Fillable Printable Hospital Survey on Patient Safety Culture
Fillable Printable Hospital Survey on Patient Safety Culture
Hospital Survey on Patient Safety Culture
INSTRUCTIONS
This survey asks for your opinions about patient safety issues, medical error, and event reporting in
your hos pital and will take about 10 to 15 minutes to complete.
If you do not wish to answer a question, or if a question does not apply to you, you ma y leave your answe r blank.
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 s pend most of your work time or provide mos t of your clinical services
.
What is your primary work area or unit in this hospital? Mar k ONE answer by filling in the circle.
a. Man y different hospital units/No specific unit
b. Med icine (nonsurgical)
g. Intensive care unit (any type)
l. Radiology
c. Surgery
h. Psychiatry/mental health
m. Anesthesiology
d. Obstetri cs
i. Rehabilitation
n. Other, pl ease speci fy:
e. Pediatrics
j. Pharmacy
f. Emergency department
k. Laboratory
Please indicate your agreement or disagreement with the following statements about your work
area/unit. Mark your answer by filling in the circle.
Strong ly
Strong ly
Think about your hospital work area/unit…
Disagre e
Disagre e
Neither
Agree
Agree
1. People support one another in this unit .......................................
2. We have enough staff to handle the workload.............................
3. When a lot of work needs to be done quickly, we work together
as a team to get the work done...................................................
4. In this uni t, people treat each other with respect..........................
5. Staff in this unit work longer hours than is best for patient care....
6. We are actively doing things to improve patient safety ................
7. We use more agency/temporary staff than is best for
patient care ................................................................................
8. Staff feel like the ir mistakes are held against them ......................
9. Mistakes have led to positive changes here ................................
10. It is just by chance that more serious mistakes don’t happen
around here................................................................................
11. When one area in this unit gets really busy, others help out ........
12. When an event is reported, it feels like the person is being
written up, not the problem..........................................................
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SECTION A: Your Work Area/Unit (continued)
Strong ly Strong ly
Disagre e
Disagre e Neithe r Agree
Agree
Think about your hospital work area/unit…
13. After w e make changes to improve patient safety, we evaluate
their effectiv eness .......................................................................
14. We work in "crisis mode" trying to do too much, too quickly.........
15. Patient safety is never sacrificed to get more work done .............
16. Staff worry that mistakes they make are ke pt in their
personnel file..............................................................................
17. We have patient safety problems in this unit ...............................
18. Our procedures and sy stems are good at preventi ng errors
from happeni ng ................................ ..........................................
SECT ION B: Your Supervisor/Manager
Please indicate your agreement or disagre ement with the fol lowing s tatements about your immediate
supervisor/ma nager or person to whom yo u directly report. Mark your answer by filling in the circle.
Strong ly Strong ly
Disagre e Disagree Neither Agree Agree
1. My s upervisor/mana ger s ays a g ood word when he/she sees a
job done according to established patient saf ety procedures.......
2. My s upervisor/mana ger s eriously conside rs staff suggestion s
for improving patient saf ety.........................................................
3. Whenever pressure builds up, my supervisor/manager wants
us to w ork fas ter, e ven if it means taking shortcuts......................
4. My supervisor/mana ger overlooks patient safety problems that
happen over and o ver.................................................................
SECTION C: Communications
How ofte n do the following t hings ha ppe n in y our w ork area/unit? Mark your answer by filling in the circle.
Some-
Most of
Never Rarely
times
the time
Always
Think about your hospital work area/unit…
1. We are given feedback about changes put into place b as ed
on e vent reports................................................................
..........
2. Staff will freely speak up if they see something that may
negatively affe ct patient care ................................
......................
3. We are informed about errors that happen in this unit
.................
4. Staff feel free to question the decisions or actions o f th os e
with more authority ................................................................
.....
5. In this uni t, we di scuss ways to prevent errors from
happening again................................................................
.........
6. Staff are afraid to ask ques tions wh en something d oes not
seem right ................................ ................................
..................
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SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the followin g mistakes happen, how often are they reported?
Mar k your answer by fillin g in the circle.
Some-
Most of
Never Rarely
times
the time
Always
1. When a mistake is made, but is caught and corrected
before affecting the patient, how often is this reported?
...............
2. When a mistake is made, but has no potential to harm the
patient, how of ten i s thi s reported?..............................................
3. When a mistake is made that could harm the patient, but
does not, how often is this reported?................................
...........
SECTION E: Patient Safety Grade
Please give your work area /unit in this hospital an overall grade on patient safety. Mark ONE answer.
A B C D E
Excellent Very Good Acceptable Poor Failing
SECTION F: Your Hosp ital
Please indicate your agreement or disagre ement with the fol lowing s tatements about your hospital.
Mar k your answer by filling in the circle.
Strong ly Strongly
Disagre e
Disagre e Neithe r Agree
Agree
Think about your hospital…
1. Hos pital manage ment pro vides a w ork climate that pro motes
patient safety..............................................................................
2. Hos pital units do not coordina te well with each other...................
3. Things “fall between the cracks” when transferring patients
from one unit to another................................ ..............................
4. There is good cooperation among hospital units that need to
work together..............................................................................
5. Important pa tient care in formation is o ften lost during
shift changes ................................................................ ..............
6. It is often unpleasant to work wi th staff from other hospital un its..
7. Problems often occu r in the exchange of information across
hos pital units ..............................................................................
8. The actions of hospi tal m anagement show that patient saf ety i s
a top prior ity................................................................................
9. Hos pital manage ment seems interested in patient safety only
after an ad verse e vent happens..................................................
10. Hos pital units work w ell together to provide the bes t care
for patients .................................................................................
11. Shift changes are problematic for patien ts in this hospital............
SECTION G: Number of Events Reported
In the past 12 months, how many event reports have you filled out and submitted? Mark ONE answer.
a. No event reports d. 6 to 10 event reports
b. 1 to 2 event reports e. 11 to 20 event reports
c. 3 to 5 event reports f. 21 e vent reports or more
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SECTION H: Background Information
This information will help in the analysis of the sur vey results. Mark ONE answer by filling in the c ircle.
1. How
long have you w orked in this hospital?
a. Less than 1 year d. 11 to 15 years
b. 1 to 5 years e. 16 to 20 years
c. 6 to 10 years f. 21 years or more
2. How long ha ve you w orked in your current hospita l work area/unit?
a. Less than 1 year d. 11 to 15 years
b. 1 to 5 years e. 16 to 20 years
c. 6 to 10 years f. 21 years or more
3. Ty
pi cally, how many hours per w eek do you work in this hospi tal?
a. Less than 20 hours per week d. 60 to 79 hours per week
b. 20 to 39 hours per week e. 80 to 99 hours per w eek
c. 40 to 59 hours per w eek f. 100 hours per w eek or more
4. Wh
at is your staff position in this hospital? Mark ONE answer that best describes your staff position.
a. Registered Nurse h. Dietician
b. Physician Assistant/Nurse Practitioner i. Unit As s is tant/Clerk/Secre tary
c. LVN/LPN j. Respiratory Therapist
d. Patient Care Assistant/Hospital Aide/Care Partner k. Physical, Occupational, or Speech Therapist
e. Attending/Staff Physician l. Technician (e.g., EKG, Lab, Radi ology)
f. Res ident Phys ician/Phys ician in Training m. Administration/Management
g. Pharmacist n. Other, pl ease specify:
5. In your staff positi on, do you typi cally have direct i nteraction or contact wi th pati ents?
a. YES, I typically have direct interaction or contact with patients.
b. NO, I typically do NOT have d irect interaction or contact w ith patients.
6. How long ha ve you w orked in your current specialty or profes s ion?
a. Less than 1 year d. 11 to 15 years
b. 1 to 5 years e. 16 to 20 years
c. 6 to 10 years f. 21 years or more
SECTION I: Your Comments
Please feel free to wr ite any comments about pa tient safe ty, error, or event reporting in your hospital.
THANK YOU FOR C OMPLETING THIS SURVEY.
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