PONE-D-24-47092Patient safety in public hospitals of Ethiopia: a systematic review and meta-analysisPLOS ONE

Dear Dr. Haile,

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Maher Abdelraheim Titi

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The author has followed the standard procedures in preparation of the manuscript. The study is scientifically sound and reliable. The methodology was sound ensuring validity of the results and the presentation of the findings and discussion is appropriate. Patient safety culture is a topical issue that needs to be explored and efforts should be made to improve it in order to achieve universal health coverage. The findings from the study should stimulate a deeper dive into the factors associated with sub optimal patient safety culture in Ethiopia and the African region.

Reviewer #2: • Clarity of Objectives:

They lack clear delineation, making it less accessible to readers.

• Abstract:

The abstract is comprehensive but dense. Key details such as the number of studies, methodology, and major findings could be presented more concisely.

• Consistency:

Phrases like "patient safety culture" and "culture of patient safety" are used interchangeably, potentially confusing readers.

• Background:

The introduction provides extensive global context but offers limited background on the Ethiopian healthcare system's specific challenges related to patient safety.

• Quality Assessment:

While the manuscript mentions the use of the Newcastle-Ottawa Scale, it does not detail the quality ratings or how low-quality studies impacted the results.

• Heterogeneity and Publication Bias:

The study reports high heterogeneity (I² = 93.9%), which is expected given the variability in healthcare settings across Ethiopia. However, the implications of such heterogeneity on the reliability of pooled estimates are not discussed.

• Implications and Recommendations:

Recommendations are general (education, training, guidelines) and lack specificity regarding implementation within Ethiopia’s resource constraints.

• Language and Grammar:

Grammatical errors and awkward phrasing detract from the manuscript's professionalism. For example:

o "Due to unsafe care, 134 million adverse events occur in hospitals in LMICs each year resulting in 2.6 million deaths" could be rephrased for clarity. Conduct a thorough language review or use professional editing services to polish the manuscript.

• Results

The narrative could benefit from restructuring for clarity. For example:

o Group statistical findings (e.g., prevalence, heterogeneity) separately from qualitative interpretations.

o Add a clear flow to the explanation of subgroup and sensitivity analyses.

• Addressing Heterogeneity:

Significant heterogeneity (I² = 93.0%) remains a limitation, and while the random-effects model mitigates this, further exploration into the sources of heterogeneity would strengthen the paper. Were differences in survey methodology, sample size, or health system infrastructure contributors?

• Discussion:

While the comparison to other countries is helpful, the discussion could elaborate on the root causes of Ethiopia's low patient safety culture prevalence (e.g., resource constraints, health system gaps, or cultural attitudes toward patient safety). The implications for practice should specify who will lead the recommended changes (e.g., government agencies, hospital administrators) and what key steps are needed for implementation. Ensure that all references are cited in alignment with journal requirements. Some critical comparisons (e.g., studies from Oman, Taiwan, and South Africa) could include more detailed descriptions of how those countries addressed patient safety culture gaps.

• Limitations Section:

The discussion of limitations is brief. Consider addressing potential publication bias (despite Egger’s test) and the challenges of using self-reported measures like the HSOPSC, which may introduce social desirability bias.

Reviewer #3: The author writes the article in a rigorous and standard language fashion.

the author selected and extracted based on the protocol and those who have used tools for data collection.

Major comments:

the author wrote different data collection periods: line 26 vs. line 104

The author report six articles are screened based on incomplete data but don't report whether contacted for obtaining and confirming data from investigators. Do you exclude them with a criteria?

The authors write the title in two phrases, alternatively "patient safety' and 'patient safety culture'. Which one is correct to align the outcome?

Did the author check these articles?

Ali M, Ademe S, Shumiye M, Hamza A. Patient safety culture and associated factors among health care workers in south Wollo zone public hospitals, north east Ethiopia. Perioperative Care and Operating Room Management. 2024;35:100374. doi:10.1016/j.pcorm.2024.100374

Mulugeta, Tigist Tedla. “Patient Safety Culture among Health Workers in Addis Ababa Regional Hospitals, Ethiopia.” TEXILA INTERNATIONAL JOURNAL OF PUBLIC HEALTH, vol. 7, no. 2, June 2019, pp. 153–66, https://doi.org/10.21522/tijph.2013.07.02.art017.

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Reviewer #1: Yes:  Dr Abduljalil Umar Abdullahi

Reviewer #2: No

Reviewer #3: No

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Attachments

Attachment

Submitted filename: Dr Abduljalil Review.docx

Attachment

Submitted filename: Comment Patient safety.docx

Patient safety culture in public hospitals of Ethiopia: a systematic review and meta-analysis

PONE-D-24-47092R1

Dear Dr. Haile,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Maher Abdelraheim Titi

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The authors have adequately addressed my comments raised in a previous round. The manuscript is edited and written in standard English. This manuscript is now acceptable for publication.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #3: No

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