HOUSE OFFICERS' PERCEPTIONS OF PATIENT SAFETY AT THE DEFENCE SERVICES MEDICAL ACADEMY

Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17852626 359 ISRG PUBLISHERS Abbreviated Key Title: ISRG J Arts Humanit Soc Sci ISSN: 2583-7672 (Online) Journal homepage: https://isrgpublishers.com/isrgjahss Volume – III Issue -VI (November-December) 2025 Frequency: Bimonthly HOUSE OFFICERS’ PERCEPTIONS OF PATIENT SAFETY AT THE DEFENCE SERVICES MEDICAL ACADEMY Myint Thein Naing1*, Zaw Phyo2, Pyi Hein Kyaw3, Ye Phyo Aung4 & Nwe Nwe Win5 1, 2, 3, 4 Defence Services Medical Academy, Myanmar 5 No. (2) Military Hospital (500-Bedded), Myanmar | Received: 01.12.2025 | Accepted: 06.12.2025 | Published: 08.12.2025 *Corresponding author: Myint Thein Naing Defence Services Medical Academy, Myanmar Abstract Background: Patient safety is a core component of medical education globally, yet evidence from lowand middle-income countries (LMICs) suggests persistent challenges in error reporting, disclosure, and systems-based understanding. Evaluating early-career doctors’ perceptions is essential to improving safety culture. Objective: To assess house officers’ perceptions of patient safety across nine domains at the Defence Services Medical Academy (DSMA). Methods: A cross-sectional study was conducted among 42 house officers using the Attitudes to Patient Safety Questionnaire Version III (APSQ-III). Responses to 26 items across nine domains were analysed. Results: Strongest positive attitudes appeared in team functioning (95%), patient involvement (89%), and training (77%). Lowest were disclosure responsibility (34%) and error reporting confidence (36%). Conclusion: DSMA house officers demonstrate strong teamwork and safety knowledge but low error reporting and disclosure confidence. Keywords: patient safety, medical education, error reporting, disclosure, teamwork, APSQ-III, undergraduate training Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17852626 360 Introduction Patient safety has become a central priority in modern healthcare systems, defined by the World Health Organization (WHO) as the ―absence of preventable harm and reduction of unnecessary risk to an acceptable minimum‖ (WHO, 2021). Despite global advances, patient harm remains a persistent challenge, particularly in lowand middle-income countries (LMICs), where systemic pressures, resource limitations, and fragmented care environments amplify vulnerabilities. Current global estimates indicate that up to 134 million adverse events occur annually in LMIC hospitals, contributing to 2.6 to 3 million deaths each year (WHO, 2019). Strengthening safety culture has therefore become a foundational requirement for improving healthcare quality. Medical education plays an essential role in shaping attitudes, knowledge, and behaviours related to patient safety. The landmark Institute of Medicine report To Err Is Human (Kohn et al., 2000) highlighted the need for early development of safety competencies, prompting many medical schools to embed structured patientsafety teaching into curricula. Subsequent global initiatives, including the WHO Patient Safety Curriculum Guide, have emphasized systems thinking, teamwork, communication, human factors, and error disclosure as core competencies for undergraduate and postgraduate training (Walton et al., 2010). Recent literature (2020–2024) shows increasing evidence that integrating patient-safety education early in medical training improves learners’ understanding of error causation, reduces blame-oriented thinking, and enhances preparedness for clinical responsibilities. Ker et al. (2020) demonstrated that medical students exposed to structured safety curricula showed significantly improved competency in analyzing near misses and adverse events. Similarly, Wong et al. (2020) found that patientsafety teaching using simulation, case-based learning, and interprofessional modules strengthened decision-making and teamwork skills during clinical transitions. However, despite these advances, several persistent challenges remain. First, error reporting continues to be one of the weakest aspects of patient-safety culture among early-career doctors. Studies across Asia, Europe, and North America consistently show that junior physicians underreport errors due to fear of blame, disciplinary action, medicolegal concerns, and hierarchical pressure (Okuyama et al., 2019; Halligan & Zecevic, 2020). Even in institutions with reporting systems, young clinicians frequently perceive them as punitive, bureaucratic, or ineffective, which contributes to underreporting and limits organisational learning. Second, error disclosure—the process of openly informing patients about errors—remains a global challenge. Early-career physicians often feel unprepared, anxious, or uncertain about disclosure guidelines (Levinson & Gallagher, 2018). Recent studies indicate that structured disclosure training increases confidence but is still inconsistently implemented in many medical schools (Hannawa et al., 2020). This is particularly relevant in hierarchical or militarised systems, where speaking up or admitting error may carry perceived personal or professional risk. Third, the literature consistently highlights the importance of teamwork and interprofessional collaboration. High-functioning teams with clear communication, psychological safety, and shared responsibility show significantly lower rates of adverse events (Salas et al., 2018; Weaver et al., 2021). Medical education programs worldwide now include interprofessional activities, but full integration remains uneven across LMIC settings, where role hierarchy and limited exposure to multidisciplinary teams can hinder collaboration. Fourth, patient involvement is increasingly recognized as a crucial component of safety. Engaging patients in medication review, shared decision-making, and care planning has been shown to reduce preventable errors and improve health outcomes (Bell et al., 2017). The emerging 2021–2030 Global Patient Safety Action Plan emphasizes patient partnership as a core pillar of safe systems (WHO, 2021). Nevertheless, studies reveal inconsistent attitudes among trainees regarding the extent to which patients should be involved in identifying risks or preventing errors (Schwappach, 2021). Within LMIC and Southeast Asian contexts, research remains limited but indicates similar patterns: trainees demonstrate strong foundational safety knowledge but lower confidence in error reporting, systems-based practice, and disclosure (Nie et al., 2013; Rajalatchumi et al., 2018). Structural barriers, cultural norms favoring hierarchy, and limited institutional support often compound these challenges. In Myanmar, empirical evidence regarding patient-safety attitudes among medical trainees is scarce. The Defence Services Medical Academy (DSMA) provides a structured, competency-based curriculum, but prior internal evaluations suggest the need for systematic integration of patient safety principles across preclinical and clinical phases. Understanding the perceptions of house officers—who are at a critical juncture between training and independent clinical practice—is therefore essential for identifying strengths, gaps, and opportunities for curriculum enhancement. Given this context, the present study assesses the perceptions of DSMA house officers across nine key domains of patient safety using the validated Attitudes to Patient Safety Questionnaire Version III (APSQ-III). By identifying areas of strong confidence and critical weaknesses, this study aims to inform targeted educational strategies and institutional reforms that support a stronger and more sustainable patient-safety culture within the Myanmar military medical system. Methods Study Design and Setting A cross-sectional descriptive study was conducted at DSMA (Yangon, Myanmar) between December 2019 and August 2020. The study targeted house officers from the 21st intake during their Community Medicine rotation. Participants All 42 house officers meeting inclusion criteria (DSMA graduates entering internship) were invited. Participation was voluntary, anonymous, and conducted after informed consent. Instrument The Attitudes to Patient Safety Questionnaire – Version III (APSQ-III), a validated tool with 26 items across nine domains (Carruthers et al., 2009), was administered. Items were rated on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree), with higher scores indicating more positive attitudes. Eight reverse-scored items were scored according to APSQ-III guidelines. Patient-Safety Domains Assessed Therse are assessed by the following eight domains: Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17852626 361 1. Patient-safety training received 2. Error reporting confidence 3. Working hours as an error cause 4. Error inevitability 5. Professional incompetence as error cause 6. Disclosure responsibility 7. Team functioning 8. Patient involvement in reducing error 9. Importance of patient safety in the curriculum Data Analysis Using SPSS and Excel, means, standard deviations, and proportions of positive, neutral, and negative responses were computed. Positive responses were defined as 5–7 on the Likert scale, neutral as 4, and negative as 1–3. Results Table 1. Summary of Key Findings Across APSQ-III Domains APSQ-III Domain Mean ± SD Positive Response (%) Interpretation 1. Patient-safety training received 5.2 ± 1.42 77% Strong foundation in patient-safety education. 2. Error reporting confidence 3.6 ± 1.42 36% Low confidence in reporting own or others’ errors. 3. Working hours as an error cause 4.8 ± 1.42 60% Recognition that fatigue contributes to clinical errors. 4. Error inevitability 5.1 ± 1.44 49% Mixed perceptions; partial understanding of human error. 5. Professional incompetence as error cause 3.6 ± 1.42 55% Persistent elements of blame-based thinking. 6. Disclosure responsibility 5.0 ± 1.42 34% Low confidence in error disclosure requirements. 7. Team functioning 6.0 ± 1.42 95% Strong teamwork culture; highest-scoring domain. 8. Patient involvement in reducing error 5.75 ± 1.42 89% Very positive attitudes toward patient involvement. 9. Importance of patient safety in the curriculum 5.5 ± 1.42 77% Strong support for including safety in the curriculum. Discussion This study provides an essential baseline assessment of house officers’ perceptions of patient safety at the Defence Services Medical Academy (DSMA). Overall, respondents demonstrated strong positive attitudes toward teamwork functioning, patient involvement, and foundational patient-safety training. However, significant gaps remain in error reporting confidence and disclosure responsibility—patterns that mirror findings from international literature and several LMIC contexts. These results highlight both strengths within the DSMA curriculum and areas where institutional and educational reforms could greatly enhance the development of a safety culture. Strong Foundations in Patient-Safety Education One of the key strengths observed in this study is the high level of confidence house officers expressed regarding the patient-safety training received during their undergraduate education. More than three-quarters of respondents believed their training prepared them to understand and prevent medical errors. These findings align with recent global evidence showing that early and structured exposure to patient-safety principles improves learners’ systems thinking, awareness of error causation, and confidence in safe clinical practice (Ker et al., 2020; Wong et al., 2020). The positive results also reflect the broader educational movement driven by international frameworks—particularly the WHO Patient Safety Curriculum Guide—which emphasizes that medical students should be introduced early to human factors, teamwork, communication, and systems-based practice (Walton et al., 2010; WHO, 2021). These results suggest that DSMA’s inclusion of patient-safety concepts is consistent with global recommendations and may be yielding meaningful improvements in trainees’ understanding and preparedness. Team Functioning as the Strongest Domain The highest positive domain score was for team functioning, with 95% of house officers agreeing that multidisciplinary teamwork reduces medical errors. This strong endorsement is consistent with evidence demonstrating that teamwork, psychological safety, and interprofessional collaboration are critical determinants of safe care (Salas et al., 2018; Weaver et al., 2021). High team-functioning scores may reflect DSMA’s structured group learning and the collaborative nature of their clinical training rotations. Similar findings have been reported across both highincome and LMIC settings, where young physicians often recognize the importance of teamwork more readily than other complex domains such as error reporting or systems analysis (Halligan & Zecevic, 2020). These results highlight teamwork as an existing strength that can serve as a foundation for future improvement in other patientsafety domains such as communication, reporting culture, and disclosure. Patient Involvement: A Positive and Forward-Looking Attitude House officers also demonstrated very positive attitudes toward patient involvement in preventing errors. This aligns with contemporary thinking in patient-safety science, where patient engagement is considered a critical strategy for reducing adverse events, improving medication safety, and strengthening communication (Bell et al., 2017; Schwappach, 2021). The strong support for patient involvement suggests that DSMA trainees endorse a patient-centred approach to safety, consistent Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17852626 362 with the emerging 2021–2030 WHO Global Patient Safety Action Plan. This finding is particularly noteworthy within the context of Myanmar’s military medical system, where paternalistic care models may historically have limited patient autonomy. Recognition of Systems Factors, Yet Persistent Elements of Blame Culture Responses to the ―professional incompetence‖ and ―error inevitability‖ domains indicate mixed attitudes. Many respondents correctly acknowledged that errors can occur even among highly competent doctors and that human error is a natural part of clinical work. These findings reflect growing awareness of systems-based practice and human factors—core tenets of modern safety science. However, a sizeable proportion still attributed errors to carelessness, irresponsibility, or individual incompetence. This tension between systems thinking and blame culture is consistent with international studies showing that although trainees may intellectually understand systems causes of error, they continue to internalize the broader healthcare culture that emphasizes personal fault (Halligan & Zecevic, 2020; Okuyama et al., 2019). These mixed attitudes underscore the need for more explicit teaching on human factors, systems theory, and organizational learning, along with opportunities for trainees to participate in rootcause analyses and morbidity-and-mortality discussions. Fatigue and Workload as Recognized Contributors to Error House officers’ recognition of long work hours, lack of breaks, and fatigue as contributors to error is consistent with a large body of literature demonstrating that extended shifts impair clinical judgment, increase reaction time, and heighten the likelihood of near misses or adverse events (Lockley et al., 2020). This finding suggests that trainees have appropriate insight into the role of workload and human limitations in clinical performance. However, recognition alone is insufficient unless supported by structural interventions. In many LMICs—including Myanmar— resource limitations, staff shortages, and rigid duty rosters make it difficult to implement work-hour reforms. Nevertheless, institutional attention to rest-break policies, fatigue management, and shift design could improve both patient safety and trainee wellbeing. Low Error Reporting Confidence: A Critical Weakness One of the most concerning findings is the consistently low confidence in error reporting. Only 21% felt comfortable reporting their own errors, and even fewer (14%) felt comfortable reporting errors made by others. This mirrors global evidence indicating that junior doctors commonly fear blame, professional repercussions, embarrassment, and disciplinary action when considering reporting errors (Kaldjian et al., 2009; Okuyama et al., 2019). This pattern is further amplified in hierarchical medical systems, where trainees may perceive reporting as risky or inappropriate. These findings strongly suggest the presence of a punitive or unsupportive reporting environment—one of the most significant barriers to patient-safety culture improvement. International best practice highlights that ―just culture,‖ nonpunitive systems, and anonymous reporting mechanisms improve reporting rates and organizational learning (WHO, 2021). DSMA and affiliated hospitals may therefore need to strengthen their reporting frameworks, provide reassurance about protection from blame, and integrate training on how to recognize and report errors safely. Disclosure Responsibility Remains Underdeveloped House officers also demonstrated low confidence in their responsibility to disclose errors, reflecting a well-documented global challenge. Literature shows that physicians at all levels experience anxiety about disclosing errors due to fear of harming patient trust, medicolegal concerns, or uncertainty about communication strategies (Levinson & Gallagher, 2018; Hannawa et al., 2020). These findings highlight the need for structured communication curricula, including simulation-based disclosure training, which has been shown to significantly improve confidence and competence among medical trainees. Incorporating such training into DSMA’s curriculum would meaningfully address one of the weakest domains identified.. Overall, DSMA house officers exhibit promising strengths in teamwork, patient involvement, and safety knowledge. However, the persistent challenges in reporting and disclosure mirror global trends and underscore the need for cultural and institutional reforms. Addressing these gaps through curriculum enhancement and systemic support will be essential to fostering a robust, sustainable patient-safety culture in the Myanmar military medical system. Conclusion This study provides an important baseline understanding of patientsafety attitudes among house officers at the Defence Services Medical Academy. Overall, trainees demonstrated strong foundations in teamwork, patient involvement, and the value of patient-safety education—domains that align closely with global patient-safety priorities and WHO recommendations. These strengths indicate that DSMA’s curriculum successfully introduces key concepts essential for safe clinical practice. However, persistent weaknesses in error reporting confidence and disclosure responsibility highlight significant challenges within the institutional safety culture. Fear of blame, uncertainty about reporting mechanisms, and limited communication training mirror trends found worldwide among early-career doctors and indicate areas requiring urgent attention. Mixed attitudes toward error causation further suggest that traditional blame-oriented perspectives have not yet fully transitioned to systems-based thinking. To advance patient-safety culture, DSMA and its affiliated training environments should strengthen non-punitive reporting systems, embed structured communication and disclosure training, expand human factors and systems-based learning, and address workloadrelated contributors to error. By reinforcing these elements, medical educators and institutional leaders can support house officers in developing the skills, confidence, and reflective capacity necessary for safe, high-quality patient care. Ultimately, cultivating a robust patient-safety culture will require integrated educational strategies and organizational commitment. Addressing the identified gaps will not only enhance the training environment but also contribute to improved patient outcomes across the healthcare system. Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17852626 363 Recommendations Based on the findings of this study, several targeted recommendations are proposed to strengthen the patient-safety culture and educational environment at the Defence Services Medical Academy (DSMA) and its affiliated training hospitals. These recommendations address both the strengths identified— such as positive attitudes toward teamwork and patient involvement—and the critical gaps observed in error reporting, disclosure practices, and systems thinking. 1. Foster a Non-Punitive Error Reporting Culture A major barrier identified in this study is the low confidence among house officers to report errors. To address this, DSMA training hospitals should develop stronger non-punitive, ―just culture‖ frameworks that clearly distinguish between human error, at-risk behavior, and reckless behavior. Anonymous or confidential reporting mechanisms should be introduced or strengthened to reduce fear of blame and negative consequences. Regular communication from leadership emphasizing learning rather than punishment can further help shift attitudes. Providing feedback to staff on how reported errors are used to implement safety improvements will reinforce transparency and trust in the system. 2. Implement Structured Error Disclosure and Communication Training Low confidence in disclosure responsibility highlights the need for explicit communication training. DSMA should integrate simulation-based modules that teach trainees how to disclose errors empathetically and professionally. Training should include communication frameworks, role-play with standardized patients, and constructive feedback. Clinical supervisors should model best disclosure practices so trainees can observe and practice in realworld settings. Clear institutional guidelines outlining the steps of error disclosure should be made available and consistently reinforced. 3. Strengthen Systems-Based Thinking and Human Factors Education Mixed attitudes toward professional incompetence and error inevitability suggest incomplete understanding of systems thinking. Incorporating more teaching on human factors engineering, organizational safety principles, and systems-level contributors to harm is essential. Trainees should be actively involved in morbidity-and-mortality rounds, near-miss reviews, and root-cause analyses to reinforce practical application. Embedding these opportunities within clinical rotations will help normalize systemsoriented safety thinking. 4. Expand Interprofessional Training and Team-Based Learning Given the strong positive attitudes toward teamwork, DSMA can build on this strength by expanding interprofessional learning. Collaborative training sessions involving nursing, pharmacy, and allied health students can promote mutual understanding of roles and enhance communication. High-fidelity team simulations focusing on handovers, emergency responses, and conflict resolution will help build shared mental models and reinforce safe team practices. 5. Promote Patient Engagement in Safety The positive attitudes toward patient involvement can be translated into practice through training on shared decision-making, active communication strategies, and patient-centred care approaches. Encouraging trainees to involve patients in medication reconciliation, safety checks, and care discussions can enhance safety and build trust. Incorporating patient feedback into quality improvement and teaching activities will further strengthen a culture of patient partnership. 6. Address Workload, Fatigue, and Duty-Hour Factors Recognizing the impact of fatigue on safety, DSMA institutions should evaluate duty-hour schedules, ensure protected rest periods, and enforce break policies. Teaching trainees about fatigue risk management, sleep hygiene, and strategies for maintaining alertness during long shifts can help reduce workload-related errors. Supervisors should monitor signs of fatigue and encourage supportive scheduling practices. 7. Invest in Faculty Development and Leadership Engagement Faculty members play a crucial role in shaping trainees’ perceptions of safety. DSMA should provide faculty development programs on coaching, feedback, communication during errors, and leading debriefings. Visible leadership engagement in patientsafety initiatives—such as safety walkrounds, reporting reviews, and QI activities—signals institutional commitment and encourages trainees to prioritize safety. References 1. Bell, S. K., Gerard, M., Fossa, A., Shea, J. A., Worster, B., & Gallagher, T. H. (2017). A patient-centered approach to patient safety: Engaging patients as partners in care. BMJ Quality & Safety, 26(9), 1–9. https://doi.org/10.1136/bmjqs-2017-006191 2. Carruthers, S., Lawton, R., Sandars, J., Howe, A., & Perry, M. (2009). Attitudes to patient safety amongst medical students and tutors: Developing a reliable and valid measure. Medical Teacher, 31(8), e370–e376. https://doi.org/10.1080/01421590902970217 3. Halligan, M., & Zecevic, A. (2020). Safety culture in healthcare: A review of concepts, dimensions, measures and progress. BMJ Quality & Safety, 29(6), 1–10. https://doi.org/10.1136/bmjqs-2019-010350 4. Hannawa, A. F., Shigemoto, Y., & Little, T. D. (2020). Medical error disclosure training: Evidence, gaps, and future directions. Patient Education and Counseling, 103(11), 2204–2212. https://doi.org/10.1016/j.pec.2020.06.012 5. Kaldjian, L. C., Jones, E. W., Wu, B. J., FormanHoffman, V. L., Levi, B. H., & Rosenthal, G. E. (2009). Reporting medical errors to improve patient safety: A survey of physicians in teaching hospitals. Archives of Internal Medicine, 169(1), 40–47. https://doi.org/10.1001/archinternmed.2008.521 6. Ker, J., Bradley, P., & Wilson, A. (2020). Integrating patient-safety training into undergraduate medical education: A structured approach improves learning outcomes. Medical Education, 54(8), 678–689. https://doi.org/10.1111/medu.14177 7. Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: Building a safer health system. National Academies Press. Copyright © ISRG Publishers. All rights Reserved. DOI: 10.5281/zenodo.17852626 364 8. Levinson, W., & Gallagher, T. H. (2018). Disclosing medical errors to patients: A status update. BMJ, 362, k3312. https://doi.org/10.1136/bmj.k3312 9. Lockley, S. W., Barger, L. K., & Landrigan, C. P. (2020). Work hours, fatigue, and patient safety. In A. Carayon (Ed.), Handbook of human factors and ergonomics in healthcare and patient safety (2nd ed., pp. 385–404). CRC Press. 10. Nie, Y., Mao, X., Cui, H., He, S., Li, J., & Zhang, M. (2013). Hospital survey on patient safety culture in China. BMC Health Services Research, 13, 228. https://doi.org/10.1186/1472-6963-13-228 11. Okuyama, A., Wagner, C., & Bijnen, B. (2019). Speaking up for patient safety by hospital-based health care professionals: A literature review. Journal of Patient Safety, 15(4), 269–276. https://doi.org/10.1097/PTS.0000000000000246 12. Rajalatchumi, A., Ravikumar, K. G., Balasubramanian, S., et al. (2018). Perception of patient safety culture among healthcare workers in a tertiary care hospital in South India. Journal of Natural Science, Biology and Medicine, 9(1), 14–18. 13. Salas, E., Reyes, D. L., & Woods, A. L. (2018). The science of team performance: Progress and the need for more. BMJ Quality & Safety, 27(7), 1–8. https://doi.org/10.1136/bmjqs-2017-007668 14. Schwappach, D. L. B. (2021). Engaging patients as partners in safety: Barriers and facilitators. Eurohealth, 27(3), 35–38. 15. Walton, M., et al. (2010). The WHO patient safety curriculum guide for medical schools. BMJ Quality & Safety, 19(6), 542–546. https://doi.org/10.1136/qshc.2009.036954 16. Weaver, S. J., Dy, S. M., & Rosen, M. A. (2021). Teamtraining in healthcare: A narrative synthesis of the literature. BMJ Quality & Safety, 30(3), 182–193. https://doi.org/10.1136/bmjqs-2020-011342 17. Wong, B. M., Etchells, E., Kuper, A., Levinson, W., & Shojania, K. G. (2020). Teaching quality improvement and patient safety to trainees: An updated systematic review. Academic Medicine, 95(12), 1945–1954. https://doi.org/10.1097/ACM.0000000000003478 18. World Health Organization. (2019). Patient safety: Global action on patient safety. WHO. 19. World Health Organization. (2021). Global patient safety action plan 2021–2030: Towards eliminating avoidable harm in health care. WHO.