Article Text

Safety culture survey among medical residents in Japan: a nationwide cross-sectional study
  1. Takashi Watari1,2,
  2. Masaru Kurihara3,
  3. Yuji Nishizaki4,
  4. Yasuharu Tokuda5,
  5. Yoshimasa Nagao6
  1. 1General Medicine Center, Shimane University Hospital, Izumo, Shimane, Japan
  2. 2Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
  3. 3Hospital Medicine, Urasoe General Hospital, Urasoe, Japan
  4. 4Juntendo University School of Medicine, Tokyo, Japan
  5. 5Muribushi Okinawa Project for Teaching Hospitals, Okinawa, Japan
  6. 6Department of Patient Safety, Nagoya University Hospital, Nagoya, Japan
  1. Correspondence to Dr Takashi Watari; wataritari{at}


Purpose This study aimed to examine safety culture among Japanese medical residents through a comparative analysis of university and community hospitals and an investigation of the factors related to safety culture.

Method This nationwide cross-sectional study used a survey to assess first and second-year medical residents’ perception of safety culture. We adapted nine key items from the Safety Awareness Questionnaire to the Japanese training environment and healthcare system. Additionally, we explored specific factors relevant to safety culture, such as gender, year of graduation, age, number of emergency room duties per month, average number of admissions per day, incident experience, incident reporting experience, barriers to incident reporting and safety culture. We analysed the data using descriptive statistics and multivariate logistic regression analysis.

Results We included 5289 residents (88.6%) from community training hospitals and 679 residents (11.4%) from university hospitals. A comparative analysis of safety culture between the two groups on nine representative questions revealed that the percentage of residents who reported a positive atmosphere at their institution was significantly lower at university hospitals (81.7%) than at community hospitals (87.8%) (p<0.001). The other items were also significantly lower for university hospital residents. After adjusting for multivariate logistic analysis, university hospital training remained significantly and negatively associated with all nine safety culture items. Furthermore, we also found that university hospital residents perceived a significantly lower level of safety culture than community hospital residents.

Implications Further research and discussion on medical professionals’ perception of safety culture in their institutions as well as other healthcare professionals’ experiences are necessary to identify possible explanations for our findings and develop strategies for improvement.

  • safety culture
  • graduate medical education
  • patient safety
  • hospital medicine
  • incident reporting

Data availability statement

Data are available on reasonable request. The data that support the findings of this study are available from the General Medicine Center, Shimane University Hospital (email., on reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Safety culture in healthcare is crucial to promote patient outcomes and medical professionals’ productivity, and strong safety cultures are associated with reduced errors, adverse events and mortality rates.


  • Results from a nationwide survey conducted in Japan showed that university hospital residents reported poor safety culture, which differs from previous reports from various countries that safety culture in academic centres is high. However, certain factors such as the number of emergency department duties and incident encounters showed a positive correlation with safety culture.


  • This study emphasises the need to investigate the causes of negative perceptions of safety culture among university hospital residents, promote teamwork and communication among professions and departments, and educate residents on incident reporting guidelines to improve safety culture awareness and error de-escalation. These findings provide information that could aid in creating policies and practices aimed at improving safety culture in Japanese healthcare settings, with global implications.


Safety culture is defined as the values, beliefs and norms that shape how patient safety is treated within an organisation. In healthcare settings, safety culture is not only crucial for patient outcomes but is also one of the most important aspects of the working environment of healthcare professionals.1 2 Previous studies have demonstrated that the fostering of a safety culture is a key element in the improvement of patient safety and can enhance the quality of care in acute healthcare settings.3 4 For example, safety culture and its related safety climate concepts have been linked to increased error reporting,5 reduced frequency of adverse events,1 6 decreased mortality rates7 8 and fewer medication errors.9 Furthermore, a strong safety culture is highly associated with behaviours that foster patient safety and plays an important role in the reduction of medical errors and improvement of staff productivity.2 However, safety culture is even more important for resident physicians because they often have less experience and are frequently the patients’ first point of contact, which makes them more likely to commit errors at the forefront of patient care.10 In one study, 34% of resident physicians reported at least one significant medical error during their training period, and over 40% reported errors at least once a year.10 Another survey found that 95% of resident physicians committed medical errors, and 20% of those errors were classified as moderate to severe.11 Furthermore, in Japan, more than 70% of resident physicians reported experiencing at least one incident, and facilities’ safety culture influenced error reporting.12 Despite the recognised importance of safety culture in resident physician training, there is limited exploratory research that directly targets resident physicians’ experiences.13–15

While teaching hospitals such as university hospitals with extensive patient safety activities in Iran and the USA have reported cultures with higher safety than their community training hospitals counterparts,16 17 the situation in Japanese training hospitals remains unclear. Therefore, the primary objective of this study was to compare university hospitals to community hospitals and explore the factors related to safety culture among resident physicians. Our secondary aim was to investigate the relationship between incident encounters, incident reporting and safety culture among Japanese medical residents.

Materials and methods


This nationwide cross-sectional study of Japanese medical school residents was conducted in adherence to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Between 18 January 2021 and 31 March 2021, first and second-year residents (PGY 1 and 2) who had completed the General Medicine-Intermittent Training Examination (GM-ITE) were surveyed. Informed consent and submission of answers to an electronic survey were part of the inclusion criteria.18 Exclusion criteria included the absence of informed consent (n=852), failure to answer to the primary outcome (safety culture, n=828), absence of age information (n=4), incident encounter (n=7), emergency department (ED) duty times (n=3) and mean number of patients (n=1). Residents who did not answer to specific survey questions such as incident reporting (n=6) were also excluded. Ultimately, 5968 residents were considered eligible for analysis (see online supplemental file 1, flow chart map of the participants)

Supplemental material

Main measurements

To evaluate safety culture, we adapted nine key items from the Safety Attitudes Questionnaire (specifically, the Teamwork Climate, Safety Climate, Perception of Management and Working Conditions sections)19 to suit the training environment and healthcare system of Japanese residents. The participants were asked to select ‘yes’ or ‘no’ for each of the following nine items: (1) My facility has a good atmosphere; (2) I am able to discuss work-related problems with my colleagues; (3) I am able to discuss personal problems with my colleagues; (4) I am able to suggest new plans or changes in procedures to my colleagues; (5) I feel comfortable speaking to my colleagues and supervisors when I make mistakes; (6) My facility is an environment where peers can point out mistakes made by others; (7) My facility is an environment where individuals who voice their opinions are highly valued by their peers; (8) My facility is an environment where team members can easily request assistance from one another and (9) My team members share information regarding each other’s problems. The questions were translated from English to Japanese by the authors and reviewed by a bilingual (English and Japanese) speaker.

Data collection

Following the GM-ITE examination,18 the Safety Attitudes Questionnaire was completed by participants. This questionnaire requested consent and collected demographic data such as gender, year of graduation, age, number of ED duties per month, average number of daily admissions, incident experience, incident reporting experience, barriers to incident reporting and safety culture. Information on hospital location was obtained from the Resident Electronic Information System website and categorised as urban or rural using established criteria.18 The primary outcomes of interest were the previously described nine safety culture items. All statistical analyses were performed using the Stata software package (StataCorp. 2015. Stata Statistical Software: Release V.14, StataCorp). Standard descriptive statistics were used to calculate counts, proportions and means for each dataset. Categorical data were compared using either χ2 or Fisher’s exact test. A multivariate logistic regression analysis was performed to identify factors associated with safety culture, using nine predictor variables that included the following parameters: age ≥27 years, ED duty at least three times per month, at least five patients per month, at least one incident encounter within 1 year and whether or not the resident had experienced an incident report within 1 year. A sensitivity analysis was conducted by the exclusion of certain variables from the multivariate regression analysis. All statistical tests were two tailed, and a p<0.05 was considered statistically significant.


Table 1 displays the demographic characteristics of the study participants (n=5968). The analysis of this study involved 5289 (88.6%) residents from regional training hospitals and 679 (11.4%) from university hospitals. The proportion of male residents was higher in community training hospitals than in university hospitals (68.6% vs 63.5%, p=0.007). The percentage of residents in the first year following graduation did not differ significantly between the two hospitals. However, there was a significant difference in the age distribution of residents between the two hospitals; university hospitals had a larger percentage of residents older than 27 years (p<0.001). The average number of ED duties per month differed significantly between the two hospitals; the duties were performed by a smaller proportion of university hospital residents than community training hospital residents. Additionally, 18.7% of residents did not complete any ED duties (p<0.001). Regional training hospitals had a higher percentage of residents working three or more ED duties per month (86.3%). Furthermore, there was a significant difference in the average number of admissions per resident between the two hospitals; community training hospitals had a higher proportion of residents who handled more inpatients than university hospitals (p<0.001).

Table 1

Profile of participating residents

Table 2 presents the results of a question regarding the number of incidents and reports experienced or witnessed by residents in the past year, as well as barriers to the submission of incident reports at university and community training hospitals. The prevalence was relatively high for both community training hospitals (76.7%) and university hospitals (74.5%), with no significant differences. However, a majority of residents in both hospitals had never filed an incident report (community hospital: 53.1%; university hospital: 55.5%). Regarding the reasons for difficulty in the submission of incident reports, the most common one was the time required to submit the report (community hospital: 45.1%; university hospital: 44.8%; p=0.88) and the second most common reason was unclear reporting criteria (community hospital: 32.3%; university hospital: 32.9%; p=0.76). At university hospitals, a significantly larger number of respondents answered that the reporting procedure was difficult to understand (community hospital: 17.5%; university hospital: 22.0%; p=0.004), that the act of reporting was an emotional burden (community hospital: 13.0%; university hospital: 16.2%; p=0.02), and that they felt punished for reporting (community hospital: 6.0%; university hospital: 8.2%; p=0.029).

Table 2

Comparison of the community and university hospitals on incident and reporting experience, and their barriers for reporting

Table 3 compares the safety culture of the two hospital groups for nine representative questions. The percentage of respondents who reported a good atmosphere at their institution was significantly higher at community training hospitals (87.8%) than at university hospitals (81.7%; p<0.001). All other safety culture items at community hospitals were also significantly better, and respondents reported a positive work environment.

Table 3

Differences in nine key safety culture items between Japanese resident physicians at community and university hospitals

Table 4 displays the correlation between the nine key safety culture items included in this study and the experience of incident reporting. The study compares the incident reporting experience of residents who filed at least one incident report (n=2783, 46.6%) to those who had not filed any (n=3185, 53.4%). The results indicate no significant association between the nine factors of safety culture (which include a positive safety culture that creates an environment wherein residents feel comfortable expressing their opinions, pointing out mistakes and suggesting improvements) and the experience of incident reporting.

Table 4

Association of the nine key elements of safety culture and experience with incident reporting

Table 5 illustrates that training at a university hospital was significantly negatively associated with all items of safety culture as perceived by residents. Factors such as gender (male) and hospital location (urban area) were significantly negatively associated with several items. However, the number of ED duties/month and experience with incident encounters were positively related to safety culture. Otherwise, no significant associations were found for age, post guraduate year (PGY) or average number of patients throughout the study.

Table 5

Factors associated with the nine safety culture elements adjusted for a multivariate analysis

Supplemental material

Finally, we performed a sensitivity analysis that incorporated several factors such as gender, age, PGY, university hospital, place, ED duty, average number of patients, incident experience and reporting experience into the multivariate logistic equation for each of the contents. However, the significantly lower trend at university hospitals persisted with this analysis.


This study was a nationwide cross-sectional survey that investigated Japanese residents’ perception of factors associated with safety culture. Notably, university hospital residency was negatively correlated with safety culture on all nine measures. However, other factors were positively associated with safety culture, such as the number of ED duties and incident encounters. Conversely, a negative association was found for gender (men). Furthermore, university hospital residents reported feeling that incident-reporting is punitive and mentally burdensome more frequently in comparison to community hospital residents. However, the two had no significant differences in residents’ actual incident-reporting experiences. We discuss three ways in which these new data contribute to the existing evidence on safety culture in Japan.

First, it is necessary to investigate the causes of university hospital residents’ perceptions that their workplace does not promote a safety culture. There are 82 university hospitals in Japan, including national, public and private universities. Generally, such institutions across the world provide advanced medical care and conduct research and education on the latest medical technologies and treatments.20 21 Furthermore, university hospitals employ more specialised staff such as quality-improvement and patient-safety experts than community hospitals as they have more resources to handle safety activities and medical errors methodically and carefully.20 21 Additionally, Japanese university hospitals are required to employ three to four full-time patient safety specialised staff members, which fosters a highly trained and educated workforce that likely impacts safety culture positively.21 22 Surprisingly, our results indicate the opposite, which implies that the general theory of patient safety does not apply to Japanese medical residents.21 Previous studies have identified that academically accomplished personnel are overwhelmingly more prevalent in Japanese university hospitals than in community hospitals, which poses strong seniority bias and academic hierarchy.23–26 Furthermore, gender bias (women) has also been noted in university hospitals.26 27 It is believed that because residents are in training and, therefore, are at the bottom of the physician hierarchy, they may be less likely to express their opinions or take part in various medical discussions.12 25 28 University hospital residents may be significantly more likely to feel punished and emotionally burdened by the act of filing an incident report, according to previous studies that found results that are similar to ours regarding reluctance to submit incident reports.12 21 22 25 28 Despite the aforementioned cultural context, other studies on registered nurses, physicians, managers and other healthcare professionals have found that managers’ opinions of patient safety culture vary widely, even in the same institutional healthcare setting.29 Therefore, it may not be prudent to assert that the safety culture of university hospitals is deficient solely based on residents’ experiential accounts and subjective impressions. Furthermore, the equilibrium of authority, the established hierarchy and the element of seniority within the medical profession are likely to vary considerably among different nations.23 Therefore, the question of whether these findings can be applied to other countries remains, indicating an ongoing concern for external validity.

Second, the number of ED duties and incident encounters are positively correlated, and gender (men) is negatively correlated with safety culture. A previous study has identified how men tend to be more apathetic, less distressed by safety risks and less willing to cooperatively and actively engage in safety culture in the facility.30 Subsequently, increased incentive of teamwork and communication with other professions and departments in the front line of clinical settings such as the ED may be positively associated with improved safety culture awareness and error de-escalation.2 6 29–31

Third, our results demonstrate no significant difference between safety culture items and actual encounters with incident errors, reporting experiences and so on, contrary to previous generalisations.5 32 In general, it has been noted that a high-safety culture increases incident reporting rates, healthy discussions, quality communication and promotes fewer errors, among other factors.1 5–9 However, when adjusted only for the Japanese residents in this study, no significant correlation was found between the nine items of safety culture and reporting experience. A previous Japanese study found that one reason for the lack of submission of incident reports was a requirement for further knowledge of the standards and actual procedures by which incident reports should be made.12 Therefore, if motivating residents to report incidents is currently a priority, perhaps the focus should be changed to educating residents about incident reporting guidelines, necessity, de-escalation processes and so on, rather than tackling the issue from a facility-wide effort perspective, such as enhancing its safety culture.12 33

The first limitation of this study is the relatively small sample size of residents from university hospitals. In Japan, the number of community hospital residents accounts for more than 60% of the total number of residents. However, only 11.4% of university hospital residents participated in this survey; therefore, selection bias could not be avoided. Second, the cross-sectional design limited our ability to infer causality. For example, it remains to be determined whether the training environment at university hospitals compels residents to perceive a lower level of safety culture or if, conversely, residents who are more likely to feel this way tend to train at university hospitals. In general, training at a community hospital involves a more extensive caseload, more obligations such as ED duties and longer working hours, as indicated in table 1.18 Residents who do not wish to be in those situations may be working at university hospitals.18 Third, although the safety culture measurement index,19 21 22 which was validated initially in Japanese, could not be used for all questions in this survey due to the limitation of the number of questions in the questionnaire, those that were consistent with the Japanese training background were extracted and included.18 19 21 29 Furthermore, there may be potential for response bias, considering that residents rely on self-reported data based on their individual training experiences at the respective institution. This potential bias is further compounded by inherent subjectivity. Fourth, studies on safety culture vary according to facility type and settings, which limits generalisability to other clinical settings across countries, healthcare systems, and cultural and ethnic backgrounds.22 29 31 Despite these limitations, our study is the first nationwide cross-sectional survey that focuses on resident safety culture in Japan. The results indicate that residents in university hospitals do not perceive their training facilities to have sufficient safety cultures. To ascertain the accuracy of residents’ perceptions and potential causes for this situation, it is imperative that university hospitals be further investigated by various types of healthcare professionals in Japan. Furthermore, as previous international studies have demonstrated,14–16 20–22 identification of the causes for low perceived safety culture and proposal of activities and strategies to improve it could play an essential role in the reduction of medical errors and promotion of higher productivity of medical staff.


This nationwide cross-sectional study of Japanese residents demonstrated that university hospitals’ residents significantly perceived a lower safety culture compared with community hospitals. However, establishing the reasons for these findings is a complex task that requires further studies that include larger sample sizes and other healthcare professions to work in the same context. Nonetheless, it is crucial to investigate the reasons for the perceived low safety culture at university hospitals in order to develop strategies for its improvement.

Data availability statement

Data are available on reasonable request. The data that support the findings of this study are available from the General Medicine Center, Shimane University Hospital (email., on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by Ethical Review Committee of Japan Institute for Advancement of Medical Education Program (No. 20-2). Participants gave informed consent to participate in the study before taking part.


We thank Mr. Juhei Matsumoto, Japan Institute for Advancement of Medical Education Program, for his careful support during this study. We also thank our team members, Dr. Ichiro Kato, Dr. Seiji Odagawa, Dr. Takeshi Endo, Dr. Nobuyuki Ueno from the Shimane University Hospital, General Medicine Center, for sharing their wisdom with us during this research. In addition, we also thank Dr. Sanjay Saint, Dr. Nathan Houchens, Dr. Ashwin Gupta for their remarkable guidance and advice on this research in Japan.


Supplementary materials

  • Supplementary Data

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  • Twitter @wataritari1

  • Contributors TW and MK designed the study, the main conceptual ideas and the proof outline. MK, YNi and YT collected the data via web survey on GM-ITE. TW, MK, YNi, YT analysed and visualised the data. TW, YNi, YT, TS and YNa aided in interpreting the results and worked on the manuscript. YT and YNa supervised the project. TW wrote the whole manuscript with support from MK. The author team acknowledges and confirms that TW, as the lead author, acts as the guarantor for this study. TW accepts full responsibility for the work and the conduct of the study. All authors had complete access to all the data, and controlled the decision to publish. Any inquiries regarding the integrity and validity of the research and its findings can be directed to TW, who ensures the accuracy and completeness of the study in all aspects.

  • Funding This work was supported by the national academic research grant funds (JSPS KAKENHI: 20H03913).

  • Competing interests Yu N received an honorarium from JAMEP as a GM-ITE project manager. YT is the JAMEP director, and he received an honorarium from JAMEP as a speaker of the JAMEP lecture.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.