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.

When the ward is busy I forget to make a report.

I am worried about litigation.

I don’t know whose responsibility it is to make the report.

My colleagues may be unsupportive.

I do not want the case discussed in meetings.

I do not know which incidents should be reported.

The circumstances/outcome of the case make reporting unnecessary.

As long as the staff involved learn from incidents it is unnecessary to discuss them further.

Adverse incident reporting makes little contribution to the quality of care.

Junior staff are often unfairly blamed for adverse incidents.

Please give any other reason(s) for not reporting incidents: