Developing a Comprehensive Medication Safety Culture Framework for Nigerian Public Hospitals: A Mixed-Methods Multi-Zonal Study

Medication safety culture, encompassing organizational attitudes, beliefs, and behaviors that collectively determine medication safety outcomes, is recognized internationally as a key determinant of hospital medication error rates and adverse event prevention. No validated medication safety culture framework developed specifically for Nigerian public hospital contexts exists, limiting both research and quality improvement efforts. This study developed and psychometrically validated a comprehensive medication safety culture framework for Nigerian public hospitals using a sequential mixed-methods, multi-zonal design spanning all six geopolitical zones. The study proceeded through four phases: systematic review of existing safety culture frameworks, qualitative framework development through focus groups and expert consultation involving 96 pharmacists, nurses, physicians, and hospital administrators across 18 hospitals, quantitative validation of a derived survey instrument with 1,400 hospital health workers, and framework refinement through expert consensus. The emergent Nigerian Medication Safety Culture Framework comprised six domains: leadership commitment to medication safety, communication and feedback systems, error reporting and learning culture, staffing and workload adequacy, medication safety knowledge competency, and patient engagement in safety. Confirmatory factor analysis supported a well-fitting six-factor structure, and the survey instrument demonstrated strong reliability and validity metrics across all zones. Significant zone-level variation in safety culture scores was documented, with North East hospitals showing the greatest cultural gaps. The framework represents the first nationally grounded tool for benchmarking and improving medication safety culture in Nigeria's public health system. Keywords: medication safety culture, framework development, Nigerian hospitals, multi-zonal study, patient safety