Patient Safety at Secondary Public Health Facilities in Low-Resource Indian Setting: Evidence From First Published Application of SaQushal Toolkit

OBJECTIVES: Patient safety at secondary-level public health facilities in low-income and middle-income countries remains critically underevaluated. This study aimed to assess the level of patient safety at secondary health facilities in Eastern Rajasthan, India, using the SaQushal toolkit, and to identify priority areas for improvement. METHODS: A cross-sectional facility-based assessment was conducted at 6 secondary health facilities in Eastern Rajasthan. Data were collected from Principal Medical Officers, nonparticipant observation, and record review, in accordance with the SaQushal toolkit, a structured self-assessment instrument developed by India's National Health Systems Resource Centre. Patient safety was measured across 4 areas of concern: Safe Patient Care Processes, Clinical Risk Management, Safe Care Environment, and Patient Safety System. Scores were expressed as percentages of maximum possible marks; means and medians were calculated for cross-facility comparison. RESULTS: None of the 6 facilities achieved an overall score exceeding 50% (maximum 800 marks). The mean overall score was 245.83 (30.7%). Clinical Risk Management recorded the highest mean score (83.50), driven by performance in Reproductive, Maternal, Newborn, Child and Adolescent Health services. Patient Safety System recorded the lowest mean score (27.33). The Reporting and Learning System standard recorded a mean score of 0.33 out of 50. CONCLUSIONS: Patient safety standards across assessed secondary health facilities were substantially below acceptable thresholds. The near-absent Reporting and Learning System represents the most critical systemic gap. Findings provide baseline evidence to guide targeted quality improvement under India's National Patient Safety Implementation Framework 2018-2025 and the WHO Global Patient Safety Action Plan 2021-2030.