Safety Culture Survey | Hospice Providers of the Desert

SAFETY CULTURE SURVEY

This survey asked for your opinion about patient safety issues, event reporting, and agency evaluation. Please answer to the best of your knowledge. If you do not wish to answer a question or if a question does not apply to you, you may leave your answer blank.

1- Strongly Disagree
2- Disagree
3- Neither
4- Agree
5- Strongly Agree

Section A. YOUR WORK TEAM

Section B. YOUR SUPERVISOR – please indicate agree or disagree about your immediate supervisor

Section C. COMMUNICATION – how often do the following things happen in your agency

Section D. FREQUENCY OF EVENTS REPORTED

1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?NeverRarelySometimesMost of the timeAlways

Section E. PATIENT SAFETY GRADE

Section F. HOSPICE PROVIDERS OF THE DESERT, INC.

Section G. NUMBER OF EVENTS REPORTED

Section H

Other (Please specify)

4. In your position, do you typically have direct interaction or contact with patientsYesNo

Section I

Please feel free to write any comments or concerns your may have on patient safety, event reporting and/or the hospice staff/management.