Patient safety culture in low- and lower-middle-income countries: a systematic review of evidence involving hospital pharmacists

BACKGROUND: Patient safety culture (PSC) promotes shared values and practices to reduce harm. In low- and lower-middle-income countries (LLMICs), PSC is limited by resources and weak reporting. Hospital pharmacists are key to preventing medication errors and are underrepresented. This review summarizes evidence on their PSC involvement, domain findings, and influencing factors. METHODS: We systematically searched PubMed, Web of Science, Scopus, and grey literature (January 2010-December 2025) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines (PROSPERO: CRD420251125507). Duplicates were removed in Rayyan. Two reviewers independently screened titles/abstracts and full texts against eligibility criteria (hospital pharmacists, PSC assessment, LMIC setting), resolving disagreements by discussion or a third reviewer. Data were extracted using a standardized form (study characteristics, PSC tool, domain scores, predictors, barriers, findings). Quality was appraised with the Joanna Briggs Institute checklist. Findings were narratively synthesized due to heterogeneity; no meta-analysis was performed. RESULTS: From 1350 records identified, 29 studies met the inclusion criteria. All included articles were cross-sectional in design. Most studies were conducted in Africa (22; 75.9%). Only six studies (20.7%) focused exclusively on pharmacists. The Hospital Survey on Patient Safety Culture (HSOPSC) was the most frequently used tool (22; 75.9%). Across studies, teamwork within units was the most consistently high-scoring domain (18; 62.1%). The lowest-scoring domains were staffing and work pace (10; 34.5%) and patient safety incidents, reporting 12 (41.4%). Common barriers identified: blame culture (55.2%), severe staffing shortages (51.7%), and resource constraints (41.4%). CONCLUSION: Evidence involving hospital pharmacists in LLMICs is limited and largely derived from mixed-profession studies. Teamwork was a relative strength, while staffing and nonpunitive response were recurrent weaknesses, highlighting priorities for strengthening PSC.