| Hospital (circle one) |
ANW |
Mercy |
PEI |
United |
Unity |
| Department/Unit |
__________________________ |
| Occupation (circle one) |
Nurse |
Physician |
Pharmacist |
Other |
___________ |
| Please rate the following: (circle one number on each
line) |
Strongly Agree |
Agree |
Disagree |
Strongly Disagree |
Not Applicable |
| 1) Senior managers at my hospital communicate to me
that patient safety is a high priority |
1 |
2 |
3 |
4 |
NA |
| 2) My department/unit acts on reported information related
to medical errors (near miss, incident, sentinel event)
to improve patient safety |
1 |
2 |
3 |
4 |
NA |
| 3) Individuals are supported for reporting medical errors
|
1 |
2 |
3 |
4 |
NA |
| 4) My department/unit places blame on individuals when
an error is reported. |
1 |
2 |
3 |
4 |
NA |
| 5) I fear there will be negative consequences associated
with reporting medical errors |
1 |
2 |
3 |
4 |
NA |
| 6) My workload interferes with my ability to practice
patient safety |
1 |
2 |
3 |
4 |
NA |
| 7) I feel comfortable reporting medical errors made
by co-workers |
1 |
2 |
3 |
4 |
NA |
| 8) The medication protocols in my hospital are too complex |
1 |
2 |
3 |
4 |
NA |
| 9) The process of reporting errors at my hospital is
cumbersome |
1 |
2 |
3 |
4 |
NA |
| 10) I believe that a medical error is the result of
a failure of a complex system |
1 |
2 |
3 |
4 |
NA |
| 11) New technologies, such as electronic medical records
or Pyxis, are creating a safer environment for patients
in my hospital |
1 |
2 |
3 |
4 |
NA |
| 12) New technologies available in my hospital are fully
utilized to help prevent medical errors |
1 |
2 |
3 |
4 |
NA |
| 13) I work in an environment where I can openly communicate
my opinions about patient care practices |
1 |
2 |
3 |
4 |
NA |
