Objective To identify potential barriers to patient safety (PS) interventions from the perspective of surgical team members working in an operating theatre in Eastern Democratic Republic of Congo (DRC).

Design In-depth interviews were conducted and analysed using qualitative content analysis.

Setting Governmental referral teaching hospital in Eastern DRC.

Participants We purposively selected 2–4 national and expatriate surgical team members from each specialisation. Of the 31 eligible surgical health workers (HWs), 17 volunteered to be interviewed.

Results Economics issues affected PS throughout the entire health system, from human resources and hospital management, to access to healthcare for patients. Surgical team members seemed embedded in a paternalistic organisational structure and blame culture accompanied by perceived inefficient support services and low salaries. The armed conflict did not only worsen these system failures, it also carried direct threats to patients and HWs, and resulted in complex indirect consequences compromising PS. The increased corruption within health organisations, and population impoverishment and substance abuse among health staff adversely altered safe care. Simultaneously, HWs’ reported resilience and resourcefulness to address barrier to PS. Participants had varying views on external aid depending on its relevance.

Conclusions The complex links between war and PS emphasise the importance of a comprehensive approach including occupational health to strengthen HWs' resilience, external clinical audits to limit corruption, and educational programmes in PS to support patient-centred care and address blame culture. Finally, improvement of equity in the health financing system seems essential to ensure access to healthcare and safe perioperative outcomes for all.