The present study revealed high almost similar percentages (93.2–98%) of an implemented safe injection, infection control, and post-exposure needle stick injury policies and procedures in both hospitals, reflecting appropriate awareness as regards safe injection practice. These results are contrary to the results reported by a similar study in Gharbia, Egypt , and by an African study reporting that 62.1% of the respondents reported that such policies are not in existence in their hospitals .
In addition, higher safe injection (94.8%) and waste sorting (84.8%) training percentages were reported among the BSUH nursing staff compared to the MCH-Qassim training (70% for each category), reflecting a higher mean safe injection awareness score among the Egyptian participants. The present findings are similar to the reported 91% safe injection practice training in a Romanian study  and higher than that reported (27–33%) in Nepal, Ethiopia, and Bangladesh [14,15,16], reflecting the national interest of safe injection training practice among the current study hospitals.
Similarly, high awareness was reported among nurses in both study hospitals as regards measures to be taken after NSI (96% and 92.8%) and blood-borne diseases transmitted by unsafe injection practice (100% and 97.9%). These findings are similar to the reported 92.1% awareness of nurses for measures to be taken after NSI in West Bengal , higher than the reported 68% in Patiala, North India , and similar to the reported high percentage of awareness of blood-borne diseases transmitted by unsafe injection practice in India , West Bengal , and Nigeria .
Complete vaccination doses against hepatitis B among the 2 hospitals’ nursing study group showed a lower percentage among the MCH-Qassim (62.4%) participants compared to the BSUH (76%) participants. Higher rates were reported by other studies conducted in Nepal (76.8%) , Pokhara, Iran (82.3%) , Rawalpindi (82.7%) , and Karachi (73%) . On the contrary, the vaccination coverage for both hospital groups of nurses was higher than that reported in two similar studies conducted in (52.2 and 21.1% .2% respectively) [24, 25]. Health care providers must be provided with full vaccination coverage for patients’ self-safety.
In this study, good awareness towards safe injection (92% and 99.2%) of the MCH-Qassim and BSUH nursing staff were reported. These rates are similar to the reported 90% good knowledge in a Nigerian study  but contrary to the low (37.7%) awareness score reported in Asaba, Nigeria , and the rate reported in Esan central LGA of Edo State, Nigeria .
Injection safety practices in both hospitals were satisfactory. Most of the observed nurses (95.6%) used new syringes and needles for each injection. These findings were consistent with the reported 95.7% new syringe and needle usage in a similar Egyptian study  and the 100% new syringe usage in a Romanian study  and higher than the reported 72% in another study in Nepal .
Safe injection practice was observed among nurses in this study with a minor difference between the 2 hospital groups. For the item safe injections are prepared on a clean tray, 94% and 79.2% of the observed nurses among MCH-Qassim and BSUH showed a correct practice respectively. A finding which is higher than a similar study conducted in SSKM Hospital, Kolkata, and West Bengal reported that 60% of the nursing personnel maintained the use of clean tray for safe injections .
As for the item washing hand or using alcohol hand rub before wearing gloves, 78% and 92% of the MCH-Qassim and the BSUH nursing staff were observed to perform a correct hand hygiene practice, percentages which are lower than the reported percentages in similar Nigerian (78.7%)  and Nepalese (63.2%) studies  and higher than the lower percentages reported in different studies for hand wash practices: 20% in Nigeria , 20% in Patiala , 12.5% in West Bengal , 4.6% in India , and 3.6% in a similar Egyptian study . The discrepancy may be attributed to the higher international awareness and practice training for the hand hygiene practice in the recent years.
Of note, for the item needles separated from its syringe inside sharps disposal box, there was a statistically significant difference between the 2 hospital nursing groups, where 97.6% of needles were found not separated inside the sharps box in BSUH vs. 92.8% for the MCH-Qassim. In addition, for the item presence of sharps disposal box near patient care areas, it was observed to be present in 97.6% in BSUH and 93.6% in MCH-Qassim (P = 0.001). These findings reflect a better practice than that reported in a similar Nigerian study which revealed that 25% of nurses frequently leave sharps at the patient’s bedside .
Preparing patient’s skin in an appropriate aseptic method was higher in MCH-Qassim (97.6%) than in BSUH (86.8%). Similarly, 99.03% of injections were prepared clean using aseptic precautions in a study conducted in India .
In the current study, a high score of safe injection practice among nurses of the 2 study hospitals was reported (97.6% and 98%). This finding is contrary to the reported low percentage (40 to 61.4% from North to West India) of safe injection practice [31, 32]. The good awareness and safe injection practices among the 2 hospital study nurses in the present study may be due to implementation of universal standard infection control practices in the Egyptian and Saudi Arabian nursing curriculum and the continuous professional training programs.
Nurses who have experienced needle stick injury in the past 12 months before the study constituted 5.6% among the MCH-Qassim nurses compared to 32.4% among the BSUH group of nurses. These findings are lower than that reported in a Nigerian study with a NSI of 15.8%  when compared with the MCH-Qassim group of nurses while higher for the BSUH-Egypt ones. In addition, NSI among both study groups are far less than that reported in other studies: 67.6% and 40.4%, in the 2 hospitals in Ibadan, Nigeria , and 50% in India . This disagreement might reflect the national interest in both countries towards safe injection training practice among the current study hospitals and positive attitude and appropriate implementation of safe injection policy and procedures.
In this study, the practice of two-handed recapping of needles after use and disposal in sharps box or disposal in non-medical waste constituted very low percentage in both hospitals (0.8% and 0.4%, respectively). Findings which are far below than that reported (71.4%) in a similar Egyptian series  and in other developing countries reported percentages of 9.05 to 17% in two Indian studies [19, 34], 11% in Pakistan , 19.1% in Nigeria , and 58% in Cambodia .
Limitations of the study
It is a single hospital questionnaire-based observational study in each country aimed to describe the pattern of safe injection practices among nurses. A single observation might not reflect the regular practice of nurses. There is a possibility of bias as healthcare providers may alter their behavior when they know that they are being observed. The possibility of bias is very high in the reported needlestick injuries; the main reasons stated for not reporting were time constraint and low perceived risk of disease transmission due to incident. This study did not aim for the consequent management of NSIs for the participants.