1. General Information

50% of survey complete.

This CONFIDENTIAL survey will help MITSS better serve you and others enduring the stress after an adverse event. There are 29 questions, some with multiple parts, included in this survey. Please complete every question in the survey. Your participation is greatly appreciated. This is a CONFIDENTIAL survey that will take approximately 10 minutes to complete. Please feel free to answer openly and honestly as your responses will help MITSS to provide information and support more effectively.

* 1. Are you male or female?

* 2. Age?

* 3. How did you find MITSS?

* 4. What city/ state/ country do you live in?

* 5. If the event did not occur in the place you currently live, in what city/ state/ country did the event take place?

* 6. What role did you have in the event?

* 7. What type of an event was it?

* 8. When did the event occur?

* 9. Were you referred to confidential support services?

* 10. If yes, what services were you offered?

* 11. Were you referred to services at the place the event occurred (in house) or were you referred to outside services?

* 12. Please check any of the following you have experienced/ are experiencing after the event.

* 13. Please indicate your level of agreement or disagreement with the following statements about your experiences following the adverse event. Please complete all questions by marking the ONE response that best reflects your experience.

  Strongly Disagree Disagree Agree Strongly Agree I Don't Know N/A
I worried a lot about what my clinical peers would think about me after the event
I wanted to speak to the patient and/ or family but was told not to do so.
I felt (or would have felt) embarrassed about seeking psychological support after the event.
The organization ensured that the needs of the patient and/ or family after the event were appropriately met.
My clinical line manager provided meaningful and sustained support after the event.
I was supported and enabled to communicate appropriately with the patient and/ or family after the event.
I had extreme anxiety about disclosing to the patient and/ or family.
I left or seriously considered leaving my PROFESSION because of the event or what happened afterwards.
There was a designated member of the organization who guided me through the processes that are followed after a serious adverse event.
I felt adequately supported by the organization and associated structures.
Memories of what happened to the patient kept troubling me for a long time after the event.
I worried a lot about a lawsuit or the possibility of one.
I think that the organization learned from the event and took appropriate steps to reduce the chance of it happening again.
My family and friends were the mainstay of my support after the event.
I knew how to access confidential emotional support within the institution if I needed it.
For a while after the event I felt shunned by some of my clinical colleagues.
I was always clearly briefed about the 'next steps' in the hospital's processes for following up after serious adverse events.
I moved or seriously considered moving to another INSTITUTION because of the event or what happened afterwards.
I found it difficult to continue to practice effectively immediately after the event.
The hospital had a clear process through which I could report any concerns I had about patient safety without fear of retribution or punitive action.

* 14. Please indicate any of the following you have experienced in the past 3 months, not otherwise explained by a known medical condition:

* 15. Please indicate any of the following that you have experienced in the past 12 months:

* 16. After the event, were you able to take a work-sanctioned break to regroup prior to caring for others?

* 17. Does your facility have a formalized peer support system for responding to adverse events?

* 18. If yes, can you briefly describe how you would access that system?

* 19. Did the patient receive a full explanation of the event?

* 20. Who provided the explanation? Please do not include names, but do include job titles and whether or not it was you who provided the explanation.

* 21. Did the patient receive a sincere apology after the event?

* 22. Who provided the apology? Again, please do not put specific names.

* 23. Have you received training regarding how to provide an appropriate explanation and/ or apology to a patient after an adverse event?

* 24. Did you follow through with your facilities policies regarding reporting such events?

* 25. If you answered 'no' to the above question, what would assist you in reporting such incidences in the future?

* 26. Have you utilized support services from MITSS in the past?

* 27. If you answered "yes" to the above question, what services did you use and how effective do you feel they were?

* 28. Please rate the user-friendliness of this website.

* 29. What, if anything, would make this website more useful to you?

* 30. Please feel free to add any additional information you would like to share with MITSS, including any feedback regarding this survey or your personal event.

* 31. If you would like a MITSS support staff to contact you, please leave your contact information below. This survey does not automatically record any identifying or contact information. Therefore, it is important that you leave such confidential information in order for a support staff member to contact you.