What are patients’ perceptions of their safety within an acute hospital setting? A study to inform the development of a measurement questionnaire.


The literature on patient safety is extensive and improvements in patient safety have focused on the development of healthcare staff, and organizational systems. Approaches to safety improvements have been driven by empirical studies focusing on healthcare staff development, and organizational improvements for example, analysing adverse events and introducing early warning scores for deteriorating patients.  Traditionally, tools used to measure safety have focused on understanding safety climate and safety culture from the healthcare professional perspective.  However, few studies have concentrated on patients’ experiences and their perceptions of safety and there are few validated tools to measure patient perceptions of safe/unsafe care.  Consequently, little is known about how patients decide if they are safe, and how their views and experiences can influence and drive safety improvements.   This study seeks to understand safety in the way in which patients’ view and experience safety.


To explore what patients understand by being safe, and how they experience safety within an acute hospital setting.  The information will be used to pilot test a questionnaire to validate key themes and refine the tool.  The tool will be used in a further research study of safety, which has involved three phases, of which this pilot (Phase 2) is part of.  The phases are outlined as follows;

  1. Undertake a critical review of the literature that will inform the topics to be examined in the tool (Phase 1).
  2. Pilot survey tool with patients to validate key themes and refine patient safety measurement questionnaire (PSMQ) (Phase 2).
  3. Conduct a cross sectional study on the patient safety measurement questionnaire (PSMQ) (Phase 3)

Aims of pilot study

The aim of the pilot study was to test the face and content validity the pre-designed questionnaire, in preparation for its application in a cross-sectional study in phase 3.

  1. Assessing the feasibility of applying the questionnaire to patients.
  2. Identifying potential sources of response errors in the questionnaire.
  3. Modifying the questionnaire as necessary.


There are differences between patients’ perceptions of their safety based on their ethnic background, mode of admission, age, sex and whether they have family support during their hospital stay.

Theoretical approach

Rathert et al (2011) used Attribution Theory to examine how patients perceived and experienced safety, illustrating that patients interpret threats to their safety differently to healthcare professionals.  The theoretical approach underpinning this study was based on Attribution Theory.  Attribution Theory is concerned with how people understand, predict and control their environments (Taylor 1984) and was therefore an appropriate framework to help direct the study from the patients’ perspective.


This was a pilot study of a questionnaire, which was conducted across five medical wards within a large acute inner London Teaching Hospital serving a diverse patient population.  Therefore a purposeful sampling technique was used to capture participants who represented this group (Bowling A 2009, Green & Thorogood 2011, Punch 2012).  Ten patients participated in the pilot study over a period of three weeks.  Patients were given the questionnaire to complete and were then interviewed by the researcher.  Cognitive interviews using verbal probing technique was used to seek feedback from patients in the design, layout and readability of the questionnaire, to test the content and face validity of the tool.


Conducting cognitive interviews with patients using the verbal probing technique proved effective in identifying problems that the researcher had not considered.  For example, patients asked whether the questionnaire should be answered based on their perceptions of previous hospital admissions and on specific departments or across their whole pathway of care during their current hospital stay.  The instructions for completing the questionnaire were changed to:

“Please remember, this questionnaire is about your most recent stay at the hospital.”

The question asking patients to rate whether there were always enough staff was changed to;

“There were always enough staff in the department I visited”

The study results therefore were valuable, indicating how the pre-designed questionnaire might be improved.  Overall, patients said the layout of the questionnaire was easy to follow.  They stated the questions were relevant to their safety, although some questions required re-wording to ensure clarity of interpretation. These comments suggest the questionnaire had good face and content validity.

Key words: attribution theory, patient safety, safety climate, safety culture, cognitive interviews, verbal probing; face validity; content validity, questionnaire design.

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