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* 1. What is your primary work area or unit in this facility?

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* 2. People support one another in this unit.

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* 3. We have enough staff to handle the workload.

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* 4. When a lot of work needs to be done quickly, we work together as a team to get the work done.

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* 5. In this unit, people treat each other with respect.

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* 6. Staff in this unit work longer hours than is best for patient care.

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* 7. We are actively doing things to improve patient safety.

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* 8. We use more agency/temporary staff than is best for patient care.

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* 9. Staff feel like their mistakes are held against them.

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* 10. Mistakes have led to positive changes here.

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* 11. It is just by chance that more serious mistakes don’t happen around here.

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* 12. When one area in this unit gets really busy, others help out.

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* 13. When an event is reported, it feels like the person is being written up, not the problem.

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* 14. After we make changes to improve patient safety, we evaluate their effectiveness.

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* 15. We work in “crisis mode” trying to do too much, too quickly.

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* 16. Patient Safety is never sacrificed to get more work done.

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* 17. Staff worry that mistakes they make are kept in their personnel file.

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* 18. We have patient safety problems in the unit.

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* 19. Our procedures and systems are good at preventing errors from happening.

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* 20. My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures.

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* 21. My supervisor/manager seriously considers staff suggestions for improving patient safety.

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* 22. Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts.

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* 23. My supervisor/manager overlooks patient safety problems that happen over and over.

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* 24. We are given feedback about changes put into place based on event reports.

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* 25. Staff will freely speak up if they see something that may negatively affect patient care.

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* 26. We are informed about errors that happen in this unit.

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* 27. Staff feel free to question the decisions or actions of those with more authority.

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* 28. In this unit, we discuss ways to prevent errors from happening again.

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* 29. Staff are afraid to ask questions when something does not seem right

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* 30. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?

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* 31. When a mistake is made, but has no potential to harm the patient, how often is this reported?

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* 32. When a mistake is made that could harm the patient, but does not, how often is this reported?

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* 33. Please give your work area/unit in this facility an overall grade on patient safety.

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* 34. Management provides a work climate that promotes patient safety.

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* 35. Units do not coordinate well with each other.

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* 36. Things “fall between the cracks” when transferring patients from one unit to another.

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* 37. There is good cooperation among units that need to work together.

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* 38. Important patient care information is often lost during shift changes.

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* 39. It is often unpleasant to work with staff from other units in this facility.

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* 40. Problems often occur in the exchange of information across units in this facility.

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* 41. The actions of management in this facility show that patient safety is a top priority.

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* 42. Management in this facility seem interested in patient safety only after an adverse event happens.

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* 43. Units in this facility work well together to provide the best care for patients.

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* 44. Shift changes are problematic for patients in this facility.

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* 45. In the past 12 months, how many event reports have you filled out and submitted?

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* 46. How long have you worked in this facility?

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* 47. How long have you worked in your current work area/unit?

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* 48. Typically, how many hours per week do you work in this facility?

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* 49. What is your staff position in this facility? Select the answer that best describes your staff position.

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

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

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* 52. Any Additional comments

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