Information Survey

Medication Safety Contest Winner
Survey to solicit information about the culture of reporting
Allina Hospitals and Clinics

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