Nurse Education in Practice 53 (2021) 103089

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

Patient safety: Knowledge and attitudes of medical and nursing students:

Cross-sectional study
Branislava Brestovački Svitlica a, *, 1, Maja Šajnović b, Dragana Simin c, 2, Jelena Ivetić d,
Dragana Milutinović c, 3
a
University of Novi Sad, Medical Faculty, Department of Nursing, Institute for Child and Youth Health Care of Vojvodina, Hajduk Veljkova 3, Novi Sad 21000, Serbia
b
Münchenstift Haus St Josef, Luise-Kiesselbach-Platz 2, München 81669, Germany
c
University of Novi Sad, Medical Faculty, Department of Nursing, Hajduk Veljkova 3, Novi Sad 21000, Serbia
d
University of Novi Sad, Faculty of Technical Sciences, Trg Dositeja Obradovića 6, Novi Sad 21000, Serbia

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: The objective of this study to research medical and nursing students’ level of knowledge of patient safety.
Patient safety curriculum Background: Patient safety represents the foundation of health care quality, while education represents a
Nursing education requirement which has to be fulfilled to achieve and maintain that quality.
Medicine education
Design: The research was conducted as a descriptive/analytical cross-sectional survey, with medical and nursing
Knowledge
students being the sample (n = 370).
Methods: The research instrument was the WHO questionnaire “What is Patient Safety? “, which displayed good
psychometric characteristics.
Results: The research results indicate that the study department has a significant influence on the level of stu­
dents’ knowledge and attitudes to patient safety. Nursing students in their final academic year show statistically
significantly higher level of knowledge in relation to the first year students. Medical students are not significantly
different, in terms of the level of knowledge and attitudes, in their first and final academic years.
Conclusions: Knowledge and attitudes regarding patient safety shown by the students in this survey significantly
contribute to the comprehension of the necessity of the implementation and development of patient safety course
into the existing curricula and syllabi of all colleges and universities related to health care.

1. Introduction
Recently patient safety problem has become one of the major issues
in the creation of national health care policies around the world. In the
publication, ’To Err is Human: Building a safer health system’ published
through the Institute of Medicine (IOM), it was stated that education
reforms and the introduction of the patient safety course into curricula
for all healthcare students are necessary (Kohn et al., 2000).
2. Background
Patient safety improvement has to begin with students’ education
(Leape et al., 2009; Cantero-López et al., 2021). In this respect the key
turning point was the publication World Health Organisation (WHO)
“Patient safety curriculum Guide for Medical Schools” (WHO, 2009), based
on the Australian National Patient Safety Education Framework (Austra­
lian Council on Safety and Quality in Health Care, 2005). Future health
professionals are expected to, apart from gaining expert and scientific
knowledge, accomplish specific competence, to be able to respond to
patients needs in the contemporary society (Kirwan et al., 2019). Stu­
dents need specific knowledge, skills and attitudes to the concept of
patient safety, such as the causes of adverse events occurrence (system
and individual), error prevention (check lists and bar codes), error an­
alyses and system improvement (analysis of causes), safety culture (open

* Corresponding author.
E-mail addresses: branislava.brestovacki@mf.uns.ac.rs (B.B. Svitlica), maja.sajnovic@mf.uns.ac.rs (M. Šajnović), dragana.simin@mf.uns.ac.rs (D. Simin),
jelenaivetic@uns.ac.rs (J. Ivetić), dragana.milutinovic@mf.uns.ac.rs (D. Milutinović).
1
ORCID861
2
ORCID94X
3
ORCID43X

https://doi.org/10.1016/j.nepr.2021.103089
Received 18 February 2021; Received in revised form 12 May 2021; Accepted 13 May 2021
Available online 18 May 2021
1471-5953/© 2021 Elsevier Ltd. All rights reserved.
B.B. Svitlica et al.
communication and error reporting systems) and policy of impunity
(ElAraby et al., 2018; Kong et al., 2019; Usher et al., 2017). Besides, the
skills identified as essential are patient care, communication, teamwork
and cooperation, practice based on evidence, critical thinking and
application of information technologies (Mansour et al., 2018; Wu and
Busch, 2019).
Walton et al. (2010) claim that students awareness of errors occur­
rence is not enough. They also need to learn how to integrate the concept
of patient safety into clinical practice (Murray et al., 2019). Likewise,
future health care professionals have to be aware that patient safety does
not only depend on the skills of individuals, but on a large number of
system factors (ElAraby et al., 2018). They have to know how the
healthcare system functions and how it can influence the quality and
safety of health protection (Gandhi et al., 2018). Future health pro­
fessionals’ education on patient safety was acknowledged as crucially
important for providing quality and safe health care (Kiesewetter et al.,
2018).
The aim of The WHO World Alliance for Patient Safety is the imple­
mentation of the patient safety course into curricula around the world to
teach medical and nursing students how to manage risks (Wu and Busch,
2019). A group of international experts conducted the evaluation of the
implementation of Curriculum Guide in nine countries which are the
members of the WHO (Patey et al., 2011). After the lectures were con­
ducted, students were polled and the survey implied the increase of the
level of knowledge and more positive attitudes of students to patient
safety (Patey et al., 2011). Patient safety as a university course is mostly
applied in the USA, Canada and the United Kingdom (Wu and Busch,
2019). There are not any guidelines at the EU level which address how
patient safety should be taught to nursing students and regulatory bodies
have not put forward criteria on the subject (Kirwan et al., 2019). When
it comes to developing countries, most countries recognized the need for
implementing this course into the curriculum, but it is still in the phase
of active planning (Ginsburg et al., 2017). Indubitably, the reason for
that could be numerous obstacles with students, university and teachers
(Wu and Busch, 2019). Hence, recommendations for successfully over­
coming obstacles are: patient safety promotion as a science to affect
students’ perception regarding the importance of this course, provide
balance between didactic and empirical studying, as well as to incor­
porate the course into the existing curricula, provide adequate support
of the faculty management and adequate teaching staff so as to secure
sustainability and to encourage connections between the faculty and the
clinical environment (Kirkman et al., 2015; Wu and Busch, 2019).
2.1. Patient safety curriculum in Serbia
In 2008, The Republic of Serbia joined the program of the WHO for
the global patient safety. The following year Ministry of Health adopted
the Strategy for continuous advancement of the quality and patient
safety (Ministry of Health of The Republic of Serbia, 2009). National
quality and safety strategies include education of health science students
about patient safety. But colleges, faculties and universities in the health
professions, including medicine, nursing and others, provide limited
education on patient safety. The only faculty which integrated the
course patient safety, by the acreditation from 2014, is the faculty where
this survey was conducted. The course of patient safety is delivered over
one semester in the final year of nursing studies as elective course with
45 teaching classes, based on the WHO Patient Safety Curriculum Guide
and adjusted to the cultural and educational contexts for our academic
setting. Teaching is performed as lecturing (interactively), clinical
practical teaching, discussions and other forms of teaching by which
students acquire knowledge and skills how to apply them into practice.
2.2. The aim of the study
Taking into consideration all previously mentioned, the aim of this
study is to research: (a) the level of knowledge of medical and nursing
2
Nurse Education in Practice 53 (2021) 103089
students regarding patient safety; (b) differences in the knowledge and
attitudes of the students regarding patient safety in relation to their
academic year (the first and the last year of university studying) and in
relation to the department (medical and nursing).
3. Methodology
3.1. Study design
The study was conducted as descriptive/analytical and comparative
cross-sectional survey study at Faculty of Medicine of the University of
Novi Sad in the Republic of Serbia, during summer semester of the ac­
ademic year 2018/2019.
3.1.1. Sample
The sample was made of the first and the final year students of
medicine (integrated studies of medicine last for 12 semesters or 6 years)
and nursing (the basic vocational nursing studies last for 6 semesters or 3
years, while basic academic nursing studies last for 8 semesters or 4
years). The data were collected by means of the questionnaires distrib­
uted after regular lectures, whereby the students were asked to stay in
the classroom, fill in the questionnaire and return it to the researcher.
The questionnaires were handed to all the students who meet the criteria
for the study participation, a total of 615 questionnaires. There were 370
valid questionnaires which were statistically analyzed, therefore, the
study response was 60.1%.
3.1.2. The research instrument
The first part of the questionnaire was related to demographic
characteristics of the respondents about the current year of studying (the
first or the final academic year) and the discipline (medical or nursing).
In the second part, the questionnaire based on the WHO Patient Safety
Curriculum Guide for Medical Schools (WHO, 2009) was used. The
curriculum guide contains 11 questionnaires for different patient safety
topics (topics 1–11) for the assessment of students’ knowledge and at­
titudes before and after the implementation of the curriculum. In this
study the questionnaire Topic 1: What is Patient Safety? was used. It
contains the basic terms related to patient safety and it consists of five
subscales:
1. Error and Patient Safety – self-assessment of the knowledge of error
types, contributing factors and procedures when the error occurs.
2. Safety of the Health Care System – evaluates the students’ knowledge
and attitudes to patient safety in the health care system.
3. Personal Influence over Safety – in terms of students’ assessment of
their own capability to provide safety, self-confidence to indicate
errors, willingness to improve safety.
4. Personal Attitudes to Patient Safety – personal attitudes regarding
patient safety, errors admitting and their analysis, dealing with the
causes of adverse events.
5. Safety at the Workplace – expectations when being employed:
behavior and expectations of nurses, doctors and managers regarding
patient safety.
The items in the first subscale were ranged by the score from 1 (very
low) to 5 (very high) and the items on other subscales were ranged by
the score from 1 (I completely disagree) to 5 (I completely agree). The
higher score in the subscales denotes a higher level of knowledge and a
more positive attitude. The items in the other subscale 2.1 and 2.3 in the
analysis were reversely coded.
The third part of the questionnaire includes two additional questions,
which were answered by respondents with Yes or No: In your opinion,
would it be useful to introduce the course on Patient Safety into the curric­
ulum? and Have you had the course on Patient Safety?
B.B. Svitlica et al. Nurse Education in Practice 53 (2021) 103089

3.1.3. Statistic data processing
For the needs of analysis, the software package SPSS 20 for Windows
(Statistical Package for Social Sciences) was used. Descriptive statistics
procedures were used: arithmetic mean and standard deviation, then
frequencies and relative frequencies for gaining descriptive statistical
indicators of attributive and numerical features. The reliability of the
used questionnaire was assessed by Cronbach alpha coefficient. For the
assessment of data adequacy for factor analysis Kaiser-Meyer-Olkin
Measure of Sampling Adequacy and Bartlett’s test of sphericity were
used. The structure and validity of the questionnaire was assessed by
means of factor analysis of the main components (principal component
analysis, PCA). Regarding statistical procedures of deduction, t-test was
used for determining the differences in relation to the studying depart­
ment (medical/nursing) and in relation to the year of studying (the first
and the final). Man Whitney U-test and Kolmogorov-Smirnov tests were
used for determining the differences in mean values of two independent
ordinal features. For determining the existence of differences between
categorical variables, chi square test was applied. As the criterion for
statistical significance, the level of significance p < 0.05 was applied.
3.1.4. Ethical consideration
The study was approved by The University of Novi Sad, Ethical Board
of the Faculty of Medicine Novi Sad (No. 01–39/292/1/2018). Students
were informed about the aim of the survey and that the participation is
voluntary and anonymous. To provide anonymity of the respondents the
polls were collected without any personal identification and all the data
were treated confidentially. All the students were guaranteed that their
(non)participation in the study will not affect their further education.
4. Results
4.1. Sample characteristics
In the total sample N = 370 (100%) of respondents, nursing students
were n = 166 (44.9%), out of which the first year students were n = 74,
students of the final year n = 91 and medical students n = 204 (55.1%),
out of which the first year students n = 113 and the final year n = 91.
4.1.1. The reliability and validity of the questionnaire
Value of Kaiser− Meyer− Oklin coefficient of sampling adequacy is
0.82, which implies that the data are adequate for analysis conducting.
Bartlett sphericity test (χ2 = 3743.10; df = 435, p < 0.00) reaches sta­
tistical significance, which also implies that the data are adequate for
factor analysis conducting. Factors extraction was done by means of PCA
analysis, Biwquartimax method and five factors were extracted, loading
> 0.5. The total percentage of the explained variance is 51.04%. Table 1

Table 1
Factor analysis of the questionnaire for the whole sample.
Subscale 1 2 3 4 5 Inter item Cronbach’s alpha if item
correlation delete

1. Error and Patient safety

1. Difeferents types of human error? 0.78 0.38 0.809
2. Factor contributing to human error? 0.77 0.40 0.809
3. Factor influencing patient safety? 0.78 0.41 0.808
4. Ways of speaking up about error? 0.74 0.48 0.805
5. What should happen if an error is made? 0.76 0.49 0.804
6. How to report an error? 0.72 0.52 0.802
7. The role of healthcare organizations in error reporting? 0.74 0.51 0.803
2. Safety of the Healthcare System
1. Most healthcare workers make errors* 0.62 0.00 0.825
2. In my country there is a safe system of healthcare 0.60 0.11 0.819
3. Medical error is very common* 0.73 -0.06 0.827
4. It is very unusual for patient to be given the wrong drug 0.65 0.05 0.822
5. Healthcare workers receive training in patient safety – 0.30 0.813
6. About one in ten hospital patient across the world will experience some kind of – 0.19 0.816
adverse event
3. Personal Influence over Safety
1. Telling others about an error I made would be easy – 0.29 0.813
2. It is easier to find someone to blame rather than focus on the causes of error – 0.09 0.826
3. I am confident about speaking to someone who is showing a lack of concern for a 0.63 0.29 0.813
patient safety
4. I know how to talk to people who have made an error 0.71 0.36 0.810
5. I am always able to ensure that patient safety is not compromised – 0.42 0.809
6. I believe that filling in reporting forms will help to improve patient safety – 0.42 0.808
7. I am able to talk about my own errors 0.56 0.41 0.809
4. Personal Attitudes to Patient Safety
1. By concentrating on the causes of incidents I can contribute to patient safety 0.70 0.35 0.811
2. If I keep learning from my mistakes, I can prevent incidents. 0.72 0.38 0.810
3. Acknowledging and dealing with my errors will be an important part of my job. 0.76 0.42 0.809
4. It is important for me to learn how best to acknowledge and deal with ma errors by 0.76 0.33 0.812
the end of medical school
5. Safety at the Workplace
1. The nurses will be committed to identifying and addressing patient safety risks 0.66 0.48 0.805
2. The nurses will not criticize me for making mistakes. – 0.08 0.820
3. The doctors will be committed to identifying and addressing patient safety risks 0.69 0.29 0.813
4. The doctors will not criticize me for making mistakes. – 0.12 0.817
5. Managers in the healthcare system will make it easy to report errors 0.73 0.46 0.807
6. Managers in the healthcare system will be more interested in meeting performance – 0.13 0.817
goals than in patient safety
7. Managers in the healthcare system will expect us to focus on patient safety 0.63 0.40 0.809
8. Being open and honest about the mistakes I make will be acceptable at my place of 0.70 0.39 0.809
work
9. Admitting an error I had made would lead to just and fair treatment by management 0.64 0.41 0.809

Note: * Reversely coded items.

3
B.B. Svitlica et al.
shows extracted factors as well as factor loading of items for each factor.
As it can be noticed, the first and the fourth factor completely corre­
spond to the subscales of the original questionnaire. Several items
showed poor saturation to the superior second and third factor, which
could be a suggestion to modify these items.
Cronbach’s alpha coefficient for the whole questionnaire is 0.817
(for nursing students 0.790 and for medical students 0.811), while the
mean value of the interitem correlation is 0.33. The values of Cronbach’s
alpha coefficient by subscales are shown in Table 2. The items from the
subscale two and three which did not belong to any factor were kept in
further analysis due to the fact that their omission does not increase the
value of Cronbach alpha coefficient of the questionnaire. While three
questions in the subscale Safety at the Workplace were excluded from the
analysis since they did not belong to any factor in factor analysis and the
value of Cronbach alpha coefficient of the subscale thereby increased
from 0.732 to 0.805.
By means of Spearman correlation coefficient it was established that
the subscales Error and Patient safety and Personal Attitudes to Patient
Safety are homogenous and consistent and all the items in the subscale
intercorrelate to a great extent, as well as the fifth subscale Safety at the
Workplace (p < 0.05). Correlation matrix between the subscales imply
that there is a statistically significant difference between almost all
subscales.
4.1.2. Descriptive analysis of the questionnaire
Table 3 shows statistically significant differences in relation to the
department and the year of studying by all subscales. By means of In­
dependent samples t-test, it was determined that statistically nursing
students have a higher level of knowledge and more positive attitudes in
relation to medical students in all subscales. Final year medical students
statistically have more positive attitudes in relation to the first year
medical students in the subscale Personal Influence over Safety p = 0.032.
Final year nursing students show statistically higher level of knowledge
in relation to the first year nursing students p = 0.004 and more positive
attitudes in the subscale Personal Attitudes to Patient Safety p = 0.005.
4.2. Analysis of the question: have you had the course patient safety until
now?
The difference between nursing students who attended the lectures
of the course (n = 29) and nursing students who did not attend lectures
(n = 62) was examined by means of Mann-Whitney U test and
Kolmogorov-Smirnov test and both tests showed that there is no statis­
tically significant differences in any subscales. The same tests were
applied to examine the difference between the nursing students who
attended the lectures (n = 29) and all other respondents (n = 341). A
statistically significant difference was determined (p < 0.001) only in
the first subscale, that is, in the knowledge, but not in other subscales.
4.3. Analysis of the question: would it be useful to introduce a curriculum
course which would study patient safety?
According to the opinion of the medical students (90.7%) and
nursing students (92.2%), it would be useful to integrate a course which
Table 2
Reliability of the questionnaire by subscales for the whole sample.
Subscale Items per scale Cronbach’s alpha
1. Error and Patient safety 7 0.887
2. Safety of the Healthcare System 6 0.427
3. Personal Influence over Safety 7 0.510
4. Personal Attitudes to Patient Safety 4 0.787
5. Safety at the Workplace 6 0.805
Note: α = Cronbach-coefficient of reliability; n = the number of items which
make the scale.
4
Nurse Education in Practice 53 (2021) 103089
would study patient safety into the curriculum. This opinion is almost
equally represented among students, that is, there is no statistically
significant difference between the students in relation to the department
(χ2 = 0.255. p = 0.614) and the studying year (χ2 = 3.135. p = 0.371).
5. Discussion
The data obtained in the analysis of the knowledge and attitudes of
students to patient safety can be considered a starting point for the
implementation of the course which would have the outcome in
knowledge and skills gaining in this field (ElAraby et al., 2018). In this
survey, by means of statistical analysis, empirical validity of the WHO
questionnaire What is Patient Safety? was confirmed. In the literature
several survey can be found regarding medical and nursing students’
knowledge and attitudes to patient safety, conducted by applying
different questionnaires with confirmed validity (Flin et al., 2009;
Ginsburg et al., 2012; Li et al., 2012; Mansour et al., 2015; Murray et al.,
2020; Taskiran et al., 2020).
5.1. The level of knowledge of medical and nursing students regarding
patient safety
Students’ responses in the questionnaire show that although they
have positive attitudes, they do not have enough knowledge of patient
safety. The lowest level of knowledge of medical and nursing students
are related to health care organisation in error reporting. Most nursing
students think they have an intermediate level of knowledge of error
types, contributing factors to human errors, the method of communi­
cation about errors, what to do when an error occurs and how to report
an error. On the other hand, medical students assess their knowledge of
these themes under average and they are not certain whether health care
system in our country is safe. They think that health professionals make
errors, errors are quite common and one in ten patients in the world
experiences an adverse event. The obtained results of our study are
consistent with the results of other authors, where most students assess
their knowledge of errors and patient safety as low or average knowl­
edge (Biresaw et al., 2020; Flin et al., 2009; García Elorrio et al., 2016;
Roh et al., 2015; Sen et al., 2019). Positive students’ attitudes are also
seen through the statement of almost all students It would be useful to
introduce patient safety course into the curriculum. The wish of almost all
students to be educated on patient safety could be explained by the fact
that students recognized the lack of the required knowledge. Similar
results can be found in several other studies where it was stated that
students emphasize the necessity of education in the field of patient
safety (Nabilou et al., 2015).
5.1.1. Differences in the knowledge and attitudes of the students regarding
patient safety
When it comes to the differences in the knowledge and attitudes to
patient safety in relation to the curriculum, nursing students achieve
significantly higher scores in all subscales in relation to medical stu­
dents. In the studies which compared the knowledge and attitudes of
medical and nursing students, a commonly reached conclusion is that
nursing students have a higher level of knowledge than medical students
(Nabilou et al., 2015). In our context, different levels of knowledge and
attitudes can be explained by differences in the structure of curricula,
syllabi and study programs, whereby nursing curriculum puts emphasis
on the development of non-technical skills in comparison to the cur­
riculum of medical students, which has a more biomedical focus
(Milutinović et al., 2018). Few authors state the importance of the
development of non-technical skills, such as social skills, risk and quality
management, communication, teamwork and others (Scott et al., 2016).
Those are actually the themes which make a significant part of the
concept of patient safety and the curriculum created by the WHO
(Taskiran et al., 2020; Wu and Busch, 2019). In favor of the above
mentioned there is also the fact that there are not any significant
B.B. Svitlica et al. Nurse Education in Practice 53 (2021) 103089

Table 3
Differences of mean values of items in relation to the department and the year of university studying.
Medicine (n-204) /nursing (n-166) Medicine 1.yr (n-113) /Medicine 6. yr (n-91) Nursing 1.yr (n-75)/ 3.yr and 4. yr (n-91)

Subscale M (SD) tdf p d M± SD tdf P d M± SD t (df) p d

1. Error and Patient safety 2.77(0.67) -9.85368 0.000* 2.72(0.90) -1.03202 0.304 0.15 3.28(0.78) -2.91164 0.004* 0.45
3.42(0.58) 1.03 2.82(0.86) 3.54(0.80)
2. Safety of the Healthcare System 3.15(0.39) -5.88368 0.000* 3.19(0.83) 1.87202 0.063 0.11 3.38(0.81) 0.28164 0.771 0.11
3.38(0.36) 0.61 3.09(0.88) 3.37(0.92)
3. Personal Influence over Safety 3.45(0.44) -4.44368 0.000* 3.39(0.47) -2.15202 0.032* 0.30ª 3.58(0.38) -1.66164 0.096 0.26ª
3.64(0.38) 0.46ª 3.52(0.39) 3.68(0.38)
4. Personal Attitudes to Patient Safety 4.25(0.50) -3.09368 0.002* 4.21(0.52) -1.18202 0.239 0.17ª 4.31(0.40) -2.80164 0.005* 0.43ª
4.41(0.45) 0.31ª 4.30(0.48) 4.49(0.48)
5. Safety at the Workplace 3.22(0.42) -2.26368 0.024* 3.26(0.38) 1.52202 0.130 0.21ª 3.60(0.55) -0.59164 0.552 0.09ª
3.34(0.57) 0.23ª 3.17(0.46) 3.66(0.73)

Note: M = mean; SD = standard deviation; t = t-test; df = degrees of freedom; p-value; d = Cohen’s d indicator; * Indicates statistical significance at p < 0.05; ªsmall
effect.

differences in the knowledge and attitudes of the first and the final year
students of medicine. In terms of comparison of nursing students who
attended the patient safety lectures and all other students, a significant
difference was determined in the knowledge, but not in their attitudes.
The results of this study imply that education has improved the
knowledge, but not enough to change the attitudes in practical sense or
to understand health care system functioning. The results of our study
are similar to the results of the surveys which assessed students’
knowledge and attitudes to patient safety. A large number of authors
imply that education has brought to positive changes in knowledge
(Aboumatar et al., 2012; Farley et al., 2015; Jahan et al., 2018; Jamal
et al., 2019; Oates et al., 2018), but they also state that the reached level
of knowledge and perceptions of the concept of patient safety might still
not be satisfactory.
5.1.2. Study limitations
This study has several downsides. The first disadvantage is when
students have to perform self-assessment of their knowledge, they can
give responses which are socially acceptable in their opinion. Further­
more, this study was conducted at only one faculty. The study does not
provide direct evidence that the training actually increased the student
knowledge (students’ amount of knowledge (and attitudes) are inevi­
tably influenced by many factors), or modified their attitudes and per­
ceptions towards patient safety. Despite the study disadvantages, it
provides significant data which implies the necessity of the impleme­
natation of patient safety course for all the students whose education is
related to medicine and that the course of patient safety should be
advanced in relation to the current one. Likewise, it is very significant
that this study represents an introduction into further research on the
need for the course of patient safety and its efficiency. Further research
is necessary to understand better how the design, teaching and delivery
of patient safety education can be adjusted to each educational system.
6. Implications
Despite a lot of evidence that education in the field of patient safety is
necessary, the implementation of the course in a large number of
countries is quite slow and it represents a great challenge. For this reason
we can pose a question: “Are all the countries which still have not
implemented the course of patient safety for all the students who are to
become health professionals facing a problem?” Since contemporary
recommendations and standards for the education of health pro­
fessionals mean that curricula have to be harmonized with specific needs
of society, the need for these students’ education in the field of patient
safety today is more obvious than ever. Healthcare systems around the
world are under extreme pressure and health professionals work in­
stitutions filled with incertitude. Responsible institutions which create
health care and educational policy and which set strategic and longterm
goals have to accept the fact that it is of extreme importance that
colleges and faculties related to health contain a comprehensive cur­
riculum on patient safety.
7. Conclusion
On the grounds of the obtained study results, it could be said that the
applied instrument has good psychometric characteristics and a stable
factor structure. Then, the study department has a significant influence
on the knowledge and attitudes to patient safety. Further, education in
the field of patient safety provides significant results in the knowledge
increase, but insufficient results to change the attitudes.
Patient safety represents the foundation of quality health care and
education represents the requirement which has to be fulfilled to ach­
ieve and maintain the quality. Teachers who educate future health
professionals have to prepare them to accept the concept of patient
safety as an integral part of everyday practice.
Author statement
We sincerely thank to the Reviewers for kind and useful suggestions.
We made the changes according to your instructions. We hope that we
have managed to reply to all your suggestions adequately. If there is a
need for further paper correcting, naturally, we are ready to accept all
the suggestions necessary for approving our paper.
Acknowledgments
Our deepest appreciation and gratitude goes to students for their
kind participation in the study, allowing us to collect valuable data and
produce this paper which is the first in this geographic region.
Author contributions
Branislava Brestovački Svitlica, Maja Šajnović, Dragana Milutinović:
Study design. Maja Šajnović: Data collection. Branislava Brestovački
Svitlica, Jelena Ivetić: Data analysis. Branislava Brestovački Svitlica,
Dragana Simin: Manuscript writing. Dragana Milutinović, Dragana
Simin: Critical revisions for important intellectual content.
Conflict of Interest
The authors declare no competing interests.
Sources of funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.

5
B.B. Svitlica et al. Nurse Education in Practice 53 (2021) 103089

References Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., Lawrence, D.,
Morath, J., O’Leary, D., O’Neill, P., Pinakiewicz, D., Isaac, T., Lucian Leape Institute
at the National Patient Safety Foundation, 2009. Transforming healthcare: a safety
Aboumatar, H.J., Thompson, D., Wu, A., Dawson, P., Colbert, J., Marsteller, J., Kent, P.,
imperative. Qual. Saf. Health Care 18 (6), 424–428. https://doi.org/10.1136/
Lubomski, L.H., Paine, L., Pronovost, P., 2012. Development and evaluation of a 3-
qshc.2009.036954.
day patient safety curriculum to advance knowledge, self-efficacy and system
Li, L., Duan, Y., Chen, P., Li, J., Mao, X., Barraclough, B.H., Zhang, M., 2012. Knowledge,
thinking among medical students. BMJ Qual. Saf. 21 (5), 416–422. https://doi.org/
skills and attitudes of medical students to patient safety: a cross-sectional pilot
10.1136/bmjqs-2011-000463.
investigation in China. J. Evid. Based Med. 5 (3), 124–133. https://doi.org/10.1111/
Australian Council on Safety and Quality in Health Care, 2005, National patient safety
j.1756-5391.2012.01187.x.
education framework. Canberra: Commonwealth of Australia. Available at. www.
Mansour, M., Skull, A., Parker, M., 2015. Evaluation of World Health Organization multi-
safetyandquality.gov.au/former-publications/national-patient-safety-education-
professional patient safety curriculum topics in nursing education: pre-test, post-test,
framework (accessed 2 February 2018).
none-experimental study. J. Prof. Nurs. 31 (5), 432–439. https://doi.org/10.1016/j.
Biresaw, H., Asfaw, N., Zewdu, F., 2020. Knowledge and attitude of nurses towards
profnurs.2015.03.002.
patient safety and its associated factors. Int. J. Afr. Nurs. Sci. 13, 100229 https://doi.
Mansour, M.J., Al Shadafan, S.F., Abu-Sneineh, F.T., AlAmer, M.M., 2018. Integrating
org/10.1016/j.ijans.2020.100229.
patient safety education in the undergraduate nursing curriculum: a discussion
Cantero-López, N., González-Chordá, V.M., Valero-Chillerón, M.J., Mena-Tudela, D.,
paper. Open Nurs. J. 12, 125–132. https://doi.org/10.2174/
andreu-Pejó, L., Vila-Candel, R., Cervera-Gasch, Á., 2021. Attitudes of
1874434601812010125.
undergraduate nursing students towards patient safety: a quasi-experimental study.
Milutinović, D., Lovrić, R., Simin, D., 2018. Interprofessional education and collaborative
Int. J. Environ. Res. Public Health 18 (4), 1429. https://doi.org/10.3390/
practice: psychometric analysis of the Readiness for Interprofessional Learning Scale
ijerph18041429.
in undergraduate Serbian healthcare student context. Nurse Educ. Today 65, 74–80.
ElAraby, S., Ra’oof, R.A., Alkhadragy, R., 2018. Learning of patient safety in health
https://doi.org/10.1016/j.nedt.2018.03.002.
professions education. In: Stawicki, S.P., Firstenberg, M.S. (Eds.), Vignettes in
Murray, M., Sundin, D., Cope, V., 2019. Benner’s model and Duchscher’s theory:
Patient Safety. IntechOpen, London. https://doi.org/10.5772/intechopen.75973.
Providing the framework for understanding new graduate nurses’ transition to
Farley, D., Zheng, H., Rousi, E., Leotsakos, A., 2015. Field test of the world health
practice. Nurse Educ. Prac. 34, 199–203. https://doi.org/10.1016/j.
organization multi-professional patient safety curriculum guide. PLoS One 10 (9),
nepr.2018.12.003.
0138510. https://doi.org/10.1371/journal.pone.0138510.
Murray, M., Sundin, D., Cope, V., 2020. Mixed-methods study on patient safety insights
Flin, R., Patey, R., Jackson, J., Mearns, K., Dissanayaka, U., 2009. Year 1 medical
of new graduate registered nurses. J. Nurs. Care Qual. 35 (3), 258–264. https://doi.
undergraduates’ knowledge of and attitudes to medical error. Med Educ. 43 (12),
org/10.1097/NCQ.0000000000000443.
1147–1155. https://doi.org/10.1111/j.1365-2923.2009.03499.x.
Nabilou, B., Feizi, A., Seyedin, H., 2015. Patient safety in medical education: students’
Gandhi, T.K., Kaplan, G.S., Leape, L., Berwick, D.M., Edgman-Levitan, S., Edmondson, A.,
perceptions, knowledge and attitudes. PloS One 10 (8), 0135610. https://doi.org/
Meyer, G.S., Michaels, D., Morath, J.M., Vincent, C., Wachter, R., 2018.
10.1371/journal.pone.0135610.
Transforming concepts in patient safety: a progress report. BMJ Qual. Saf. 27,
Oates, K., Wilson, I., Hu, W., Walker, B., Nagle, A., Wiley, J., 2018. Changing medical
1019–1026. https://doi.org/10.1136/bmjqs-2017-007756.
student attitudes to patient safety: a multicentre study. BMC Med. Educ. 18 (1), 205.
García Elorrio, E., Macchiavello, D., Rodriguez, V., Catalano, Y., Corna, G., Dahinten, J.,
https://doi.org/10.1186/s12909-018-1313-0.
Ontivero, M., 2016. Knowledge, beliefs and attitudes report on patient care and
Ministry of Health Republic of Serbia, 2009. The strategy for continuous improvement of
safety in undergraduate students: validating the modified APSQ-III questionnaire.
healthcare quality and patient safety. Official Gazette of the RS, 65/2009. Belgrade,
Medwave 16 (11), 6809. https://doi.org/10.5867/medwave.2016.11.6809.
Serbia. Available at. http://www.zdravlje.gov.rs/downloads/Zakoni/Strategije/
Ginsburg, L., Castel, E., Tregunno, D., Norton, P.G., 2012. The H-PEPSS: an instrument to
(accessed 24 March 2015) (Serbian).
measure health professionals’ perceptions of patient safety competence at entry into
Patey, R., Flin, R., Ross, S., Parker, S., Cleland, J., Jackson, J., Moffat, M., Thomson, A.,
practice. BMJ Qual. Saf. 21, 676–684. https://doi.org/10.1136/bmjqs-2011-
2011, Patient Safety Curriculum Guide for Medical Schools Evaluation Study Report
000601.
to WHO Patient Safety Programme. Available at. https://www.who.int/
Ginsburg, L.R., Dhingra-Kumar, N., Donaldson, L.J., 2017. What stage are low-income
patientsafety/education/curriculum/PSP_Eval_Study_Report-2011_March-2012.pdf?
and middleincome countries (LMICs) at with patient safety curriculum
ua=1 (accessed 14 April 2018).
implementation and what are the barriers to implementation? A two-stage cross-
Roh, H., Park, S.J., Kim, T., 2015. Patient safety education to change medical students’
sectional study. BMJ Open 7 (6), 016110. https://doi.org/10.1136/bmjopen-2017-
attitudes and sense of responsibility. Med. Teach. 37 (10), 908–914. https://doi.org/
016110.
10.3109/0142159X.2014.970988.
Jahan, F., Naeem, S.M., Siddiqui, M.A., Qasim, R., Khan, M.M., 2018. Medical students’
Sen, M., Azzani, M.M., Rezaei, A., Sen, P.K., 2019. A study to determine patient safety
perception and attitude before and after implementing patient safety curriculum in
awareness and attitudes among medical students in a Malaysian University. Indian J.
clinical years. Int J. Public Health Res. 6 (4), 122–129. 〈http://www.openscienceon
Med. Sci. 71 (2), 66–81. https://doi.org/10.25259/IJMS_25_2019.
line.com/journal/ijphr〉.
Scott, J., Revera Morales, D., McRitchie, A., Riviello, R., Smink, D., Yule, S., 2016. Non-
Jamal, N., Bowe, S.N., Brenner, M.J., Balakrishnan, K., Bent, J.P., 2019. Impact of a
technical skills and health care provision in low- and middle-income countries: a
formal patient safety and quality improvement curriculum: a prospective, controlled
systematic review. Med. Educ. 50 (4), 441–455. https://doi.org/10.1111/
trial. Laryngoscope 129 (5), 1100–1106. https://doi.org/10.1002/lary.27527.
medu.12939.
Kirwan, M., Riklikiene, O., Gotlib, J., Fuster, P., Borta, M., 2019. Regulation and current
Taskiran, G., Bacaksiz, F.E., Seren, A.K.H., 2020. Psychometric testing of the Turkish
status of patient safety content in pre-registration nurse education in 27 countries:
version of the Health Professional Education in Patient Safety Survey: H-PEPSSTR.
Findings from the Rationing - Missed nursing care (RANCARE) COST Action project.
Nurse Educ. Pr. 42, 102640 https://doi.org/10.1016/j.nepr.2019.102640.
Nurse Educ. Prac. 37, 132–140. https://doi.org/10.1016/j.nepr.2019.04.013.
Usher, K., Woods, C., Parmenter, G., Hutchinson, M., Mannix, J., Power, T.,
Kirkman, M.A., Sevdalis, N., Arora, S., Beker, P., Vincent, C., Ahmed, M., 2015. The
Chaboyer, W., Latimer, S., Mills, J., Siegloff, L., Jackson, D., 2017. Self-reported
outcomes of recent patient safety education interventions for trainee physicians and
confidence in patient safety knowledge among Australian undergraduate nursing
medical students: a systematic review. BMJ Open 5 (5), 007705. https://doi.org/
students: a multi-site cross-sectional survey study. Int. J. Nurs. Stud. 71, 89–96.
10.1136/bmjopen-2015-007705.
https://doi.org/10.1016/j.ijnurstu.2017.03.006.
Kiesewetter, J., Drossard, S., Gaupp, R., Baschnegger, H., Kiesewetter, I., Hoffmann, S.,
Walton, M., Woodward, H., Van Staalduinen, S., Lemer, C., Greaves, F., Noble, D.,
2018. How could the topic patient safety be embedded in the curriculum? A
Ellis, B., Donaldson, L., Barraclough, B., 2010. Expert Group convened by the World
recommendation by the Committee for Patient Safety and Error Management of the
alliance of Patient Sfety, as Expert Lead the Sub-Programme, The WHO patient safety
GMA. GMS J. Med. Educ. 35 (1), 15. https://doi.org/10.3205/zma001162.
curriculum guide for medical schools. Qual. Saf. Health Care 19 (6), 542–546.
Kohn, L.T., Corrigan, J.M., Donaldson, M.S., 2000. To Err is Human: Building a Safer
https://doi.org/10.1136/qshc.2009.036970.
Health System. Institute of Medicine (US) Committee on Quality of Health Care in
Wu, A.W., Busch, I.M., 2019. Patient safety: a new basic science for professional
America. National Academy Press, Waschington, DC. https://www.nap.edu/.
education. GMS J. Med. Educ. 36 (2), 21. https://doi.org/10.3205/zma001229.
Kong, L.N., Zhu, W.F., He, S., Chen, S.Z., Yang, L., Qi, L., Peng, X., 2019. Attitudes
World Health Organisation (WHO), 2009, Patient Safety Curriculum Guide for Medical
towards patient safety culture among postgraduate nursing students in China: a
Schools, Available at: https://www.who.int/patientsafety/education/curriculum_
cross-sectional study. Nurse Educ. Pr. 38 (1–6), 1–6. https://doi.org/10.1016/j.
guide_medical_schools/en/ (accessed 10 January 2017).
nepr.2019.05.014.