quality in healthcare has different dimensions and elements ( 1 - 4 ) , of which patient safety ( ps ) is one of the most important dimensions ( 5 ) . ps is a serious global challenge and a very important dimension of healthcare quality ( 6 - 8 ) . according to who , in low and middle income countries ( lmic ) one out of ten patients is harmed while receiving health services ( 9 ) . institute of medicine ( iom ) report entitled " to err is human " showed that more than 98 thousand patients die in the united states every year as a result of medical errors ( 10 ) . for this reason ps has received considerable focus from policy - makers and other stakeholders ( 11 ) . patient safety culture ( psc ) is an important factor of ps in healthcare system ( 12 ) . the iom offers that the very important challenge to achieve a safer healthcare system is to improve the psc ( 13 ) . measurement of psc is a top priority aim to improve quality of ps ( 14 - 20 ) . neiva and sorra ( 15 ) defined psc as :  the product of individual and group values , attitudes , perceptions , competencies , and patterns of behavior that determine the commitment to , and the style and proficiency of , an organization 's safety management  . previous studies results show that there is a positive relationship between high psc and safety performance in hospitals ( good ps ) ( 14,21 ) . 
 
 globally , several international organizations attempted to promote psc : the world alliance for patient safety ( waps ) , the national patient safety agency ( npsa ) , the agency for healthcare research and quality ( ahrq ) and the australia commission of safety and quality ( acsq ) ( 22 - 24 ) . in this regard , several instruments have been developed to measure psc ( 25 - 27 ) . the hospital survey on patient safety culture ( hsopsc ) of ahrq is a valid and reliable instrument to measure psc in the hospitals ( 28 - 31 ) . this tool is translated to many languages and validated psychometrically ( 32 - 34 ) . a review of the literature showed that psc status in iranian hospitals is not satisfactory ( 35 ) . thus , the aim of the current study was to clarify psc status in iranian hospitals through a meta - analysis of studies which used hsopsc instrument in iran . a meta - analysis study was conducted in 2014 , and the required data were collected searching following keywords : patient safety , patient safety culture , patient safety climate and its combination with hospital ( such as  hospital survey on patient safety culture  ) , measurement , assessment , survey , and iran , in google scholar , pubmed , scopus , cochrane library , magiran , iranian scientific information ( sid ) and iranmedex . manual journal and website searching was also conducted . to increase confidence level of identification of the articles , the inclusion criteria for the study were : articles published in persian and english languages , articles that measured psc in hospital , and articles that measured psc using hsopsc instrument . exclusion criteria included : articles that measured overall safety culture , articles that measured psc in primary healthcare , articles that not measured all dimension of hsopsc instrument , conference presentations , case reports , and interventional and qualitative studies . two reviewers evaluated the articles according to the checklist of strengthening the reporting of observational studies in epidemiology ( strobe ) ( appendix 1 ) . 
 
 of 961 retrieved articles , endnote x5 software was used for organizing titles and abstracts and also identification of duplication studies ( 36 ) . to calculate the overall psc score , comprehensive meta - analysis ( cma ) software v. 2 and to report the results , forest plot were used . in forest plot , the size of each square shows sample size and lines on each side of the square show confidence interval . literature review and retrieval flow diagram 
 psc score was calculated based on random model with 95% confidence interval . in random models either all or some of the variables are treated as if they are from random causes . random model was in contrast to fixed model that demonstrate the observed quantities in regard of explanatory variables which are treated as if the variables are not random . this instrument has 3 parts , 12 dimensions , 44 items and 2 single questions ( box . 1 ) . all of questions are in the 5-point likert scale (  strongly disagree  to  strongly agree  ) or frequency (  never  to  always  ) ( 37,38 ) . a total of 11articles initially were reviewed ( 39 - 49).the characteristics of the reviewed articles are shown in table 1 . the overall numbers of participants were 2972 ( 270 each study ) . 
 
 * 1- overall perception of safety , 2- organizational learning / continuous improvement , 3- supervisor / manager expectations & actions promoting 
 safety,4- teamwork within hospital units , 5- non - punitive response to error , 6- staffing , 7- hospital management support for patient safety , 8- 
 teamwork across hospital units , 9- hospital handoffs & transitions , 10- communication openness , 11- feedback & communication about error , 12- 
 adverse event reporting & recording , * * including wide range of health care provider in hospital such as : physicians , nurses , clinical and non - clinical 
 staff , pharmacy and laboratory staff , supervisors and hospital managers 
 
 the psc score based on the random effect model was determined to be 50.1% ( 95% confidence interval , lower limit= 43.4% , upper limit= 56.9% , i= 99.8 , q - value= 5716.2 , df = 10 , and p 2 ) . 
  patients safety culture score in the evaluated studies with 95% ci ( based on random model ) 
 in this study due to high heterogeneity , sensitive analysis was done by excluding one of the studies ( abdi et al , 2010 ) . finally , after excluding this study , the psc score changed to 52.8% ( 95% confidence interval , lower limit= 48% , upper limit= 57.6% , i=96.8 , q - value= 3456.2 , df = 9 , p patients safety culture score in the evaluated studies with 95%ci ( based on random model ) after sensitive analysis ( abdi et al : 2010 ) mean of 12 dimensions of hsopsc in iran 
 as shown in fig . 4 ,  teamwork within hospital units dimension has the highest score of psc ( 67.4% ) and  non - punitive response to error  has the lowest score ( 32.4% ) . mean of psc status ( excellent , very good , acceptable , poor , failing ) in hsopsc questionnaire are shown in fig . ,  very good  grade has the highest mean ( % 32.3 ) and  excellent  the lowest ( % 8.3 ) . average percentage of respondents giving their psc grade 
 mean of reporting number of adverse events in the past 12 months are shown in fig . 6 , which shows that approximately % 52.7 of participants did not report any adverse event in the past 12 months . average percentage reporting events in the past 12 months 
 funnel plot of psc shows that there is no symmetry in gathered data ( fig . the hsopsc questionnaire has been used to measure psc in the high income countries ( hics ) , especially , the united states . in present study , we systematically reviewed the psc status in iran using studies that administered hsopsc tool . overall , the mean response rate for the 12 psc dimensions of the hsopsc questionnaire in iranian hospitals was 50.5% . this was lower than many of other previous studies , especially in hics ( 15,16,50 - 54 ) . also mean response rate in some studies in lmic was higher compared to that of current study ( 55 - 57 ) . furthermore , the ndings of this study demonstrated that " non - punitive response to error " dimension has lowest score among 12 dimensions of the hsopsc questionnaire . van geest and cummings study showed that absence of a non - punitive response system to errors is an important barrier for identications and reduction of errors in healthcare setting ( 60).non - punitive response system defined as " the extent to which personnel feel that their mistakes are not held against them and that mistakes are not recorded in their personnel document " ( 61 ) . unreserved system is an effective method for risk reduction in hospitals , which can start with adverse event reporting without punishing , and continue with encourage to report and learning from adverse events . the present study revealed that about 41% of participants evaluate their hospitals psc status as  excellent /very good. el - jardali and colleagues study in lebanese hospitals demonstrated that about 70% of participants evaluated their hospitals psc status as  excellent / very good ( 55 ) . one study reported a higher  excellent / very good for psc than this study ( 62,63 ) . 
 
 according to the reviewed articles in this study , about 52% of participants did not report any adverse event in the past 12 months . contrary to this study , el - jardali and colleagues showed that about 60% of participants did not completed any event in the past 12 months ( 55 ) . also , jasti and colleagues showed that 64% of internal medicine house staff in academic teaching hospital did not report an adverse event in the past 12 months ( 62 ) . possible reasons for lower rate of reporting adverse events in current study might be the followings : no adverse event occurred in the hospitals during this period ; or , staff did not report adverse events due to punishment system in the hospitals . the first reason seems to be impossible due to frequent reports of adverse events or medical errors in the hospitals ( 64 - 66 ) . therefore , hospitals managers better off to change current punishment system into participating system for improvement of ps . hospital managers should try to remove scold , fear and silence from their system ( 67 ) . 
 
 according to published years of reviewed articles in this study ( from 2010 to 2013 ) , it revealed that psc is a very new concept in iranian hospitals and unfortunately this issue has been neglected . in iran , the psc received attention due to ps friendly hospital initiatives since 2010 , which was started in 10 hospitals and recently , ministry of health and medical education ( mohme ) has decided to expand this program to 50 more hospitals ( 68 ) . also from 2009 in iranian healthcare system , clinical governance has been introduced as a framework to quality improving of hospitals services ( 69,70 ) . these and other similar programs such as hospital accreditation are very useful and important for psc improvement , but , it should be noted that improvement of psc in hospitals and other organizations is highly related to continues quality improvement ( cqi ) culture , organization leadership commitment , creating learning atmosphere in hospitals and a customer - oriented culture in hospitals in long - run . the present study has some limitations such as no access to some of databases , and that , included articles were conducted only in hospitals . nowadays , measuring psc in healthcare organizations is being increasingly welcome , especially in the hics , and by iranian hospitals . in this regard , review of related studies showed that iranian hospitals performance in psc filed is weak . hence , improving psc should be prioritized in iranian hospitals . in this regard hospitals staff * give information separately for cases and controls in case - control studies and , if applicable , for exposed and unexposed groups in cohort and cross - sectional studies . note : an explanation and elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting . the strobe checklist is best used in conjunction with this article ( freely available on the web sites of plos medicine at http://www.plosmedicine.org/ , annals of internal medicine at http://www.annals.org/ , and epidemiology at http://www.epidem.com/ ) .
background : nowadays , for quality improvement , measuring patient safety culture ( psc ) in 
 healthcare organizations is being increasingly used . 
 the aim of this study was to clarify psc status 
 in iranian hospitals using a meta - analysis method . 
 methods : six databases were searched : pubmed , scopus , google scholar , cochrane library , magiran , 
 sid and iranmedex using the search terms including patient safety , patient safety culture , patient 
 safety climate and combined with hospital ( such as " hospital survey on patient safety culture " ) , 
 measurement , assessment , survey and iran . 
 a total of 11 articles which conducted using hospital 
 survey on patient safety culture ( hsopsc ) questionnaire initially were reviewed . to estimate 
 overall psc status and perform the meta - analyses , comprehensive meta - analysis ( cma ) software 
 v. 2 
 was employed . 
 results : the overall psc score based on the random model was 50.1% . " teamwork within hospital 
 units " dimension received the highest score of psc ( 67.4% ) and " non - punitive response to error " 
 the lowest score ( 32.4% ) . 
 about 41% of participants in reviewed articles evaluate their hospitals 
 performance in psc as  excellent / very good. approximately % 52.7 of participants did not report 
 any adverse event in the past 12 months . 
 conclusion : the results of this study show that iranian hospitals performances in psc were poor . 
 among the 12 dimensions of hsopsc questionnaire , 
 the " non - punitive response to error " achieved 
 the lowest score and could be a priority for future interventions . in this regard , hospitals staff 
 should 
 be encouraged to report adverse event without fear of punitive action .