6/15/05 cp
ID_______________
Adverse Event Reporting Follow-Up Survey
8-19-08 (per 7/29/08 mail version)
Q1. First, does your hospital collect information where harm has occurred or might have occurred to a patient during the course of his or her care?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Q1 Note (no data item): For the remaining questions, we refer to instances where harm occurred or might have occurred to the patient as “occurrences.”
Q2. We are interested in the sources from which you might learn about these occurrences. Have you ever learned about these occurrences…
a. From hospital staff filling out an occurrence form?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
b. From hospital staff calling you directly?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
c. Through a hotline?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
d. By attending a committee meeting?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
e. By conducting rounds or walk arounds?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
f. By a patient notifying the hospital?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
g. By a Federal or state agency contacting the hospital?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Q3. At this time, is your hospital storing information on occurrences in a central location?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Q4. At this time, is the occurrence information stored on paper only, computer only or both?
PAPER ONLY 1 (SKIP TO Q5INTRO)
COMPUTER ONLY 2
BOTH PAPER AND COMPUTER 3
REFUSED 7
DON’T KNOW 8
Q4a. Which types of software does your hospital use? Do you use…
YES NO RF DK
1. A prepackaged patient safety software
such as DoctorQuality.com, RiskMaster, or Meditech? 1 2 7 8
2. A non-commercially available software designed specifically
for your hospital? 1 2 7 8
3. Software designed for external reporting systems, such as
NHSN or for state health departments? 1 2 7 8
(SPECIFY)_______________________________________________
4. Standard office software such as Microsoft Word, Excel, or Access 1 2 7 8
5. Any other software? (SPECIFY)______________________________ 1 2 7 8
Q5INTRO. For the remainder of this interview, we will be referring to your collection of occurrences as your hospital’s “reporting system.” Please respond for the reporting system currently in place.
Q5. Does your hospital’s current reporting system allow for descriptive accounts of the occurrences?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Q6. Does your hospital’s current reporting system collect the severity of harm that occurred to the patient?
YES 1
NO 2 (SKIP TO Q7)
REFUSED 7 (SKIP TO Q7)
DON’T KNOW 8 (SKIP TO Q7)
Q6a. How many levels of severity does the hospital’s current reporting system have?
|___|___|
REFUSED 97
DON’T KNOW 98
Q7. In your opinion, how important is it to have formats that allow standardized reporting for hospitals?
Very important 1
Somewhat important 2
Somewhat unimportant 7
Not important at all 8
Q7. Is the information in the hospital’s current reporting system protected from legal discovery in your state?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Q9. I’m going to read a list of groups and committees. Please tell me if occurrences, either individually or in aggregate form, are discussed in these committees. If so, are the discussions protected from legal discovery? If your hospital does not have the committee or group I read, please just say so.
Are occurrences discussed at the…
Quality Management Committee?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8 (SKIP TO b)
(Are occurrences discussed at the) Performance Improvement Committee?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at the) Patient Safety Committee?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at the) Departmental Peer Review Committee?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at the) Hospital Peer Review Committee?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at the) Morbidity and Mortality Conference?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at the) Medical Executive Committee?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at the) Senior Management Administrative Committee?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at the) Risk Management Committee?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at the) The Board or Committee of the Board?
YES 1
NO 2
DON’T HAVE GROUP/COMMITTEE 3
REFUSED 7
DON’T KNOW 8
(Are occurrences discussed at) Any other committee?
YES 1
(SPECIFY)___________________________________________
NO 2
REFUSED 7
DON’T KNOW 8
Q10. Now we would like to talk about who may report occurrences to your current reporting system. Of the total occurrences in your reporting system, please indicate how many come from READ ITEM FROM LIST. Would you say all, most, some, a few or none of the reports? [IF R BEGINS TO TRY AND MAKE ANSWERS “ADD UP,” LET HIM/HER KNOW WE ARE INTERESTED IN A GENERAL IMPRESSION.]
a. Nursing staff?
ALL 1
MOST 2
SOME 3
A FEW 4
NONE 5
DO NOT HAVE THIS TYPE OF STAFF 6
REFUSED 7
DON’T KNOW 8
b. Physicians in training including medical students, interns, residents and fellows? (Would you say all, most, some, a few or none of the reports come from them?)
ALL 1
MOST 2
SOME 3
A FEW 4
NONE 5
DO NOT HAVE THIS TYPE OF STAFF 6
REFUSED 7
DON’T KNOW 8
c. Other physicians? (For instance, physicians not employed by your hospital). (Would you say all, most, some, a few or none of the reports come from them?)
ALL 1
MOST 2
SOME 3
A FEW 4
NONE 5
DO NOT HAVE THIS TYPE OF STAFF 6
REFUSED 7
DON’T KNOW 8
d. Other medical staff? (For example, Nurse Practitioners and Physician Assistants). Would you say all, most, some, a few or none of the reports come from them?)
ALL 1
MOST 2
SOME 3
A FEW 4
NONE 5
DO NOT HAVE THIS TYPE OF STAFF 6
REFUSED 7
DON’T KNOW 8
e. Technicians, technologists, or therapists? (Would you say all, most, some, a few or none of the reports come from them?)
ALL 1
MOST 2
SOME 3
A FEW 4
NONE 5
DO NOT HAVE THIS TYPE OF STAFF 6
REFUSED 7
DON’T KNOW 8
f. Pharmacy staff? (Would you say all, most, some, a few or none of the reports come from them?)
ALL 1
MOST 2
SOME 3
A FEW 4
NONE 5
DO NOT HAVE THIS TYPE OF STAFF 6
REFUSED 7
DON’T KNOW 8
g. Administrative staff? (Would you say all, most, some, a few or none of the reports come from them?)
ALL 1
MOST 2
SOME 3
A FEW 4
NONE 5
DO NOT HAVE THIS TYPE OF STAFF 6
REFUSED 7
DON’T KNOW 8
h. Any other staff? (SPECIFY)______________________________________
ALL 1
MOST 2
SOME 3
A FEW 4
NONE 5
REFUSED 7
DON’T KNOW 8
Q11. Do physicians who are not employed by your hospital but working in your hospital report occurrences to your reporting system?
YES 1
NO 2
ALL PHYSICIANS ARE EMPLOYED BY HOSPITAL 3
REFUSED 7
DON’T KNOW 8
Q12. Do other individuals who are not employed by your hospital but working in your hospital report occurrences to your reporting system? For example, agency nurses.
YES 1
NO 2
DO NOT HAVE SUCH EMPLOYEES 3
REFUSED 7
DON’T KNOW 8
Q13. Can individuals report occurrences without identifying themselves?
Yes, in all cases 1
Yes, in some cases 2
Never, in no case 3
REFUSED 7
DON’T KNOW 8
Q14. If the reporter identifies him/herself, is that person’s identity protected?
Yes, in all cases 1
Yes, in some cases 2
Never, in no case 3
REFUSED 7
DON’T KNOW 8
15. Are nosocomial (no-so-CO-me-al ) infections generally reported to your reporting system?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Q16. Of the total occurrences in your reporting system, please estimate the percentage that resulted in patient harm. Do not include near misses, variances, and the like, in your percentage estimate. (Your best estimate is fine.)
|___|___|___| %
REFUSED 997
DON’T KNOW 998
Q19. Does risk management receive reports of occurrences from all areas or departments?
YES 1 (SKIP TO Q20INTRO)
NO 2
REFUSED 7 (SKIP TO Q20INTRO)
DON’T KNOW 8 (SKIP TO Q20INTRO)
Q19a. From which areas or departments does risk management not receive reports of occurrences?
____________________________________________________________
____________________________________________________________
REFUSED 7
DON’T KNOW 8
Q18INTRO. The next questions are about how your hospital may use collected occurrence data.
Q18. How often does your hospital use the occurrence information READ ITEM FROM LIST.
a. To develop performance or quality indicators?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
b. To produce trends of occurrences?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
c. For Failure Mode Effects or FME analysis?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
d. To conduct root cause analysis?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
e. To educate or train?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
f. To compare against other hospitals?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
g. To fill a state or federal agency’s requirement such as an FDA or CDC requirement?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
h. To report sentinel (sent i nal) events to the Joint Commission on Accreditation of Healthcare Organizations or JCAHO?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
i. To counsel or correct physicians?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
j. To counsel or correct other employees?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
k. To perform actions to improve performance?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
Q19. Are reports of occurrences routinely kept in an employee’s personnel file?
Yes, in all cases 1
Yes, in some cases 2
Never, in no case 3
REFUSED 7
DON’T KNOW 8
Q20. In the last year, how often has learning about occurrences led to immediate action at your hospital?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
Q21. In the last year, how often has learning about occurrences led to launching a quality or performance improvement at your hospital?
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
Q22. Does your hospital produce reports of its occurrence data? These reports could be either written summaries or presentations at meetings.
YES 1
NO 2 (SKIP TO Q23)
REFUSED 7 (SKIP TO Q23)
DON’T KNOW 8 (SKIP TO Q23)
Q22a. On average, how often does your hospital produce reports of occurrence data? Would you say…
Weekly, 1
Monthly, 2
Quarterly, 3
Yearly, or 4
Something else? (SPECIFY)_____________________________ 5
REFUSED 7
DON’T KNOW 8
Q22b. Does your hospital distribute any occurrence reports within the hospital?
YES 1
NO 2 (SKIP to Q25)
REFUSED 7 (SKIP to Q25)
DON’T KNOW 8 (SKIP to Q25)
Q22c. I’m going to read a list of possible areas or departments in your hospital. Please tell me how frequently your hospital distributes a report of occurrences, either directly or through a committee meeting, to the following hospital departments.
How often is READ ITEM FROM LIST provided with a report?
a. Nursing
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
HOSPITAL DOES NOT HAVE THIS DEPARTMENT 6
REFUSED 7
DON’T KNOW 8
b. Pharmacy
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
HOSPITAL DOES NOT HAVE THIS DEPARTMENT 6
REFUSED 7
DON’T KNOW 8
c. Laboratory Medicine
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
HOSPITAL DOES NOT HAVE THIS DEPARTMENT 6
REFUSED 7
DON’T KNOW 8
d. Transfusion Medicine
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
HOSPITAL DOES NOT HAVE THIS DEPARTMENT 6
REFUSED 7
DON’T KNOW 8
e. Infection Control
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
HOSPITAL DOES NOT HAVE THIS DEPARTMENT 6
REFUSED 7
DON’T KNOW 8
f. Medical Leadership
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
HOSPITAL DOES NOT HAVE THIS DEPARTMENT 6
REFUSED 7
DON’T KNOW 8
g. Quality Management or Performance Improvement
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
HOSPITAL DOES NOT HAVE THIS DEPARTMENT 6
REFUSED 7
DON’T KNOW 8
h. Central Hospital Administration
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
HOSPITAL DOES NOT HAVE THIS DEPARTMENT 6
REFUSED 7
DON’T KNOW 8
i. Any other department
(SPECIFY) ______________________________________
Always, 1
Often, 2
Sometimes, 3
Rarely, or 4
Never? 5
REFUSED 7
DON’T KNOW 8
Q22d. How long after the reporting period closes does it take to get the reports distributed to relevant departments? Would you say…
Less than one week, 1
One to two weeks, 2
More than two weeks, less than one month, 3
More than one month, or 4
More than two months? 5
REFUSED 7
DON’T KNOW 8
Q23. Does your hospital currently have an organized patient safety program that manages or coordinates all the hospital's patient safety activities?
YES 1
NO 2 (SKIP TO Q24 INTRO)
REFUSED 7 (SKIP TO Q24 INTRO)
DON’T KNOW 8 (SKIP TO Q24 INTRO)
Q23a. When was the current patient safety program organized relative to the current reporting system?
Patient safety program started first, 1
Reporting system started first, 2
Patient safety program and reporting system started at about the same time 3
Or, we currently do not have a reporting system 4
REFUSED 7
DON’T KNOW 8
Q24. Does your hospital have a SINGLE individual, regardless of his or her job title, who functions as a patient safety officer?
YES 1
NO 2
Q25NOTE: The next few questions refer to the governing board of the hospital, which may be called the board of directors or board of trustees. If this hospital does not have a governing board with decision-making authority, but has an advisory board, the question applies to the advisory board.
Q25. Which of the following actions does this hospital’s governing board perform regularly in its oversight of the hospital’s patient safety issues and activities?
Does this hospital’s governing board regularly…
25a. Review policies or guidelines on patient safety goals, priorities, and strategies?
YES 1
NO 2
25b. Review reports on risks and hazards identified by hospital management
YES 1
NO 2
25c. Review reports from all patient safety culture survey or other culture measures
YES 1
NO 2
25d. Review progress in patient safety improvement activities
YES 1
NO 2
25e. Review level of participation by patients and families in the hospital’s patient safety activities
YES 1
NO 2
Q26. Does this hospital’s governing board (directors, trustees, or advisory), or one of its standing committees, include the review of patient safety issues and improvements in a standing agenda item for every board meeting, either as a separate agenda item on safety or as part of a larger agenda item?
Yes, done by the governing board 1 (SKIP TO 27)
Yes, done by a standing committee 2
No 3 (SKIP TO 27)
Q26a. Specify how: ____________________________________________________________
Q27. Has this hospital conducted a standardized survey to assess its patient safety culture?
YES 1
NO 2
Q28. Which of the following products developed by the Agency for Healthcare Research and Quality (AHRQ) to improve safety in health care have you used?
Have you used…
Q28a. A hospital survey on patient safety culture (SOPS)?
YES 1
NO 2
Q28b. TeamSTEPPS system and tools for teamwork improvement?
YES 1
NO 2
Q28c. Patient Safety Improvement Corps training DVD?
YES 1
NO 2
Q28d. Patient Safety Evidence Report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices?
YES 1
NO 2
Q28e. Other publications or reports on patient safety?
YES 1
NO 2
Q28f. AHRQ fact sheets for providers?
YES 1
NO 2
Q28g. AHRQ fact sheets for patients and families?
YES 1
NO 2
Q28h. Patient brochures or pamphlets?
YES 1
NO 2
Q28i. Patient Safety Network (PSNet) Website?
YES 1
NO 2
Q28j. WebM&M web site?
YES 1
NO 2
Q28k. Patient Safety Organizations web site (about the Patient Safety Quality Improvement Act of 2005?
YES 1
NO 2
Q29. The Partnerships in Implementing Patient Safety (PIPS) projects funded by AHRQ developed a number of toolkits that health care providers can use to implement specific practices to improve safety in health care. The toolkits are posted on the AHRQ web site. Have you used any of these toolkits?
YES 1
NO 2 (SKIP TO Q30INTRO)
Q29a. Which toolkit(s) did you use? (Please Specify): ________________________________
Q30INTRO. The last few questions are about you and your hospital so that we can better understand your hospital's staffing and structure.
Q30. Do you have a nursing or other clinical degree?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Q31. Do you have a law degree?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Q32. Do you have any other credentials related to your job as risk manager?
YES 1
NO 2 (SKIP TO Q29)
REFUSED 7 (SKIP TO Q29)
DON’T KNOW 8 (SKIP TO Q29)
Q28a. What are they?
__________________________________________________________
__________________________________________________________
REFUSED 7
DON’T KNOW 8
Q33. Did you answer the questions in this survey for your hospital only, or did you include other inpatient hospitals or inpatient facilities in your answers?
OWN HOSPITAL ONLY 1
OWN HOSPITAL AND OTHER HOSPITALS OR FACILITIES 2
REFUSED 7
DON’T KNOW 8
Q34. How many of the doctors working in your hospital are employed by the hospital? Would you say…
All, 1
Most, 2
Some, 3
A few, or 4
None? 5
REFUSED 7
DON’T KNOW 8
Q35. Finally, is your hospital a teaching hospital?
YES 1
NO 2
REFUSED 7
DON’T KNOW 8
Those are all the questions I have. Thank you very much for your time.
| File Type | application/msword |
| File Title | Event Reporting Survey |
| Author | Caren Ginsberg |
| Last Modified By | IST |
| File Modified | 2008-08-19 |
| File Created | 2008-08-19 |