Background: Patient safety culture is a modifiable determinant of harm in hospitals, yet evidence from Nigeria's Niger Delta is almost absent. Most studies also stop at the global safety grade, which may hide important differences between levels of care. We compared patient safety culture in secondary and tertiary hospitals in Bayelsa State, Nigeria. Methods: Between December 2015 and March 2016, we conducted a multicentre cross-sectional survey of 438 healthcare workers (response rate 87.6%) in five general (secondary) hospitals (n = 252) and one federal tertiary hospital (n = 186). We used an adapted version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture (HSOPSC). Composite scores were expressed as a mean score index (mean/5 × 100) and classified as strength (≥75%), area for improvement (50–74.9%) or weakness (<50%). Levels were compared item by item with Welch's t-test and Hedges' g, with Holm correction across 41 items. Patient safety grades were compared with the chi-square test. Results: The mean composite index was 66.6% in secondary and 72.3% in tertiary hospitals. Tertiary hospitals had six areas of strength; secondary hospitals had one (teamwork within units, 76.4%) and one weakness (non-punitive response to error, 48.0%). Secondary respondents more often awarded an "Excellent" grade (31.1% vs 21.4%; p = 0.026), but the proportion grading safety excellent or very good did not differ (68.5% vs 72.5%; p = 0.37). Of 30 items outside the reporting and blame domains, 21 differed after correction, 19 in favour of tertiary hospitals. The largest gaps were at system interfaces: information exchange across units (g = 1.07), supervisors overlooking recurring problems (g = 1.05) and inter-unit collaboration (g = 0.92). Tertiary staff scored lower on "patient safety is never sacrificed to get more work done" (g = −0.41) and "mistakes have led to positive changes" (g = −0.46). Conclusions: A favourable global grade concealed large, level-specific deficits. Secondary hospitals need investment at handoffs, inter-unit coordination, staffing and leadership follow-through. Tertiary hospitals need to convert visible improvement activity into learning from error while protecting safety from production pressure. Safety culture assessments in Nigeria should report dimension-level and item-level results, not the grade alone.

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