Sage Journals: Discover world-class research

Abstract

OBJECTIVE

To review the senior resident health trainee's perceived status and need for quality improvement and patient safety (QIPS) education in the residency training program of Saudi Arabia.

METHODS

Residents of medical, dentistry, and pharmacy education were surveyed in 2023 by using pretested 10 QIPS questions. The median and interquartile range (IQR) of the score was correlated to gender, branch, and level of residency training.

RESULTS

We surveyed 202 senior residents. Males were 131 (64.9%). Residents of medical (126, 62.4%), dentistry (39, 19.3%), and pharmacy (37, 18.3%). The median score of responses to the QIPS survey was 7.0 (IQR 4.0, 11.6). The median score of residents of dentistry, medicine, and pharmacy were 10 (IQR 7.0, 12.5), 6.75 (IQR 4.0, 12.0), and 5.0 (IQR 2.5, 8.0) respectively, and was significantly different (Kruskal Wallis (KW) chi-square = 19.8, P = .001). The exposure to the QIPS project was significantly and positively associated with a high QIPS score (MW U P = .02). The variations in the score by gender (Mann Whitney P = .148) and the level of residency (KW P = .86) were not statistically significant. Three-fourths of participants feel the need for formal training about QIPS. Nearly half of the participants were not happy with the current method of QIPS training methodology. More than 40% of participants were not sure about questions about opportunities and mentorship of QIPS projects. One-third were involved in QIPS projects.

CONCLUSIONS

Although senior residents were interested in QIPS, they were dissatisfied with current methods and opportunities to execute supervised QIPS projects. Residents of dentistry and those having performed QIPS projects had higher QPIS knowledge and satisfaction with training.

Keywords

Patients’ safety quality improvement postgraduate health education medical education vision 2030 Saudi Arabia

Introduction

As per the recommendations of the World Health Organization (WHO) and the Eastern Mediterranean Region of WHO (EMRO) to improve patient safety, the Ministry of Health of Saudi Arabia prioritized strategies to implement patient safety-related activities within the Vision 2030 initiative.^1–3 Accordingly, postgraduate health staff training programs prepare trainees to provide high-quality and safe care to patients. These staff include doctors, dentists, nursing staff, pharmacists, and mid-level health care professionals. Quality improvement and patient safety (QIPS) education are essential components of these training programs.¹ QIPS can be defined as the utilization of robust methodological and statistical techniques to bring about positive changes in the delivery of healthcare.⁴ Faculty understanding and choosing to impart the importance of QIPS to their trainees could be the first step. QIPS's role in equipping healthcare professionals with the knowledge, skills, and foundations to improve healthcare systems is well understood in the health sector.^5,6

QIPS is fundamental to the provision and advancement of healthcare, as preventable errors have been identified as key causes of adverse patient events. Four residents who were exposed to QIPS in their medical education experienced greater confidence in identifying and addressing patient safety issues.⁷ Surveys of physicians at primary health-care centers, residents of internal medicine and staff of tertiary hospitals reported a positive attitude toward patient safety but highlighted the need for training in QIPS.^8–10 Canadian emergency medicine residents perceive a lack of QIPS educational opportunities and support in their projects and mentorship.⁴ The patient safety culture perceptions in the college of dentistry were of moderate grade and varied among seniors and students.¹¹ The awareness of safe ergonomic practices among dentists and ophthalmologists was found to make safe and healthy working conditions for service providers and their patients.^12,13

Pharmacy education in Saudi Arabia (SA) comprises diploma and degree courses. After graduation in pharmacy, there is a 2-year residency program for postgraduation and three years for PhD in SA.¹⁴ They are labeled as clinical pharmacists and were included in the present study.

The senior (5th and more years) residents in health faculties are a vital workforce and need to be trained in QIPS within their training curriculum of SA. While preparing and revising such training modules, feedback from senior resident trainees will be essential to be effective and acceptable. To the best of our knowledge, no such study has been conducted in the kingdom to understand trainees’ perspectives about QIPS in existing training modules. We present the feedback of senior residents of medical, dental, and pharmacy faculties about opportunities and needs in SA, and their determinants and accordingly recommend revision of training for the QIPS.

Methods

The study was approved by the Medical Research Ethics Committee, College of Dentistry, Taibah University, SA. Ethical approval was obtained in May 2023 (TUCDREC/230523). The study was held from the first June until 10th August 2023. The senior residents of medical, dentistry, and pharmacy faculties registered with the Saudi Commission for Health Specialties were our study population. They included 2373 senior medical and dental residents plus around 1500 senior pharmacy students. The residents of the first and second years of training were excluded from the survey. Senior residents were included if they had three or more years of residency training. The participants were further grouped into “3 to 4” and “5 and more” years of residency.

To represent a population of 6000 Saudi senior residents in 3 branches, we assumed that the rate of good understanding of the need for patient safety and its inclusion in the curriculum was 85% of residents.¹⁵ To achieve a 95% confidence interval, and 5% acceptable error margin of a cross-sectional survey, we needed to survey 190 participants. To compensate for clustering and incomplete responses, we increased the sample by 10%. Thus, the final sample for this survey was 208. We used Openepi software to calculate the sample for this survey.¹⁶ We used graduates in health colleges of Saudi Arabia in 2020-2021 and published by the Ministry of Health as reference population to calculate the sample size.¹⁷

Three field investigators were involved in this research. One each from medical, dentistry, and pharmacy faculty. The survey information was disseminated by colleagues and trainees to all active residents of all regions of Saudi Arabia. Messages to encourage participation were sent through WhatsApp groups and faculty emails with the help of faculty administration. A Google-based questionnaire was prepared, pretested, and used for the survey. The questions were adapted from a previous study in Canada by Trivedi et al.⁴ Written informed consent was obtained from all participants for the survey. There were two questions regarding participants’ awareness of QIPS. Five questions were regarding participants’ attitudes toward the status of training for QIPS. Two questions were related to the participant's practice of QIPS implementation (Table 1). During the pilot stage, we carried out a validity test of responses to ten questions and Cronbach's alpha was 0.76.

Table 1.

Responses of resident trainees of health faculties in Saudi Arabia to the questionnaire for quality improvement and patient safety (QIPS) education.

S No.	Questions	Responses	Number	Percentage
1	To what extent would you describe your familiarity with QIPS methodologies?	I don’t know what QIPS entails Not so familiar Familiar Very familiar	27 81 74 20	13.4 40.1 36.6 9.9
2	Are there readily available opportunities to participate in projects surrounding QIPS in your training environment	No Yes Not sure	52 58 92	25.5 28.7 45.5
3	Are there readily available opportunities for mentorship in QIPS at your training center?	No Yes Not sure	59 57 86	29.2 28.2 42.6
4	Do you feel that QIPS methodologies should be formally taught in your residency program?	No Yes Already taught in curriculum	33 151 18	16.3 74.8 8.9
5	If QIPS methodologies are currently taught, how satisfied are you with the overall level of QIPS teaching in your residency program?	Very satisfied Satisfied Somewhat satisfied Dissatisfied Not applicable	28 21 43 10 57	13.9 10.4 21.3 5.0 28.2
6	Are you aware of the different ways to seek training in QIPS outside of your normal residency education?	Yes No	63 139	31.2 68.8
7	Have you previously been involved in a QIPS project?	Yes No	62 140	30.7 69.3
8	Have you previously presented or published work relating to QIPS?	Yes No	41 161	20.3 79.7
9	Do you feel that your current work environment allows for adequate mentorship regarding QIPS?	Yes No	96 106	47.5 52.5
10	How interested are you in becoming involved with QIPS training and initiatives.	Very much interested Interested Slightly interested Not interested Not at all interested	65 47 46 32 12	32.2 23.3 22.8 15.8 5.9

If responses were five graded, they were given points −2 to +2 for score calculation. If the response was of 3 grades, no was given −1 and yes was given a +1 score. While for unsure responses “0” score was given. The sum of all response scores was further graded into excellent, good, poor, and very poor with 75%, 50%, and 25% as the cutoff of the total possible range of the score.¹⁸

Statistical Analysis

The data was transferred into a spreadsheet of Statistical Package for Social Studies (SPSS 25) (IBM, NY, USA). Univariate analysis was carried out. The qualitative variables were presented as numbers and percentage proportions. The quantitative outcomes were plotted to study their distribution. A normally distributed variable was presented as mean and standard deviation. If the distribution was “not normal” or the sample was small, we presented the results as the median and interquartile range (IQR). The comparison of the qualitative outcome of 2 subgroups was carried out by Mann Whitney (MW) U test and chi-square value (χ²) and two-sided P values were calculated. For more than 2 subgroups, the Kruskal Wallis (KW) H test was conducted, chi-square value (χ²) and two-sided P values were presented. A “P value” of <.05 was considered statistically significant.

Results

We surveyed 202 senior residents in training for three health branches. Of the 131 (64.9%) were males and 46 (22.8%) were in fifth and more years of residency. The participants in medicine, dentistry, and pharmacy branches of health sciences were 126 (62.4%), 39 (19.3%), and 37 (18.3%), respectively. The proportion of residents of medical faculties was more than the other 2 branches.

The responses to different questions related to QIPS are given in Table 1. More than 40% of participants were not sure about questions about opportunities and mentorship of QIPS projects. Three-fourths of the participants feel the need for formal training about QIPS. Nearly half of the participants were dissatisfied or very dissatisfied with the current method of QIPS training methodology. Less than one-third were involved in a QIPS project. The median and IQR response scores of all participants and subgroups are given in Figure 1.

Figure 1.

The senior resident perceived quality improvement and patient safety (QIPS) education in the postgraduate training program. The x-axis denoted the total surveyed sample and subgroups. y-axis denotes senior residents’ perceived QIPS score. The high low bar denotes 25% and 75% interquartile range. ▪ denotes the median of QIPS score.

The response score was compared by gender, branch of education in health, and years of study in health faculty (Table 2). Trainees in dentistry had the highest score while trainees in pharmacy had the lowest score of responses to the questions related to QIPS. The median score of responses to the QIPS survey was 7.0 (IQR 4.0, 11.6). The median scores of residents of dentistry, medicine, and pharmacy were 10 (IQR 7.0, 12.5), 6.75 (IQR 4.0, 12.0), and 5.0 (IQR 2.5, 8.0), respectively, and were significantly different (KW chi-square = 19.8, P = .001). The variations in the score by gender (MW P = .148) and the level of residency (KW P = .86) were not statistically significant.

Table 2.

Association of variables to the total score of senior Saudi residents’ responses about quality improvement and patient safety education.

		Number of participants	Median	IQR	Validity
Total		202	7.0	4.0, 11.6
Gender	MaleFemale	13171	7.06.5	4.0, 12.04.0, 11.0	Χ²= 3.8P = .148
Branch of Health study	MedicineDentistryPharmacy	1263937	6.7510.05.0	4.0, 12.07.0,12.52.5, 8.0	Χ²= 19.8P = .001
Year of residency	3 to 45 and more	15646	6.57.8	4.0, 11.55.0, 12.0	P = .465

The median score of 62 participants who had previous exposure to the QIPS project was 8.0 (IQR 5.5, 12). The median score of 140 participants without exposure to the QIPS project was 6.5 (IQR 3.5; 11.5). The exposure to the QIPS project was significantly and positively associated with a high QIPS score (MW U P = .02).

Discussion

The survey of senior residents of three branches of Saudi Arabia revealed that three-fourths of them are aware of the need for QIPS as part of their postgraduate training program. However, nearly half of them were dissatisfied or very dissatisfied with the current method of QIPS training methodology. Participants were not sure about opportunities and mentorship of QIPS projects during their training. Only one-third were involved in QIPS projects. Dentistry residents had the highest score while the pharmacy residents had the lowest score related to QIPS. The trends suggest that there could be variability in QIPS training and project implementation in 3 branches of health: medical, dental, and pharmacy. The residents performing QIPS projects had higher satisfaction scores.

Of the surveyed trainees, 75% knew about the need for QIPS in improving the skills of service providers and ensuring the safety of patients. After intense promotion by the WHO and Ministry of Health, it is surprising that the message has still not reached all the health trainees. Among medical students in Hong Kong, 80% were aware of patient safety issues and the need to be included in the new undergraduate program.¹⁹ A study in Pakistan suggested that although the medical students had a positive attitude toward patient safety, they believed that the curriculum should include patient safety education needs.²⁰ In a study in 6 developing countries that included SA, researchers noted that two-thirds of pharmacy students had a positive attitude toward QIPS.²¹ The inclusion of QIPS in the curriculum significantly improved the knowledge of efficiency and positive thinking for patient safety in an institute in Baltimore, USA.²² Thus, the positive attitude of senior health trainees in our study is a first step in building a patient safety culture. QIPS is taught in 2 ways, as part of a curriculum accredited by the Saudi Commission of Health Specialty (Formal) and by hospital-related teaching methods (hospital policies). Not all residency programs involve a formal QIPS teaching curriculum. It is mandatory to start QIPS teaching during residency programs. However, not all residency programs seem to have them uniformly applied. This is the reason for 9% of additional respondents meaning that it is part of the curriculum but not yet implemented.

In the present survey, senior trainees expressed that they had limited opportunity to apply QIPS, and the mentor's skills in supervising the QIPS application of trainees also needed to be strengthened. Demanding existing clinicians to mentor students in QIPS projects could be at the cost of patient care time and productivity, and they also need specialized training.²³ Special educator and fellowship courses are developed in the field of QIPS and should be applied by national postgraduate health education boards.²⁴

Although the participants of our survey were from three branches of health services namely medical, dentistry, and pharmacy, the sample size was not calculated for each branch and therefore survey outcomes of subgroups show trends only and should be interpreted with caution. The QIPS score of dental residents was the highest followed by medical residents. The score of pharmacy residents was the lowest among the subgroups. This could be due to variations in training courses on QIPS introduced in these subgroups. The seven CanMEDS physician competencies were incorporated in 2014 into the residency program at various academic activity venues. As medical experts, physicians integrate all of the CanMEDS roles, applying medical knowledge, clinical skills, and professional attitudes to the provision of patient-centered care. The role of the medical expert is the physician's central role in the CanMEDS framework (contribute to the enhancement of quality care and patient safety in practice, integrating the best evidence and practices available).^25–27 Dentists and pharmacologist residency programs curricula involved the fundamentals of QIPS. There are no specific curriculum formats and QI topics written for each branch, but QIPS is written as a general element that should be taught to all trainees. Less clinical exposure of pharmacy residents may also explain opportunities to apply QIPS resulting in high dissatisfaction among these responders. The QIPS proponents and educators should note this observation and review the underlying causes of these differences by 3 branches of the health sector.

We did not find a significant difference in QIPS methods-related responses by gender. Attitude for patient safety among female PHC doctors was more compared to male doctors in a study in Saudi Arabia.⁷ In a study in Ethiopia, female pharmacy students had more positive attitudes toward patient safety compared to male students.²⁸ In contrast, scores about patient safety and experience with medical error were not different among both genders of medical students in a study held in Pakistan.²⁰ In a survey covering 6 developing countries including SA, female health students had a more positive attitude toward patient safety compared to males. It seems that the training of health students about QIPS need not be separate for male and female residents but could be adopted based on the local culture.

The senior residents of 3rd and 4th years had similar QIPS response scores compared to 5th to 7th-year students in the present study. Naser et al noted that higher levels of pharmacy residents were predictors of negative attitudes toward patient safety.²¹ A similar association was noted by Bari et al in their study of nursing students in Pakistan.²⁹ It seems in the present study area although with exposure to clinical care, QIPS awareness and medical error related increased. A study with a larger subsample could enable us to know the effect of the number of years in health studies.

The residents exposed to the QPIS project seem to have better QIPS scores. This could be due to strengthening their skills after undertaking a project or those aware of QIPS may have undertaken the projects. The impact of such training including supervised project assignments has shown a positive impact on the knowledge, attitude, and practice of trainees and faculty of medical services.³⁰

Strength of the Study

This is perhaps the first study among Arab countries to generate feedback from senior residents of 3 health faculties about methods and opportunities for applying QIPS as part of their residency training. Dentistry and medicine residents seem to be exposed to the need and application of QIPS, but pharmacy residents are less aware of QIPS. Its inclusion in accrediting hospitals since 2005 was followed by its introduction to the dental and medical curriculum.^31,32 The need for further strengthening by adopting to accommodate senior residents’ feedback will improve high-quality patient care and safety within VISION 2030 Saudi Arabia. A follow-up survey after implementing the inclusion of QIPS in the curriculum and providing supervised QIPS projects is recommended to review the impact of such initiatives.

Limitations of the Survey

There were a few limitations in our study. Being a cross-sectional study with no stratification of subgroups, extrapolation of outcomes in subgroups and comparison should be done with caution as it reflects trends only and does not establish causal/temporal relationships of the outcomes with determinants. The participation was based on the online questionnaire. Nowadays ergometric issues are included in safety both for service providers as well as patients.^11,33,34 We did not include questions related to ergometric injury prevention and safety in the recent study. As many as 28% of respondents did not answer the questions related to current QIPS teaching. It is difficult to interpret as no teaching and therefore current status of QIPS teaching could be an underestimate.

Recommendations and Further Research

Improving the quality of health services and patient safety is teamwork and nursing staff, and mid-level professionals (paramedical staff) are vital for comprehensive efforts to reach the VISION 2030 goals of Saudi Arabia. More studies covering feedback from other health staff are encouraged. Periodic assessment after altering the training module for effective inclusion of patient safety culture will help in understanding the impact of such initiatives. The introduction of the QIPS curriculum into a Graduate Medical Education program was well-received by residents in the United States.³⁵ The feedback of senior residents in SA using a similar methodology for QIPS acceptance would be useful.

Incentive-based promotion of patient safety culture and inclusion of accreditation norms both of individual senior residents as well as training institutions could be an effective strategy for QIPS inclusion in the health education curriculum. Health institutions should look for QIPS educators who can be mentors of health students and thus clinicians can reduce the burden of such specialized education and focus on patient care in institutions with high workloads. Both on national and international platforms, residents should be encouraged and supported to share their experiences and outcomes of QIPS-related projects.

Conclusions

In this effort to generate evidence about senior residents’ perceived status of QIPS, we found that they were interested in QIPS but were dissatisfied with the current methods and opportunities to execute supervised QIPS projects. The trend suggested that the residents of dentistry followed by medical branches of health science were more satisfied with training and opportunities for QIPS projects compared to the residents of pharmacy faculty. The inclusion of QIPS within the health science curriculum and encouraging the mentors to support residents’ QIPS projects will enable the institutions to reach the goal of building a patient safety environment. The gender and number of years in senior residency seem not to influence the responses in this survey. Such studies, if complemented by clinical competency assessment would be a step forward in strengthening the movement for QIPS in different health services. The periodic feedback from residents will also help in understanding their perceptions about the action taken.

Footnotes

Acknowledgments

We would like to thank all resident participants who completed the questionnaires and the colleagues who supported them in this task.

FUNDING

The authors received no financial support for the research, authorship, and/or publication of this article.

DECLARATION OF CONFLICTING INTERESTS

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Authors Contributions

Yahya: planning, field part, data management, and manuscript writing; Mousa: planning, field part, and manuscript writing; Muntasir: planning, field part, and manuscript writing; Ibrahim: planning and manuscript writing.

Appendix

References

World Health Organization. Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care. World Health Organization. 2016. accessed January 01, 2023. Global Patient Safety Action Plan 2021-2030 (who.int)

World Health Organization. Improving the quality of care and patient safety in the eastern Mediterranean region. East Mediterr Health J. 2015;21(2):147-150.

Saudi Patients Safety Centre. Ministry of Health, Saudi Arabia. Saudi Patient Safety Taxonomy. Saudi-Patient-Safety-Taxonomy.pdf (moh.gov.sa). Accessed August 13, 2023.

Trivedi

Hartmann

Hall

, et al. Residents’ perspective of quality improvement and patient safety education in Canadian emergency medicine residency programs. CJEM. 2020;22(2):224-231.

Goldman

Smeraglio

, et al. Theory in quality improvement and patient safety education: a scoping review. Perspect Med Educ. 2021;10(6):319-326.

. Expanding training in quality improvement and patient safety through a multispecialty graduate medical education curriculum designed for fellows. MedEdPORTAL. 2020;16:11064.

Wong

Etchells

Kuper

, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med. 2010;85(9):1425-1439.

Al-Khaldi

. Attitude of primary care physicians toward patient safety in Aseer region, Saudi Arabia. J Family Community Med. 2013;20(3):153-158.

Al Qarni

Al-Nasser

Alzahem

, et al. Quality improvement and patient safety education in internal medicine residency training program: an exploratory qualitative study. Adv Med Educ Pract. 2021;12:499-506.

. Patient safety culture awareness among healthcare providers in a tertiary hospital in Riyadh, Saudi Arabia. Front Public Health. 2022;10:953393.

. Patient safety culture perceptions in the college of dentistry. Medicine (Baltimore). 2018;97(2):e9570.

. Optimizing human factors in dentistry. Dent Res J (Isfahan). 2013;10(2):254-259.

13.

Herzog

Beharic

, et al. Ergonomic analysis and simulation in department of ophthalmology. Procedia Manufacturing. 2015;3:128-135. https://doi.org/10.1016/j.promfg.2015.07.117

, et al. Clinical pharmacy definition, required education, training and practice in Saudi Arabia: a position statement by the Saudi Society of Clinical Pharmacy. Saudi Pharm J. 2021;29(11):1343-1347.

15.

Liu

Zhao

, et al. Perceptions of patient safety culture among medical students: a cross-sectional investigation in Heilongjiang Province, China. BMJ Open. 2018;8(7):e020200.

. OpenEpi: open-source epidemiologic statistics for public health, version. updated April 4, 2013. Accessed May 12, 2023. www.OpenEpi.com

17.

Ministry of Health & Vision 2030 Kingdom of Saudi Arabia. Statistical Yearbook 2021. Graduates in health colleges of Saudi Arabia in 2020–21. Table 2–42. Page 168–70. Statistical-Yearbook-2021.pdf (moh.gov.sa) accessed on 01/05/2023.

18.

Joshi

Kale

Chandel

Pal

. Likert scale: explored and explained. Br J Appl Sci Technol. 2015;7(4):396-403.

19.

Leung

Patil

. Patient safety in the undergraduate curriculum: medical students’ perception. Hong Kong Med J. 2010;16(2):101-105.

20.

Kamran

Bari

Khan

, et al. Patient safety awareness among undergraduate medical students in Pakistani medical school. Pak J Med Sci. 2018;34(2):305-309. doi:10.12669/pjms.342.14563

21.

Naser

Alsairafi

Awaisu

, et al. Attitudes of pharmacy students towards patient safety: a cross-sectional study from six developing countries. BMJ open. 2020;10(12):e039459.

22.

Aboumatar

Thompson

, et al. Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students. BMJ Qual Saf. 2012;21(5):416-422.

23.

Wong

Baum

Headrick

, et al. Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care. Acad Med. 2020;95(1):59-68.

24.

Myers

Tess

Glasheen

, et al. The quality and safety educator's academy: fulfilling an unmet need for faculty development. Am J Med Qual. 2014;29(1):5-12.

25.

Pritchard

Alavian

Soogoor

Bartels

Hall

. Global health competencies in postgraduate medical education: a scoping review and mapping to the CanMEDS physician competency framework. Can Med Educ J. 2023;14(1):70-79.

26.

Widdifield

Ryan

O'Sullivan

. Understanding the role of the qualified professional: a comparison of medical and dental students’ attitudes. Ir Med J. 2006;99(9):273-276.

27.

Paradis

Zhao

Kellar

Thompson

. How are competency frameworks perceived and taught?: An exploratory study in the context of pharmacy education. Perspect Med Educ. 2018;7(3):200-206.

28.

Tegegn

Abebe

Ayalew

, et al. Patient safety attitudes of pharmacy students in an Ethiopian university: a cross-sectional study. Drug Health Patient Saf. 2017;9:19-24.

29.

Bari A, Jabeen U, Bano I, et al. Patient safety awareness among postgraduate students and nurses in a tertiary health care facility. Pak J Med Sci. 2017;33(5):1059-1064.

30.

Kirkman

Sevdalis

Arora

Baker

Vincent

Ahmed

. The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review. BMJ Open. 2015;5(5):e007705.

31.

World Health Organization. Regional Committee for the Eastern Mediterranean. Technical Paper Regional Strategy for Enhancing Patient Safety. Fifty-Second Session Agenda Item 5 (b). 2005. Accessed September 28, 2023. http://www.emro.who.int/rc52/media/pdf/EMRC5204en.pdf.

32.

al Awa

Jacquery

Almazrooa

, et al. Comparison of patient safety and quality of care indicators between pre and post-accreditation periods in King Abdulaziz University Hospital. Res J Med Sci. 2011;5(1):61-66.

33.

Betsch

Gjerde

Lewis

, et al. Ergonomics in the operating room: it doesn't hurt to think about it, but it may hurt not to!. Can J Ophthalmol. 2020;55(3):17-21.

34.

Honavar

. Head up, heels down, posture perfect: ergonomics for an ophthalmologist. Indian J Ophthalmol. 2017;65(8):647-650.

35.

Mustafa

Gillenwater

Miller

, et al. QIPS CURE: implementing a quality improvement and patient safety curriculum and resident experience. J Grad Med Educ. 2020;12(4):469-477.

Quality Improvement and Patient Safety Education in Postgraduate Training Program—A Survey of Residents in Saudi Arabia