Patient safety knowledge and compliance among physicians in public hospitals in Lebanon

INTRODUCTION

Patient safety (PS) remains a paramount concern within the global healthcare landscape. Estimations from the World Health Organization (WHO) suggest that 1 in 10 patients suffers harm during hospital care. The repercussions of such incidents result in extended hospital stays, long-term disabilities, potential fatalities, and a substantial financial burden on healthcare infrastructures.¹ An initial report by the US Institute of Medicine (IOM) in 1999 titled “To Err is Human: Building a Safer Health System” called for a comprehensive approach to improving PS culture (PSC).² Within such a culture, healthcare practitioners prioritize PS and are motivated to report any adverse occurrences.² Among healthcare practitioners, physicians, by virtue of their central role in healthcare, have a major direct and indirect influence on PS. Their knowledge and practices shape the safety culture and the prevention of adverse events. Challenges like insufficient training and workload pressures can impede their proactive involvement in PS.³

The International Patient Safety Goals (IPSGs) were established in the early 2000s by the Joint Commission International (JCI) to help accredited hospitals address specific priority areas of PS and reduce medical errors.⁴ The current set of IPSGs focuses on 6 areas of PS: patient identification, communication, high-alert medications, wrong-site/patient/procedure surgery, healthcare-associated infections, and falls. The Hospital Survey on Patient Safety Culture (HSOPSC), developed by the Agency for Healthcare Research and Quality (AHRQ), provides a standardized instrument to assess PS culture at both unit and hospital-wide levels.^5,6

The Eastern Mediterranean Region (EMR) has been comparatively slow in adopting PS measures, with limited studies on PSC available from this region.⁷ In Lebanon, previous research focuses primarily on private hospitals and nursing staff rather than public hospital physicians and staffing.^8,9

The Ministry of Public Health (MOPH) in Lebanon has incorporated certain PS standards in the hospital accreditation system.¹⁰ Nevertheless, significant gaps exist pertaining to the evaluation of compliance with PS among various stakeholders in general and among physicians in particular. This research aims to bridge this gap by evaluating physician knowledge of IPSG, patient safety culture attitudes, IPSG compliance practices, and their determinants among physicians in Lebanese public hospitals. The study will also examine patient safety event reporting patterns and identify personal and structural factors that influence compliance behaviors.

METHODS

This study is a secondary data analysis from a survey conducted with healthcare workers in Lebanese public hospitals in 2020-2021. While a previous paper focused on PS dimensions among nurses, this analysis specifically examines physicians working in all 28 public hospitals under the Ministry of Public Health supervision across Lebanon.⁹ The participating hospitals are geographically diverse, with 13 in urban/suburban regions and 15 in semi-rural/rural zones. Two public hospitals declined participation due to the COVID-19 crisis. The study targeted all physicians who had served in the same hospital for over six months and were available on the survey date, ensuring adequate exposure to departmental and hospital protocols, working environment, and orientation initiatives. The data collection instrument was a self-administered questionnaire combining elements from the Hospital Survey of patient safety culture (HSOPSC) and knowledge assessment of IPSG from Joint Commission International hospital accreditation standards.^6,11 Initially drafted in English, the questionnaire underwent translation to Arabic with expert assistance, followed by back-translation validation by the American Language Center. Both versions were expert-reviewed for relevance, comprehensiveness, and clarity before finalization. The questionnaire covered personal and professional attributes, hospital variables, organizational factors, PS culture elements, knowledge of IPSG, and observed medical errors.

The study's dependent variable was self-reported compliance with IPSG, measured on a 5-point Likert scale (1-Rare to 5-Always) across six key areas: patient identification, effective communication, safety of high-alert medications, correct patient procedures & surgery, prevention of hospital-acquired infection, and patient fall prevention. A composite compliance score was calculated by summing all question scores, ranging from 0 (total non-compliance) to 90 (complete compliance).

Independent variables included knowledge of IPSG, measured through multiple-choice questions across the same six areas, with correct answers scored as 1 and incorrect or "don't know" responses as 0. A composite knowledge score ranged from 0 to 94. Patient safety culture (PSC) was assessed through 11 dimensions: teamwork, response to error, communication openness, reporting patient safety events, staffing and work pace, organizational learning, leadership support, communication about error, hospital management support, hand-off information exchange, and overall perceptions of patient safety. A composite PSC score ranged from 0 to 160.

Personal and professional characteristics included age, gender, medical activity domain, medical school type, PS course exposure, and years of experience. Hospital characteristics encompassed hospital type, location, accreditation level, and PS structures (including committees, officers, programs, surveys, orientation, audits, and training). Additional outcomes measured included reported errors in the previous year and unreported witnessed medical errors.

For statistical analysis, all variables were described using frequencies and percentages for categorical variables, and means, standard deviations, and ranges for continuous ones. Associations between independent variables and IPSG compliance were examined using t-tests or ANOVA for categorical variables, while Pearson correlation coefficients were calculated for continuous variables. Multivariate linear regression was conducted to adjust for independent effects of variables with significant bivariate associations. Associations with p values ≤0.05 were considered significant. The R² coefficient was calculated to assess the percentage of outcome variability explained by the final multivariate model. All analyses were performed using SPSS statistical package.

RESULTS

The survey included 111 physicians, of whom 67% were men and 33% were women. The average age of the group was 34 years, with women significantly younger on average (30 years) compared to men (36 years), and over half of the group was single (55%) at the time of the survey. The majority were attending physicians (62.2%), with an average work experience of 11.5 years (SD=7). In their current practice, the respondents were distributed in university (48.6%) or general (51.4%) hospitals. Most work locations (62.2%) were in rural areas. The vast majority of the hospitals were accredited at levels C and D (66.7%). Work hours varied, with only about 40.5% working 8 hours a day or less, and a majority (82.9%) alternating day shifts with night duties. About 65% reported the absence of PS training in their medical curriculum. Details regarding the personal and professional characteristics of the respondents can be found in Table 1.

*Mean years of experience for resident=3 (SD=1.5) and for attending=11.5 (SD=7); **Mean number of daily work hours was 15.1 (SD=7.6) (Range=8-34) and of weekly work hours 56.3 (12.7) (Range=35-72)

Regarding organizational factors related to PS, 28% of physicians reported the presence of an office for PS and risk management in their hospital, and 32% stated that their hospital had established an integrated PS program. Furthermore, 15% indicated that their hospital had conducted a standardized survey of its staff to assess its PS culture, and 14% mentioned the existence of a periodic training program on PS in their hospital. Only nine (8%) of participants reported that their hospital conducted periodic audits of the implementation of PS policies and procedures. Likewise, a mere four (4%) reported that the new employees' orientation program included PS policies and procedures. Details are presented in Table 2.

*Not remaining in the rest of the analysis for lack of variability.

Each item includes several specific associated questions.

Six dimensions of PS knowledge were assessed. The overall mean was 60 on a scale of 0-100 (SD=19.9). The dimension with the highest mean score was “patient identification”. All other items were relatively lower. The same approach was used to assess the organizational “culture” supportive of PS. This variable was composed of ten dimensions. The overall mean of PS culture score across all ten dimensions was 60.6 (SD=6.5) on a 0-100 standardized scale. The dimension with the highest mean score was the perception of “hospital management support for PS” (mean=66.0). The dimension with the lowest mean score was “reporting PS events” (mean=44.0).

The outcome variable for this analysis was the actual “compliance” of participants with IPSG, with an overall score derived from six dimensions with Likert scale responses. The overall mean IPSG compliance score across the six dimensions was 58.8 (SD=10.7) on a 0-100 standardized range. Of those dimensions included in “compliance”, the one with the highest score was for “identification of surgical site” (mean=71.3). The dimension with the lowest mean compliance was “infection prevention and control” (mean=46). Details regarding PS knowledge and organizational culture, and respondents’ PS compliance are available in Table 3.

In bivariate analysis, it was found that personal characteristics significantly associated with higher IPSG compliance were: being an attendant (vs. a resident), having been exposed to PS training in the medical curriculum, working in an urban/suburban hospital (vs. a rural one), and working in day and night alternating shifts (vs. in day shifts only). Remarkably, there were no differences in compliance by gender, age, marital status, years of professional experience, type of hospital or its accreditation, or number of patients under care. Details are presented in Table 4.

Two of the four hospitals’ organizational characteristics remaining in the analysis were significantly correlated with the “compliance” outcome. These were the existence of a dedicated PS/risk management office and the existence of periodic PS training in the hospitals. Having an integrated PS program established at the hospital and conducting staff surveys on PS culture did not show significant differences in reported compliance (Details in Table 5).

Physicians' overall knowledge of PS guidelines positively correlated with compliance with recommended practices. All the knowledge dimensions composing this score were also significantly associated with “compliance”. In contrast, neither the overall score of organizational culture nor any of its particular dimensions were associated with compliance. The only exception was “reporting PS events” with an inverse significant association whereby lower reporting was associated with higher compliance. Details can be found in Table 6.

All significantly associated variables found in the bivariate analysis were included in a multivariate analysis to assess their independent effects on IPSG compliance among the surveyed physicians in Lebanese hospitals. In the full model, the variables with significant adjusted effects with higher compliance were: physicians who were residents compared to attending physicians, physicians in urban or suburban hospitals compared to rural ones, those with higher PS knowledge scores and those working only daytime shifts compared to those with alternating shifts. The presence of an office for PS and risk management was significantly linked to better. However, a higher frequency of PS events observed and reported was related to lower compliance (p=0.02). The best-fitting regression model included the hospital location, work schedule, presence of a PS office, PS knowledge score, and frequency of reporting events explained 52.5% of the variance in IPSG compliance. Details can be found in Table 7.

The study investigated medical errors ever witnessed but not reported by physicians in public hospitals in Lebanon in 2020. All 111 participating physicians had witnessed a medical error in the year before the survey, but the majority (66%) did not report the error(s). The most commonly unreported medical error was inappropriate medical diagnosis (70%), followed by a nosocomial infection in a patient (68%), error in laboratory test results (66%), patient fall (65%), and error in patient surgery (65%). The medical error with the highest reporting rate was an error in patient identification (51%) and an error in radiology test results (49%). Details can be found in Table 8.

DISCUSSION

This analysis of physicians working in public hospitals offers crucial insights into PS practice in Lebanon despite its limited sample. Institutional structures for PS were found to be limited, with inconsistent implementation of audits and orientation programs across surveyed hospitals. Compliance was generally higher in urban hospitals with university affiliations, though notable exceptions suggest that location and affiliation alone don't guarantee robust PS practices. The rural public hospital in Nabatieh, for instance, reported results comparable to those of the largest public hospital in Beirut, demonstrating that smaller rural hospitals can achieve high compliance levels with sufficient physician commitment to international PS goals.

Physicians from Nabatieh who reported PS audits and orientation programs were significantly older (median age 32 years versus 28 years overall), suggesting they may hold senior positions contributing to institutional compliance. Their overlapping reports regarding both PS measures highlight a proactive stance toward PS, potentially serving as a model for other smaller institutions in resource-limited settings. These findings, though from a limited sample, emphasize that effective PS practices can be implemented with adequate commitment and leadership regardless of hospital size or location, though further research with larger samples is needed to validate these observations.

Physician engagement, institutionalized prioritization of patient safeguards, and enforced protocols appear to be vital determinants of successful implementation across the rural-urban divide. Discrepancies in PS knowledge and practice among physicians underscore an urgent need for systematic professional education and stricter institutional monitoring to uphold PS norms across all Lebanese public healthcare facilities. Building comprehensive, standardized PS training and audit processes could lead to more uniformly high standards of patient care regardless of hospital location or physician experience.

The significant association between the presence of a PS office and higher compliance with IPSG underscores the value of active monitoring and oversight mechanisms targeting physicians. As leaders in establishing PS standards, physicians may be more inclined to maintain rigorous compliance when they feel their practices are being consistently monitored through formal channels like a PS office. This accountability fosters a culture where physicians take personal responsibility for ongoing education, protocol adherence, and proactive incident reporting. Implementing robust monitoring systems could therefore drive sustained improvements in PS practices across facilities.

Hospital accreditation may be one avenue to ensure proper implementation of PS culture. In Lebanon, the Ministry of Public Health (MOPH) manages accreditation for both public and private hospitals. Historically, these accreditations focused on structural elements rather than outcomes and quality measures, highlighting the need for reform.^12,13 Recognizing this gap, MOPH comprehensively revised its hospital accreditation standards in December 2022, developed with the French National Authority for Health and national experts. The new standards emphasize quality management and clinical outcomes, covering critical PS areas like medication management, infection prevention, surgical safety, and high-risk situation management.¹⁴ This demonstrates MOPH's commitment to aligning Lebanon's healthcare system with international best PS practices.

Individual knowledge of IPSG is also crucial for physicians' practices. Physicians demonstrated higher knowledge in dimensions like "patient identification," which may be more intuitive, but exhibited lower knowledge and compliance in areas traditionally associated with nursing duties, such as infection prevention and control. Doctors working only daytime shifts, when nurses are more available, appeared less familiar with PS dimensions than those working alternating schedules, who may occasionally handle non-medical tasks. This occupation-based difference is evident in the concomitant study of PS among nurses in public hospitals, whose knowledge and awareness exceeded that of physicians using the same measurement tools.⁹ While nurses receive comprehensive PS protocol training, similar adapted training should be developed for physicians, as some hospitals have begun implementing PS awareness in orientation programs for residents and younger attending physicians.

Regarding error reporting, physicians tended to disregard errors related to their own medical practices while emphasizing those outside their domain. Despite all physicians witnessing medical errors, less than a third reported such events, likely relying on nursing staff for monitoring and reporting. The tendency to report radiology and laboratory errors more than medical diagnosis and surgical errors suggests a cultural bias viewing errors as causes for blame rather than opportunities for system improvement. In contrast, nurses in the same context were more likely to report various errors they noticed.⁹ These negative perceptions affecting physician compliance represent a crucial area for continued professional education.

This study has several limitations. The convenience sampling approach could introduce selection bias, and the relatively small sample size focusing on public hospitals may limit generalizability. However, non-participants were randomly distributed across specialties and experience, and only two of twenty-eight public hospitals refused access due to COVID-19 patient burdens. While a larger sample would enhance statistical power, the data likely reflect the general state of PS in public hospitals, though physician recall bias or social desirability bias may have led to overestimation of positive results and underestimation of negative aspects.Public hospitals represent only a minor component of Lebanon's hospital sector compared to private institutions. PS in private hospitals was assessed over ten years ago, showing concerns like understaffing, poor communication, and fear of punitive responses to error reporting.^13,15 El-Jardali et al found that rural private hospitals had more positive safety perceptions, suggesting that more affluent patients in the private sector may demand higher quality services compared to poorer patients in public hospitals.¹⁶ However, staffing and workload issues affecting PS culture were identified in both sectors.¹⁶ While competition has incentivized private hospital progress, the public system serving disadvantaged populations requires focused attention to address PS concerns through system-wide efforts promoting transparency, non-punitive error management, leadership commitment, and continuous monitoring.

Progress in patient safety across Lebanese hospitals requires concerted efforts from multiple stakeholders addressing issues at different levels. The Ministry of Public Health should implement a comprehensive training program with clear PS guidelines to effectively leverage the revised accreditation standards. A robust monitoring and evaluation framework with regular data analysis and feedback loops is essential to assess impact and identify areas for enhancement.

The Syndicate of Private Hospitals, influential in setting norms across Lebanon's hospital care system, can impact the public sector through physicians working in both sectors and by shaping patient expectations for standards of care.¹⁷ The SPH should fulfill a social responsibility role by supporting PS training and awareness needs of nearby public hospitals and encouraging collaboration and knowledge-sharing between public and private institutions. Joint training programs, workshops, and a national PS network could identify best practices and develop innovative solutions for improving outcomes. A successful example of such collaboration occurred in the United States in 2004, where hospitals, healthcare organizations, and PS experts implemented evidence-based interventions that saved an estimated 122,300 lives over 18 months.¹⁸

Hospital managers play a major role in advancing PS, even in resource-limited public rural facilities. Accreditation requirements can motivate managers, as demonstrated by successful PS implementation in Lebanese hospitals that underwent accreditation.¹⁹ Public reporting of PS improvements may attract more self-paying patients, as a study by Ammar et al found that Lebanese patients prioritize safety and quality when selecting healthcare providers.²⁰ Managers should establish and maintain PS offices, committees, and regular training programs to ensure consistent adherence to IPSG among all healthcare professionals. This cultural shift requires leadership commitment demonstrated through clear communication of objectives, resource provision, data collection and reporting, and prioritization of PS as a strategic goal.¹⁵ Regular surveys and audits can encourage patients and families to voice safety concerns and allow healthcare professionals to report issues confidentially without fear of blame. Dayekh et al emphasized that including patient families in safety training alongside healthcare professionals can result in measurable outcome improvements.²¹

The Lebanese orders of physicians can develop specialized continued medical education modules addressing PS issues from physicians' perspectives. A systematic review by Cervero et al found that CME activities positively impact physician performance and patient outcomes.²² LOP should require PS modules during orientation for all physicians joining hospitals, aligning with WHO recommendations in the "Global Patient Safety Action Plan 2021-2030" emphasizing PS training for all healthcare professionals.²³ Some Lebanese hospitals already include PS criteria in new doctors' orientation as a voluntary measure influenced by PS-related ISO requirements.

Medical education curricula should formally prepare physicians for PS practices rather than leaving this to informal guidance from senior attendants and nursing staff. In Lebanon, 18.4% of hospital managers and directors suggested that PS integration into medical curricula would benefit patients, while 93% of medical students considered such integration important.¹⁵ This academic approach to PS education is also proposed in the WHO action plan for PS.²⁴

Research on patient safety culture remains under-prioritized in health management and policies across the MENA region, as evidenced by the scarcity of publications on this issue in Lebanon and neighboring Arab countries. Funding for PS research should be prioritized by both private and public sectors, focusing on developing and evaluating interventions to improve outcomes and exploring the long-term impact on healthcare quality, patient outcomes, and costs. This aligns with the Jeddah Declaration from the 4th Global Ministerial Summit on PS (2019), which emphasized investing in research to develop evidence-based solutions, especially in low- and middle-income countries.²⁵

Policymakers and hospital leaders should prioritize investments in PS infrastructure, training, and support systems across both public and private sectors, including establishing dedicated PS units, providing ongoing education for healthcare professionals, and fostering a culture of transparency and shared responsibility. By learning from each other's experiences, hospitals can identify best practices and develop innovative solutions to improve PS outcomes, enhancing the quality of hospital care for Lebanon's increasingly aging and fragile population.²⁶

CONCLUSION

In conclusion, addressing PS challenges in Lebanese hospitals requires participation from multiple stakeholders. Lebanon's small size facilitates cooperation among these entities. This study advances understanding of patient safety implementation in resource-limited healthcare settings by demonstrating that effective patient safety practices can be achieved in smaller public hospitals when sufficient physician leadership and institutional commitment are present, regardless of location or university affiliation. The findings reveal that structural factors such as dedicated patient safety offices and systematic monitoring mechanisms are more predictive of compliance with IPSGs than hospital size or geographic location. The research identifies critical knowledge gaps among physicians in areas traditionally managed by nursing staff and highlights physician-specific barriers to error reporting in the Middle Eastern context, providing evidence that targeted interventions focusing on physician engagement and institutional accountability can significantly improve patient safety outcomes within constrained public healthcare systems.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of the American University of Beirut

REFERENCES

1. 1. WHO. Patient Safety. WHO. Accessed 11 September 2023, 2023. Available at: https://www.who.int/newsroom/factsheets/detailpatientsafety#:~:text=Key%20facts,from%20unsafe%20care%20(1). Accessed on 3 March 2025.
2. 2. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. In: Kohn LT, Corrigan JM, Donaldson MS, eds. Washington, DC: National Academies Press (US); 2000.
3. 3. Leape L, Berwick D, Clancy C, Conway J, Gluck P, Guest J, et al. Transforming healthcare: a safety imperative. Qual Saf Health Care. 2009;18(6):424-8.
4. 4. Joint Commission I, Joint Commission on Accreditation of Healthcare O. Joint Commission International accreditation standards for hospitals: including standards for Academic Medical Center Hospitals. Seventh edition ed. Joint Commission Resources Oak Brook, Illinois; 2020. Available at: https://www.clinicalkey.com/dura/browse/bookChapter/3-s2.0-B9781635851489X50013. Accessed on 3 March 2025.
5. 5. Sorra J. Hospital survey on patient safety culture. AHRQ publication: 2004.
6. 6. Sorra J YN, Famolaro T, et al. Quality AfHRa, ed. AHRQ Hospital Survey on Patient Safety Culture Version 2.0: User’s Guide. Agency for Healthcare Research and Quality; 2021. Available at: https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-users-guide.pdf Accessed on 3 March 2025.
7. 7. Elmontsri M, Almashrafi A, Banarsee R, Majeed A. Status of patient safety culture in Arab countries: a systematic review. BMJ Open. 2017;7(2):e013487.
8. 8. El-Jardali F, Jaafar M, Dimassi H, Jamal D, Hamdan R. The current state of patient safety culture in Lebanese hospitals: a study at baseline. Int J Qual Health Care. 2010;22(5):386-95.
9. 9. Al Akoum HASMA, Akoum HA, El Abed AA, Salameh PR. Patient Safety Knowledge and Compliance Among Nurses In Public Hospitals In Lebanon. IOSR J Nurs Health Sci (IOSR-JNHS). 2022;11(3):11.
10. 10. Ministry of Public Health L. Accreditation Standards for Hospitals in Lebanon. Ministry of Public Health, Lebanon. Accessed December, 2022. Available at: https://www.moph.gov.lb/en/Pages/3/20553/-revised-hospital-accreditation-standards-in-lebanon-december-2022. Accessed on 3 March 2025.
11. 11. JCI. Joint Commission International Accreditation Standards for Hospitals (7 ed.). Available at: https://www.jointcommissioninternational.org/-/media/jci/jci-documents/accreditation/hospital-and-amc/jci-errata-standards-only_7th-ed-hospital.pdf. Accessed on 14 March 2025.
12. 12. El-Jardali F, Jamal D, Dimassi H, Ammar W, Tchaghchaghian V. The impact of hospital accreditation on quality of care: perception of Lebanese nurses. Int J Quality Health Care. 2008;20(5):363-71.
13. 13. El-Jardali F, Fadlallah R. A review of national policies and strategies to improve quality of health care and patient safety: a case study from Lebanon and Jordan. BMC Health Serv Res. 2017;17(1):568.
14. 14. (MOPH) TLMoPH. Revised Hospital Accreditation Standards in Lebanon- December 2022. Available at: https://www.moph.gov.lb/en/Pages/3/20553/-revised-hospital-accreditation-standards-in-lebanon-december-2022. Accessed on 3 March 2025.
15. 15. El-Jardali F, Jaafar M, Jamal D, Rabbaa S. Integrating patient safety standards into the accreditation program: a qualitative study to assess the readiness of Lebanese hospitals to implement into routine practice. J Patient Saf. 2012;8(3):97-103.
16. 16. El-Jardali F, Dimassi H, Jamal D, Jaafar M, Hemadeh N. Predictors and outcomes of patient safety culture in hospitals. BMC Health Serv Res. 2011;11:45.
17. 17. Schibler C. Les enjeux de l’hospitalisation privée. Les Tribunes de la santé. 2023;76(2):85-92.
18. 18. Berwick DM, Calkins DR, McCannon CJ, Hackbarth AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA. 2006;295(3):324-7.
19. 19. Saleh S, Sleiman J, Dagher D, Sbeit H, Natafgi N. Accreditation of hospitals in Lebanon: Is it a worthy investment? International journal for quality in health care: journal of the International Society for Quality in Health Care / ISQua. 02/13 2013;25.
20. 20. Ammar W, Khalife J, El-Jardali F, Romanos J, Harb H, Hamadeh G, et al. Hospital accreditation, reimbursement and case mix: links and insights for contractual systems. BMC Health Services Res. 2013;13(1):505.
21. 21. Dayekh AY, Naseridine M, Dakroub F, Olleik A. Impact, obstacles and boundaries of patient partnership: A qualitative interventional study in Lebanon. PLOS ONE. 2022;17(7):e0270654.
22. 22. Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: an updated synthesis of systematic reviews. J Contin Educ Health Prof. Spring 2015;35(2):131-8.
23. 23. Organization WH. Global Patient Safety Action Plan 2021-2030. Available at: https://www.who.int/publications/i/item/9789240032705. Accessed on 14 March 2025.
24. 24. WHO. Patient safety curriculum guide: multi-professional edition, 2011. Available at: https://www.who.int/publications/i/item/9789241501958. Accessed on 14 March 2025.
25. 25. WHO. Global Ministerial Summits on Patient Safety. Available at: https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-ministerial-summits-on-patient-safety#:~:text=The%20Fourth%20Global%20Ministerial%20Summit,the%20global%20patient%20harm%20burden. Accessed on 14 March 2025.
26. 26. Abu-Saad Huijer H, Sailian SD, Fares S, Bassila J. Predictors of quality of life in older adult patients in Lebanon: a cross sectional study. Ann Palliat Med. 2023;12(2):356-64.