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BMJ Qual Saf. 2014 Oct;23(10):847-56. doi: 10.1136/bmjqs-2013-002664. Epub 2014 Apr 15.

Development of a patient safety climate survey for Chinese hospitals: cross-national adaptation and psychometric evaluation.

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Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
School of Nursing, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
International Education College, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
Tufts Medical Center, Boston, Massachusetts, USA.



Existing patient safety climate instruments, most of which have been developed in the USA, may not accurately reflect the conditions in the healthcare systems of other countries.


To develop and evaluate a patient safety climate instrument for healthcare workers in Chinese hospitals.


Based on a review of existing instruments, expert panel review, focus groups and cognitive interviews, we developed items relevant to patient safety climate in Chinese hospitals. The draft instrument was distributed to 1700 hospital workers from 54 units in six hospitals in five Chinese cities between July and October 2011, and 1464 completed surveys were received. We performed exploratory and confirmatory factor analyses and estimated internal consistency reliability, within-unit agreement, between-unit variation, unit-mean reliability, correlation between multi-item composites, and association between the composites and two single items of perceived safety.


The final instrument included 34 items organised into nine composites: institutional commitment to safety, unit management support for safety, organisational learning, safety system, adequacy of safety arrangements, error reporting, communication and peer support, teamwork and staffing. All composites had acceptable unit-mean reliabilities (≥0.74) and within-unit agreement (Rwg ≥0.71), and exhibited significant between-unit variation with intraclass correlation coefficients ranging from 9% to 21%. Internal consistency reliabilities ranged from 0.59 to 0.88 and were ≥0.70 for eight of the nine composites. Correlations between composites ranged from 0.27 to 0.73. All composites were positively and significantly associated with the two perceived safety items.


The Chinese Hospital Survey on Patient Safety Climate demonstrates adequate dimensionality, reliability and validity. The integration of qualitative and quantitative methods is essential to produce an instrument that is culturally appropriate for Chinese hospitals.

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