (±1.11)		29.4%
8		Staff feel like their mistakes are held against them*		2.86 (±1.14)		28.4%
9		Mistakes have led to positive changes here		3.73 (±0.92)		59.9%
10		It is just by chance that more serious mistakes don’t happen around here*		3.13 (±1.14)		37.5%
11		When one area in this unit gets really busy, others help out		3.84 (±1.05)		65.6%
12		When an event is reported, it feels like the person is being written up, not the problem*		2.83 (±1.1)		26.7%
13		After we make changes to improve patient safety, we evaluate their effectiveness		3.89 (±0.91)		66.2%
14		We work in “crisis mode” trying to do too much, too quickly*		2.48 (±1.07)		17.8%
15		Patient safety is never sacrificed to get more work done		3.93 (±1.02)		65.2%
16		Staff worry that mistakes they make may be kept in their personnel file*		2.41 (±1.05)		13.6%
17		We have patient safety problems in this unit*		3.19 (±1.14)		41.5%
18		Our procedures and systems are good at preventing errors from happening		3.71 (±0.93)		61.3%
Your supervisor/manager
19		My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures		4.02 (±0.92)		73.3%
20		My supervisor/manager seriously considers staff suggestions for improving patient safety		3.99 (±0.91)		71.2%
21		Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts*		3.16 (±1.10)		39.9%
22		My supervisor/manager overlooks patient safety problems that happen over and over*		3.22 (±1.21)		41.6%
Communications
23		We are given feedback about changes put into place based on event reports		3.63 (±0.97)		52.8%
24		Staff will freely speak up if they see something that may negatively affect patient care		3.9 (±0.93)		69.0%
25		We are informed about errors that happen in this unit		3.66 (±1.01)		57.9%
26		Staff feel free to question the decisions or actions of those with more authority		3.44 (±1.05)		48.2%
27		In this unit, we discuss ways to prevent errors from happening again		3.89 (±0.94)		66.8%
28		Staff are afraid to ask questions when something does not seem right*		3.31 (±1.18)		45.8%
Frequency of events reported
29		When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?		3.31 (±1.01)		40.8%
30		When a mistake is made, but has no potential to harm the patient, how often is this reported?		3.3 (±1.03)		40.1%
31		When a mistake is made that could harm the patient, but does not, how often is this reported?		3.45 (±1.00)		46.7%
Your hospital
32		Hospital management provides a work climate that promotes patient safety		3.85 (±0.96)		64.1%
33		Hospital units do not coordinate well with each other*		3.37 (±1.11)		47.2%
34		Things “fall between the cracks” when transferring patients from one unit to another*		3.17 (±1.08)		37.9%
35		There is good cooperation among hospital units that need to work together		3.77 (±0.93)		59.2%
36		Important patient care information is often lost during shift changes*		3.41 (±1.16)		49.5%
37		It is often unpleasant to work with staff from other hospital units*		3.58 (±1.14)		54.4%
38		Problems often occur in the exchange of information across hospital units*		3.09 (±1.07)		34.2%
39		The actions of hospital management show that patient safety is a top priority		3.99 (±0.95)		71.1%
40		Hospital management seems interested in patient safety only after an adverse event happens*		3.16 (±1.17)		41.1%
41		Hospital units work well together to provide the best care for patients		4.04 (±0.89)		72.4%
42		Shift changes are problematic for patients in this hospital/clinic*		3.31 (±1.12)		43.8%
Number of events reported
43		In the past 12 months, how many event reports have you filled out and submitted?
Event class		0		3–5		6–10
Reported event		387		56		8.00

*Reverse items (% disagree or strongly disagree; never or rarely were reported). **Higher scores indicated more affirmative responses

Incident reporting remained limited across all event types, with fewer than half of respondents indicating routine reporting of near-miss or no-harm events [Table 2]. More than 60% reported submitting no incident reports in the preceding 12 months, highlighting a substantial gap between perceived safety norms and reporting behavior.

Differences in safety culture by working conditions

Comparisons of overall HSOPSC mean scores by work-related characteristics are shown in Table 3. Differences by professional work experience were not statistically significant across most comparisons (all P > 0.05). Similarly, comparisons involving longer hospital experience (≥6 years) did not demonstrate significant differences in safety culture scores.

Table 3.

Comparison results of HSOPSC according to working conditions

Work-related characteristic		n		Mean (±SD)		Reference		Mean difference (95% CI)		P
Professional work experience (years)
<1		339		3.47 (±0.49)		1–5		–0.04 (–0.13,0.06)		0.644
						6–20		–0.10 (–0.35,0.15)		0.638
1–5		266		3.5 (±0.52)		6–20		–0.06 (–0.31,0.19)		0.846
6–20		24		3.56 (±0.37)
Hospital experience (years)
<1		186		3.41 (±0.48)		1–5		–0.10 (–0.21,0.00)		0.047
						6–20		–0.08 (–0.34,0.19)		0.761
1–5		421		3.52 (±0.52)		6–20		0.03 (–0.23,0.28)		0.971
6–20		22		3.49 (±0.37)
Work in the same unit experience (years)
<1		438		3.45 (±0.49)		1–5		–0.13 (–0.24,–0.03)		0.007
						6–20		–0.10 (–0.43,0.23)		0.773
1–5		178		3.58 (±0.52)		6–20		0.04 (–0.30,0.37)		0.963
6–20		13		3.54 (±0.38)
Working hours per week
<20		66		3.4 (±0.57)		>80		–0.14 (–0.50,0.22)		0.838
						20–39		0.01 (–0.19,0.2)		1.000
						40–59		–0.17 (–0.35,0.02)		0.094
						60–79		–0.02 (–0.27,0.24)		1.000
>80		18		3.54 (±0.59)		20–39		0.15 (–0.19,0.48)		0.763
						40–59		–0.03 (–0.36,0.30)		0.999
						60–79		0.12 (–0.25,0.49)		0.905
20–39		178		3.39 (±0.47)		40–59		–0.18 (–0.3,–0.05)		0.002
						60–79		–0.03 (–0.24,0.19)		0.998
40–59		316		3.57 (±0.48)		60–79		0.15 (–0.06,0.36)		0.267
60–79		51		3.42 (±0.55)

CI=Confidence interval; HSOPSC=Hospital Survey on Patient Safety Culture; SD=Standard deviation

In contrast, hospital experience and time working in the same unit were associated with modest but statistically significant differences. Respondents with 1–5 years of hospital experience reported slightly higher safety culture scores than those with less than one year (mean difference = −0.10; 95% confidence interval (CI) = −0.21 to 0.00; P = 0.047). Likewise, respondents with 1–5 years in the same unit had higher mean scores than those with less than one year (mean difference = −0.13; 95% CI = −0.24 to −0.03; P = 0.007).

Working hours per week were also associated with differences in safety culture perceptions. Respondents working 40–59 hours per week reported higher mean HSOPSC scores than those working 20–39 hours (mean difference = −0.18; 95% CI = −0.30 to − 0.05; P = 0.002). Other comparisons across working-hour categories were not statistically significant.

Table 3 shows modest differences in HSOPSC mean scores across experience categories, with statistically significant differences observed for selected comparisons, while most comparisons were not significant.

Reporting barriers and patient safety culture

Associations between perceived reporting barriers and HSOPSC scores are shown in Table 4. Across all barrier domains, a consistent and graded relationship was observed, with lower perceived barriers associated with significantly higher patient safety culture scores. Respondents who were seldom unsure how to submit a report reported substantially higher HSOPSC scores compared with those unsure most of the time (mean difference = −0.43; 95% CI − 0.62 to − 0.24; P < 0.001). Similar patterns were observed for uncertainty about what constitutes a patient safety event (mean difference = −0.46; P < 0.001) and time required to submit a report (mean difference = −0.44; P < 0.001).

Table 4.

Comparison HSOPSC based on barriers to reporting safety

Variable		n		Mean (±SD)		Reference		Mean difference (95% CI)		P
Unsure how to submit a report
Most of the time		53		3.26 (±0.46)		Often		–0.04 (–0.25,0.17)		0.960
						Seldom		–0.43 (–0.62,–0.24)		<0.001
						Sometimes		–0.16 (–0.34,0.03)		0.129
Often		103		3.3 (±0.44)		Seldom		–0.39 (–0.53,–0.24)		<0.001
						Sometimes		–0.12 (–0.26,0.03)		0.154
Seldom		230		3.69 (±0.52)		Sometimes		0.27 (0.16,0.38)		<0.001
Sometimes		243		3.42 (±0.45)
Time it takes to submit an event report
Most of the time		41		3.33 (±0.56)		Often		0.08 (–0.14,0.3)		0.773
						Seldom		–0.44 (–0.64,–0.23)		<0.001
						Sometimes		–0.11 (–0.31,0.09)		0.465
Often		129		3.25 (±0.4)		Seldom		–0.52 (–0.65,–0.38)		<0.001
						Sometimes		–0.19 (–0.32,–0.07)		0.001
Seldom		182		3.76 (±0.53)		Sometimes		0.32 (0.21,0.44)		<0.001
Sometimes		277		3.44 (±0.44)
Unsure of what is considered a patient safety event
Most of the time		39		3.23 (±0.48)		Often		–0.09 (–0.32,0.14)		0.734
						Seldom		–0.46 (–0.67,–0.25)		<0.001
						Sometimes		–0.15 (–0.36,0.06)		0.280
Often		106		3.32 (±0.37)		Seldom		–0.37 (–0.51,–0.23)		<0.001
						Sometimes		–0.06 (–0.2,0.09)		0.749
Seldom		254		3.69 (±0.52)		Sometimes		0.31 (0.2,0.43)		<0.001
Sometimes		230		3.38 (±0.46)
Fear of retribution to self
Most of the time		42		3.17 (±0.51)		Often		–0.06 (–0.28,0.16)		0.878
						Seldom		–0.53 (–0.73,–0.33)		<0.001
						Sometimes		–0.29 (–0.49,–0.08)		0.002
Often		109		3.23 (±0.39)		Seldom		–0.47 (–0.61,–0.33)		<0.001
						Sometimes		–0.22 (–0.36,–0.08)		<0.001
Seldom		239		3.7 (±0.51)		Sometimes		0.25 (0.14,0.36)		<0.001
Sometimes		239		3.45 (±0.45)
Fear of retribution to others
Most of the time		44		3.23 (±0.5)		Often		–0.12 (–0.34,0.1)		0.521
						Seldom		–0.47 (–0.67,–0.26)		<0.001
						Sometimes		–0.18 (–0.38,0.02)		0.083
Often		112		3.35 (±0.41)		Seldom		–0.35 (–0.5,–0.21)		<0.001
						Sometimes		–0.07 (–0.21,0.07)		0.582
Seldom		204		3.7 (±0.52)		Sometimes		0.28 (0.17,0.4)		<0.001
Sometimes		269		3.42 (±0.47)
Fear of violating hierarchy
Most of the time		58		3.14 (±0.53)		Often		–0.2 (–0.39,0)		0.043
						Seldom		–0.58 (–0.76,–0.4)		<0.001
						Sometimes		–0.32 (–0.49,–0.14)		<0.001
Often		119		3.34 (±0.43)		Seldom		–0.38 (–0.52,–0.24)		<0.001
						Sometimes		–0.12 (–0.25,0.01)		0.101
Seldom		194		3.72 (±0.51)		Sometimes		0.26 (0.15,0.38)		<0.001
Sometimes		258		3.46 (±0.44)
Lack of perceived change due to submitting a patient safety event
Most of the time		37		3.06 (±0.52)		Often		–0.24 (–0.47,–0.02)		0.028
						Seldom		–0.67 (–0.88,–0.46)		<0.001
						Sometimes		–0.39 (–0.6,–0.18)		<0.001
Often		125		3.3 (±0.39)		Seldom		–0.43 (–0.56,–0.29)		<0.001
						Sometimes		–0.15 (–0.28,–0.02)		0.020
Seldom		203		3.73 (±0.52)		Sometimes		0.28 (0.17,0.39)		<0.001
Sometimes		264		3.45 (±0.44)
Medical error is seen as a sign of incompetence
Most of the time		54		3.18 (±0.51)		Often		–0.13 (–0.33,0.06)		0.303
						Seldom		–0.55 (–0.74,–0.37)		<0.001
						Sometimes		–0.24 (–0.42,–0.06)		0.004
Often		116		3.31 (±0.4)		Seldom		–0.42 (–0.56,–0.28)		<0.001
						Sometimes		–0.11 (–0.24,0.03)		0.181
Seldom		216		3.73 (±0.48)		Sometimes		0.31 (0.2,0.43)		<0.001
Sometimes		243		3.42 (±0.47)
Increased scrutiny threatens medical autonomy
Most of the time		35		3.06 (±0.57)		Often		–0.21 (–0.44,0.02)		0.094
						Seldom		–0.65 (–0.87,–0.43)		<0.001
						Sometimes		–0.38 (–0.59,–0.16)		<0.001
Often		115		3.27 (±0.37)		Seldom		–0.44 (–0.58,–0.31)		<0.001
						Sometimes		–0.17 (–0.3,–0.03)		0.007
Seldom		227		3.71 (±0.52)		Sometimes		0.27 (0.17,0.38)		<0.001
Sometimes		252		3.44 (±0.43)

CI=Confidence interval; HSOPSC=Hospital Survey on Patient Safety Culture; SD=Standard deviation

Perceived fear of retribution was strongly associated with safety culture perceptions. Respondents who seldom feared retribution to themselves reported significantly higher HSOPSC scores than those who feared retribution most of the time (mean difference = −0.53; P < 0.001). Comparable findings were observed for fear of retribution toward others (mean difference = −0.47; P < 0.001).

Barriers related to hierarchy, medical autonomy, and perceived consequences of reporting also demonstrated strong associations. Respondents who seldom feared violating hierarchy had higher safety culture scores than those who feared this most of the time (mean difference = −0.58; P < 0.001). Similarly, perceptions that increased scrutiny threatens medical autonomy (mean difference = −0.65; P < 0.001), that medical error signifies incompetence (mean difference = −0.55; P < 0.001), and that reporting does not lead to meaningful change (mean difference = −0.67; P < 0.001) were all associated with significantly lower HSOPSC scores. These findings should be interpreted as associative rather than causal. These results indicate that while interpersonal respect and teamwork are perceived positively, incident reporting remains limited. Perceived organizational and psychological barriers, including procedural uncertainty, time constraints, fear of retribution, hierarchical concerns, and lack of visible change following reporting, show the strongest and most consistent associations with overall patient safety culture, exceeding the influence of demographic or professional characteristics.

Discussion

The current study examined patient safety culture using HSOPSC and demonstrates that perceived barriers to incident reporting are closely linked to safety culture performance. Within the United Arab Emirates, where published data on patient safety culture remain limited and are predominantly descriptive, this study provides a more integrated analysis by examining reporting barriers alongside HSOPSC domains across multiple professional groups. The findings indicate that although interpersonal dimensions, such as teamwork and mutual respect, were rated highly, reporting of near-miss and no-harm events was low, with many participants indicating that no incidents had been reported in the preceding year. This suggests a gap between perceived safety culture and actual reporting behavior.

This divergence between relational culture and reporting behavior has been described in prior HSOPSC-based research, where teamwork and organizational learning often score highly while nonpunitive response to error and reporting frequency remain weaker. Studies from diverse healthcare settings, including sub-Saharan Africa and Latin America, report similar patterns, indicating that positive perceptions of teamwork do not necessarily translate into effective reporting or organizational learning.[33,34] However, most of these studies are descriptive. The present findings extend this literature by demonstrating that perceived reporting barriers are consistently associated with lower safety culture scores, suggesting that these barriers are not peripheral but central to the functioning of safety culture.

The barriers identified in this study, including fear of retribution, hierarchical constraints, uncertainty about reporting processes, and lack of feedback, are consistent with those identified in recent systematic reviews and qualitative studies.[35,36] These barriers appear to operate through mechanisms related to psychological safety and organizational trust. In settings where staff anticipate negative consequences or perceive reporting as unlikely to lead to change, reporting behavior may be suppressed even when teamwork and interpersonal relations are strong. This interpretation is supported by recent work emphasizing the role of leadership behavior and psychological safety in shaping reporting practices.[37]

At the same time, the relationship between safety culture and reporting behavior is not straightforward. Increased reporting may reflect improved awareness rather than increased incidence of errors, and reporting patterns may evolve as systems mature. In this study, the low reporting of near-miss events may indicate under-reporting, limited engagement with reporting systems, or both. Without qualitative data or objective reporting measures, these possibilities cannot be distinguished. This highlights a limitation of relying solely on survey-based assessments and reinforces the need to interpret safety culture scores alongside behavioral indicators.

The findings also have implications for how safety culture is assessed and interpreted. High scores in teamwork and mutual respect may give an impression of a positive safety culture, yet may not capture whether organizations are effectively identifying and learning from errors. Previous work has cautioned against interpreting safety climate measures as direct indicators of safety performance, particularly in the absence of effective reporting and learning systems.[38] The present findings support this view, suggesting that relational and structural components of safety culture may develop at different rates.

Several limitations should be considered. The use of convenience sampling limits the generalizability of the findings, and the recruitment process was not fully characterized. The sample was predominantly composed of early-career healthcare professionals, which may influence perceptions of hierarchy and reporting behavior. The analysis was based on bivariate comparisons, and the absence of multivariable modelling limits the ability to control for confounding variables. The cross-sectional design precludes causal inference, and reverse relationships cannot be excluded. In addition, reporting barriers were measured as perceived constructs, and the absence of qualitative data limits insight into the underlying reasons for these perceptions.

Despite these limitations, the study has several strengths. It provides one of the few analyses in the UAE that combines a validated safety culture instrument with a structured assessment of reporting barriers across different professional groups. This approach offers a more comprehensive understanding of safety culture than studies focusing solely on descriptive scores. It also identifies specific organizational factors that may be amenable to intervention.

From a practical perspective, the findings suggest that improving reporting behavior requires attention to organizational systems and not only individual awareness. Interventions that address nonpunitive responses to error, clarify reporting processes, and ensure timely feedback are likely to be more effective than education alone. Evidence from recent systematic reviews supports the importance of leadership engagement, psychological safety, and structured reporting systems in improving reporting behavior and patient safety outcomes.[36]

At a policy level, the findings suggest that safety culture assessments should incorporate both attitudinal and behavioral measures, including reporting activity and perceived barriers. Without addressing these factors, improvements in safety culture scores may not translate into meaningful improvements in patient safety.

Future research should include qualitative approaches to explore the reasons underlying reporting behavior and longitudinal designs to assess changes over time. Studies incorporating multivariable analysis and more representative samples would strengthen the evidence base and improve understanding of the relationship between reporting barriers and safety culture.

Conclusion

This study shows that positive perceptions of teamwork and mutual respect can coexist with low levels of incident reporting when organizational and psychological barriers are present. Addressing these barriers is essential to improving reporting systems and supporting organizational learning. Without system-level changes that promote nonpunitive reporting and effective feedback, improvements in safety culture may remain limited to perceptions rather than resulting in safer care.

AI use statement

No artificial intelligence tools were used in the design, data collection, or analysis of this study. Language editing assistance tools were used to improve clarity, and the authors take full responsibility for the content of the manuscript.

Abbreviations

HSOPSC: Hospital Survey on Patient Safety Culture; AHRQ: Agency for Healthcare Research and Quality; UAE: United Arab Emirates; HCP: Healthcare professionals; SD: Standard deviation; CI: Confidence interval; ANOVA: Analysis of variance; SPSS: Statistical Package for the Social Sciences.

Ethics approval and consent to participate

Ethical approval for this study was obtained from the relevant institutional ethics review board (Study ID: ERS_2020_7224). All participants were informed about the purpose of the study and their right to withdraw at any stage. Informed consent was obtained before participation. All data were anonymized and handled confidentially with restricted access.

Author’s contributions

AMA: Conceptualization, study design, data collection, data management, data interpretation, manuscript drafting, and final approval of the manuscript. SAT: Literature review, manuscript review, and final approval of the manuscript. FA: Literature review, manuscript drafting, and final approval of the manuscript. MSOAF: Data verification, manuscript review, and final approval of the manuscript. MAAA: Data verification, manuscript review, and final approval of the manuscript. LA: Literature review, manuscript review, and final approval of the manuscript. MHA: Data verification, manuscript review, and final approval of the manuscript. HMA: Literature review, manuscript review, and final approval of the manuscript. SA: Methodology, statistical analysis, interpretation of findings, critical revision of the manuscript for important intellectual content, and final approval of the manuscript. MAK: Conceptualization, study design, data collection, supervision, interpretation of findings, manuscript drafting and critical revision, project administration, corresponding author responsibilities, and final approval of the manuscript. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.

Data availability statement

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflict of interest

The authors declare that they have no competing interests.

Funding Statement

The authors received no specific funding for this work.