Background: Incident reporting and speaking up are how hospitals learn from error. Both are thought to depend on a non punitive, "just" culture. Evidence on how these behaviours vary across levels of care in sub-Saharan Africa is scarce. We examined event reporting, response to error, communication openness and feedback in secondary and tertiary hospitals in Bayelsa State, Nigeria. Methods: Between December 2015 and March 2016, we conducted a cross-sectional survey of 438 healthcare workers (response rate 87.6%) in five general hospitals (n = 252) and one federal teaching hospital (n = 186). We used 11 items from four dimensions of the Hospital Survey on Patient Safety Culture, plus respondents' free-text comments. Items were compared with Welch's t-test, Hedges' g and Holm correction across all 41 survey items. Results: Secondary hospitals had the most punitive climate in the survey (non-punitive response index 48.0% vs 65.8%). Their staff were far more worried that mistakes are kept in personnel files (g = 1.10, the largest difference in the survey). Yet they reported events more often (70.8% vs 60.4%), especially mistakes with no potential for harm (3.63 vs 2.82; g = −0.82). Tertiary staff were the least free to question the decisions of those with more authority (mean 2.10, the lowest item score at that level; g = −0.43) and less likely to speak up freely (g = −0.34). They were, however, less afraid to ask questions (g = 0.54). They also received more feedback about errors. Among coded free-text comments, 18.3% described doctors not admitting prescription errors. Field observations, mainly in the general hospitals, showed that incidents went unrecorded for fear of disciplinary queries, allowing them to recur. Conclusions: The levels of care showed two distinct failure modes. Secondary hospitals showed defensive reporting: events are reported, but in a climate of blame. The teaching hospital showed filtered silence: blame is lower, but reporting is severity-filtered and upward challenge is muted by hierarchy. A non-punitive climate was necessary but not sufficient for reporting. Interventions should combine just-culture policy in general hospitals with structured speaking-up and hierarchy-flattening practices in teaching hospitals.

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