Adverse Event Reporting Pre-Survey Patient Safety Education Program If you are human, leave this field blank. Participant Demographics First Name * Last Name * Email Address * Gender * Male Female Age * Position (Resident, Faculty, Nurse, Pharmacist, etc.) * Hospital * Years of Experience/Resident Year * Program/Specialty * Please rate the following statements on a 5 point scale: 5 - Strongly agree 4 - Agree 3 - Neither agree nor disagree 2 - Disagree 1 - Strongly disagree I MAY NOT BE WILLING TO REPORT AN ADVERSE EVENTS BECAUSE: I am worried about disciplinary action. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree When the ward is busy I forget to make a report. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree I am worried about litigation. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree I don’t know whose responsibility it is to make the report. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree My colleagues may be unsupportive. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree I do not want the case discussed in meetings. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree I do not know which incidents should be reported. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree The circumstances/outcome of the case make reporting unnecessary. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree As long as the staff involved learn from incidents it is unnecessary to discuss them further. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree Adverse incident reporting makes little contribution to the quality of care. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree Junior staff are often unfairly blamed for adverse incidents. SELECT ANSWER 5- Strongly Agree 4- Agree 3- Neither Agree or Disagree 2- Disagree 1- Strongly Disagree Please give any other reason(s) for not reporting incidents: