Hospital Survey Form (Text Version)

Instructions

---

Development of this survey on patient safety culture was sponsored by the Agency for Healthcare Research and Quality (AHRQ). This tool is useful for assessing the safety culture of a hospital as a whole, or for specific units within hospitals. Moreover, the survey can be used to track changes in patient safety over time and to evaluate the impact of patient safety interventions.

The survey asks for your opinions about patient safety issues, medical error, and event reporting in your hospital and will take about 10 to 15 minutes to complete.

---

An "event" is defined as any type of error, mistake, incident, accident, or deviation, regardless of whether or not it results in patient harm. "Patient safety" is defined as the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery.

Section A: Your Work Area/Unit

In this survey, think of your "unit" as the work area, department, or clinical area of the hospital where you spend most of your work time or provide most of your clinical services.

What is your primary work area or unit in this hospital? Check one answer.

__ a. Many different hospital units/No specific unit
__ b. Medicine (non-surgical)
__ c. Surgery
__ d. Obstetrics
__ e. Pediatrics
__ f. Emergency department
__ g. Intensive care unit (any type)
__ h. Psychiatry/mental health
__ i. Rehabilitation
__ j. Pharmacy
__ k. Laboratory
__ l. Radiology
__ m. Anesthesiology
__ n. Other, please specify: _____________________________

Please indicate your agreement or disagreement with the following statements about your work area/unit. Mark your answer by checking the box.

Think about your hospital work area/unit...	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
1. People support one another in this unit.	1	2	3	4	5
2. We have enough staff to handle the workload.	1	2	3	4	5
3. When a lot of work needs to be done quickly, we work together as a team to get the work done.	1	2	3	4	5
4. In this unit, people treat each other with respect.	1	2	3	4	5
5. Staff in this unit work longer hours than is best for patient care.	1	2	3	4	5
6. We are actively doing things to improve patient safety.	1	2	3	4	5
7. We use more agency/temporary staff than is best for patient care.	1	2	3	4	5
8. Staff feel like their mistakes are held against them.	1	2	3	4	5
9. Mistakes have led to positive changes here.	1	2	3	4	5
10. It is just by chance that more serious mistakes don't happen around here.	1	2	3	4	5
11. When one area in this unit gets really busy, others help out.	1	2	3	4	5
12. When an event is reported, it feels like the person is being written up, not the problem.	1	2	3	4	5
13. After we make changes to improve patient safety, we evaluate their effectiveness.	1	2	3	4	5
14. We work in "crisis mode" trying to do too much, too quickly.	1	2	3	4	5
15. Patient safety is never sacrificed to get more work done.	1	2	3	4	5
16. Staff worry that mistakes they make are kept in their personnel file.	1	2	3	4	5
17. We have patient safety problems in this unit.	1	2	3	4	5
18. Our procedures and systems are good at preventing errors from happening.	1	2	3	4	5

Section B: Your Supervisor/Manager

Please indicate your agreement or disagreement with the following statements about your immediate supervisor/manager or person to whom you directly report. Mark your answer by checking the box.

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
1. My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures.	1	2	3	4	5
2. My supervisor/manager seriously considers staff suggestions for improving patient safety.	1	2	3	4	5
3. Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts.	1	2	3	4	5
4. My supervisor/manager overlooks patient safety problems that happen over and over.	1	2	3	4	5

Section C: Communications

How often do the following things happen in your work area/unit? Mark your answer by checking the box.

Think about your hospital work area/unit...	Never	Rarely	Sometimes	Most of the time	Always
1. We are given feedback about changes put into place based on event reports.	1	2	3	4	5
2. Staff will freely speak up if they see something that may negatively affect patient care.	1	2	3	4	5
3. We are informed about errors that happen in this unit.	1	2	3	4	5
4. Staff feel free to question the decisions or actions of those with more authority.	1	2	3	4	5
5. In this unit, we discuss ways to prevent errors from happening again.	1	2	3	4	5
6. Staff are afraid to ask questions when something does not seem right.	1	2	3	4	5

Section D: Frequency of Events Reported

In your hospital work area/unit, when the following mistakes happen, how often are they reported? Mark your answer by checking the box.

Think about your hospital work area/unit...	Never	Rarely	Sometimes	Most of the time	Always
1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?	1	2	3	4	5
2. When a mistake is made, but has no potential to harm the patient, how often is this reported?	1	2	3	4	5
3. When a mistake is made that could harm the patient, but does not, how often is this reported?	1	2	3	4	5

Section E: Patient Safety Grade

Please give your work area/unit in this hospital an overall grade on patient safety. Check one answer.

A Excellent	B Very Good	C Acceptable	D Poor	E Failing

Section F: Your Hospital

Please indicate your agreement or disagreement with the following statements about your hospital. Mark your answer by checking the box.

Think about your hospital...	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
1. Hospital management provides a work climate that promotes patient safety.	1	2	3	4	5
2. Hospital units do not coordinate well with each other.	1	2	3	4	5
3. Things "fall between the cracks" when transferring patients from one unit to another.	1	2	3	4	5
4. There is good cooperation among hospital units that need to work together.	1	2	3	4	5
5. Important patient care information is often lost during shift changes.	1	2	3	4	5
6. It is often unpleasant to work with staff from other hospital units.	1	2	3	4	5
7. Problems often occur in the exchange of information across hospital units.	1	2	3	4	5
8. The actions of hospital management show that patient safety is a top priority.	1	2	3	4	5
9. Hospital management seems interested in patient safety only after an adverse event happens.	1	2	3	4	5
10. Hospital units work well together to provide the best care for patients.	1	2	3	4	5
11. Shift changes are problematic for patients in this hospital.	1	2	3	4	5

Section G: Number of Events Reported

In the past 12 months, how many event reports have you filled out and submitted? Check one answer.

__ a. No event reports
__ b. 1 to 2 event reports
__ c. 3 to 5 event reports
__ d. 6 to 10 event reports
__ e. 11 to 20 event reports
__ f. 21 event reports or more

Section H: Background Information

This information will help in the analysis of the survey results. Check one answer for each question.

1. How long have you worked in this hospital?

__ a. Less than 1 year
__ b. 1 to 5 years
__ c. 6 to 10 years
__ d. 11 to 15 years
__ e. 16 to 20 years
__ f. 21 years or more

2. How long have you worked in your current hospital work area/unit?

__ a. Less than 1 year
__ b. 1 to 5 years
__ c. 6 to 10 years
__ d. 11 to 15 years
__ e. 16 to 20 years
__ f. 21 years or more

3. Typically, how many hours per week do you work in this hospital?

__ a. Less than 20 hours per week
__ b. 20 to 39 hours per week
__ c. 40 to 59 hours per week
__ d. 60 to 79 hours per week
__ e. 80 to 99 hours per week
__ f. 100 hours per week or more

4. What is your staff position in this hospital? Mark ONE answer that best describes your staff position.

__ a. Registered Nurse
__ b. Physician Assistant/Nurse Practitioner
__ c. LVN/LPN
__ d. Patient Care Assistant/Hospital Aide/Care Partner
__ e. Attending/Staff Physician
__ f. Resident Physician/Physician in Training
__ g. Pharmacist
__ h. Dietician
__ i. Unit Assistant/Clerk/Secretary
__ j. Respiratory Therapist
__ k. Physical, Occupational, or Speech Therapist
__ l. Technician (e.g., EKG, Lab, Radiology)
__ m. Administration/Management
__ n. Other, please specify:__________________________________________

5. In your staff position, do you typically have direct interaction or contact with patients?

__ a. Yes, I typically have direct interaction or contact with patients.
__ b. No, I typically do NOT have direct interaction or contact with patients.

6. How long have you worked in your current specialty or profession?

__ a. Less than 1 year
__ b. 1 to 5 years
__ c. 6 to 10 years
__ d. 11 to 15 years
__ e. 16 to 20 years
__ f. 21 years or more

Section I: Your Comments

Please feel free to write any comments about patient safety, error, or event reporting in your hospital.

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Return to Contents