Patient safety is a critical component of healthcare quality. Evaluation of safety culture is the primary step towards improving the patient healthcare services in any healthcare organization and investigates the organizational conditions that negatively impact the patient and cause adverse events .
The overall mean score for positive perception of patient safety culture dimensions was calculated to be 46.56%, compared to 39.3% by El-Shabrawy et al.  in Beni Suef and 69% by Mohamed et al.  in Alexandria. In comparison with other Arab countries, these results were lower than the findings documented by Ghobashi et al. in a Kuwaiti study (69%) , El-Jardali et al. in Lebanon (61.5%) , Alahmadi in Saudi Arabia (61%) , and Hamdan and Saleem in Palestine (54%) . Globally, our findings were less than what were detected in China , Taiwan , the USA , and the Netherlands  to be 65%, 64%, 65%, and 52.2% respectively, but were higher than a study by Mekonnen et al. (46%) in Ethiopia . These findings were explained by a study done in Egypt  as a part of a WHO study in the Eastern Mediterranean region, which addressed the relation between reduced positive perception of patient safety culture dimensions and the culture of blame. The low perception resulted in a decline of the rate of reported errors by 6% which, in turn, contributed to 18% of patient’s permanent disability and mortality rate.
Targeting a positive score above 75% in any domain was reported to be the success level. Unfortunately, in the current study, no domain has achieved this level, and the highest scores were reported for organizational learning-continuous improvement as 65.36% and teamwork within hospital units as 63.09%. The least four dimensions less than 50% that need improvement were non-punitive response to error (34.7%), communication openness (17.9%), feedback and communication about error )20.3% ,(and number of events (30%). These findings were in line with previous findings reported by Aboul-Fotouh et al. .
Unlike the findings documented by Mekonnen et al.  in Ethiopia with two thirds of staff reported at least one adverse event in the previous year, approximately 44.3% of participants in the current study reported one to two events in the past 1 year. In agreement with the same study, nurses significantly reported better in the overall patient safety score compared with other paramedical personnel. The paramedics of internal medicine were better than the general surgery ones. Additionally, staffing was negatively correlated with all other dimensions except organizational learning and feedback about errors.
The dimension “frequency of adverse events (AEs) reported” had also a low score 30.48%. This could be explained by a lack of a reporting culture and the fact that errors are always considered as a lack of skill not as an opportunity to learn. The staff feels that the errors are alleged against them, and when a mistake is made, they feel that it is the person’s problem. Van Geest and Cummins mentioned three common barriers to report AEs: the punitive systems, humiliation, and fear .
The mean composite score for organizational learning-continuous improvement was 65.36% which is less than what was revealed by a study done in a teaching hospital in Egypt to be 78.2% , meaning that there is a learning culture only when mistakes are disclosed. A similar finding was reported among Iranian nursing staff (67%)  and the hospital staff in Saudi Arabia (75.9%) .
In line with other studies [16, 30], the next highest scoring dimension was teamwork within hospital units, 63.09%. This means that people like to actively perform and cooperate with their close peers in the same unit. Similarly, the score of teamwork within units documented in Saudi Arabia in King Fahd general hospital and Ajyad emergency hospital revealed that the teamwork within units for patient safety had 84% positivity . The current study revealed that staffing work condition score was above 50 (57.6%). Duffield et al.  referred to the association of lack of staff, work overload and unpleasant work environment with the adverse effects on patients, and the occurrence of errors in medical and surgical areas.
The lowest reported score was communication openness (17.9%) which is very low compared with the proportion reported by a study in Kuwait (45%) . That could explain the low number of reported events. A research conducted by Putri et al. addressed that communication openness has a positive and significant effect on the willingness to report patient safety incident . A culture of communication openness in an organization will encourage the feeling of being supported by the managerial office if something is wrong, which will lead to confidence to act appropriately. In other words, the communication needs to be more supportive and open and apply less blame . Handoffs and transition in the current study achieved 55.1% positivity which indicates that there is a real problem regarding the safe continuity of care.
More perception of safety dimensions was seen in females than males in dimensions as teamwork within hospital units, supervisor/manager expectations, and actions promoting safety; this was inconsistent with previous research in Egypt  and in Tunisia  as they documented no gender difference. The difference may be attributed to the differences in the female to male ratio which was higher in our study (0.98) compared to 0.72 in Tunisia  and 0.31 in the Egyptian study .
The current study revealed that overall perceptions of PS, communication openness, teamwork across units, handoffs and transitions, and number of events were significantly higher in participants in direct contact with patients which goes along with a study conducted in Kuwait .
Participants’ perception of PS grade showed that the proportion of participants’ perceived patient safety grade as excellent was 41.3%. On the other hand, the overall PS was rated as excellent or very good by 60% of respondents in a study done by Alahmadi, in Saudi Arabia . The difference could be the pursuing efforts to improve quality and safety of healthcare services. An initiative has been implemented to improve safety mainly through establishing standards and initiating accreditation schemes in seven developing countries .
Study strengths and limitations
This study was done among healthcare paramedics in secondary-care hospitals belonging to the Ministry of Health in Fayoum Governorate to determine which dimension affects PS culture most. To our knowledge, no study has investigated the perception of patient safety among paramedics. To increase generalizability and strength of the study, this study was carried out in urban and rural health facilities in Fayoum Governorate, with a sufficient sample size and a high response rate of 95.8%. The authors acknowledge some limitations during this study. The first limitation arises from the fact that the data were obtained from paramedics, most of them were nurses, without including physicians. This could be explained by the fact that the main goal of the current study was to focus on this group as was mentioned before. Additionally, the nurses were more available in the hospital during all day and night shifts, so they were the group that most likely to be easily approached for interviews. The study intended to support the concept that paramedic is an essential part of the healthcare team that needs to get attention from stalk holders and be trained on patient safety and identifying the risky behavior and reporting it without fear of repercussions. The second limitation was that the study did not cover the private sector. That was due to the inability of the authors to get the necessary approval.