Enhancing adoption of patient safety culture assessments in Brazil: a strategy informed by CFIR and ERIC

Abstract Background Regular assessments of Patient Safety Culture (PSC) are recommended by the World Health Organization to strengthen healthcare systems. In Brazil, despite national campaigns, hospital adherence to PSC assessments has remained low. This study aimed to design a tailored implementation strategy to improve the uptake of PSC assessments in Brazilian hospitals, addressing the key barriers faced in previous national efforts. Methods We conducted a sequential exploratory mixed-methods study in three phases. First, a qualitative survey with 82 patient safety center coordinators identified perceived barriers and facilitators to implementing PSC assessments. Then, a quantitative survey with 297 coordinators prioritized the most relevant barriers. Finally, we used the Consolidated Framework for Implementation Research (CFIR) and the Expert Recommendations for Implementation Change (ERIC) to guide the design of a tailored implementation strategy aligned with the prioritized barriers. Results The main barriers included insufficient dissemination of PSC assessments, lack of training for staff, resistance to completing the survey, the excessive length of the questionnaire, and technical limitations of the data collection platform. The co-design implementation strategy includes 16 actions such as improving communication, offering training, adapting the technology platform, and revising roles and responsibilities within hospitals. These actions were aligned with the identified barriers and aim to enhance organizational readiness, reduce complexity, and promote engagement. Conclusions Our findings highlight critical factors limiting the adoption of PSC assessments in Brazil and offer a data-driven, context-sensitive implementation strategy to overcome them. These results provide actionable recommendations for policymakers, healthcare managers, and regulators aiming to strengthen patient safety culture in large-scale, resource-constrained health systems.