Patient safety culture across hospital tiers in China: a cross-sectional survey of healthcare professionals

BACKGROUND: Patient safety culture (PSC) is a key component of healthcare quality and system resilience. Despite extensive research, limited evidence is available on how PSC differs across hospital tiers within structured health systems or how such differences are patterned. Understanding tier-specific variation in PSC is important for informing safety improvement efforts in health systems characterised by resource stratification and tiered service delivery. This study aimed to assess PSC across hospital tiers in China and to examine factors associated with healthcare professionals' (HCPs') perceptions of PSC. METHODS: A multicentre cross-sectional survey was conducted between December 2023 and August 2024 in Chongqing, China, using a multistage stratified sampling design. A total of 4,030 valid questionnaires were collected from HCPs working in primary, secondary, and tertiary hospitals. PSC was measured using the validated Chinese version of the Hospital Survey on Patient Safety Culture (HSOPSC) 2.0. Post-stratification weighting was applied, and data were analysed using descriptive statistics, one-way analysis of variance (ANOVA), and multiple linear regression. RESULTS: PSC scores differed significantly across hospital tiers (F = 171.448, p < 0.001), increasing from primary (112.45 ± 12.08) to secondary (117.05 ± 13.43) and tertiary hospitals (121.17 ± 13.77). The regression model explained 29.2% of the variance in PSC perceptions (adjusted R² =0.288). Higher self-assessed safety level (β = 0.477, p < 0.001), higher monthly income (β = 0.152, p < 0.001), and female gender (β = 0.071, p < 0.001) were positively associated with PSC, while working in an allied health department was negatively associated (β = -0.054, p = 0.001). Across all tiers, "identifying patients correctly" and "medication safety" were the most frequently prioritised patient safety goals. CONCLUSION: PSC perceptions varied systematically across hospital tiers in Chongqing. These differences appear to coexist with variations in organisational context, workforce composition, and institutional characteristics across tiers. By applying an organisational ecosystem perspective, this study offers an additional framework for interpreting PSC variation within tiered healthcare systems. The findings highlight the potential value of tier-sensitive approaches to patient safety improvement and may inform safety strategies in other health systems with similar structural arrangements.