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pdfHospital Survey on Patient Safety Culture:
2009 Comparative Database Report
Part II:
Appendix A—Overall Results by
Hospital Characteristics
Appendix B—Overall Results by
Respondent Characteristics
Part III: Appendix C—Trending Results by
Hospital Characteristics
Appendix D—Trending Results by
Respondent Characteristics
Prepared for:
Agency for Healthcare Research and Quality (AHRQ)
U.S. Department of Health and Human Services (HHS)
540 Gaither Road
Rockville, MD 20850
http://www.ahrq.gov
Contract No. HHSA 290200710024C
Managed and prepared by:
Westat, Rockville, MD
Joann Sorra, Ph.D.
Theresa Famolaro, M.P.S.
Naomi Dyer, Ph.D.
Kabir Khanna, M.A.
Dawn Nelson
These appendixes are for the Hospital Survey on Patient Safety Culture: 2009 Comparative
Database Report, AHRQ Publication No. XX-XXXX, January 2009
The authors of this report are responsible for its content. Statements in the report should not be
construed as endorsement by the Agency for Healthcare Research and Quality or the U.S.
Department of Health and Human Services.
This document is in the public domain and may be used and reprinted without permission except
those copyrighted materials noted for which further reproduction is prohibited without specific
permission of copyright holders.
Suggested citation:
Sorra J, Famolaro T, Dyer N, Nelson D, Khanna K. Hospital Survey on Patient Safety Culture
2009 Comparative Database Report, Appendixes, Parts II and III (Appendixes for AHRQ
Publication No. XX-XXXX). (Prepared by Westat, Rockville, MD, under contract No. HHSA
290200710024C). Rockville, MD: Agency for Healthcare Research and Quality. January 2009.
No investigators have any affiliations or financial involvement (e.g., employment,
consultancies, honoraria, stock options, expert testimony, grants or patents received or
pending, or royalties) that conflict with material presented in this report.
List of Tables
Page
Highlights from Appendix A: Overall Results by Hospital Characteristics ................................ v
Highlights from Appendix B: Overall Results by Respondent Characteristics........................... vi
Highlights from Appendix C: Trending Results by Hospital Characteristics ........................... viii
Highlights from Appendix D: Trending Results by Respondent Characteristics........................ ix
Part II
Appendix A: Overall Results By Hospital Characteristics
Overall Results by (1) Bed Size............................................................................................... 2
Table A-1. Composite-level Average Percent Positive Response by Bed Size ........................... 3
Table A-2. Item-level Average Percent Positive Response by Bed Size ..................................... 4
Table A-3. Average Percent Distribution of Work Area/Unit Patient Safety Grades by
Bed Size............................................................................................................. 8
Table A-4. Average Percent Distribution of Number of Events Reported in the Past 12
Months by Bed Size ........................................................................................... 8
Overall Results by (2) Teaching Status and (3) Ownership and Control.............................. 9
Table A-5. Composite-level Average Percent Positive Response by Hospital Teaching
Status, and Ownership and Control .................................................................. 10
Table A-6. Item-level Average Percent Positive Response by Hospital Teaching Status,
and Ownership and Control.............................................................................. 11
Table A-7. Average Percent Distribution of Work Area/Unit Patient Safety Grades by
Teaching Status, and Ownership and Control ................................................... 15
Table A-8. Average Percent Distribution of Number of Events Reported in the Past 12
Months by Teaching Status, and Ownership and Control.................................. 15
Overall Results by (4) Geographic Region........................................................................... 16
Table A-9. Composite-level Average Percent Positive Response by Geographic Region ....... 17
Table A-10. Item-level Average Percent Positive Response by Geographic Region................. 18
Table A-11. Average Percent Distribution of Work Area/Unit Patient Safety Grades by
Geographic Region .......................................................................................... 22
Table A-12. Average Percent Distribution of Number of Events Reported in the Past 12
Months by Geographic Region......................................................................... 22
Apppendix B: Overall Results By Respondent Characteristics
Overall Results by (1) Work area/Unit................................................................................. 24
Table B-1. Composite-level Average Percent Positive Response by Work Area/Unit .............. 25
Table B-2. Item-level Average Percent Positive Response by Work Area/Unit ........................ 26
Table B-3. Average Percent Distribution of Work Area/Unit Patient Safety Grades by
Work Area/Unit ............................................................................................... 30
Table B-4. Average Percent Distribution of Number of Events Reported in the Past 12
Months by Work Area/Unit .............................................................................. 30
i
Overall Results by (2) Staff Position..................................................................................... 31
Table B-5. Composite-level Average Percent Positive Response by Staff Position .................. 32
Table B-6. Item-level Average Percent Positive Response by Staff Position............................ 33
Table B-7. Average Percent Distribution of Work Area/Unit Patient Safety Grades by
Staff Position ................................................................................................... 37
Table B-8. Average Percent Distribution of Number of Events Reported in the Past 12
Months by Staff Position.................................................................................. 37
Overall Results by (3) Interaction with Patients.................................................................. 38
Table B-9. Composite-level Average Percent Positive Response by Interaction with
Patients ............................................................................................................ 39
Table B-10. Item-level Average Percent Positive Response by Interaction with Patients ......... 40
Table B-11. Average Percent Distribution of Work Area/Unit Patient Safety Grades by
Interaction with Patients................................................................................... 44
Table B-12. Average Percent Distribution of Number of Events Reported in the Past 12
Months by Interaction with Patients ................................................................. 44
Part III
Appendix C: Trending Results By Hospital Characteristics
Trending Results by (1) Bed Size.......................................................................................... 46
Table C-1. Trending: Composite-level Average Percent Positive Response by Bed Size ......... 47
Table C-2. Trending: Item-level Average Percent Positive Response by Bed Size ................... 49
Table C-3. Trending: Average Percent Distribution of Work Area/Unit Patient Safety
Grades by Bed Size .......................................................................................... 55
Table C-4. Trending: Average Percent Distribution of Number of Events Reported in
the Past 12 Months by Bed Size ....................................................................... 56
Trending Results by (2) Teaching Status and (3) Ownership and Control......................... 57
Table C-5. Trending: Composite-level Average Percent Positive Response by Hospital
Teaching Status, and Ownership and Control ................................................... 58
Table C-6. Trending: Item-level Average Percent Positive Response by Hospital
Teaching Status, and Ownership and Control ................................................... 60
Table C-7. Trending: Average Percent Distribution of Work Area/Unit Patient Safety
Grades by Teaching Status, and Ownership and Control................................... 66
Table C-8. Trending: Average Percent Distribution of Number of Events Reported in
the Past 12 Months by Teaching Status, and Ownership and Control................ 68
ii
Appendix D: Trending Results By Respondent Characteristics
Trending Results by Work Area/Unit .................................................................................. 69
Table D-1. Trending: Composite-level Average Percent Positive Response by Work
Area/Unit ......................................................................................................... 70
Table D-2. Trending: Item-level Average Percent Positive Response by Work
Area/Unit ......................................................................................................... 72
Table D-3. Trending: Average Percent Distribution of Work Area/Unit Patient Safety
Grade by Work Area/Unit ................................................................................ 78
Table D-4. Trending: Average Percent Distribution of Number of Events Reported in
the Past 12 Months by Work Area/Unit ............................................................ 79
Trending Results by Staff Position ....................................................................................... 80
Table D-5. Trending: Composite-level Average Percent Positive Response by Staff
Position............................................................................................................ 81
Table D-6. Trending: Item-level Percent Positive Response by Staff Position.......................... 83
Table D-7. Trending: Average Percent Distribution of Work Area/Unit Patient Safety
Grade by Staff Position .................................................................................... 89
Table D-8. Trending: Average Percent Distribution of Number of Events Reported in
the Past 12 Months by Staff Position ................................................................ 90
Trending Results by Interaction with Patients .................................................................... 91
Table D-9. Trending: Composite-level Average Percent Positive Response by
Interaction with Patients ................................................................................... 92
Table D-10. Trending: Item-level Average Percent Positive Response by Interaction
with Patients..................................................................................................... 94
Table D-11. Trending: Average Percent Distribution of Work Area/Unit Patient
Safety Grade by Interaction with Patients ....................................................... 100
Table D-12. Trending: Average Percent Distribution of Number of Events Reported
in the Past 12 Months by Interaction with Patients.......................................... 101
iii
Part II: Appendixes A & B: Overall Results by Hospital
and Respondent Characteristics
Appendixes A and B present data tables that show average percent positive scores on the
survey composites and items across database hospitals broken down by the following hospital
and respondent characteristics:
Appendix A: Overall Results by Hospital Characteristics
Bed size
Teaching status
Ownership and control
Geographic region
Appendix B: Overall Results by Respondent Characteristics
Work area/unit
Staff position
Interaction with patients
Highlights from these results by hospital and respondent characteristics were presented in the
main body of the report, Part I: Comparative Database Report, at the end of Chapter 6 and are
also shown on the next two pages. Highlights were based on results for the 12 patient safety
culture composites, and on patient safety grade and number of events reported. In the bottom row
of the composite-level tables, an overall average across composites is shown as a summary
statistic when comparing across breakout categories.
To ensure hospital confidentiality, a rule was established requiring at least 20 hospitals to be
in a particular breakout category before data would be displayed by that category. Therefore, in
Appendix A two of the standard AHA regions have been combined.
You can compare your hospital’s percent positive scores on the patient safety culture
composites and items against the averages shown in Appendix A for hospitals with your same
bed size, teaching status, ownership and control, and geographic region. You can use a 5 percent
difference as a rule of thumb for determining what differences to pay attention to.
To compare your hospital’s results against Appendix B, your hospital will have to compute
percent positive scores on the safety culture composites and items broken down by Work
Area/Unit, staff position, and interaction with patients. You would then compare your hospital’s
percent positive scores against the averages shown in the tables.
Again, you can use a 5 percent difference as a rule of thumb for determining what differences
to pay attention to. Hospitals that did not ask respondents for their work area/unit, staff position,
or about interaction with patients will not be able to make comparisons by these categories, and
such hospitals were excluded from the breakout tables in Appendix B. Also, respondents who
selected “Many different work areas/No specific work area” (for their work area), “Other” (for
their work area or staff position), or did not answer (missing) were not included in the breakout
tables in Appendix B.
iv
Highlights from Appendix A:
Overall Results by Hospital Characteristics
Bed Size (Tables A-1, A-3, A-4)
Smaller hospitals (49 beds or fewer) had the highest average percent positive
response on all 12 patient safety culture composites.
The largest difference by bed size was on Handoffs & Transitions where the smallest
hospitals (6-24 beds) scored 22 percent higher than large hospitals (400-499 beds)
(55 percent compared to 33 percent positive).
Large hospitals (400-499 beds) scored lowest on the percent of respondents who gave
their work area/unit a patient safety grade of “Excellent” or “Very good” (64 percent
for 400-499 beds compared to 78 percent for 25-49 beds).
There were no noticeable differences on number of events reported based on bed size
(all differences were 3 percent or less).
Teaching Status, and Ownership and Control (Tables A-5, A-7, A-8)
Non-teaching hospitals had the highest average percent positive response on
Handoffs & Transitions (46 percent compared to 41 percent respectively).
Government-owned hospitals were more positive than non-government on Handoffs
& Transitions (6 percent more positive), and Staffing (5 percent more positive).
There were no noticeable differences on patient safety grade or number of events
reported based on teaching status or ownership and control (all differences were 3
percent or less).
Geographic Region (Tables A-9, A-11, A-12)
East South Central hospitals had the highest average percent positive response across
the 12 patient safety culture composites; Pacific hospitals had the lowest.
The largest difference by region was on Staffing and Handoffs & Transitions where
West North Central hospitals were 10 percent more positive than Mid Atlantic/New
England hospitals (for Staffing) and Pacific hospitals (for Handoffs & Transitions).
West South Central hospitals scored highest on the percent of respondents who gave
their work area/unit a patient safety grade of “Excellent” or “Very good” (77 percent).
Pacific hospitals had the highest percent of respondents who reported one or more
events in the past year (53 percent); the lowest percent of respondents reporting
events was in the West South Central region (40 percent).
v
Highlights from Appendix B:
Overall Results by Respondent Characteristics
Work Area/Unit (Tables B-1, B-3, B-4)
Respondents in Rehabilitation had the highest average percent positive response on 8
of the 12 patient safety culture composites.
The largest difference by work area/unit was on Nonpunitive Response to Error (22
percent). On this composite, Rehabilitation was 59 percent positive and Emergency
was 37 percent positive.
Rehabilitation had the highest percent of respondents who gave their work area/unit a
patient safety grade of “Excellent” or “Very good” (81 percent); Emergency and
Medicine had the lowest percent (62 percent).
ICU (any type) had the highest percent of respondents reporting one or more events
in the past year (66 percent); Anesthesiology had the lowest percent of respondents
reporting events (43 percent).
Staff Position (Tables B-5, B-7, B-8)
Respondents in Administration/Management had the highest average percent positive
response on 11 of the 12 patient safety culture composites.
The largest difference (26 percent) by staff position was on Nonpunitive Response to
Error; Administration/Management was 62 percent positive and Patient Care
Assistants Aides/Care Partners were 36 percent positive.
Administration/Management had the highest percent of respondents who gave their
work area/unit a patient safety grade of “Excellent” or “Very good” (82 percent);
Registered Nurse/LVN/LPN had the lowest percent (66 percent).
Pharmacists had the highest percent of respondents reporting one or more events in
the past year (75 percent); Unit Assistants/Clerks/Secretaries had the lowest percent
reporting events (22 percent).
Interaction With Patients (Tables B-9, B-11, B-12)
Respondents with direct patient interaction were 7 percent more positive on Handoffs
& Transitions compared to those without direct patient interaction (45 percent
compared to 38 percent positive).
Respondents without direct patient interaction were 7 percent more positive about
Management Support for Patient Safety than those with direct patient interaction (76
percent compared to 69 percent positive).
Respondents without direct patient interaction had the highest percent of respondents
who gave their work area/unit a patient safety grade of “Excellent” or “Very good”
(77 percent) compared to those with direct patient interaction (72 percent).
More respondents with direct patient interaction reported one or more events in the
past year (53 percent) than respondents without direct patient interaction (32 percent).
vi
Part III: Appendixes C & D: Trending Results by
Hospital and Respondent Characteristics
In Part III of the report, Appendixes C and D show trends over time for the 204 hospitals (of
the 622 total database hospitals) that administered the survey and submitted data twice. Average
percent positive scores across hospitals from the most recent and previous administrations are
shown on the survey composites and items, broken down by the following respondent
characteristics:
Appendix C: Trending Results by Hospital Characteristics
Bed size
Teaching status
Ownership and control
Appendix D: Trending Results by Respondent Characteristics
Work area/unit
Staff position
Interaction with patients
To ensure hospital confidentiality, a rule was established requiring at least 20 hospitals to be
in a particular breakout category before data would be displayed by that category. As a result of
not having 20 hospitals in each breakout category, in Appendix C the trending results for the
standard AHA regions are not displayed.
Tables 1 and 2 below show examples of the statistics shown in this appendix. The tables
show the average percent of respondents who answered positively among the trending hospitals
for the hospitals’ most recent survey administration (top row) and their previous administration
(middle row). The change over time is shown in the bottom row as a negative number if the most
recent administration showed a decline, or is shown as a positive number if the most recent
administration showed an increase. Changes in scores of 5 percent or greater, whether positive or
negative, are bolded.
Table 1: Example of Decrease in Average Score Over Time (Negative Change)
Most Recent
Previous
Change
85%
90%
-5%
Table 2: Example of Increase in Average Score Over Time (Positive Change)
Most Recent
Previous
Change
70%
60%
10%
Highlights of the findings from the breakout tables in these appendixes are provided on the
following pages.
vii
Highlights from Appendix C:
Trending Results by Hospital Characteristics
Bed Size (Tables C-1, C-3, C-4)
Hospitals with 100-299 beds had the largest increases in percent positive response over
time on 10 of the 12 patient safety culture composites (average increase across the 10
composites was 5 percent).
Hospitals with 200-299 beds had the greatest average change across the 12 patient safety
culture composites (average 5 percent change).
The largest increase over time was for medium-large hospitals (200-299 beds) on
Teamwork Within Units and Organizational Learning—Continuous Improvement, both
increasing 8 percent from the previous administration.
The largest decrease over time was for large hospitals (500 or more beds) on the Overall
Perceptions of Patient Safety, decreasing 6 percent from the previous administration.
Small hospitals (6-24 beds) had the highest increase in percent of respondents who gave
their work area/unit a patient safety grade of “Excellent” or “Very good” (a 7 percent
increase, from 71 percent in the previous administration to 78 percent in the most recent
administration).
Small hospitals (6-24 beds) also had the highest increase in percent of respondents
reporting one or more events in the past year (a 6 percent increase, from 41 percent to 47
percent).
Teaching Status, and Ownership and Control (Tables C-5, C-7, C-8)
There were no noticeable differences or changes across the patient safety culture
composites for teaching versus non-teaching hospitals or government-owned versus
non-government hospitals (all changes and differences were 4 percent or less).
Non-teaching hospitals had a greater increase than teaching hospitals in the percent of
respondents who gave their work area/unit a patient safety grade of “Excellent” or “Very
good” (a 5 percent increase, from 69 percent to 74 percent).
Government-owned hospitals had a greater increase than non-government hospitals in
the percent of respondents who gave their work area/unit a patient safety grade of
“Excellent” or “Very good” (a 6 percent increase, from 69 percent to 75 percent).
There were no noticeable differences or changes on the percent of respondents who
reported one or more events in the past year based on teaching status.
Government-owned hospitals had a greater increase than non-government hospitals in
the percent of respondents who reported one or more events in the past year (a 5 percent
increase, from 42 percent to 47 percent).
viii
Highlights from Appendix D:
Trending Results by Respondent Characteristics
Appendix
Trending
Results by
Work Area/Unit
(Tables D-1,C:
D-3,
D-4)
Respondents in Psych/Mental Health had the greatest average change in percent
positive response across the 12 patient safety culture composites, with an average
change of 5 percent.
Respondents in Obstetrics had the largest increases in positive response over time on 5
of the 12 patient safety culture composites (average increase across the 5 composites
was 6 percent).
Respondents in Anesthesiology had the largest decreases in positive response over time
on 4 of the 12 patient safety culture composites (average decrease across the 4
composites was 5 percent).
Medicine had the largest average percent of respondents who increased over time in
giving their work area/unit a patient safety grade of “Excellent” or “Very good” (an 8
percent increase from 56 to 64 percent), followed by ICU (7 percent increase), Surgery
(6 percent increase), and Lab (5 percent increase).
Lab had the largest average percent of respondents who increased over time in their
reporting of one or more events in the past year (a 7 percent increase: from 48 to 55
percent) followed by Anesthesiology, Radiology, and Rehabilitation (all increasing by 5
percent); the largest decrease in percent reporting was in Obstetrics (a 6 percent
decrease from 58 to 52 percent).
Staff Position (Tables D-5, D-7, D-8)
Pharmacists had the largest increases in positive response over time on 4 of the 12
patient safety culture composites (average increase across the 4 composites was 6
percent).
Admin/Mgmt, RN/LVN/LPN, and Technicians had the largest average percent of
respondents who increased over time in giving their work area/unit a patient safety
grade of “Excellent” or “Very good” (5 percent increases).
There were no noticeable differences in the percent of respondents reporting one or
more events over time based on staff position (all changes over time were less than +/5 percent).
Interaction With Patients (Tables D-9, D-11, D-12)
There were no noticeable composite differences over time based on respondent
interaction with patients (all were increases over time of 4 percent or less).
There were no noticeable differences in the percent of respondents giving their work
unit/area a patient safety grade of “Excellent” or “Very good” or those reporting one or
more events over time based on respondent direct patient interaction.
ix
Part II
Appendix A: Overall Results by Hospital Characteristics
1
Appendix A: Overall Results by Hospital Characteristics
(1) Bed Size
NOTE: The number of hospitals and respondents in each breakout category is shown in each table (e.g., the number of
hospitals and respondents by bed size). However, the precise number of hospitals and respondents corresponding to each data
cell in a table will vary because hospitals may have omitted a specific survey item and because of individual nonresponse/missing data.
2
Table A-1. Composite-level Average Percent Positive Response by Bed Size
Bed Size
Patient Safety Culture Composites
# Hospitals
# Respondents
6-24
beds
60
3,703
25-49
beds
139
13,426
50-99
beds
111
15,766
100-199
beds
111
28,539
200-299
beds
74
31,990
300-399
beds
55
35,153
400-499
beds
23
14,636
500+
beds
49
53,249
1. Teamwork Within Units
83%
82%
79%
79%
77%
78%
75%
77%
2. Supervisor/Manager Expectations &
Actions Promoting Patient Safety
76%
78%
76%
74%
72%
72%
70%
72%
3. Org Learning--Continuous
Improvement
71%
74%
71%
70%
68%
70%
67%
68%
4. Management Support for Patient
Safety
74%
76%
72%
68%
66%
68%
63%
65%
5. Overall Perceptions of Patient Safety
69%
70%
66%
62%
60%
61%
56%
56%
6. Feedback & Communication About
Error
64%
65%
63%
62%
61%
63%
59%
60%
7. Communication Openness
64%
63%
62%
61%
61%
61%
58%
60%
8. Frequency of Events Reported
63%
63%
60%
60%
58%
60%
57%
57%
9. Teamwork Across Units
66%
63%
59%
54%
50%
53%
48%
50%
10. Staffing
62%
61%
56%
51%
49%
50%
48%
49%
11. Handoffs & Transitions
55%
50%
47%
41%
36%
40%
33%
38%
12. Nonpunitive Response to Error
48%
48%
45%
43%
41%
40%
38%
38%
66%
66%
63%
60%
58%
60%
56%
58%
Average Across Composites
3
Table A-2. Item-level Average Percent Positive Response by Bed Size (Page 1 of 4)
Item
Survey Items By Composite
# Hospitals
# Respondents
1.
A1
A3
A4
A11
2.
B1
B2
B3R
B4R
3.
A6
Teamwork Within Units
1. People support one another in this unit.
2. When a lot of work needs to be done quickly,
we work together as a team to get the work
done.
3. In this unit, people treat each other with
respect.
4. When one area in this unit gets really busy,
others help out.
Supervisor/Manager Expectations & Actions
Promoting Patient Safety
1. My supv/mgr says a good word when he/she
sees a job done according to established patient
safety procedures.
2. My supv/mgr seriously considers staff
suggestions for improving patient safety.
3. Whenever pressure builds up, my supv/mgr
wants us to work faster, even if it means taking
shortcuts.
4. My supv/mgr overlooks patient safety
problems that happen over and over.
Organizational Learning— Continuous
Improvement
1. We are actively doing things to improve
patient safety.
Bed Size
100-199
200-299
beds
beds
111
74
28,539
31,990
300-399
beds
55
35,153
400-499
beds
23
14,636
500+
beds
49
53,249
83%
84%
83%
84%
85%
84%
85%
82%
83%
78%
78%
75%
76%
74%
75%
72%
68%
68%
65%
67%
63%
65%
71%
73%
72%
72%
71%
71%
69%
71%
76%
80%
77%
76%
75%
74%
72%
74%
79%
79%
76%
72%
70%
70%
67%
68%
77%
80%
78%
76%
74%
74%
71%
74%
82%
84%
83%
81%
79%
82%
77%
79%
6-24
beds
60
3,703
25-49
beds
139
13,426
50-99
beds
111
15,766
87%
87%
85%
85%
90%
89%
86%
80%
81%
74%
A9
2. Mistakes have led to positive changes here.
65%
66%
63%
62%
60%
62%
58%
60%
A13
3. After we make changes to improve patient
safety, we evaluate their effectiveness.
66%
71%
68%
67%
66%
67%
64%
65%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly
disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
4
Table A-2. Item-level Average Percent Positive Response by Bed Size (Page 2 of 4)
Bed Size
Item
Survey Items By Composite
# Hospitals
# Respondents
4.
F1
Management Support for Patient Safety
1. Hospital mgmt provides a work climate that
promotes patient safety.
6-24
beds
60
3,703
25-49
beds
139
13,426
50-99
beds
111
15,766
100-199
beds
111
28,539
200-299
beds
74
31,990
300-399
beds
55
35,153
400-499
beds
23
14,636
500+
beds
49
53,249
84%
85%
81%
77%
75%
77%
72%
74%
F8
2. The actions of hospital mgmt show that
patient safety is a top priority.
75%
76%
73%
70%
69%
71%
65%
67%
F9R
3. Hospital mgmt seems interested in patient
safety only after an adverse event happens.
64%
66%
61%
57%
54%
56%
51%
52%
66%
66%
62%
58%
56%
57%
52%
51%
2. Patient safety is never sacrificed to get more
work done.
72%
71%
66%
61%
59%
59%
55%
56%
A17R 3. We have patient safety problems in this unit.
69%
69%
64%
60%
58%
57%
53%
50%
70%
74%
72%
69%
68%
69%
65%
66%
5.
Overall Perceptions of Patient Safety
1. It is just by chance that more serious mistakes
A10R
don’t happen around here.
A15
A18
4. Our procedures and systems are good at
preventing errors from happening.
6.
Feedback and Communication About Error
C1
1. We are given feedback about changes put
into place based on event reports.
52%
54%
52%
53%
53%
56%
52%
54%
C3
2. We are informed about errors that happen in
this unit.
68%
67%
65%
63%
61%
63%
59%
61%
C5
3. In this unit, we discuss ways to prevent errors
from happening again.
73%
73%
71%
69%
68%
69%
65%
66%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly
disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
5
Table A-2. Item-level Average Percent Positive Response by Bed Size (Page 3 of 4)
Bed Size
Item
Survey Items By Composite
# Hospitals
# Respondents
6-24
beds
60
3,703
25-49
beds
139
13,426
50-99
beds
111
15,766
100-199
beds
111
28,539
200-299
beds
74
31,990
300-399
beds
55
35,153
400-499
beds
23
14,636
500+
beds
49
53,249
7.
Communication Openness
C2
1. Staff will freely speak up if they see something
that may negatively affect patient care.
78%
77%
76%
76%
74%
75%
71%
73%
C4
2. Staff feel free to question the decisions or
actions of those with more authority.
50%
48%
47%
46%
47%
47%
44%
46%
C6R
3. Staff are afraid to ask questions when
something does not seem right.
66%
65%
63%
62%
61%
61%
58%
60%
54%
53%
52%
51%
51%
53%
50%
50%
8.
D1
Frequency of Events Reported
1. When a mistake is made, but is caught and
corrected before affecting the patient, how often
is this reported?
D2
2. When a mistake is made, but has no potential
to harm the patient, how often is this reported?
58%
58%
55%
55%
54%
55%
53%
52%
D3
3. When a mistake is made that could harm the
patient, but does not, how often is this reported?
76%
76%
73%
72%
71%
72%
68%
69%
Teamwork Across Units
1. Hospital units do not coordinate well with each
other.
54%
50%
47%
42%
37%
41%
34%
37%
F4
2. There is good cooperation among hospital
units that need to work together.
68%
64%
60%
55%
51%
54%
49%
50%
F6R
3. It is often unpleasant to work with staff from
other hospital units.
65%
64%
60%
56%
52%
55%
50%
52%
F10
4. Hospital units work well together to provide
the best care for patients.
77%
73%
69%
64%
60%
63%
58%
59%
9.
F2R
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly
disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
6
Table A-2. Item-level Average Percent Positive Response by Bed Size (Page 4 of 4)
Bed Size
# Hospitals
# Respondents
6-24
beds
60
3,703
25-49
beds
139
13,426
50-99
beds
111
15,766
100-199
beds
111
28,539
200-299
beds
74
31,990
300-399
beds
55
35,153
400-499
beds
23
14,636
500+
beds
49
53,249
10.
Staffing
A2
1. We have enough staff to handle the workload.
63%
62%
56%
49%
48%
47%
46%
46%
A5R
2. Staff in this unit work longer hours than is best
for patient care.
58%
57%
53%
48%
48%
47%
46%
47%
A7R
3. We use more agency/temporary staff than is
best for patient care.
69%
69%
65%
62%
60%
63%
61%
62%
A14R
4. We work in “crisis mode” trying to do too
much, too quickly.
59%
57%
52%
44%
42%
42%
39%
40%
54%
48%
44%
37%
31%
34%
28%
32%
Item
11.
F3R
Survey Items By Composite
Handoffs & Transitions
1. Things “fall between the cracks” when
transferring patients from one unit to another.
F5R
2. Important patient care information is often lost
during shift changes.
57%
53%
51%
47%
43%
47%
41%
46%
F7R
3. Problems often occur in the exchange of
information across hospital units.
52%
48%
44%
39%
34%
37%
31%
35%
F11R
4. Shift changes are problematic for patients in
this hospital.
57%
52%
48%
41%
35%
40%
33%
38%
56%
55%
53%
50%
48%
47%
45%
44%
12.
A8R
Nonpunitive Response to Error
1. Staff feel like their mistakes are held against
them.
A12R
2. When an event is reported, it feels like the
person is being written up, not the problem.
48%
49%
46%
44%
44%
43%
41%
41%
A16R
3. Staff worry that mistakes they make are kept
in their personnel file.
41%
39%
37%
34%
32%
31%
28%
28%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly
disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
7
Table A-3. Average Percent Distribution of Work Area/Unit Patient Safety Grades by Bed Size
Bed Size
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
6-24
beds
60
3,703
25-49
beds
139
13,426
50-99
beds
111
15,766
100-199
beds
111
28,539
200-299
beds
74
31,990
300-399
beds
55
35,153
400-499
beds
23
14,636
500+
beds
49
53,249
A
Excellent
26%
27%
25%
24%
23%
24%
21%
22%
B
Very Good
51%
51%
49%
47%
45%
46%
43%
45%
C
Acceptable
20%
20%
22%
24%
25%
24%
27%
26%
D
Poor
3%
2%
4%
5%
5%
5%
7%
6%
E
Failing
0%
0%
1%
1%
1%
1%
1%
1%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table A-4. Average Percent Distribution of Number of Events Reports in the Past 12 Months by Bed Size
Bed Size
Number of Events
Reported by Respondents
# Hospitals
# Respondents
6-24
beds
60
3,703
25-49
beds
139
13,426
50-99
beds
111
15,766
100-199
beds
111
28,539
200-299
beds
74
31,990
300-399
beds
55
35,153
400-499
beds
23
14,636
500+
beds
49
53,249
No events
50%
52%
53%
53%
51%
53%
53%
53%
1 to 2 events
29%
28%
28%
27%
27%
28%
27%
28%
3 to 5 events
14%
12%
12%
13%
13%
12%
12%
13%
6 to 10 events
4%
4%
5%
4%
5%
4%
4%
4%
11 to 20 events
2%
2%
2%
2%
2%
1%
2%
1%
21 event reports or more
1%
1%
1%
1%
1%
1%
1%
1%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
8
Appendix A: Overall Results by Hospital Characteristics
(2) Teaching Status and (3) Ownership and Control
NOTE: The number of hospitals and respondents in each breakout category is shown in each table (e.g., the number of hospitals
and respondents by teaching status and ownership and control). However, the precise number of hospitals and respondents
corresponding to each data cell in a table will vary because hospitals may have omitted a specific survey item and because of
individual non-response/missing data.
9
Table A-5. Composite-level Average Percent Positive Response by Teaching Status, and Ownership and Control
Teaching Status
Patient Safety Culture Composites
# Hospitals
# Respondents
Ownership and Control
Teaching
190
94,772
Non-teaching
432
101,690
Govt
139
20,837
Non-govt
483
175,625
1. Teamwork Within Units
78%
80%
79%
79%
2. Supervisor/Manager Expectations &
Actions Promoting Patient Safety
73%
75%
76%
74%
3. Org Learning—Continuous
Improvement
70%
71%
72%
70%
4. Management Support for Patient Safety
68%
71%
72%
70%
5. Overall Perceptions of Patient Safety
62%
65%
67%
63%
6. Feedback & Communication About
Error
61%
63%
63%
62%
7. Communication Openness
60%
63%
63%
62%
8. Frequency of Events Reported
58%
61%
61%
60%
9. Teamwork Across Units
54%
58%
60%
56%
10. Staffing
53%
56%
59%
54%
11. Handoffs & Transitions
41%
46%
49%
43%
12. Nonpunitive Response to Error
42%
45%
45%
43%
60%
63%
64%
61%
Average Across Composites
10
Table A-6. Item-level Average Percent Positive Response by Teaching Status, and Ownership and Control (Page 1 of 4)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
Ownership and Control
Teaching
190
94,772
Non-teaching
432
101,690
Govt
139
20,837
Non-govt
483
175,625
84%
85%
85%
85%
1.
A1
Teamwork Within Units
1. People support one another in this unit.
A3
2. When a lot of work needs to be done quickly, we
work together as a team to get the work done.
84%
87%
87%
86%
A4
3. In this unit, people treat each other with respect.
77%
78%
77%
78%
A11
4. When one area in this unit gets really busy, others
help out.
67%
69%
69%
68%
Supervisor/Manager Expectations & Actions
Promoting Patient Safety
1. My supv/mgr says a good word when he/she sees
a job done according to established patient safety
procedures.
2. My supv/mgr seriously considers staff suggestions
for improving patient safety.
71%
72%
71%
72%
75%
77%
76%
76%
3. Whenever pressure builds up, my supv/mgr wants
us to work faster, even if it means taking shortcuts.
72%
75%
77%
73%
75%
77%
79%
76%
81%
82%
82%
81%
2.
B1
B2
B3R
B4R
3.
A6
4. My supv/mgr overlooks patient safety problems
that happen over and over.
Organizational Learning— Continuous
Improvement
1. We are actively doing things to improve patient
safety.
A9
2. Mistakes have led to positive changes here.
61%
63%
65%
62%
A13
3. After we make changes to improve patient safety,
we evaluate their effectiveness.
66%
68%
69%
67%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who
responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
11
Table A-6. Item-level Average Percent Positive Response by Teaching Status, and Ownership and Control (Page 2 of 4)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
4.
F1
F8
F9R
5.
A10R
Management Support for Patient Safety
1. Hospital mgmt provides a work climate that
promotes patient safety.
2. The actions of hospital mgmt show that patient
safety is a top priority.
3. Hospital mgmt seems interested in patient safety
only after an adverse event happens.
Overall Perceptions of Patient Safety
1. It is just by chance that more serious mistakes
don’t happen around here.
Ownership and Control
Teaching
190
94,772
Non-teaching
432
101,690
Govt
139
20,837
Non-govt
483
175,625
77%
80%
82%
79%
70%
72%
74%
71%
57%
60%
61%
59%
58%
61%
62%
59%
A15
2. Patient safety is never sacrificed to get more work
done.
61%
65%
69%
63%
A17R
3. We have patient safety problems in this unit.
58%
64%
66%
61%
A18
4. Our procedures and systems are good at
preventing errors from happening.
69%
71%
71%
70%
54%
53%
52%
54%
6.
C1
Feedback and Communication About Error
1. We are given feedback about changes put into
place based on event reports.
C3
2. We are informed about errors that happen in this
unit.
62%
65%
67%
63%
C5
3. In this unit, we discuss ways to prevent errors from
happening again.
69%
71%
71%
70%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who
responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
12
Table A-6. Item-level Average Percent Positive Response by Teaching Status, and Ownership and Control (Page 3 of 4)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
7.
C2
Communication Openness
1. Staff will freely speak up if they see something that
may negatively affect patient care.
Ownership and Control
Teaching
190
94,772
Non-teaching
432
101,690
Govt
139
20,837
Non-govt
483
175,625
74%
77%
76%
76%
C4
2. Staff feel free to question the decisions or actions
of those with more authority.
46%
48%
47%
47%
C6R
3. Staff are afraid to ask questions when something
does not seem right.
61%
64%
65%
62%
8.
Frequency of Events Reported
51%
52%
52%
52%
54%
57%
57%
55%
71%
74%
74%
73%
41%
46%
48%
44%
54%
60%
61%
57%
D1
D2
1. When a mistake is made, but is caught and
corrected before affecting the patient, how often is
this reported?
2. When a mistake is made, but has no potential to
harm the patient, how often is this reported?
D3
3. When a mistake is made that could harm the
patient, but does not, how often is this reported?
9.
Teamwork Across Units
F2R
1. Hospital units do not coordinate well with each
other.
2. There is good cooperation among hospital units
that need to work together.
F4
F6R
3. It is often unpleasant to work with staff from other
hospital units.
56%
59%
61%
58%
F10
4. Hospital units work well together to provide the
best care for patients.
64%
69%
70%
66%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who
responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
13
Table A-6. Item-level Average Percent Positive Response by Teaching Status, and Ownership and Control (Page 4 of 4)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
Ownership and Control
Teaching
190
94,772
Non-teaching
432
101,690
Govt
139
20,837
Non-govt
483
175,625
10.
Staffing
A2
1. We have enough staff to handle the workload.
51%
55%
59%
52%
A5R
2. Staff in this unit work longer hours than is best for
patient care.
49%
53%
55%
51%
A7R
3. We use more agency/temporary staff than is best
for patient care.
64%
65%
66%
64%
A14R
4. We work in “crisis mode” trying to do too much, too
quickly.
46%
50%
55%
47%
11.
Handoffs & Transitions
F3R
1. Things “fall between the cracks” when transferring
patients from one unit to another.
36%
43%
47%
39%
F5R
2. Important patient care information is often lost
during shift changes.
47%
50%
52%
48%
F7R
3. Problems often occur in the exchange of
information across hospital units.
38%
43%
46%
40%
F11R
4. Shift changes are problematic for patients in this
hospital.
41%
46%
50%
43%
12.
Nonpunitive Response to Error
A8R
1. Staff feel like their mistakes are held against them.
49%
52%
53%
51%
A12R
2. When an event is reported, it feels like the person
is being written up, not the problem.
44%
46%
46%
45%
A16R
3. Staff worry that mistakes they make are kept in
their personnel file.
33%
36%
38%
34%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who
responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
14
Table A-7. Average Percent Distribution of Work Area/Unit Patient Safety Grades by Teaching
Status, and Ownership and Control
Teaching Status
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
Ownership and Control
Teaching
190
94,772
Non-teaching
432
101,690
Govt
139
20,837
Non-govt
483
175,625
A
Excellent
24%
25%
24%
25%
B
Very Good
46%
48%
50%
47%
C
Acceptable
24%
22%
22%
23%
D
Poor
5%
4%
3%
5%
E
Failing
1%
1%
0%
1%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table A-8. Average Percent Distribution of Number of Events Reported in the Past 12 Months by
Teaching Status, and Ownership and Control
Teaching Status
Number of Events
Reported by Respondents
# Hospitals
# Respondents
Ownership and Control
Teaching
190
94,772
Non-teaching
432
101,690
Govt
139
20,837
Non-govt
483
175,625
No events
53%
52%
52%
52%
1 to 2 events
28%
28%
27%
28%
3 to 5 events
12%
13%
13%
12%
6 to 10 events
4%
5%
5%
4%
11 to 20 events
1%
2%
2%
2%
21 event reports or more
1%
1%
1%
1%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
15
Appendix A: Overall Results by Hospital Characteristics
(4) Geographic Region
NOTE: The number of hospitals and respondents in each breakout category is shown in each table (e.g., the number of hospitals
and respondents by region). However, the precise number of hospitals and respondents corresponding to each data cell in a table
will vary because hospitals may have omitted a specific survey item and because of individual non-response/missing data.
16
Table A-9. Composite-level Average Percent Positive Response by Geographic Region
Geographic Region
East
West
South
North
Central
Central
34
104
8,978
20,986
Mid Atlantic/
New England
37
20,546
South
Atlantic
104
36,825
East
North
Central
165
54,909
West
South
Central
45
13,242
Mountain
58
17,264
Pacific
75
23,712
1. Teamwork Within Units
77%
79%
79%
81%
81%
81%
81%
78%
2. Supervisor/Manager Expectations &
Actions Promoting Patient Safety
73%
77%
73%
78%
74%
78%
74%
73%
3. Org Learning—Continuous Improvement
70%
73%
69%
74%
71%
74%
70%
68%
4. Management Support for Patient Safety
70%
70%
69%
74%
72%
73%
70%
67%
5. Overall Perceptions of Patient Safety
63%
62%
63%
67%
68%
67%
66%
60%
6. Feedback & Communication About Error
62%
64%
61%
64%
61%
67%
63%
60%
7. Communication Openness
62%
62%
61%
63%
61%
64%
63%
62%
8. Frequency of Events Reported
61%
60%
58%
65%
61%
63%
61%
59%
9. Teamwork Across Units
55%
56%
55%
62%
61%
58%
59%
54%
10. Staffing
50%
53%
54%
54%
60%
55%
55%
52%
11. Handoffs & Transitions
42%
43%
42%
48%
50%
45%
45%
40%
12. Nonpunitive Response to Error
41%
42%
42%
45%
48%
46%
47%
42%
61%
62%
61%
65%
64%
64%
63%
60%
Patient Safety Culture Composites
# Hospitals
# Respondents
Average Across Composites
NOTE: States are categorized into AHA-defined regions as follows:
Mid Atlantic/New England: NY, NJ, PA, ME, NH, VT, MA, RI, CT
South Atlantic: DE, MD, DC, VA, WV, NC, SC, GA, FL
East North Central: OH, IN, IL, MI, WI
East South Central: KY, TN, AL, MS
West North Central: MN, IA, MO, ND, SD, NE, KS
West South Central: AR, LA, OK, TX
Mountain: MT, ID, WY, CO, NM, AZ, UT, NV
Pacific: WA, OR, CA, AK, HI
17
Table A-10. Item-level Average Percent Positive Response by Geographic Region (Page 1 of 4)
Geographic Region
Item
Survey Items By Composite
# Hospitals
# Respondents
1.
A1
A3
A4
A11
2.
B1
B2
B3R
B4R
3.
A6
Teamwork Within Units
1. People support one another in this unit.
2. When a lot of work needs to be done
quickly, we work together as a team to get the
work done.
3. In this unit, people treat each other with
respect.
4. When one area in this unit gets really busy,
others help out.
Supervisor/Manager Expectations &
Actions Promoting Patient Safety
1. My supv/mgr says a good word when
he/she sees a job done according to
established patient safety procedures.
2. My supv/mgr seriously considers staff
suggestions for improving patient safety.
3. Whenever pressure builds up, my supv/mgr
wants us to work faster, even if it means
taking shortcuts.
4. My supv/mgr overlooks patient safety
problems that happen over and over.
Organizational Learning— Continuous
Improvement
1. We are actively doing things to improve
patient safety.
Mid Atlantic/
New England
South
Atlantic
E. North
Central
E. South
Central
W. North
Central
W. South
Central
Mountain
Pacific
37
20,546
104
36,825
165
54,909
34
8,978
104
20,986
45
13,242
58
17,264
75
23,712
84%
84%
85%
87%
86%
87%
86%
85%
84%
85%
86%
88%
88%
87%
86%
84%
76%
78%
77%
81%
78%
80%
78%
78%
65%
67%
68%
69%
70%
70%
72%
67%
70%
74%
71%
75%
69%
77%
71%
71%
75%
78%
75%
79%
75%
79%
76%
75%
72%
75%
72%
76%
76%
77%
76%
72%
75%
79%
76%
81%
78%
79%
75%
73%
81%
83%
80%
84%
81%
84%
81%
81%
A9
2. Mistakes have led to positive changes here.
60%
64%
61%
64%
64%
66%
63%
61%
A13
3. After we make changes to improve patient
safety, we evaluate their effectiveness.
69%
70%
67%
74%
68%
73%
66%
61%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly
disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
18
Table A-10. Item-level Average Percent Positive Response by Geographic Region (Page 2 of 4)
Geographic Region
Item
Survey Items By Composite
# Hospitals
# Respondents
4.
F1
F8
F9R
5.
A10R
A15
A17R
A18
6.
C1
Management Support for Patient Safety
1. Hospital mgmt provides a work climate that
promotes patient safety.
2. The actions of hospital mgmt show that
patient safety is a top priority.
3. Hospital mgmt seems interested in patient
safety only after an adverse event happens.
Overall Perceptions of Patient Safety
1. It is just by chance that more serious
mistakes don’t happen around here.
2. Patient safety is never sacrificed to get
more work done.
3. We have patient safety problems in this
unit.
4. Our procedures and systems are good at
preventing errors from happening.
Feedback and Communication About Error
1. We are given feedback about changes put
into place based on event reports.
Mid Atlantic/
New England
South
Atlantic
E. North
Central
E. South
Central
W. North
Central
W. South
Central
Mountain
Pacific
37
20,546
104
36,825
165
54,909
34
8,978
104
20,986
45
13,242
58
17,264
75
23,712
78%
79%
79%
83%
82%
80%
80%
77%
72%
72%
71%
76%
72%
75%
72%
69%
58%
59%
59%
63%
62%
62%
59%
55%
58%
55%
59%
62%
66%
63%
64%
57%
64%
64%
62%
67%
67%
65%
68%
61%
58%
58%
62%
66%
68%
66%
66%
57%
70%
70%
69%
73%
72%
74%
69%
67%
54%
55%
53%
54%
50%
58%
53%
52%
C3
2. We are informed about errors that happen
in this unit.
64%
67%
63%
67%
63%
70%
65%
60%
C5
3. In this unit, we discuss ways to prevent
errors from happening again.
68%
71%
68%
71%
71%
73%
72%
69%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly
disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
19
Table A-10. Item-level Average Percent Positive Response by Geographic Region (Page 3 of 4)
Geographic Region
Item
Survey Items By Composite
# Hospitals
# Respondents
7.
C2
C4
C6R
8.
D1
D2
D3
9.
F2R
Communication Openness
1. Staff will freely speak up if they see
something that may negatively affect patient
care.
2. Staff feel free to question the decisions or
actions of those with more authority.
3. Staff are afraid to ask questions when
something does not seem right.
Frequency of Events Reported
1. When a mistake is made, but is caught and
corrected before affecting the patient, how
often is this reported?
2. When a mistake is made, but has no
potential to harm the patient, how often is this
reported?
3. When a mistake is made that could harm
the patient, but does not, how often is this
reported?
Teamwork Across Units
1. Hospital units do not coordinate well with
each other.
Mid Atlantic/
New England
South
Atlantic
E. North
Central
E. South
Central
W. North
Central
W. South
Central
Mountain
Pacific
37
20,546
104
36,825
165
54,909
34
8,978
104
20,986
45
13,242
58
17,264
75
23,712
76%
76%
76%
77%
75%
77%
76%
76%
48%
48%
46%
47%
45%
51%
49%
48%
62%
63%
62%
64%
62%
66%
64%
62%
54%
52%
50%
56%
51%
57%
54%
50%
57%
55%
54%
60%
58%
58%
57%
54%
73%
72%
72%
78%
75%
74%
72%
72%
42%
44%
43%
51%
49%
45%
45%
40%
F4
2. There is good cooperation among hospital
units that need to work together.
55%
57%
56%
64%
62%
60%
60%
55%
F6R
3. It is often unpleasant to work with staff from
other hospital units.
56%
58%
56%
61%
62%
57%
61%
57%
F10
4. Hospital units work well together to provide
the best care for patients.
65%
65%
65%
72%
71%
68%
69%
65%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly
disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
20
Table A-10. Item-level Average Percent Positive Response by Geographic Region (Page 4 of 4)
Geographic Region
Item
Survey Items By Composite
# Hospitals
# Respondents
10.
A2
Staffing
1. We have enough staff to handle the
workload.
Mid Atlantic/
New England
South
Atlantic
E. North
Central
E. South
Central
W. North
Central
W. South
Central
Mountain
Pacific
37
20,546
104
36,825
165
54,909
34
8,978
104
20,986
45
13,242
58
17,264
75
23,712
49%
51%
52%
50%
61%
55%
56%
52%
A5R
2. Staff in this unit work longer hours than is
best for patient care.
47%
51%
51%
53%
55%
52%
52%
50%
A7R
3. We use more agency/temporary staff than
is best for patient care.
61%
64%
67%
65%
69%
64%
61%
58%
A14R
4. We work in “crisis mode” trying to do too
much, too quickly.
44%
48%
46%
49%
54%
51%
53%
46%
37%
40%
38%
47%
47%
43%
41%
36%
11.
F3R
Handoffs & Transitions
1. Things “fall between the cracks” when
transferring patients from one unit to another.
F5R
2. Important patient care information is often
lost during shift changes.
50%
48%
48%
53%
54%
49%
50%
45%
F7R
3. Problems often occur in the exchange of
information across hospital units.
40%
40%
40%
46%
46%
43%
43%
39%
F11R
4. Shift changes are problematic for patients
in this hospital.
42%
43%
42%
48%
53%
44%
47%
41%
47%
49%
50%
53%
55%
53%
54%
48%
12.
A8R
Nonpunitive Response to Error
1. Staff feel like their mistakes are held
against them.
A12R
2. When an event is reported, it feels like the
person is being written up, not the problem.
44%
44%
44%
46%
48%
47%
48%
43%
A16R
3. Staff worry that mistakes they make are
kept in their personnel file.
31%
34%
33%
36%
40%
37%
38%
33%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly
disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
21
Table A-11. Average Percent Distribution of Work Area/Unit Patient Safety Grades by Geographic Region
Geographic Region
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
Mid Atlantic/
New England
37
20,546
South
Atlantic
104
36,825
E. North
Central
165
54,909
E. South
Central
34
8,978
W. North
Central
104
20,986
W. South
Central
45
13,242
Mountain
58
17,264
Pacific
75
23,712
A
Excellent
25%
23%
24%
27%
24%
30%
27%
24%
B
Very Good
45%
47%
48%
48%
50%
47%
49%
46%
C
Acceptable
24%
25%
23%
22%
22%
19%
20%
23%
D
Poor
4%
5%
5%
3%
3%
4%
4%
6%
E
Failing
1%
1%
1%
0%
0%
1%
1%
1%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table A-12. Average Percent Distribution of Number of Events Reported in the Past 12 Months by Geographic Region
Number of Events Reported
by Respondents
# Hospitals
# Respondents
Geographic Region
E. South
W. North
Central
Central
34
104
8,978
20,986
Mid Atlantic/
New England
37
20,546
South
Atlantic
104
36,825
E. North
Central
165
54,909
W. South
Central
45
13,242
Mountain
58
17,264
Pacific
75
23,712
No events
56%
53%
52%
55%
50%
60%
54%
47%
1 to 2 events
26%
28%
29%
27%
28%
24%
27%
30%
3 to 5 events
11%
12%
12%
11%
14%
10%
12%
15%
6 to 10 events
4%
4%
4%
4%
5%
4%
4%
5%
11 to 20 events
2%
2%
2%
2%
2%
1%
2%
2%
21 event reports or more
1%
1%
1%
1%
1%
1%
1%
1%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
22
Appendix B: Overall Results by Respondent Characteristics
23
Appendix B: Overall Results by Respondent Characteristics
(1) Work area/Unit
NOTE 1: Hospitals that did not ask respondents to indicate their work area/unit were excluded from these breakout tables. In
addition, respondents who selected “Many different work areas/No specific work area,” “Other,” or did not answer (missing)
were not included.
NOTE 2: The number of hospitals and respondents in each work area/unit is shown. The number of hospitals is based on: 1)
hospitals that asked respondents to indicate their work area/unit (not all hospitals asked this question), and 2) whether the
hospital had at least 1 respondent in a particular work area/unit. However, the precise number of hospitals and respondents
corresponding to each data cell in the tables will vary because hospitals may have omitted a specific survey item and because of
individual non-response/missing data.
24
Table B-1. Composite-level Average Percent Positive Response by Work Area/Unit
Work Area/Unit
Emergency
ICU
(any
type)
Pharmacy
Psych/
Mental
Hlth
Lab
Medicine
Radiology
Rehabilitation
177
1,184
486
9,703
401
12,040
526
9,273
518
17,143
345
8,088
Surgery
236
4,534
464
5,226
232
4,298
539
10,528
464
7,429
506
17,393
79%
79%
83%
79%
74%
80%
80%
78%
79%
79%
86%
78%
74%
72%
72%
75%
72%
73%
75%
77%
76%
76%
81%
74%
71%
65%
69%
72%
69%
69%
72%
75%
70%
69%
74%
74%
4. Mgmt Support for Patient
Safety
65%
62%
59%
71%
65%
66%
67%
70%
67%
72%
75%
68%
5. Overall Perceptions of
Patient Safety
64%
55%
56%
70%
55%
61%
65%
65%
59%
72%
76%
67%
6. Feedback & Communication
About Error
64%
56%
56%
65%
57%
60%
61%
67%
66%
63%
70%
64%
7. Communication Openness
66%
61%
61%
63%
56%
63%
63%
70%
63%
64%
72%
64%
8. Frequency of Events
Reported
58%
56%
56%
64%
61%
60%
60%
59%
63%
54%
61%
64%
9. Teamwork Across Units
54%
48%
53%
56%
56%
54%
53%
55%
53%
56%
61%
53%
10. Staffing
58%
49%
52%
54%
50%
56%
58%
56%
55%
62%
62%
56%
11. Handoffs & Transitions
41%
48%
47%
37%
47%
53%
46%
32%
39%
41%
40%
40%
12. Nonpunitive Response to
Error
44%
37%
39%
43%
39%
42%
41%
56%
46%
46%
59%
45%
62%
57%
59%
62%
58%
61%
62%
63%
61%
63%
68%
62%
AnesthePatient Safety Culture Composites siology
# Hospitals
# Respondents
1. Teamwork Within Units
2. Supv/Mgr Expectations &
Actions Promoting Patient
Safety
3. Org Learning--Continuous
Improvement
Average Across Composites
25
Obstetrics
Pediatrics
Table B-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 1 of 4)
Work Area/Unit
Item
Survey Items by Composite
# Hospitals
# Respondents
1.
A1
A3
A4
A11
2.
B1
Teamwork Within Units
1. People support one another in this
unit.
2. When a lot of work needs to be done
quickly, we work together as a team to
get the work done.
3. In this unit, people treat each other
with respect.
4. When one area in this unit gets really
busy, others help out.
Supv/Mgr Expectations & Actions
Promoting Patient Safety
1. My supv/mgr says a good word when
he/she sees a job done according to
established patient safety procedures.
Anesthesiology
Emergency
ICU
(any
type)
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
177
1,184
486
9,703
401
12,040
Surgery
236
4,534
464
5,226
232
4,298
539
10,528
464
7,429
506
17,393
85%
85%
87%
86%
85%
84%
85%
91%
83%
87%
80%
88%
87%
84%
84%
87%
90%
87%
76%
74%
77%
80%
78%
79%
77%
88%
74%
74%
70%
61%
68%
67%
67%
70%
66%
76%
65%
69%
68%
69%
70%
70%
71%
71%
74%
69%
77%
71%
Medicine
Obstetrics
Pediatrics
526
9,273
518
17,143
345
8,088
88%
83%
83%
87%
88%
85%
78%
75%
80%
65%
70%
70%
Lab
B2
2. My supv/mgr seriously considers staff
suggestions for improving patient safety.
76%
73%
73%
74%
73%
74%
76%
80%
77%
77%
84%
76%
B3R
3. Whenever pressure builds up, my
supv/mgr wants us to work faster, even if
it means taking shortcuts.
74%
72%
70%
80%
72%
72%
75%
78%
73%
78%
80%
71%
76%
75%
75%
77%
74%
76%
78%
79%
78%
80%
84%
77%
85%
77%
83%
80%
81%
80%
84%
87%
81%
80%
88%
86%
B4R
3.
A6
4. My supv/mgr overlooks patient safety
problems that happen over and over.
Organizational Learning—
Continuous Improvement
1. We are actively doing things to
improve patient safety.
A9
2. Mistakes have led to positive changes
here.
63%
56%
57%
69%
59%
61%
60%
73%
60%
62%
62%
64%
A13
3. After we make changes to improve
patient safety, we evaluate their
effectiveness.
64%
62%
67%
66%
68%
67%
71%
66%
69%
65%
73%
71%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
26
Table B-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 2 of 4)
Work Area/Unit
Anesthesiology
Emergency
ICU
(any
type)
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
177
1,184
486
9,703
401
12,040
Surgery
236
4,534
464
5,226
232
4,298
539
10,528
464
7,429
506
17,393
Mgmt Support for Patient Safety
1. Hospital mgmt provides a work climate
that promotes patient safety.
75%
70%
76%
76%
77%
75%
83%
84%
78%
F8
2. The actions of hospital mgmt show that
patient safety is a top priority.
67%
67%
68%
68%
71%
68%
74%
77%
69%
F9R
3. Hospital mgmt seems interested in
patient safety only after an adverse event
happens.
60%
55%
54%
55%
61%
58%
60%
63%
58%
5.
Overall Perceptions of Patient Safety
A10R
54%
64%
53%
60%
62%
62%
58%
67%
74%
63%
55%
51%
70%
54%
55%
64%
63%
62%
74%
76%
64%
64%
51%
55%
70%
50%
60%
62%
62%
50%
72%
74%
66%
4. Our procedures and systems are good
at preventing errors from happening.
72%
61%
63%
78%
63%
68%
71%
72%
68%
75%
79%
75%
Feedback and Communication About
Error
1. We are given feedback about changes
put into place based on event reports.
55%
48%
47%
52%
50%
53%
52%
53%
59%
51%
61%
53%
C3
2. We are informed about errors that
happen in this unit.
61%
57%
55%
69%
55%
59%
62%
73%
67%
69%
70%
65%
C5
3. In this unit, we discuss ways to prevent
errors from happening again.
74%
63%
64%
72%
65%
68%
68%
75%
73%
70%
79%
73%
Medicine
Obstetrics
Pediatrics
526
9,273
518
17,143
345
8,088
68%
81%
73%
63%
61%
73%
54%
52%
49%
1. It is just by chance that more serious
mistakes don’t happen around here.
63%
52%
A15
2. Patient safety is never sacrificed to get
more work done.
58%
A17R
3. We have patient safety problems in this
unit.
A18
Item
Survey Items by Composite
# Hospitals
# Respondents
4.
F1
6.
C1
Lab
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
27
Table B-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 3 of 4)
Work Area/Unit
Item
Survey Items by Composite
# Hospitals
# Respondents
Anesthesiology
Emergency
ICU
(any
type)
177
1,184
486
9,703
401
12,040
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
Surgery
236
4,534
464
5,226
232
4,298
539
10,528
464
7,429
506
17,393
Medicine
Obstetrics
Pediatrics
526
9,273
518
17,143
345
8,088
Lab
7.
Communication Openness
C2
1. Staff will freely speak up if they see
something that may negatively affect
patient care.
76%
74%
75%
76%
71%
78%
78%
79%
77%
79%
84%
80%
C4
2. Staff feel free to question the decisions
or actions of those with more authority.
53%
48%
44%
47%
40%
48%
49%
58%
50%
47%
57%
48%
C6R
3. Staff are afraid to ask questions when
something does not seem right.
68%
63%
63%
66%
56%
63%
63%
72%
63%
67%
73%
63%
8.
Frequency of Events Reported
D1
1. When a mistake is made, but is caught
and corrected before affecting the patient,
how often is this reported?
53%
44%
44%
55%
50%
50%
50%
46%
55%
44%
54%
57%
D2
2. When a mistake is made, but has no
potential to harm the patient, how often is
this reported?
52%
53%
52%
58%
58%
56%
56%
57%
59%
48%
56%
60%
D3
3. When a mistake is made that could harm
the patient, but does not, how often is this
reported?
70%
71%
71%
80%
74%
74%
74%
75%
74%
69%
73%
75%
9.
Teamwork Across Units
F2R
1. Hospital units do not coordinate well with
each other.
39%
38%
39%
43%
43%
39%
41%
43%
39%
43%
47%
40%
F4
2. There is good cooperation among
hospital units that need to work together.
53%
48%
52%
58%
56%
56%
54%
55%
52%
58%
61%
53%
F6R
3. It is often unpleasant to work with staff
from other hospital units.
58%
51%
60%
56%
60%
57%
56%
58%
60%
56%
65%
55%
F10
4. Hospital units work well together to
provide the best care for patients.
64%
57%
60%
66%
64%
65%
62%
65%
61%
66%
70%
62%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
28
Table B-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 4 of 4)
Work Area/Unit
Anesthesiology
Emergency
ICU
(any
type)
177
1,184
486
9,703
401
12,040
Staffing
1. We have enough staff to handle the
workload.
62%
43%
A5R
2. Staff in this unit work longer hours than
is best for patient care.
49%
A7R
3. We use more agency/temporary staff
than is best for patient care.
A14R
4. We work in “crisis mode” trying to do too
much, too quickly.
Item
Survey Items by Composite
# Hospitals
# Respondents
10.
A2
11.
F3R
Handoffs & Transitions
1. Things “fall between the cracks” when
transferring patients from one unit to
another.
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
Surgery
236
4,534
464
5,226
232
4,298
539
10,528
464
7,429
506
17,393
53%
57%
51%
51%
60%
56%
55%
48%
52%
54%
56%
53%
58%
60%
49%
66%
64%
73%
73%
69%
67%
73%
70%
70%
46%
48%
43%
47%
51%
48%
51%
55%
62%
49%
46%
37%
29%
42%
44%
41%
26%
33%
40%
38%
40%
Medicine
Obstetrics
Pediatrics
526
9,273
518
17,143
345
8,088
48%
49%
44%
51%
51%
55%
68%
63%
64%
54%
40%
39%
Lab
F5R
2. Important patient care information is
often lost during shift changes.
45%
57%
58%
44%
51%
63%
52%
36%
46%
46%
42%
45%
F7R
3. Problems often occur in the exchange of
information across hospital units.
40%
45%
41%
36%
44%
46%
40%
33%
35%
39%
41%
39%
F11R
4. Shift changes are problematic for
patients in this hospital.
37%
46%
53%
40%
48%
59%
48%
34%
42%
41%
37%
36%
Nonpunitive Response to Error
1. Staff feel like their mistakes are held
against them.
54%
45%
47%
51%
46%
49%
50%
63%
52%
52%
65%
51%
42%
38%
41%
44%
42%
44%
45%
57%
51%
46%
59%
47%
36%
29%
30%
33%
30%
31%
29%
49%
37%
39%
53%
37%
12.
A8R
2. When an event is reported, it feels like
A12R the person is being written up, not the
problem.
A16R
3. Staff worry that mistakes they make are
kept in their personnel file.
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
29
Table B-3. Average Percent Distribution of Work Area/Unit Patient Safety Grades by Work Area/Unit
Work Area/Unit
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
Anesthesiology
177
1,184
Emergency
486
9,703
ICU
(any
type)
401
12,040
Lab
526
9,273
Medicine
518
17,143
Obstetrics
345
8,088
Pediatrics
236
4,534
Pharmacy
464
5,226
Psych/
Mental
Health
232
4,298
Radiology
539
10,528
Rehabilitation
464
7,429
Surgery
506
17,393
A
Excellent
35%
16%
18%
26%
15%
21%
24%
25%
23%
28%
35%
32%
B
Very Good
42%
46%
49%
51%
47%
47%
49%
49%
44%
49%
46%
45%
C
Acceptable
19%
30%
26%
20%
31%
25%
22%
20%
22%
19%
16%
18%
D
Poor
3%
7%
6%
3%
6%
6%
5%
5%
9%
3%
2%
4%
E
Failing
1%
1%
1%
0%
1%
1%
0%
1%
1%
0%
1%
1%
Radiology
539
10,528
Rehabilitation
464
7,429
Surgery
506
17,393
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table B-4. Average Percent Distribution of Number of Events Reported in the Past 12 Months by Work Area/Unit
Work Area/Unit
Number of Events
Reported by
Respondents
# Hospitals
# Respondents
Anesthesiology
177
1,184
Emergency
486
9,703
ICU
(any
type)
401
12,040
Lab
526
9,273
Medicine
518
17,143
Obstetrics
345
8,088
Pediatrics
236
4,534
Pharmacy
464
5,226
Psych/
Mental
Health
232
4,298
No events
56%
46%
34%
49%
38%
43%
44%
42%
51%
55%
55%
46%
1 to 2 events
30%
32%
38%
29%
33%
36%
34%
18%
26%
31%
33%
32%
3 to 5 events
7%
13%
20%
12%
20%
15%
16%
15%
14%
10%
8%
14%
6 to 10 events
4%
5%
6%
5%
6%
4%
4%
10%
6%
2%
3%
5%
11 to 20 events
1%
2%
2%
3%
2%
1%
2%
8%
2%
1%
0%
1%
21 event reports or
more
1%
2%
0%
3%
1%
0%
0%
8%
1%
0%
0%
1%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
30
Appendix B: Overall Results by Respondent Characteristics
(2) Staff Position
NOTE 1: Hospitals that did not ask respondents to indicate their staff position were excluded from these breakout tables. In
addition, respondents who selected “Other,” or did not answer (missing) were not included.
NOTE 2: The number of hospitals and respondents in each staff position is shown. The number of hospitals is based on: 1)
hospitals that asked respondents to indicate their staff position (not all hospitals asked this question), and 2) whether the hospital
had at least 1 respondent in a particular staff position. However, the precise number of hospitals and respondents corresponding
to each data cell in the tables will vary because hospitals may have omitted a specific survey item and because of individual nonresponse/missing data.
31
Table B-5. Composite-level Average Percent Positive Response by Staff Position
Staff Position
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
RN/LVN/LPN
Technician
(EKG, Lab,
Radiology)
581
13,750
444
8,084
320
1,195
530
10,386
434
3,123
606
66,261
549
19,230
529
9,026
573
11,914
1. Teamwork Within Units
88%
82%
81%
74%
80%
79%
77%
84%
77%
2. Supervisor/Manager Expectations
& Actions Promoting Patient Safety
84%
71%
77%
75%
77%
73%
75%
77%
76%
3. Org Learning--Continuous
Improvement
81%
71%
69%
73%
74%
70%
69%
70%
70%
4. Management Support for Patient
Safety
83%
69%
75%
73%
68%
64%
70%
71%
73%
5. Overall Perceptions of Patient
Safety
73%
63%
66%
61%
61%
59%
70%
69%
65%
6. Feedback & Communication About
Error
74%
61%
68%
64%
64%
58%
63%
65%
65%
7. Communication Openness
75%
63%
65%
57%
71%
61%
62%
67%
60%
8. Frequency of Events Reported
66%
55%
57%
65%
52%
61%
59%
55%
65%
9. Teamwork Across Units
63%
59%
61%
59%
55%
54%
54%
61%
57%
10. Staffing
63%
55%
55%
49%
56%
56%
56%
58%
51%
11. Handoffs & Transitions
45%
44%
37%
49%
30%
47%
39%
41%
45%
12. Nonpunitive Response to Error
62%
42%
45%
36%
60%
43%
43%
50%
39%
71%
61%
63%
61%
62%
60%
61%
64%
62%
Patient Safety Culture Composites
# Hospitals
# Respondents
Average Across Composites
32
Therapist
Unit
(Respiratory,
Asst/
Phys, Occup,
Clerk/
Speech)
Secretary
Table B-6. Item-level Average Percent Positive Response by Staff Position (Page 1 of 4)
Staff Position
Item
Patient Safety Culture Composites
# Hospitals
# Respondents
1.
A1
A3
A4
A11
2.
B1
B2
B3R
B4R
3.
A6
A9
A13
Teamwork Within Units
1. People support one another in this unit.
2. When a lot of work needs to be done
quickly, we work together as a team to get
the work done.
3. In this unit, people treat each other with
respect.
4. When one area in this unit gets really
busy, others help out.
Supv/Mgr Expectations & Actions
Promoting Patient Safety
1. My supv/mgr says a good word when
he/she sees a job done according to
established patient safety procedures.
2. My supv/mgr seriously considers staff
suggestions for improving patient safety.
3. Whenever pressure builds up, my
supv/mgr wants us to work faster, even if it
means taking shortcuts.
4. My supv/mgr overlooks patient safety
problems that happen over and over.
Organizational Learning— Continuous
Improvement
1. We are actively doing things to improve
patient safety.
2. Mistakes have led to positive changes
here.
3. After we make changes to improve patient
safety, we evaluate their effectiveness.
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
581
13,750
444
8,084
320
1,195
530
10,386
434
3,123
606
66,261
549
19,230
529
9,026
573
11,914
93%
88%
86%
80%
87%
86%
83%
89%
82%
93%
87%
86%
80%
85%
86%
85%
87%
83%
88%
84%
80%
72%
80%
78%
75%
84%
75%
77%
70%
73%
65%
68%
67%
67%
75%
68%
82%
69%
78%
73%
70%
70%
68%
74%
74%
87%
75%
81%
76%
79%
75%
75%
81%
76%
84%
66%
75%
74%
78%
73%
77%
76%
77%
85%
72%
76%
76%
79%
76%
78%
78%
77%
88%
79%
81%
85%
86%
83%
80%
83%
81%
80%
68%
62%
60%
76%
60%
63%
59%
62%
76%
66%
64%
73%
61%
68%
65%
68%
68%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
33
Table B-6. Item-level Average Percent Positive Response by Staff Position (Page 2 of 4)
Staff Position
Item
Patient Safety Culture Composites
# Hospitals
# Respondents
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
581
13,750
Pharmacist
RN/
LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
444
8,084
320
1,195
530
10,386
434
3,123
606
66,261
549
19,230
529
9,026
573
11,914
4.
Mgmt Support for Patient Safety
F1
1. Hospital mgmt provides a work climate that
promotes patient safety.
89%
77%
86%
82%
74%
73%
81%
81%
83%
F8
2. The actions of hospital mgmt show that
patient safety is a top priority.
84%
71%
78%
77%
69%
65%
72%
71%
75%
F9R
3. Hospital mgmt seems interested in patient
safety only after an adverse event happens.
75%
59%
61%
59%
60%
55%
58%
59%
61%
5.
Overall Perceptions of Patient Safety
72%
62%
58%
51%
61%
59%
64%
67%
56%
72%
63%
65%
63%
56%
56%
70%
68%
69%
70%
60%
66%
60%
57%
56%
70%
69%
65%
77%
68%
74%
69%
71%
66%
74%
74%
71%
64%
54%
60%
55%
51%
51%
51%
56%
55%
77%
62%
67%
66%
69%
57%
68%
65%
68%
82%
69%
76%
71%
73%
66%
70%
73%
71%
1. It is just by chance that more serious
mistakes don’t happen around here.
2. Patient safety is never sacrificed to get
A15
more work done.
3. We have patient safety problems in this
A17R
unit.
A10R
A18
6.
C1
C3
C5
4. Our procedures and systems are good
at preventing errors from happening.
Feedback and Communication About
Error
1. We are given feedback about changes
put into place based on event reports.
2. We are informed about errors that
happen in this unit.
3. In this unit, we discuss ways to prevent
errors from happening again.
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
34
Table B-6. Item-level Average Percent Positive Response by Staff Position (Page 3 of 4)
Staff Position
Item Patient Safety Culture Composites
# Hospitals
# Respondents
7.
C2
Communication Openness
1. Staff will freely speak up if they see
something that may negatively affect
patient care.
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
581
13,750
444
8,084
83%
Pharmacist
RN/
LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
320
1,195
530
10,386
434
3,123
606
66,261
549
19,230
529
9,026
573
11,914
72%
76%
74%
79%
75%
77%
80%
76%
C4
2. Staff feel free to question the decisions
or actions of those with more authority.
68%
55%
56%
41%
61%
45%
46%
53%
42%
C6R
3. Staff are afraid to ask questions when
something does not seem right.
74%
63%
62%
57%
74%
62%
64%
69%
61%
58%
48%
53%
62%
35%
48%
51%
48%
61%
62%
50%
50%
61%
50%
59%
52%
49%
60%
78%
69%
69%
74%
72%
76%
74%
67%
75%
52%
48%
50%
46%
43%
41%
42%
48%
46%
65%
60%
62%
60%
55%
55%
56%
62%
58%
63%
61%
61%
59%
61%
58%
54%
67%
55%
74%
67%
71%
72%
63%
63%
65%
69%
68%
8.
D1
Frequency of Events Reported
1. When a mistake is made, but is caught
and corrected before affecting the patient,
how often is this reported?
2. When a mistake is made, but has no
potential to harm the patient, how often is
this reported?
3. When a mistake is made that could
harm the patient, but does not, how often
D3
is this reported?
9.
Teamwork Across Units
1. Hospital units do not coordinate well
F2R
with each other.
2. There is good cooperation among
F4
hospital units that need to work together.
3. It is often unpleasant to work with staff
F6R
from other hospital units.
4. Hospital units work well together to
F10
provide the best care for patients.
D2
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
35
Table B-6. Item-level Average Percent Positive Response by Staff Position (Page 4 of 4)
Staff Position
Item
Patient Safety Culture Composites
# Hospitals
# Respondents
10.
A2
Staffing
1. We have enough staff to handle the
workload.
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
581
13,750
444
8,084
67%
Pharmacist
RN/
LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
320
1,195
530
10,386
434
3,123
606
66,261
549
19,230
529
9,026
573
11,914
57%
57%
44%
49%
52%
53%
53%
49%
A5R
2. Staff in this unit work longer hours than
is best for patient care.
59%
51%
53%
44%
59%
54%
54%
56%
48%
A7R
3. We use more agency/temporary staff
than is best for patient care.
69%
61%
58%
62%
71%
71%
67%
69%
59%
56%
51%
52%
47%
46%
47%
49%
55%
50%
41%
43%
32%
46%
25%
43%
34%
36%
44%
49%
46%
40%
57%
33%
53%
45%
44%
51%
44%
44%
39%
43%
31%
44%
37%
42%
43%
46%
40%
37%
50%
31%
49%
40%
41%
44%
69%
48%
53%
43%
65%
50%
50%
57%
45%
68%
45%
47%
37%
62%
46%
43%
51%
39%
50%
31%
35%
28%
54%
33%
35%
43%
32%
A14R
11.
F3R
F5R
F7R
4. We work in “crisis mode” trying to do
too much, too quickly.
Handoffs & Transitions
1. Things “fall between the cracks” when
transferring patients from one unit to
another.
2. Important patient care information is
often lost during shift changes.
3. Problems often occur in the exchange
of information across hospital units.
4. Shift changes are problematic for
patients in this hospital.
12.
Nonpunitive Response to Error
1. Staff feel like their mistakes are held
A8R
against them.
2. When an event is reported, it feels like
A12R the person is being written up, not the
problem.
F11R
A16R
3. Staff worry that mistakes they make are
kept in their personnel file.
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
36
Table B-7. Average Percent Distribution of Work Area/Unit Patient Safety Grades by Staff Position
Staff Position
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
RN/LVN/LPN
Technician
(EKG, Lab,
Radiology)
581
444
13,750
Therapist
Unit
(Respiratory,
Asst/
Phys, Occup,
Clerk/
Speech)
Secretary
320
530
434
606
549
529
573
8,084
1,195
10,386
3,123
66,261
19,230
9,026
11,914
A
Excellent
30%
25%
27%
24%
21%
19%
27%
29%
27%
B
Very Good
52%
47%
48%
46%
49%
47%
49%
46%
47%
C
Acceptable
16%
22%
21%
24%
23%
26%
20%
20%
22%
D
Poor
2%
5%
3%
5%
6%
6%
3%
4%
3%
E
Failing
1%
1%
0%
1%
1%
1%
1%
1%
1%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table B-8. Average Percent Distribution of Number of Events Reported in the Past 12 Months by Staff Position
Staff Position
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
RN/LVN/LPN
Technician
(EKG, Lab,
Radiology)
444
320
530
434
606
549
529
573
13,750
8,084
1,195
10,386
3,123
66,261
19,230
9,026
11,914
No events
45%
59%
75%
75%
25%
29%
57%
59%
77%
1 to 2 events
24%
27%
16%
19%
22%
38%
29%
31%
17%
3 to 5 events
16%
9%
6%
4%
20%
22%
9%
7%
4%
6 to 10 events
8%
3%
2%
1%
13%
7%
3%
2%
1%
11 to 20 events
4%
1%
0%
0%
10%
3%
1%
0%
0%
21 event reports or more
3%
1%
0%
0%
10%
1%
1%
0%
0%
Number of Events Reported
by Respondents
# Hospitals
# Respondents
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
581
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
37
Therapist
Unit
(Respiratory,
Asst/
Phys, Occup,
Clerk/
Speech)
Secretary
Appendix B: Overall Results by Respondent Characteristics
(3) Interaction with Patients
NOTE 1: Hospitals that did not ask respondents to indicate their interaction with patients were excluded from these breakout
tables. In addition, respondents who did not answer (missing) were not included.
NOTE 2: The number of hospitals and respondents is shown in each table. The number of hospitals is based on: 1) hospitals that
asked respondents to indicate their interaction with patients (not all hospitals asked this question), and 2) whether the hospital
had at least 1 respondent in the response categories (WITH or WITHOUT direct interaction with patients). However, the precise
number of hospitals and respondents corresponding to each data cell in the tables will vary because hospitals may have omitted a
specific survey item and because of individual non-response/missing data.
38
Table B-9. Composite-level Average Percent Positive Response by Interaction with Patients
Interaction with Patients
WITH
direct interaction
614
143,052
WITHOUT
direct interaction
596
43,658
1. Teamwork Within Units
79%
81%
2. Supervisor/Manager Expectations & Actions
Promoting Patient Safety
75%
76%
3. Org Learning--Continuous Improvement
71%
72%
4. Management Support for Patient Safety
69%
76%
5. Overall Perceptions of Patient Safety
64%
66%
6. Feedback & Communication About Error
62%
66%
7. Communication Openness
62%
64%
8. Frequency of Events Reported
60%
62%
9. Teamwork Across Units
57%
58%
10. Staffing
56%
53%
11. Handoffs & Transitions
45%
38%
12. Nonpunitive Response to Error
43%
47%
62%
63%
Patient Safety Culture Composites
# Hospitals
# Respondents
Average Across Composites
39
Table B-10. Item-level Average Percent Positive Response by Interaction with Patients (Page 1 of 4)
Interaction with Patients
Item
Survey Items By Composite
# Hospitals
# Respondents
WITH
direct interaction
614
143,052
WITHOUT
direct interaction
596
43,658
85%
86%
1.
A1
Teamwork Within Units
1. People support one another in this unit.
A3
2. When a lot of work needs to be done quickly, we work
together as a team to get the work done.
86%
87%
A4
3. In this unit, people treat each other with respect.
77%
80%
A11
4. When one area in this unit gets really busy, others help out.
68%
69%
2.
Supervisor/Manager Expectations & Actions Promoting
Patient Safety
1. My supv/mgr says a good word when he/she sees a job
done according to established patient safety procedures.
71%
75%
B1
B2
2. My supv/mgr seriously considers staff suggestions for
improving patient safety.
76%
78%
B3R
3. Whenever pressure builds up, my supv/mgr wants us to
work faster, even if it means taking shortcuts.
74%
76%
B4R
4. My supv/mgr overlooks patient safety problems that happen
over and over.
77%
77%
3.
Organizational Learning— Continuous Improvement
A6
1. We are actively doing things to improve patient safety.
82%
80%
A9
2. Mistakes have led to positive changes here.
62%
69%
A13
3. After we make changes to improve patient safety, we
evaluate their effectiveness.
68%
68%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based
on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
40
Table B-10. Item-level Average Percent Positive Response by Interaction with Patients (Page 2 of 4)
Interaction with Patients
Item
Survey Items By Composite
# Hospitals
# Respondents
4.
F1
F8
Management Support for Patient Safety
1. Hospital mgmt provides a work climate that promotes
patient safety.
2. The actions of hospital mgmt show that patient safety is a
top priority.
WITH
direct interaction
614
143,052
WITHOUT
direct interaction
596
43,658
78%
85%
70%
78%
58%
66%
F9R
3. Hospital mgmt seems interested in patient safety only after
an adverse event happens.
5.
Overall Perceptions of Patient Safety
A10R
1. It is just by chance that more serious mistakes don’t happen
around here.
60%
61%
A15
2. Patient safety is never sacrificed to get more work done.
64%
66%
A17R
3. We have patient safety problems in this unit.
62%
65%
A18
4. Our procedures and systems are good at preventing errors
from happening.
70%
72%
53%
56%
6.
C1
Feedback and Communication About Error
1. We are given feedback about changes put into place based
on event reports.
C3
2. We are informed about errors that happen in this unit.
63%
69%
C5
3. In this unit, we discuss ways to prevent errors from
happening again.
70%
74%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on
those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
41
Table B-10. Item-level Average Percent Positive Response by Interaction with Patients (Page 3 of 4)
Interaction with Patients
Item
Survey Items By Composite
# Hospitals
# Respondents
7.
C2
Communication Openness
1. Staff will freely speak up if they see something that may
negatively affect patient care.
WITH
direct interaction
614
143,052
WITHOUT
direct interaction
596
43,658
76%
76%
C4
2. Staff feel free to question the decisions or actions of those
with more authority.
46%
51%
C6R
3. Staff are afraid to ask questions when something does not
seem right.
63%
66%
51%
56%
8.
D1
Frequency of Events Reported
1. When a mistake is made, but is caught and corrected before
affecting the patient, how often is this reported?
D2
2. When a mistake is made, but has no potential to harm the
patient, how often is this reported?
56%
57%
D3
3. When a mistake is made that could harm the patient, but
does not, how often is this reported?
73%
73%
9.
Teamwork Across Units
F2R
1. Hospital units do not coordinate well with each other.
44%
47%
F4
2. There is good cooperation among hospital units that need to
work together.
58%
59%
F6R
3. It is often unpleasant to work with staff from other hospital
units.
59%
57%
F10
4. Hospital units work well together to provide the best care for
patients.
66%
70%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on
those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
42
Table B-10. Item-level Average Percent Positive Response by Interaction with Patients (Page 4 of 4)
Item
Survey Items By Composite
# Hospitals
# Respondents
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
614
596
143,052
43,658
10.
Staffing
A2
1. We have enough staff to handle the workload.
53%
57%
A5R
2. Staff in this unit work longer hours than is best for patient
care.
53%
49%
A7R
3. We use more agency/temporary staff than is best for patient
care.
67%
57%
A14R
4. We work in “crisis mode” trying to do too much, too quickly.
49%
48%
11.
Handoffs & Transitions
1. Things “fall between the cracks” when transferring patients
from one unit to another.
42%
35%
F3R
F5R
2. Important patient care information is often lost during shift
changes.
51%
43%
F7R
3. Problems often occur in the exchange of information across
hospital units.
43%
38%
F11R
4. Shift changes are problematic for patients in this hospital.
46%
39%
12.
Nonpunitive Response to Error
A8R
1. Staff feel like their mistakes are held against them.
50%
55%
A12R
2. When an event is reported, it feels like the person is being
written up, not the problem.
45%
49%
A16R
3. Staff worry that mistakes they make are kept in their
personnel file.
35%
38%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on
those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
43
Table B-11. Average Percent Distribution of Work Area/Unit Patient Safety
Grades by Interaction with Patients
Interaction with Patients
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
WITH
direct interaction
614
143,052
WITHOUT
direct interaction
596
43,658
A
Excellent
24%
28%
B
Very Good
48%
49%
C
Acceptable
23%
20%
D
Poor
5%
3%
E
Failing
1%
0%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table B-12. Average Percent Distribution of Number of Events Reported in
the Past 12 Months by Interaction with Patients
Interaction with Patients
Number of Events Reported
by Respondents
# Hospitals
# Respondents
WITH
direct interaction
614
143,052
WITHOUT
direct interaction
596
43,658
No events
48%
68%
1 to 2 events
31%
16%
3 to 5 events
14%
8%
6 to 10 events
5%
4%
11 to 20 events
2%
2%
21 event reports or more
1%
2%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
44
Part III
Appendix C: Trending Results by Hospital Characteristics
45
Appendix C: Trending Results by Hospital Characteristics
(1) Bed Size
NOTE: The number of hospitals and respondents in each breakout category is shown in each table (e.g., the number of
hospitals and respondents by bed size). However, the precise number of hospitals and respondents corresponding to each
data cell in a table will vary because hospitals may have omitted a specific survey item and because of individual nonresponse/missing data.
46
Table C-1. Trending: Composite-level Average Percent Positive Response by Bed Size (Page 1 of 2)
Bed Size
Patient Safety Culture Composites
# Hospitals
# Respondents
1. Teamwork Within Units
2. Supervisor/Manager
Expectations & Actions
Promoting Patient Safety
3. Org Learning--Continuous
Improvement
4. Management Support for
Patient Safety
5. Overall Perceptions of Patient
Safety
6. Feedback & Communication
About Error
Database Year
Both Years
Most Recent
Previous
6-24
beds
21
1,054
1,362
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
Most Recent
83%
83%
78%
79%
77%
78%
76%
Previous
81%
82%
77%
73%
69%
75%
77%
Change
2%
1%
1%
6%
8%
3%
-1%
Most Recent
76%
80%
74%
75%
73%
72%
72%
Previous
75%
78%
73%
74%
69%
71%
72%
Change
1%
2%
1%
1%
4%
1%
0%
Most Recent
73%
75%
72%
72%
70%
70%
68%
Previous
71%
74%
69%
65%
62%
67%
69%
Change
2%
1%
3%
7%
8%
3%
-1%
Most Recent
77%
77%
70%
71%
66%
67%
64%
Previous
76%
77%
68%
65%
61%
66%
65%
Change
1%
0%
2%
6%
5%
1%
-1%
Most Recent
74%
72%
65%
64%
61%
61%
52%
Previous
71%
68%
63%
60%
54%
58%
58%
Change
3%
4%
2%
4%
7%
3%
-6%
Most Recent
66%
65%
62%
63%
60%
61%
60%
Previous
66%
65%
61%
58%
55%
60%
61%
Change
0%
0%
1%
5%
5%
1%
-1%
47
Table C-1. Trending: Composite-level Average Percent Positive Response by Bed Size (Page 2 of 2)
Bed Size
Patient Safety Culture Composites
# Hospitals
# Respondents
7. Communication Openness
8. Frequency of Events Reported
9. Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to
Error
Database Year
Both Years
Most Recent
Previous
6-24
beds
21
1,054
1,362
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
Most Recent
65%
64%
61%
61%
60%
60%
59%
Previous
65%
62%
60%
58%
56%
61%
61%
Change
0%
2%
1%
3%
4%
-1%
-2%
Most Recent
64%
65%
60%
63%
59%
60%
57%
Previous
64%
63%
60%
58%
54%
57%
57%
Change
0%
2%
0%
5%
5%
3%
0%
Most Recent
68%
65%
58%
57%
50%
52%
49%
Previous
66%
64%
57%
53%
47%
50%
50%
Change
2%
1%
1%
4%
3%
2%
-1%
Most Recent
65%
61%
54%
53%
50%
52%
47%
Previous
62%
59%
55%
51%
46%
49%
49%
Change
3%
2%
-1%
2%
4%
3%
-2%
Most Recent
59%
53%
47%
43%
37%
38%
37%
Previous
55%
51%
46%
41%
36%
37%
38%
Change
4%
2%
1%
2%
1%
1%
-1%
Most Recent
53%
50%
43%
44%
41%
41%
38%
Previous
49%
47%
42%
42%
39%
39%
38%
Change
4%
3%
1%
2%
2%
2%
0%
48
Table C-2. Trending: Item-level Average Percent Positive Response by Bed Size (Page 1 of 6)
Item
Survey Items by Composite
# Hospitals
# Respondents
1.
Teamwork Within Units
A1
1. People support one another
in this unit.
A3
2. When a lot of work needs to
be done quickly, we work
together as a team to get the
work done.
A4
3. In this unit, people treat
each other with respect.
A11
4. When one area in this unit
gets really busy, others help
out.
2.
B1
B2
B3R
B4R
Database Year
Both Years
Most Recent
Previous
6-24
beds
21
1,054
1,362
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
Most Recent
88%
88%
83%
Previous
86%
86%
Change
2%
Most Recent
Previous
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
84%
83%
84%
84%
82%
78%
73%
81%
83%
2%
1%
6%
10%
3%
1%
91%
90%
84%
84%
85%
84%
82%
89%
89%
85%
79%
76%
82%
82%
Change
2%
1%
-1%
5%
9%
2%
0%
Most Recent
80%
82%
75%
77%
76%
76%
75%
Previous
Change
80%
0%
80%
2%
76%
-1%
72%
5%
68%
8%
74%
2%
75%
0%
Most Recent
74%
73%
69%
69%
66%
67%
65%
67%
2%
64%
5%
59%
7%
64%
3%
66%
-1%
70%
72%
72%
70%
72%
69%
67%
65%
67%
71%
1%
5%
7%
3%
1%
75%
75%
0%
75%
77%
71%
6%
75%
75%
67%
8%
71%
73%
71%
2%
71%
74%
75%
-1%
68%
73%
73%
67%
69%
69%
2%
2%
4%
2%
-1%
77%
75%
2%
77%
72%
5%
74%
67%
7%
73%
71%
2%
75%
73%
2%
Previous
70%
71%
Change
4%
2%
Supervisor/Manager Expectations & Actions Promoting Patient Safety
1. My supv/mgr says a good
Most Recent
71%
76%
word when he/she sees a job
Previous
69%
74%
done according to established
Change
2%
2%
patient safety procedures.
Most Recent
2. My supv/mgr seriously
77%
81%
considers staff suggestions for
Previous
77%
80%
improving patient safety.
Change
0%
1%
3. Whenever pressure builds
Most Recent
80%
80%
up, my supv/mgr wants us to
Previous
78%
78%
work faster, even if it means
Change
2%
2%
taking shortcuts.
4. My supv/mgr overlooks
patient safety problems that
happen over and over.
Bed Size
100-199
beds
32
8,886
7,573
Most Recent
Previous
Change
76%
76%
0%
82%
80%
2%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
49
Table C-2. Trending: Item-level Average Percent Positive Response by Bed Size (Page 2 of 6)
Item
3.
A6
Database
6-24
Survey Items by Composite
Year
beds
# Hospitals
Both Years
21
Most Recent
1,054
# Respondents
Previous
1,362
Organizational Learning— Continuous Improvement
Most Recent
83%
1. We are actively doing
Previous
things to improve patient
82%
safety.
Change
1%
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
86%
83%
85%
Bed Size
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
83%
81%
81%
79%
81%
75%
71%
79%
80%
1%
2%
8%
10%
2%
-1%
Most Recent
Previous
Change
67%
64%
3%
68%
67%
1%
63%
61%
2%
65%
59%
6%
61%
53%
8%
62%
59%
3%
60%
61%
-1%
Most Recent
Previous
Change
Management Support for Patient Safety
Most Recent
1. Hospital mgmt provides a
Previous
work climate that promotes
patient safety.
Change
69%
68%
1%
73%
70%
3%
69%
66%
3%
70%
62%
8%
67%
60%
7%
67%
64%
3%
65%
66%
-1%
85%
85%
0%
86%
86%
0%
80%
78%
2%
80%
74%
6%
75%
71%
4%
76%
76%
0%
73%
75%
-2%
F8
2. The actions of hospital
mgmt show that patient safety
is a top priority.
Most Recent
Previous
Change
78%
76%
2%
78%
78%
0%
71%
69%
2%
73%
66%
7%
69%
60%
9%
70%
67%
3%
67%
69%
-2%
F9R
3. Hospital mgmt seems
interested in patient safety
only after an adverse event
happens.
Most Recent
Previous
67%
66%
68%
66%
58%
57%
59%
55%
55%
51%
56%
54%
52%
52%
Change
1%
2%
1%
4%
4%
2%
0%
A9
A13
4.
F1
2. Mistakes have led to
positive changes here.
3. After we make changes to
improve patient safety, we
evaluate their effectiveness.
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
50
Table C-2. Trending: Item-level Average Percent Positive Response by Bed Size (Page 3 of 6)
Item
5.
Database
Survey Items by Composite
Year
# Hospitals
Both Years
Most Recent
# Respondents
Previous
Overall Perceptions of Patient Safety
Most Recent
1. It is just by chance that
A10R more serious mistakes don’t
happen around here.
69%
67%
61%
Previous
65%
64%
Bed Size
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
60%
56%
59%
45%
61%
57%
52%
55%
54%
4%
3%
0%
3%
4%
4%
-9%
77%
75%
2%
73%
69%
4%
63%
64%
-1%
65%
60%
5%
61%
52%
9%
59%
56%
3%
55%
58%
-3%
Most Recent
Previous
Change
4. Our procedures and
Most Recent
systems are good at
Previous
preventing errors from
Change
happening.
Feedback and Communication About Error
Most Recent
1. We are given feedback
74%
72%
2%
75%
70%
5%
70%
68%
2%
76%
73%
3%
63%
62%
1%
71%
67%
4%
62%
58%
4%
71%
64%
7%
57%
51%
6%
69%
60%
9%
58%
56%
2%
68%
66%
2%
44%
55%
-11%
65%
66%
-1%
52%
53%
52%
54%
53%
54%
54%
about changes put into place
based on event reports.
Previous
53%
53%
50%
49%
48%
53%
56%
Change
Most Recent
Previous
Change
Most Recent
-1%
72%
69%
3%
73%
0%
67%
68%
-1%
74%
2%
65%
65%
0%
70%
5%
5%
65%
60%
5%
70%
61%
58%
3%
67%
1%
61%
60%
1%
68%
-2%
60%
60%
0%
66%
Previous
75%
74%
69%
64%
60%
67%
68%
Change
-2%
0%
1%
6%
7%
1%
-2%
A17R
3. We have patient safety
problems in this unit.
C1
50-99
beds
37
4,360
4,686
Change
2. Patient safety is never
sacrificed to get more work
done.
6.
25-49
beds
42
3,550
3,401
Most Recent
Previous
Change
A15
A18
6-24
beds
21
1,054
1,362
C3
2. We are informed about
errors that happen in this unit.
C5
3. In this unit, we discuss
ways to prevent errors from
happening again.
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
51
Table C-2. Trending: Item-level Average Percent Positive Response by Bed Size (Page 4 of 6)
Item
Survey Items by Composite
# Hospitals
# Respondents
7.
Communication Openness
C2
1. Staff will freely speak up if
they see something that may
negatively affect patient care.
C4
2. Staff feel free to question the
decisions or actions of those
with more authority.
C6R
8.
D1
D2
D3
3. Staff are afraid to ask
questions when something
does not seem right.
Frequency of Events Reported
1. When a mistake is made,
but is caught and corrected
before affecting the patient,
how often is this reported?
2. When a mistake is made,
but has no potential to harm
the patient, how often is this
reported?
3. When a mistake is made
that could harm the patient, but
does not, how often is this
reported?
Database Year
Both Years
Most Recent
Previous
6-24
beds
21
1,054
1,362
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
Bed Size
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
Most Recent
Previous
Change
Most Recent
78%
80%
-2%
50%
78%
76%
2%
48%
75%
75%
0%
46%
75%
70%
5%
48%
74%
68%
6%
47%
74%
74%
0%
46%
72%
74%
-2%
46%
Previous
50%
47%
45%
44%
44%
47%
48%
Change
0%
1%
1%
4%
3%
-1%
-2%
Most Recent
Previous
Change
67%
66%
1%
66%
63%
3%
61%
60%
1%
62%
59%
3%
59%
55%
4%
61%
61%
0%
59%
60%
-1%
Most Recent
55%
56%
51%
55%
52%
53%
51%
Previous
55%
54%
51%
50%
47%
51%
51%
Change
0%
2%
0%
5%
5%
2%
0%
Most Recent
61%
61%
56%
59%
55%
55%
53%
Previous
Change
61%
0%
59%
2%
55%
1%
54%
5%
50%
5%
52%
3%
52%
1%
Most Recent
77%
78%
73%
73%
70%
71%
68%
Previous
78%
77%
72%
70%
65%
69%
67%
Change
-1%
1%
1%
3%
5%
2%
1%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
52
Table C-2. Trending: Item-level Average Percent Positive Response by Bed Size (Page 5 of 6)
Item
Survey Items by Composite
# Hospitals
# Respondents
9.
F2R
F4
F6R
F10
10.
A2
Teamwork Across Units
1. Hospital units do not
coordinate well with each
other.
2. There is good cooperation
among hospital units that
need to work together.
3. It is often unpleasant to
work with staff from other
hospital units.
4. Hospital units work well
together to provide the best
care for patients.
Staffing
1. We have enough staff to
handle the workload.
A5R
2. Staff in this unit work longer
hours than is best for patient
care.
A7R
3. We use more
agency/temporary staff than is
best for patient care.
4. We work in “crisis mode”
A14R trying to do too much, too
quickly.
Database
Year
Both Years
Most Recent
Previous
6-24
beds
21
1,054
1,362
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
Most Recent
Previous
Change
Most Recent
57%
54%
3%
71%
54%
52%
2%
67%
45%
45%
0%
59%
Previous
68%
67%
Change
3%
Most Recent
Previous
Change
Most Recent
Previous
Change
Bed Size
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
45%
42%
3%
59%
37%
37%
0%
51%
39%
37%
2%
53%
37%
37%
0%
50%
60%
53%
47%
50%
51%
0%
-1%
6%
4%
3%
-1%
67%
65%
2%
78%
76%
2%
65%
63%
2%
75%
75%
0%
58%
57%
1%
68%
68%
0%
58%
53%
5%
68%
62%
6%
51%
49%
2%
59%
56%
3%
54%
52%
2%
62%
59%
3%
51%
53%
-2%
58%
60%
-2%
Most Recent
64%
63%
53%
51%
47%
50%
44%
Previous
63%
62%
54%
51%
43%
47%
47%
Change
1%
1%
-1%
0%
4%
3%
-3%
Most Recent
Previous
Change
Most Recent
61%
56%
5%
69%
55%
55%
0%
68%
51%
51%
0%
63%
51%
48%
3%
62%
48%
45%
3%
64%
50%
49%
1%
65%
45%
46%
-1%
61%
Previous
69%
64%
65%
59%
55%
60%
60%
Change
Most Recent
Previous
Change
0%
64%
58%
6%
4%
59%
55%
4%
-2%
50%
49%
1%
3%
48%
47%
1%
9%
43%
40%
3%
5%
43%
41%
2%
1%
39%
41%
-2%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
53
Table C-2. Trending: Item-level Average Percent Positive Response by Bed Size (Page 6 of 6)
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
39%
38%
32%
31%
32%
32%
32%
32%
-1%
1%
1%
0%
0%
55%
55%
0%
51%
49%
2%
55%
52%
3%
50%
50%
0%
45%
45%
0%
47%
44%
3%
48%
45%
3%
42%
37%
5%
43%
43%
0%
44%
41%
3%
36%
34%
2%
37%
37%
0%
45%
44%
1%
36%
34%
2%
39%
38%
1%
44%
46%
-2%
34%
35%
-1%
36%
38%
-2%
61%
57%
50%
51%
48%
47%
44%
Previous
58%
55%
49%
49%
45%
45%
44%
Change
3%
2%
1%
2%
3%
2%
0%
2. When an event is reported,
it feels like the person is
A12R
being written up, not the
problem.
Most Recent
53%
51%
44%
46%
43%
43%
41%
Previous
48%
48%
42%
43%
41%
41%
40%
Change
5%
3%
2%
3%
2%
2%
1%
3. Staff worry that mistakes
A16R they make are kept in their
personnel file.
Most Recent
45%
42%
36%
35%
33%
31%
28%
Previous
41%
38%
35%
35%
30%
30%
28%
Change
4%
4%
1%
0%
3%
1%
0%
Survey Items by Composite
# Hospitals
# Respondents
11.
F3R
Handoffs & Transitions
1. Things “fall between the
cracks” when transferring
patients from one unit to
another.
F5R
2. Important patient care
information is often lost
during shift changes.
F7R
3. Problems often occur in
the exchange of information
across hospital units.
4. Shift changes are
F11R problematic for patients in
this hospital.
12.
Nonpunitive Response to Error
A8R
1. Staff feel like their
mistakes are held against
them.
6-24
beds
21
1,054
1,362
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
Most Recent
Previous
58%
55%
52%
50%
44%
45%
Change
3%
2%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
59%
56%
3%
57%
52%
5%
61%
58%
3%
Most Recent
Bed Size
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
Item
Database
Year
Both Years
Most Recent
Previous
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
54
Table C-3. Trending: Average Percent Distribution of Work Area/Unit Patient Safety Grades by Bed Size
Bed Size
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
A
B
C
D
E
Excellent
Very Good
Acceptable
Poor
Failing
Database Year
Both Years
Most Recent
Previous
6-24
beds
21
1,054
1,362
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
Most Recent
28%
28%
22%
27%
25%
24%
21%
Previous
25%
25%
20%
24%
20%
22%
21%
Change
3%
3%
2%
3%
5%
2%
0%
Most Recent
50%
50%
49%
46%
42%
46%
44%
Previous
46%
49%
45%
47%
42%
46%
44%
Change
4%
1%
4%
-1%
0%
0%
0%
Most Recent
20%
20%
23%
21%
27%
24%
27%
Previous
21%
20%
26%
24%
29%
25%
27%
Change
-1%
0%
-3%
-3%
-2%
-1%
0%
Most Recent
3%
2%
5%
5%
6%
6%
7%
Previous
6%
4%
8%
4%
7%
6%
6%
Change
-3%
-2%
-3%
1%
-1%
0%
1%
Most Recent
0%
0%
1%
1%
1%
1%
1%
Previous
2%
1%
2%
1%
2%
1%
2%
Change
-2%
-1%
-1%
0%
-1%
0%
-1%
55
Table C-4. Trending: Average Percent Distribution of Number of Events Reported in the Past 12 Months by Respondent Bed Size
Bed Size
Number of Events Reported
by Respondents
# Hospitals
# Respondents
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 event reports or more
Database Year
Both Years
Most Recent
Previous
6-24
beds
21
1,054
1,362
25-49
beds
42
3,550
3,401
50-99
beds
37
4,360
4,686
100-199
beds
32
8,886
7,573
200-299
beds
22
8,408
8,108
300-499
beds
26
15,678
14,300
500+
beds
24
27,605
25,891
Most Recent
53%
52%
51%
53%
50%
53%
55%
Previous
60%
53%
55%
55%
50%
53%
53%
Change
-7%
-1%
-4%
-2%
0%
0%
2%
Most Recent
26%
28%
29%
27%
28%
28%
28%
Previous
22%
27%
26%
25%
27%
27%
27%
Change
4%
1%
3%
2%
1%
1%
1%
Most Recent
14%
13%
12%
12%
14%
12%
12%
Previous
12%
12%
12%
12%
14%
13%
12%
Change
2%
1%
0%
0%
0%
-1%
0%
Most Recent
4%
5%
4%
4%
5%
4%
4%
Previous
4%
5%
5%
5%
6%
4%
4%
Change
0%
0%
-1%
-1%
-1%
0%
0%
Most Recent
2%
2%
2%
2%
2%
1%
2%
Previous
2%
2%
2%
2%
2%
2%
2%
Change
0%
0%
0%
0%
0%
-1%
0%
Most Recent
1%
1%
1%
1%
2%
1%
1%
Previous
1%
1%
1%
1%
2%
1%
1%
Change
0%
0%
0%
0%
0%
0%
0%
56
Appendix C: Trending Results by Hospital Characteristics
(2) Teaching Status and (3) Ownership and Control
NOTE: The number of hospitals and respondents in each breakout category is shown in each table (e.g., the number of hospitals
and respondents by teaching status and ownership and control). However, the precise number of hospitals and respondents
corresponding to each data cell in a table will vary because hospitals may have omitted a specific survey item and because of
individual non-response/missing data.
57
Table C-5. Trending: Composite-level Average Percent Positive Response by Hospital Teaching Status, and Ownership and
Control (Page 1 of 2)
Teaching Status
Patient Safety Culture Composites
# Hospitals
# Respondents
1. Teamwork Within Units
2. Supervisor/Manager Expectations &
Actions Promoting Patient Safety
3. Org Learning--Continuous
Improvement
4. Management Support for Patient
Safety
5. Overall Perceptions of Patient Safety
6. Feedback & Communication About
Error
Ownership and Control
Database
Year
Both Years
Most Recent
Previous
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Most Recent
77%
81%
80%
79%
Previous
73%
78%
79%
76%
Change
4%
3%
1%
3%
Most Recent
73%
76%
76%
74%
Previous
71%
75%
75%
73%
Change
2%
1%
1%
1%
Most Recent
69%
73%
73%
71%
Previous
66%
70%
71%
67%
Change
3%
3%
2%
4%
Most Recent
66%
73%
74%
70%
Previous
64%
71%
73%
67%
Change
2%
2%
1%
3%
Most Recent
58%
67%
69%
63%
Previous
57%
64%
66%
61%
Change
1%
3%
3%
2%
Most Recent
61%
63%
64%
62%
Previous
59%
62%
63%
60%
Change
2%
1%
1%
2%
58
Table C-5. Trending: Composite-level Average Percent Positive Response by Hospital Teaching Status, and Ownership and
Control (Page 2 of 2)
Teaching Status
Patient Safety Culture Composites
# Hospitals
# Respondents
7. Communication Openness
8. Frequency of Events Reported
9. Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to Error
Ownership and Control
Database
Year
Both Years
Most Recent
Previous
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Most Recent
59%
62%
63%
61%
Previous
58%
61%
61%
60%
Change
1%
1%
2%
1%
Most Recent
58%
63%
63%
61%
Previous
56%
61%
62%
58%
Change
2%
2%
1%
3%
Most Recent
51%
61%
62%
56%
Previous
50%
58%
61%
54%
Change
1%
3%
1%
2%
Most Recent
50%
57%
59%
54%
Previous
49%
55%
57%
52%
Change
1%
2%
2%
2%
Most Recent
38%
48%
52%
42%
Previous
39%
46%
49%
42%
Change
-1%
2%
3%
0%
Most Recent
40%
47%
47%
43%
Previous
38%
44%
45%
42%
Change
2%
3%
2%
1%
59
Table C-6. Trending: Item-level Average Percent Positive Response by Hospital Teaching Status, and Ownership and Control
(Page 1 of 6)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
1.
Teamwork Within Units
A1
1. People support one another in this unit.
A3
2. When a lot of work needs to be done
quickly, we work together as a team to get
the work done.
A4
A11
2.
B1
1. My supv/mgr says a good word when
he/she sees a job done according to
established patient safety procedures.
2. My supv/mgr seriously considers staff
suggestions for improving patient safety.
B3R
3. Whenever pressure builds up, my
supv/mgr wants us to work faster, even if it
means taking shortcuts.
4. My supv/mgr overlooks patient safety
problems that happen over and over.
Ownership and Control
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Most Recent
83%
78%
5%
83%
86%
83%
3%
87%
84%
84%
0%
87%
85%
81%
4%
86%
Previous
79%
86%
87%
82%
1%
78%
77%
1%
71%
68%
3%
0%
77%
77%
0%
69%
68%
1%
4%
78%
74%
4%
69%
65%
4%
Most Recent
Previous
Change
Change
4%
Most Recent
75%
3. In this unit, people treat each other with
Previous
71%
respect.
Change
4%
Most Recent
66%
4. When one area in this unit gets really
Previous
63%
busy, others help out.
Change
3%
Supervisor/Manager Expectations & Actions Promoting Patient Safety
B2
B4R
Database
Year
Both Years
Most Recent
Previous
Most Recent
71%
72%
72%
72%
Previous
67%
70%
70%
69%
Change
Most Recent
4%
75%
71%
4%
71%
2%
77%
75%
2%
76%
2%
77%
76%
1%
78%
3%
76%
73%
3%
73%
Previous
70%
75%
76%
72%
Change
1%
1%
2%
1%
Most Recent
75%
78%
79%
76%
Most Recent
Previous
Change
Previous
71%
76%
77%
73%
Change
4%
2%
2%
3%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
60
Table C-6. Trending: Item-level Average Percent Positive Response by Hospital Teaching Status, and Ownership and Control
(Page 2 of 6)
Teaching Status
Item
3.
A6
Database
Survey Items by Composite
Year
# Hospitals
Both Years
Most Recent
# Respondents
Previous
Organizational Learning— Continuous Improvement
1. We are actively doing things to
improve patient safety.
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Change
80%
77%
3%
61%
58%
3%
66%
63%
3%
83%
81%
2%
65%
62%
3%
70%
67%
3%
84%
83%
1%
65%
63%
2%
71%
69%
2%
82%
78%
4%
63%
60%
3%
68%
64%
4%
Most Recent
75%
82%
83%
78%
Previous
73%
81%
83%
76%
Change
2%
1%
0%
2%
Most Recent
Most Recent
69%
66%
3%
55%
74%
71%
3%
62%
75%
74%
1%
63%
72%
68%
4%
59%
Previous
53%
60%
61%
56%
Change
2%
2%
2%
3%
Most Recent
Previous
Change
A9
2. Mistakes have led to positive
changes here.
A13
3. After we make changes to improve
patient safety, we evaluate their
effectiveness.
4.
Management Support for Patient Safety
F1
1. Hospital mgmt provides a work
climate that promotes patient safety.
F8
2. The actions of hospital mgmt show
that patient safety is a top priority.
F9R
3. Hospital mgmt seems interested in
patient safety only after an adverse
event happens.
Ownership and Control
Most Recent
Previous
Change
Most Recent
Previous
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
61
Table C-6. Trending: Item-level Average Percent Positive Response by Hospital Teaching Status, and Ownership and Control
(Page 3 of 6)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
5.
2. Patient safety is never sacrificed to
get more work done.
3. We have patient safety problems in
A17R this unit.
A18
6.
C1
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
53%
54%
-1%
59%
57%
2%
52%
54%
-2%
67%
63%
4%
63%
61%
2%
68%
65%
3%
66%
63%
3%
73%
69%
4%
63%
60%
3%
70%
68%
2%
68%
65%
3%
73%
69%
4%
59%
58%
1%
63%
60%
3%
59%
59%
0%
70%
66%
4%
Most Recent
54%
52%
2%
53%
52%
1%
51%
51%
0%
54%
52%
2%
61%
59%
2%
66%
65%
1%
68%
67%
1%
63%
62%
1%
68%
65%
3%
71%
70%
1%
72%
72%
0%
70%
67%
3%
Overall Perceptions of Patient Safety
1. It is just by chance that more serious
A10R
mistakes don’t happen around here.
A15
4. Our procedures and systems are
good at preventing errors from
happening.
Feedback and Communication About Error
1. We are given feedback about
changes put into place based on event
reports.
Previous
Change
Most Recent
C3
2. We are informed about errors that
happen in this unit.
Previous
Change
Most Recent
C5
Ownership and Control
Database
Year
Both Years
Most Recent
Previous
3. In this unit, we discuss ways to
prevent errors from happening again.
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
62
Table C-6. Trending: Item-level Average Percent Positive Response by Hospital Teaching Status, and Ownership and Control
(Page 4 of 6)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Both Years
Most Recent
Previous
7.
Communication Openness
Most Recent
C2
1. Staff will freely speak up if they see
something that may negatively affect
patient care.
2. Staff feel free to question the
decisions or actions of those with more
authority.
Most Recent
C4
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
73%
71%
2%
46%
46%
0%
59%
58%
1%
76%
75%
1%
48%
46%
2%
63%
62%
1%
75%
75%
0%
48%
47%
1%
65%
63%
2%
75%
73%
2%
47%
46%
1%
61%
60%
1%
51%
48%
3%
54%
53%
1%
55%
54%
1%
53%
50%
3%
54%
51%
3%
59%
57%
2%
60%
58%
2%
56%
54%
2%
70%
68%
2%
75%
73%
2%
75%
75%
0%
73%
71%
2%
Previous
Change
Most Recent
8.
Frequency of Events Reported
Most Recent
D1
1. When a mistake is made, but is
caught and corrected before affecting
the patient, how often is this reported?
2. When a mistake is made, but has no
potential to harm the patient, how often
is this reported?
Most Recent
3. When a mistake is made that could
harm the patient, but does not, how
often is this reported?
Most Recent
D3
Non-teaching
145
28,702
26,640
Change
3. Staff are afraid to ask questions when
something does not seem right.
D2
Teaching
59
40,839
38,681
Previous
C6R
Ownership and Control
Previous
Change
Previous
Change
Previous
Change
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
63
Table C-6. Trending: Item-level Average Percent Positive Response by Hospital Teaching Status, and Ownership and Control
(Page 5 of 6)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
9.
Teamwork Across Units
F2R
1. Hospital units do not coordinate well
with each other.
F4
2. There is good cooperation among
hospital units that need to work
together.
F6R
3. It is often unpleasant to work with
staff from other hospital units.
F10
4. Hospital units work well together to
provide the best care for patients.
10.
Staffing
A2
1. We have enough staff to handle the
workload.
A5R
A7R
2. Staff in this unit work longer hours
than is best for patient care.
3. We use more agency/temporary staff
than is best for patient care.
4. We work in “crisis mode” trying to do
A14R
too much, too quickly.
Ownership and Control
Database
Year
Both Years
Most Recent
Previous
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
38%
39%
-1%
51%
50%
1%
53%
52%
1%
61%
59%
2%
49%
46%
3%
63%
60%
3%
61%
58%
3%
71%
69%
2%
50%
49%
1%
64%
63%
1%
61%
60%
1%
72%
71%
1%
44%
42%
2%
57%
55%
2%
57%
55%
2%
66%
63%
3%
Most Recent
47%
48%
-1%
47%
47%
0%
62%
58%
4%
43%
43%
0%
57%
55%
2%
54%
52%
2%
66%
64%
2%
53%
50%
3%
59%
58%
1%
55%
54%
1%
64%
64%
0%
57%
52%
5%
52%
51%
1%
51%
49%
2%
65%
61%
4%
47%
46%
1%
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
64
Table C-6. Trending: Item-level Average Percent Positive Response by Hospital Teaching Status, and Ownership and Control
(Page 6 of 6)
Teaching Status
Item
Survey Items by Composite
# Hospitals
# Respondents
11.
F3R
Handoffs & Transitions
1. Things “fall between the cracks”
when transferring patients from one unit
to another.
F5R
2. Important patient care information is
often lost during shift changes.
F7R
3. Problems often occur in the
exchange of information across hospital
units.
F11R
4. Shift changes are problematic for
patients in this hospital.
12.
Nonpunitive Response to Error
A8R
1. Staff feel like their mistakes are held
against them.
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
33%
34%
-1%
45%
45%
0%
35%
36%
-1%
38%
40%
-2%
46%
44%
2%
52%
50%
2%
47%
44%
3%
49%
47%
2%
51%
49%
2%
54%
53%
1%
49%
46%
3%
53%
50%
3%
38%
38%
0%
48%
47%
1%
41%
40%
1%
43%
42%
1%
Most Recent
46%
44%
2%
54%
52%
2%
54%
53%
1%
50%
48%
2%
42%
41%
1%
48%
45%
3%
47%
45%
2%
46%
43%
3%
31%
30%
1%
39%
36%
3%
40%
37%
3%
35%
33%
2%
Previous
Change
2. When an event is reported, it feels
A12R like the person is being written up, not
the problem.
Most Recent
Previous
Change
Most Recent
3. Staff worry that mistakes they make
A16R
are kept in their personnel file.
Ownership and Control
Database
Year
Both Years
Most Recent
Previous
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
65
Table C-7. Trending: Average Percent Distribution of Work Area/Unit Patient Safety Grades by Hospital Teaching Status, and
Ownership and Control
Teaching Status
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
A
B
C
D
E
Excellent
Very Good
Acceptable
Poor
Failing
Ownership and Control
Database
Year
Both Years
Most Recent
Previous
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Most Recent
22%
26%
25%
25%
Previous
20%
23%
22%
23%
Change
2%
3%
3%
2%
Most Recent
44%
48%
50%
46%
Previous
45%
46%
47%
46%
Change
-1%
2%
3%
0%
Most Recent
25%
21%
21%
23%
Previous
27%
23%
24%
24%
Change
-2%
-2%
-3%
-1%
Most Recent
7%
4%
3%
5%
Previous
7%
6%
6%
6%
Change
0%
-2%
-3%
-1%
Most Recent
1%
1%
0%
1%
Previous
1%
1%
1%
1%
Change
0%
0%
-1%
0%
66
Table C-8. Trending: Average Percent Distribution of Number of Events Reported in the Past 12 Months by Hospital Teaching
Status, and Ownership and Control
Teaching Status
Number of Events Reported
by Respondents
# Hospitals
# Respondents
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 events reports or more
Ownership and Control
Database
Year
Both Years
Most Recent
Previous
Teaching
59
40,839
38,681
Non-teaching
145
28,702
26,640
Govt
63
10,036
10,007
Non-Govt
141
59,505
55,314
Most Recent
53%
52%
53%
52%
Previous
52%
55%
58%
52%
Change
1%
-3%
-5%
0%
Most Recent
28%
27%
26%
29%
Previous
27%
25%
23%
27%
Change
1%
2%
3%
2%
Most Recent
12%
13%
13%
12%
Previous
13%
12%
12%
13%
Change
-1%
1%
1%
-1%
Most Recent
4%
5%
5%
4%
Previous
5%
5%
4%
5%
Change
-1%
0%
1%
-1%
Most Recent
2%
2%
2%
2%
Previous
2%
2%
2%
2%
Change
0%
0%
0%
0%
Most Recent
1%
1%
1%
1%
Previous
1%
1%
1%
1%
Change
0%
0%
0%
0%
67
Appendix D: Trending Results by Respondent Characteristics
68
Appendix D: Trending Results by Respondent Characteristics
(1) Work Area/Unit
NOTE 1: The number of hospitals and respondents in each breakout category is shown in each table (e.g., the number of
hospitals and respondents by work area/unit). However, the precise number of hospitals and respondents corresponding to
each data cell in a table will vary because hospitals may have omitted a specific survey item and because of individual nonresponse/missing data.
NOTE 2: Only hospitals that had at least 1 respondent in the particular work area/unit for both their previous and most
recent administrations of the survey are included.
NOTE 3: Respondents who selected "Many different work areas/No specific work area," "Other," or those who did not
answer (missing) are not included.
69
Table D-1. Trending: Composite-level Average Percent Positive Response by Work Area/Unit (Page 1 of 2)
Work Area/Unit
Patient Safety
Culture Composites
# Hospitals
# Respondents
1. Teamwork
Within Units
2. Supv/Mgr
Expectations &
Actions
Promoting
Patient Safety
3. Org Learning-Continuous
Improvement
4. Management
Support for
Patient Safety
5. Overall
Perceptions of
Patient Safety
6. Feedback &
Communication
About Error
Database
Year
Both Years
Most Recent
Previous
Anesthesiology
Emergency
ICU
(any
type)
Pharmacy
Psych/
Mental
Hlth
Lab
Radiology
Rehabilitation
42
293
406
146
3,442
3,120
114
4,032
3,895
Surgery
62
1,356
1,525
135
1,705
1,560
60
1,174
1,220
161
3,275
3,082
139
2,090
1,941
154
5,282
5,328
Most Recent
83%
79%
81%
77%
78%
77%
79%
86%
79%
Previous
77%
72%
74%
77%
75%
71%
78%
82%
75%
Change
1%
3%
7%
0%
3%
6%
1%
4%
4%
70%
75%
72%
74%
78%
76%
77%
77%
83%
74%
73%
71%
75%
72%
72%
72%
76%
74%
76%
80%
74%
5%
-2%
-1%
0%
0%
2%
6%
0%
3%
1%
3%
0%
Most Recent
71%
65%
69%
73%
71%
72%
74%
75%
70%
71%
75%
75%
Previous
71%
63%
68%
69%
67%
68%
65%
74%
66%
67%
71%
71%
Change
0%
2%
1%
4%
4%
4%
9%
1%
4%
4%
4%
4%
Most Recent
64%
63%
59%
72%
65%
69%
66%
69%
65%
74%
74%
69%
Previous
70%
60%
59%
71%
63%
64%
65%
68%
61%
70%
74%
67%
Change
-6%
3%
0%
1%
2%
5%
1%
1%
4%
4%
0%
2%
Most Recent
59%
54%
56%
71%
55%
62%
64%
64%
57%
73%
74%
68%
Previous
61%
55%
55%
71%
53%
58%
63%
64%
57%
70%
73%
65%
Change
-2%
-1%
1%
0%
2%
4%
1%
0%
0%
3%
1%
3%
Most Recent
66%
55%
54%
65%
56%
62%
62%
65%
68%
64%
71%
64%
Previous
60%
55%
53%
63%
56%
58%
60%
63%
58%
64%
68%
63%
Change
6%
0%
1%
2%
0%
4%
2%
2%
10%
0%
3%
1%
Medicine
Obstetrics
Pediatrics
164
2,926
2,865
171
7,598
6,220
101
2,600
1,876
82%
79%
75%
76%
80%
78%
6%
3%
2%
Most Recent
75%
71%
Previous
70%
Change
70
Table D-1. Trending: Composite-level Average Percent Positive Response by Work Area/Unit (Page 2 of 2)
Work Area/Unit
Patient Safety
Culture Composites
# Hospitals
# Respondents
7. Communication
Openness
8. Frequency of
Events
Reported
9. Teamwork
Across Units
10. Staffing
11. Handoffs &
Transitions
12. Nonpunitive
Response to
Error
Database
Year
Both Years
Most Recent
Previous
Anesthesiology
Emergency
ICU
(any
type)
Pharmacy
Psych/
Mental
Hlth
Lab
Radiology
Rehabilitation
42
293
406
146
3,442
3,120
114
4,032
3,895
Surgery
62
1,356
1,525
135
1,705
1,560
60
1,174
1,220
161
3,275
3,082
139
2,090
1,941
154
5,282
5,328
Most Recent
62%
60%
63%
64%
69%
66%
63%
71%
64%
Previous
70%
55%
62%
64%
66%
59%
61%
67%
64%
Change
0%
0%
1%
0%
3%
7%
2%
4%
0%
57%
66%
62%
62%
62%
60%
65%
56%
61%
65%
57%
57%
64%
59%
58%
57%
57%
57%
52%
62%
62%
14%
0%
0%
2%
3%
4%
5%
3%
8%
4%
-1%
3%
Most Recent
50%
47%
52%
57%
56%
54%
53%
53%
51%
57%
60%
53%
Previous
54%
49%
50%
55%
56%
52%
50%
54%
46%
55%
58%
52%
Change
-4%
-2%
2%
2%
0%
2%
3%
-1%
5%
2%
2%
1%
Most Recent
53%
47%
54%
54%
51%
58%
60%
54%
53%
64%
61%
55%
Previous
46%
49%
52%
54%
51%
51%
60%
52%
51%
62%
60%
55%
Change
7%
-2%
2%
0%
0%
7%
0%
2%
2%
2%
1%
0%
Most Recent
37%
47%
46%
38%
49%
54%
47%
31%
40%
44%
38%
40%
Previous
36%
48%
48%
38%
47%
49%
45%
31%
37%
42%
42%
41%
Change
1%
-1%
-2%
0%
2%
5%
2%
0%
3%
2%
-4%
-1%
Most Recent
43%
38%
38%
44%
41%
42%
43%
54%
51%
45%
57%
45%
Previous
39%
35%
38%
43%
40%
37%
46%
52%
39%
44%
56%
46%
Change
4%
3%
0%
1%
1%
5%
-3%
2%
12%
1%
1%
-1%
Medicine
Obstetrics
Pediatrics
164
2,926
2,865
171
7,598
6,220
101
2,600
1,876
61%
62%
55%
58%
60%
62%
-8%
2%
1%
Most Recent
59%
57%
Previous
45%
Change
71
Table D-2. Trending: Item-level Average Percent Positive Response by Work Area/Unit (Page 1 of 6)
Work Area/Unit
Item Survey Items by Composite
# Hospitals
# Respondents
1.
Teamwork Within Units
A1
1. People support one another in
this unit.
A3
2. When a lot of work needs to
be done quickly, we work
together as a team to get the
work done.
A4
A1
1
2.
Anesthesiology
Emergency
ICU
(any
type)
42
293
406
146
3,442
3,120
Most Recent
90%
83%
7%
89%
Previous
79%
Database
Year
Both Years
Most Recent
Previous
Most Recent
Previous
Change
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
Surgery
114
4,032
3,895
164
2,926
2,865
171
7,598
6,220
101
2,600
1,876
62
1,356
1,525
135
1,705
1,560
60
1,174
1,220
161
3,275
3,082
139
2,090
1,941
154
5,282
5,328
84%
82%
2%
86%
86%
84%
2%
89%
85%
81%
4%
86%
84%
79%
5%
82%
88%
78%
10%
89%
81%
80%
1%
83%
85%
82%
3%
84%
82%
74%
8%
83%
83%
82%
1%
88%
89%
88%
1%
90%
85%
80%
5%
88%
83%
87%
84%
80%
84%
82%
80%
77%
88%
85%
84%
2%
77%
76%
1%
71%
70%
1%
2%
74%
71%
3%
61%
59%
2%
5%
78%
72%
6%
68%
63%
5%
1%
75%
76%
-1%
67%
69%
-2%
4%
79%
74%
5%
65%
63%
2%
6%
75%
72%
3%
68%
61%
7%
0%
75%
75%
0%
68%
66%
2%
5%
87%
83%
4%
77%
72%
5%
4%
76%
73%
3%
66%
62%
4%
10%
3%
2%
83%
75%
77%
3. In this unit, people treat each
78%
74%
78%
other with respect.
5%
1%
-1%
70%
69%
75%
4. When one area in this unit
69%
67%
70%
gets really busy, others help out.
5%
1%
2%
Supervisor/Manager Expectations & Actions Promoting Patient Safety
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
1. My supv/mgr says a good
Most Recent
71%
68%
65%
69%
68%
72%
71%
70%
75%
70%
78%
73%
word when he/she sees a job
Previous
B1
63%
69%
66%
67%
66%
65%
66%
69%
62%
70%
73%
69%
done according to established
Change
8%
7%
5%
13%
5%
-1%
-1%
2%
2%
1%
0%
4%
patient safety procedures.
Most Recent
2. My supv/mgr seriously
77%
73%
72%
74%
73%
75%
81%
77%
77%
77%
84%
77%
Previous
B2
considers staff suggestions for
74%
72%
70%
75%
70%
70%
74%
72%
69%
74%
81%
75%
Change
improving patient safety.
5%
7%
5%
8%
3%
1%
2%
-1%
3%
3%
3%
2%
3. Whenever pressure builds up,
Most Recent
71%
70%
70%
80%
72%
73%
79%
79%
76%
79%
82%
71%
my supv/mgr wants us to work
Previous
B3R
68%
73%
69%
78%
72%
72%
73%
78%
77%
76%
79%
72%
faster, even if it means taking
Change
6%
3%
-3%
1%
2%
0%
1%
1%
-1%
3%
3%
-1%
shortcuts.
Most Recent
4. My supv/mgr overlooks
79%
74%
72%
76%
74%
75%
81%
79%
78%
82%
86%
78%
Previous
B4R patient safety problems that
71%
72%
71%
74%
74%
71%
67%
77%
72%
77%
79%
75%
Change
happen over and over.
8%
14%
6%
5%
7%
2%
1%
2%
0%
4%
2%
3%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
72
Table D-2. Trending: Item-level Average Percent Positive Response by Work Area/Unit (Page 2 of 6)
Work Area/Unit
Item
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Both Years
Most Recent
Previous
Anesthesiology
Emergency
ICU
(any
type)
42
293
406
146
3,442
3,120
89%
81%
8%
62%
61%
1%
61%
71%
-10%
3.
Organizational Learning— Continuous Improvement
A6
1. We are actively doing
things to improve patient
safety.
A9
A13
2. Mistakes have led to
positive changes here.
3. After we make changes to
improve patient safety, we
evaluate their effectiveness.
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
Surgery
114
4,032
3,895
164
2,926
2,865
171
7,598
6,220
101
2,600
1,876
62
1,356
1,525
135
1,705
1,560
60
1,174
1,220
161
3,275
3,082
139
2,090
1,941
154
5,282
5,328
77%
72%
5%
56%
56%
0%
63%
60%
3%
84%
81%
3%
56%
56%
0%
68%
66%
2%
81%
76%
5%
70%
65%
5%
67%
64%
3%
82%
77%
5%
61%
59%
2%
69%
63%
6%
84%
77%
7%
63%
61%
2%
69%
65%
4%
86%
79%
7%
64%
54%
10%
69%
63%
6%
86%
84%
2%
72%
73%
-1%
67%
67%
0%
78%
76%
2%
61%
56%
5%
71%
65%
6%
82%
78%
4%
63%
59%
4%
67%
63%
4%
88%
84%
4%
62%
58%
4%
74%
71%
3%
87%
84%
3%
65%
62%
3%
73%
68%
5%
71%
71%
0%
64%
59%
5%
68%
68%
0%
60%
59%
1%
82%
81%
1%
74%
73%
1%
74%
73%
1%
67%
63%
4%
77%
74%
3%
71%
65%
6%
77%
76%
1%
68%
61%
7%
76%
74%
2%
70%
71%
-1%
72%
69%
3%
68%
62%
6%
84%
81%
3%
74%
70%
4%
81%
83%
-2%
77%
75%
2%
79%
76%
3%
70%
68%
2%
4.
Management Support for Patient Safety
Most Recent
F1
1. Hospital mgmt provides a
work climate that promotes
patient safety.
F8
2. The actions of hospital
mgmt show that patient
safety is a top priority.
Most Recent
Change
73%
81%
-8%
66%
70%
-4%
Most Recent
53%
53%
49%
60%
54%
58%
54%
60%
56%
63%
64%
57%
F9R
3. Hospital mgmt seems
interested in patient safety
only after an adverse event
happens.
Previous
58%
-5%
49%
4%
49%
0%
59%
1%
53%
1%
53%
5%
58%
-4%
60%
0%
52%
4%
58%
5%
63%
1%
57%
0%
Previous
Change
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
73
Table D-2. Trending: Item-level Average Percent Positive Response by Work Area/Unit (Page 3 of 6)
Work Area/Unit
Item
Survey Items by Composite
# Hospitals
# Respondents
5.
2. Patient safety is never
sacrificed to get more work
done.
3. We have patient safety
A17R
problems in this unit.
A18
Emergency
42
293
406
146
3,442
3,120
Previous
58%
61%
-3%
52%
56%
-4%
57%
57%
0%
70%
71%
Change
Database
Year
Both Years
Most Recent
Previous
4. Our procedures and
systems are good at
preventing errors from
happening.
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
6.
Feedback and Communication About Error
Most Recent
C1
1. We are given feedback
about changes put into place
based on event reports.
2. We are informed about
errors that happen in this
unit.
Most Recent
3. In this unit, we discuss
ways to prevent errors from
happening again.
Most Recent
C3
C5
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
Surgery
114
4,032
3,895
164
2,926
2,865
171
7,598
6,220
101
2,600
1,876
62
1,356
1,525
135
1,705
1,560
60
1,174
1,220
161
3,275
3,082
139
2,090
1,941
154
5,282
5,328
52%
52%
0%
55%
55%
0%
50%
52%
-2%
60%
59%
54%
55%
-1%
54%
50%
4%
55%
51%
4%
63%
63%
65%
65%
0%
73%
70%
3%
68%
70%
-2%
78%
78%
53%
54%
-1%
55%
51%
4%
50%
49%
1%
64%
60%
60%
56%
4%
59%
55%
4%
59%
57%
2%
70%
65%
60%
64%
-4%
62%
60%
2%
62%
60%
2%
73%
66%
60%
62%
-2%
65%
61%
4%
60%
61%
-1%
73%
71%
55%
57%
-2%
61%
63%
-2%
48%
48%
0%
66%
61%
67%
63%
4%
76%
73%
3%
73%
71%
2%
76%
72%
72%
70%
2%
75%
74%
1%
71%
71%
0%
79%
77%
63%
60%
3%
66%
64%
2%
66%
65%
1%
76%
71%
-1%
1%
0%
0%
4%
5%
7%
2%
5%
4%
2%
5%
59%
46%
13%
61%
60%
1%
78%
76%
2%
47%
48%
-1%
55%
56%
-1%
62%
62%
0%
45%
47%
-2%
54%
51%
3%
63%
62%
1%
52%
51%
1%
71%
68%
3%
73%
71%
2%
49%
49%
0%
55%
56%
-1%
65%
62%
3%
56%
53%
3%
61%
57%
4%
69%
65%
4%
54%
52%
2%
63%
61%
2%
68%
67%
1%
50%
50%
0%
71%
66%
5%
73%
72%
1%
59%
48%
11%
71%
58%
13%
73%
67%
6%
52%
53%
-1%
70%
69%
1%
70%
69%
1%
61%
59%
2%
72%
69%
3%
80%
76%
4%
54%
49%
5%
66%
66%
0%
74%
72%
2%
Overall Perceptions of Patient Safety
1. It is just by chance that
A10R more serious mistakes don’t
happen around here.
A15
Anesthesiology
ICU
(any
type)
Previous
Change
Previous
Change
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
74
Table D-2. Trending: Item-level Average Percent Positive Response by Work Area/Unit (Page 4 of 6)
Work Area/Unit
Item
Survey Items by Composite
# Hospitals
# Respondents
7.
C2
C4
Communication Openness
1. Staff will freely speak up if
they see something that may
negatively affect patient
care.
2. Staff feel free to question
the decisions or actions of
those with more authority.
3. Staff are afraid to ask
C6R questions when something
does not seem right.
8.
D1
D2
D3
Anesthesiology
Emergency
ICU
(any
type)
42
293
406
146
3,442
3,120
Previous
71%
81%
Change
Most Recent
Database
Year
Both Years
Most Recent
Previous
Most Recent
Previous
Change
Most Recent
Previous
Change
Frequency of Events Reported
1. When a mistake is made,
Most Recent
but is caught and corrected
Previous
before affecting the patient,
Change
how often is this reported?
2. When a mistake is made,
Most Recent
but has no potential to harm
Previous
the patient, how often is this
Change
reported?
3. When a mistake is made
Most Recent
that could harm the patient,
Previous
but does not, how often is
Change
this reported?
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
Surgery
114
4,032
3,895
164
2,926
2,865
171
7,598
6,220
101
2,600
1,876
62
1,356
1,525
135
1,705
1,560
60
1,174
1,220
161
3,275
3,082
139
2,090
1,941
154
5,282
5,328
72%
70%
75%
70%
77%
74%
70%
69%
78%
75%
78%
74%
78%
77%
78%
70%
77%
74%
84%
81%
79%
78%
-10%
2%
5%
3%
1%
3%
4%
1%
8%
3%
3%
1%
48%
58%
-10%
68%
71%
-3%
48%
45%
3%
61%
59%
2%
45%
48%
-3%
61%
61%
0%
46%
45%
1%
64%
66%
-2%
40%
40%
0%
55%
55%
0%
48%
49%
-1%
64%
61%
3%
52%
52%
0%
62%
65%
-3%
57%
52%
5%
71%
69%
2%
54%
49%
5%
67%
59%
8%
46%
47%
-1%
66%
62%
4%
58%
53%
5%
70%
67%
3%
48%
50%
-2%
64%
64%
0%
55%
33%
48%
45%
45%
46%
57%
55%
52%
50%
55%
46%
52%
46%
48%
46%
58%
50%
47%
44%
54%
56%
57%
53%
22%
3%
-1%
2%
2%
9%
6%
2%
8%
3%
-2%
4%
57%
44%
53%
56%
54%
53%
61%
59%
60%
57%
57%
54%
58%
54%
57%
53%
60%
52%
50%
47%
57%
56%
61%
57%
13%
-3%
1%
2%
3%
3%
4%
4%
8%
3%
1%
4%
65%
59%
71%
71%
70%
71%
80%
78%
75%
71%
74%
75%
75%
71%
75%
72%
77%
70%
70%
66%
73%
72%
77%
75%
6%
0%
-1%
2%
4%
-1%
4%
3%
7%
4%
1%
2%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
75
Table D-2. Trending: Item-level Average Percent Positive Response by Work Area/Unit (Page 5 of 6)
Work Area/Unit
Item
Survey Items by Composite
# Hospitals
# Respondents
9.
Teamwork Across Units
F2R
1. Hospital units do not
coordinate well with each
other.
F4
2. There is good cooperation
among hospital units that
need to work together.
F6R
3. It is often unpleasant to
work with staff from other
hospital units.
F10
4. Hospital units work well
together to provide the best
care for patients.
10.
Staffing
A2
1. We have enough staff to
handle the workload.
2. Staff in this unit work
A5R longer hours than is best for
patient care.
3. We use more
A7R agency/temporary staff than
is best for patient care.
4. We work in “crisis mode”
A14R trying to do too much, too
quickly.
Anesthesiology
Emergency
ICU
(any
type)
42
293
406
146
3,442
3,120
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
32%
39%
-7%
50%
54%
-4%
53%
61%
-8%
64%
63%
1%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
59%
49%
10%
38%
33%
5%
69%
57%
12%
46%
44%
2%
Database
Year
Both Years
Most Recent
Previous
Lab
Medicine
Obstet
-rics
Pediatrics
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
Surgery
114
4,032
3,895
164
2,926
2,865
171
7,598
6,220
101
2,600
1,876
62
1,356
1,525
135
1,705
1,560
60
1,174
1,220
161
3,275
3,082
139
2,090
1,941
154
5,282
5,328
36%
41%
-5%
47%
48%
-1%
48%
47%
1%
56%
59%
-3%
36%
37%
-1%
51%
52%
-1%
59%
53%
6%
62%
57%
5%
44%
43%
1%
60%
57%
3%
57%
56%
1%
68%
64%
4%
44%
44%
0%
57%
54%
3%
60%
60%
0%
65%
64%
1%
38%
38%
0%
57%
54%
3%
58%
54%
4%
65%
61%
4%
38%
41%
-3%
56%
51%
5%
55%
56%
-1%
63%
55%
8%
41%
42%
-1%
52%
56%
-4%
56%
53%
3%
63%
64%
-1%
35%
31%
4%
50%
44%
6%
59%
56%
3%
59%
55%
4%
45%
43%
2%
59%
57%
2%
56%
55%
1%
68%
65%
3%
45%
46%
-1%
61%
60%
1%
63%
60%
3%
70%
65%
5%
41%
39%
2%
55%
51%
4%
53%
56%
-3%
64%
61%
3%
41%
44%
-3%
50%
49%
1%
60%
59%
1%
38%
43%
-5%
50%
49%
1%
54%
53%
1%
65%
61%
4%
45%
46%
-1%
49%
54%
-5%
53%
51%
2%
67%
65%
2%
48%
46%
2%
46%
46%
0%
49%
50%
-1%
63%
64%
-1%
47%
44%
3%
54%
43%
11%
53%
48%
5%
75%
69%
6%
51%
44%
7%
59%
53%
6%
54%
53%
1%
73%
76%
-3%
53%
56%
-3%
47%
48%
-1%
54%
54%
0%
67%
61%
6%
49%
45%
4%
48%
45%
3%
49%
49%
0%
65%
64%
1%
51%
44%
7%
64%
60%
4%
61%
60%
1%
73%
69%
4%
58%
59%
-1%
54%
54%
0%
59%
58%
1%
69%
70%
-1%
61%
59%
2%
54%
53%
1%
48%
49%
-1%
69%
69%
0%
50%
50%
0%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
76
Table D-2. Trending: Item-level Average Percent Positive Response by Work Area/Unit (Page 6 of 6)
Work Area/Unit
Item
Database
Year
Both Years
Most Recent
Previous
Anesthesiology
Emergency
ICU
(any
type)
42
293
406
146
3,442
3,120
Most Recent
Previous
35%
34%
Change
2. Important patient care
information is often lost
during shift changes.
Most Recent
3. Problems often occur in
the exchange of information
across hospital units.
Most Recent
Survey Items by Composite
# Hospitals
# Respondents
11.
F3R
F5R
F7R
Handoffs & Transitions
1. Things “fall between the
cracks” when transferring
patients from one unit to
another.
4. Shift changes are
F11R problematic for patients in
this hospital.
12.
Previous
Change
Previous
Change
Most Recent
Previous
Change
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Hlth
Radiology
Rehabilitation
114
4,032
3,895
164
2,926
2,865
171
7,598
6,220
101
2,600
1,876
62
1,356
1,525
135
1,705
1,560
60
1,174
1,220
161
3,275
3,082
139
2,090
1,941
154
5,282
5,328
44%
48%
35%
38%
31%
29%
46%
44%
46%
43%
43%
37%
26%
24%
36%
26%
43%
42%
36%
39%
39%
40%
1%
-4%
-3%
2%
2%
3%
6%
2%
10%
1%
-3%
-1%
42%
40%
2%
37%
37%
0%
36%
33%
3%
55%
55%
0%
44%
45%
-1%
44%
45%
-1%
57%
58%
-1%
39%
39%
0%
53%
56%
-3%
43%
44%
-1%
38%
36%
2%
41%
41%
0%
52%
50%
2%
46%
43%
3%
52%
50%
2%
65%
58%
7%
59%
53%
6%
39%
42%
-3%
46%
48%
-2%
48%
45%
3%
34%
34%
0%
41%
45%
-4%
47%
46%
1%
43%
38%
5%
41%
46%
-5%
47%
40%
7%
33%
32%
1%
31%
30%
1%
34%
37%
-3%
42%
43%
-1%
39%
42%
-3%
37%
41%
-4%
46%
47%
-1%
40%
40%
0%
37%
38%
-1%
55%
48%
7%
46%
45%
1%
40%
40%
54%
51%
3%
44%
43%
47%
47%
0%
43%
42%
49%
44%
5%
61%
59%
2%
55%
52%
56%
46%
10%
44%
38%
54%
57%
-3%
47%
45%
57%
41%
51%
50%
1%
46%
45%
64%
63%
1%
55%
55%
52%
52%
0%
48%
49%
61%
56%
5%
Surgery
Nonpunitive Response to Error
1. Staff feel like their
A8R mistakes are held against
them.
Most Recent
2. When an event is
reported, it feels like the
A12R person is being written up,
not the problem.
Most Recent
3. Staff worry that mistakes
A16R they make are kept in their
personnel file.
Previous
38%
44%
44%
41%
3%
40%
37%
Change
-6%
3%
0%
1%
1%
6%
2%
3%
16%
1%
0%
-1%
Most Recent
37%
25%
12%
29%
27%
2%
29%
30%
-1%
35%
34%
1%
32%
31%
1%
33%
30%
3%
28%
34%
-6%
46%
44%
2%
41%
31%
10%
37%
36%
1%
52%
49%
3%
38%
36%
2%
Previous
Change
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
77
Table D-3. Trending: Average Percent Distribution of Work Area/Unit Patient Safety Grades by Work Area/Unit
Work Area/Unit
Work Area/Unit
Patient Safety
Grade
# Hospitals
# Respondents
A Excellent
B Very Good
C Acceptable
D Poor
E Failing
Emergency
Anesthesiology
Both Years
Most Recent
Previous
42
146
114
164
171
101
62
135
60
161
139
154
293
3,442
4,032
2,926
7,598
2,600
1,356
1,705
1,174
3,275
2,090
5,282
406
3,120
3,895
2,865
6,220
1,876
1,525
1,560
1,220
3,082
1,941
5,328
Most Recent
33%
16%
18%
26%
15%
24%
25%
26%
24%
29%
33%
33%
Previous
34%
17%
18%
27%
12%
20%
21%
23%
21%
24%
31%
28%
Change
-1%
-1%
0%
-1%
3%
4%
4%
3%
3%
5%
2%
5%
Most Recent
40%
44%
50%
52%
49%
45%
45%
46%
39%
48%
47%
45%
Previous
41%
41%
43%
46%
44%
46%
46%
47%
41%
50%
48%
44%
Change
-1%
3%
7%
6%
5%
-1%
-1%
-1%
-2%
-2%
-1%
1%
Most Recent
24%
30%
25%
20%
30%
24%
22%
21%
24%
18%
18%
18%
Previous
18%
29%
28%
21%
33%
26%
26%
22%
26%
20%
17%
20%
Change
6%
1%
-3%
-1%
-3%
-2%
-4%
-1%
-2%
-2%
1%
-2%
Most Recent
3%
8%
5%
2%
5%
6%
8%
6%
11%
4%
2%
4%
Previous
4%
10%
9%
5%
9%
7%
7%
6%
10%
5%
3%
6%
Change
-1%
-2%
-4%
-3%
-4%
-1%
1%
0%
1%
-1%
-1%
-2%
Most Recent
0%
1%
2%
0%
1%
1%
0%
1%
2%
0%
0%
1%
Previous
3%
3%
3%
1%
1%
1%
0%
2%
2%
1%
1%
1%
Change
-3%
-2%
-1%
-1%
0%
0%
0%
-1%
0%
-1%
-1%
0%
ICU
Lab
Medicine
78
Obstetrics
Pediatrics
Psych/
Mental
Health
Database
Year
Pharmacy
Radiology
Rehabilitation
Surgery
Table D-4. Trending: Average Percent Distribution of Number of Events Reported in the Past 12 Months by Work Area/Unit
Work Area/Unit
Number of Events
Reported by
Respondents
# Hospitals
# Respondents
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 event reports
or more
Database
Year
Anesthesiology
Emergency
ICU
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
Both Years
42
146
114
164
171
101
62
135
60
161
139
154
Most Recent
293
3,442
4,032
2,926
7,598
2,600
1,356
1,705
1,174
3,275
2,090
5,282
Previous
406
3,120
3,895
2,865
6,220
1,876
1,525
1,560
1,220
3,082
1,941
5,328
Most Recent
57%
45%
36%
45%
37%
48%
41%
38%
47%
55%
54%
48%
Previous
62%
45%
32%
51%
41%
41%
42%
40%
45%
59%
59%
45%
Change
-5%
0%
4%
-6%
-4%
7%
-1%
-2%
2%
-4%
-5%
3%
Most Recent
34%
32%
38%
30%
33%
31%
34%
18%
26%
32%
34%
30%
Previous
25%
31%
35%
27%
28%
36%
33%
16%
29%
28%
28%
32%
Change
9%
1%
3%
3%
5%
-5%
1%
2%
-3%
4%
6%
-2%
Most Recent
6%
14%
18%
14%
20%
16%
22%
16%
16%
10%
8%
14%
Previous
11%
14%
21%
11%
20%
14%
20%
19%
15%
9%
9%
14%
Change
-5%
0%
-3%
3%
0%
2%
2%
-3%
1%
1%
-1%
0%
Most Recent
3%
5%
7%
5%
7%
3%
3%
10%
9%
1%
3%
7%
Previous
0%
6%
8%
6%
7%
5%
4%
10%
9%
2%
2%
6%
Change
3%
-1%
-1%
-1%
0%
-2%
-1%
0%
0%
-1%
1%
1%
Most Recent
0%
2%
1%
3%
2%
2%
1%
8%
2%
1%
0%
1%
Previous
1%
3%
3%
2%
3%
3%
1%
6%
1%
1%
1%
2%
Change
-1%
-1%
-2%
1%
-1%
-1%
0%
2%
1%
0%
-1%
-1%
Most Recent
0%
2%
1%
3%
1%
0%
1%
11%
1%
1%
0%
0%
Previous
1%
1%
1%
2%
2%
0%
0%
9%
1%
0%
0%
1%
Change
-1%
1%
0%
1%
-1%
0%
1%
2%
0%
1%
0%
-1%
79
Appendix D: Trending Results by Respondent Characteristics
(2) Staff Position
NOTE: The number of hospitals and respondents in each breakout category is shown in each table (e.g., the number of
hospitals and respondents by staff position). However, the precise number of hospitals and respondents corresponding to
each data cell in a table will vary because hospitals may have omitted a specific survey item and because of individual nonresponse/missing data.
NOTE 2: Only hospitals that had at least 1 respondent in the particular staff position for both their previous and most
recent administrations of the survey are included.
NOTE 3: Respondents who selected "Other" or those who did not answer (missing) are not included.
80
Table D-5. Trending: Composite-level Average Percent Positive Response by Staff Position (Page 1 of 2)
Staff Position
Patient Safety Culture Composites
# Hospitals
# Respondents
1. Teamwork Within Units
2. Supervisor/Manager
Expectations & Actions
Promoting Patient Safety
3. Org Learning--Continuous
Improvement
4. Management Support for
Patient Safety
5. Overall Perceptions of Patient
Safety
6. Feedback & Communication
About Error
Admin/
Mgmt
187
Attending/
Physician/
Resident/
PA or NP
120
Dietician
80
Pat Care
Asst/Aide/
Care
Partner
158
Pharmacist
116
RN/LVN/
LPN
201
Most Recent
Previous
4,881
4,608
2,869
2,492
365
371
3,755
3,512
985
909
22,584
20,928
5,948
5,322
2,831
2,675
3,700
3,741
Most Recent
89%
83%
84%
73%
80%
79%
77%
82%
77%
Previous
84%
81%
81%
69%
73%
78%
73%
81%
76%
Change
5%
2%
3%
4%
7%
1%
4%
1%
1%
Most Recent
86%
72%
82%
74%
76%
73%
76%
78%
77%
Previous
83%
67%
76%
71%
73%
72%
72%
75%
79%
Change
3%
5%
6%
3%
3%
1%
4%
3%
-2%
Most Recent
84%
72%
72%
72%
72%
71%
70%
71%
71%
Previous
80%
66%
73%
68%
69%
69%
66%
69%
69%
Change
4%
6%
-1%
4%
3%
2%
4%
2%
2%
Most Recent
83%
69%
75%
74%
67%
64%
72%
71%
76%
Previous
80%
65%
74%
69%
64%
63%
70%
67%
73%
Change
3%
4%
1%
5%
3%
1%
2%
4%
3%
Most Recent
73%
62%
68%
62%
60%
60%
70%
68%
66%
Previous
70%
60%
66%
59%
58%
57%
68%
67%
67%
Change
3%
2%
2%
3%
2%
3%
2%
1%
-1%
Most Recent
76%
60%
71%
63%
63%
58%
63%
65%
65%
Previous
73%
57%
67%
60%
59%
57%
60%
63%
67%
Change
3%
3%
4%
3%
4%
1%
3%
2%
-2%
Database
Year
Both Years
81
Therapist
Technician (Resp, Phys, Unit Asst/
(EKG, Lab,
Occup,
Clerk/
Radiology)
Speech)
Secretary
165
162
179
Table D-5. Trending: Composite-level Average Percent Positive Response by Staff Position (Page 2 of 2)
Staff Position
Patient Safety Culture Composites
# Hospitals
# Respondents
7. Communication Openness
8. Frequency of Events
Reported
9. Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to
Error
Database
Year
Both Years
Admin/
Mgmt
187
Attending/
Physician/
Resident/
PA or NP
120
Dietician
80
Pat Care
Asst/Aide/
Care
Partner
158
Pharmacist
116
RN/LVN/L
PN
201
Most Recent
Previous
4,881
4,608
2,869
2,492
365
371
3,755
3,512
985
909
22,584
20,928
5,948
5,322
2,831
2,675
3,700
3,741
Most Recent
76%
64%
64%
55%
69%
60%
61%
66%
60%
Previous
72%
62%
64%
56%
67%
60%
59%
65%
61%
Change
4%
2%
0%
-1%
2%
0%
2%
1%
-1%
Most Recent
67%
56%
60%
65%
52%
62%
60%
54%
67%
Previous
63%
54%
52%
61%
47%
59%
59%
55%
63%
Change
4%
2%
8%
4%
5%
3%
1%
-1%
4%
Most Recent
64%
58%
60%
58%
54%
56%
54%
62%
59%
Previous
60%
55%
63%
58%
51%
53%
54%
57%
58%
Change
4%
3%
-3%
0%
3%
3%
0%
5%
1%
Most Recent
64%
54%
56%
50%
56%
56%
57%
60%
53%
Previous
60%
53%
58%
47%
50%
55%
54%
57%
52%
Change
4%
1%
-2%
3%
6%
1%
3%
3%
1%
Most Recent
47%
44%
39%
49%
28%
49%
39%
41%
48%
Previous
46%
40%
42%
49%
28%
47%
39%
40%
46%
Change
1%
4%
-3%
0%
0%
2%
0%
1%
2%
Most Recent
63%
40%
47%
37%
60%
44%
42%
52%
39%
Previous
59%
41%
43%
34%
55%
42%
40%
49%
41%
Change
4%
-1%
4%
3%
5%
2%
2%
3%
-2%
82
Therapist
Technician
(Respir,
Unit Asst/
(EKG, Lab, Phys, Occup,
Clerk/
Radiology)
Speech)
Secretary
165
162
179
Table D-6. Trending: Item-level Average Percent Positive Response by Staff Position (Page 1 of 6)
Staff Position
Item
Patient Safety Culture
Composites
# Hospitals
#Respondents
1.
A1
A3
A4
A11
2.
B1
B2
B3R
B4R
Database
Year
Both Years
Most Recent
Previous
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
187
4,881
4,608
120
2,869
2,492
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
80
365
371
158
3,755
3,512
116
985
909
201
22,584
20,928
165
5,948
5,322
162
2,831
2,675
179
3,700
3,741
77%
74%
3%
78%
77%
1%
72%
66%
6%
64%
60%
4%
87%
80%
7%
84%
80%
4%
81%
71%
10%
67%
61%
6%
86%
83%
3%
87%
85%
2%
77%
76%
1%
67%
66%
1%
82%
77%
5%
85%
82%
3%
74%
71%
3%
67%
64%
3%
88%
85%
3%
85%
85%
0%
82%
81%
1%
74%
72%
2%
83%
81%
2%
84%
82%
2%
73%
74%
-1%
69%
68%
1%
72%
68%
4%
77%
70%
7%
74%
71%
3%
76%
71%
5%
70%
65%
5%
76%
75%
1%
78%
75%
3%
80%
73%
7%
69%
68%
1%
74%
73%
1%
72%
72%
0%
75%
73%
2%
70%
66%
4%
76%
73%
3%
78%
74%
4%
79%
73%
6%
76%
70%
6%
82%
77%
5%
77%
74%
3%
77%
75%
2%
74%
72%
2%
76%
79%
-3%
78%
79%
-1%
78%
79%
-1%
Teamwork Within Units
Most Recent
Previous
Change
Most Recent
94%
89%
88%
89%
87%
85%
5%
2%
3%
2. When a lot of work needs to
94%
86%
88%
be done quickly, we work
Previous
90%
86%
85%
together as a team to get the
Change
4%
0%
3%
work done.
Most Recent
89%
86%
86%
3. In this unit, people treat each
Previous
83%
85%
81%
other with respect.
Change
6%
5%
1%
Most Recent
79%
69%
74%
4. When one area in this unit
gets really busy, others help
Previous
73%
67%
72%
out.
Change
6%
2%
2%
Supervisor/Manager Expectations & Actions Promoting Patient Safety
1. My supv/mgr says a good
Most Recent
84%
71%
81%
word when he/she sees a job
Previous
78%
60%
78%
done according to established
Change
6%
11%
3%
patient safety procedures.
Most Recent
89%
76%
85%
2. My supv/mgr seriously
considers staff suggestions for
Previous
86%
70%
77%
improving patient safety.
Change
6%
8%
3%
3. Whenever pressure builds
Most Recent
85%
67%
76%
up, my supv/mgr wants us to
Previous
81%
66%
68%
work faster, even if it means
Change
8%
4%
1%
taking shortcuts.
Most Recent
87%
74%
85%
4. My supv/mgr overlooks
patient safety problems that
Previous
81%
71%
74%
happen over and over.
Change
6%
11%
3%
1. People support one another
in this unit.
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
83
Table D-6. Trending: Item-level Average Percent Positive Response by Staff Position (Page 2 of 6)
Staff Position
Item
Patient Safety Culture
Composites
# Hospitals
# Respondents
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
187
4,881
4,608
120
2,869
2,492
80
365
371
158
3,755
3,512
Previous
90%
85%
5%
83%
78%
5%
79%
75%
81%
79%
2%
68%
62%
6%
65%
59%
84%
81%
3%
65%
66%
-1%
68%
71%
Change
4%
6%
Previous
90%
88%
2%
85%
80%
5%
74%
72%
Change
2%
Database
Year
Both Years
Most Recent
Previous
3.
Organizational Learning— Continuous Improvement
A6
1. We are actively doing
things to improve patient
safety.
A9
2. Mistakes have led to
positive changes here.
A13
3. After we make changes
to improve patient safety,
we evaluate their
effectiveness.
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
4.
Management Support for Patient Safety
Most Recent
F1
1. Hospital mgmt provides a
work climate that promotes
patient safety.
2. The actions of hospital
mgmt show that patient
safety is a top priority.
Most Recent
3. Hospital mgmt seems
interested in patient safety
only after an adverse event
happens.
Most Recent
F8
F9R
Previous
Change
Previous
Change
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
116
985
909
201
22,584
20,928
165
5,948
5,322
162
2,831
2,675
179
3,700
3,741
86%
80%
6%
60%
56%
4%
71%
68%
83%
83%
0%
72%
68%
4%
61%
57%
83%
81%
2%
61%
60%
1%
70%
65%
81%
77%
4%
65%
59%
6%
66%
62%
83%
80%
3%
61%
58%
3%
68%
68%
83%
80%
3%
62%
59%
3%
70%
69%
-3%
3%
4%
5%
4%
0%
1%
75%
76%
-1%
71%
63%
8%
60%
56%
84%
86%
-2%
81%
76%
5%
60%
59%
82%
78%
4%
78%
73%
5%
60%
56%
73%
68%
5%
68%
67%
1%
60%
58%
73%
73%
0%
66%
63%
3%
55%
54%
83%
79%
4%
73%
71%
2%
59%
58%
81%
79%
2%
73%
68%
5%
60%
54%
85%
83%
2%
79%
75%
4%
63%
62%
4%
1%
4%
2%
1%
1%
6%
1%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
84
Table D-6. Trending: Item-level Average Percent Positive Response by Staff Position (Page 3 of 6)
Staff Position
Item
Patient Safety Culture
Composites
# Hospitals
# Respondents
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
187
4,881
4,608
120
2,869
2,492
80
365
371
158
3,755
3,512
Previous
72%
70%
2%
73%
69%
4%
68%
67%
1%
79%
75%
58%
62%
-4%
63%
59%
4%
59%
55%
4%
66%
62%
64%
67%
-3%
63%
63%
0%
66%
60%
6%
Change
4%
Previous
Database
Year
Both Years
Most Recent
Previous
5.
Overall Perceptions of Patient Safety
Most Recent
A10R
1. It is just by chance that
more serious mistakes
don’t happen around here.
2. Patient safety is never
sacrificed to get more work
done.
Most Recent
A15
A17R
3. We have patient safety
problems in this unit.
Previous
Change
Previous
Change
Most Recent
Previous
Change
A18
4. Our procedures and
systems are good at
preventing errors from
happening.
Most Recent
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
116
985
909
201
22,584
20,928
165
5,948
5,322
162
2,831
2,675
179
3,700
3,741
78%
73%
55%
52%
3%
64%
62%
2%
59%
55%
4%
69%
66%
59%
55%
4%
55%
53%
2%
55%
55%
0%
71%
67%
59%
58%
1%
57%
54%
3%
57%
55%
2%
67%
63%
63%
61%
2%
72%
68%
4%
69%
69%
0%
76%
73%
66%
65%
1%
67%
68%
-1%
65%
65%
0%
74%
70%
55%
58%
-3%
72%
70%
2%
64%
67%
-3%
74%
71%
4%
5%
3%
4%
4%
3%
4%
3%
65%
63%
52%
49%
64%
60%
55%
53%
50%
49%
50%
49%
51%
48%
59%
54%
53%
58%
6.
Feedback and Communication About Error
Most Recent
C1
1. We are given feedback
about changes put into
place based on event
reports.
Change
2%
3%
4%
2%
1%
1%
3%
5%
-5%
2. We are informed about
errors that happen in this
unit.
Most Recent
3. In this unit, we discuss
ways to prevent errors from
happening again.
Most Recent
78%
74%
4%
85%
81%
4%
59%
57%
2%
69%
64%
5%
69%
65%
4%
80%
74%
6%
65%
64%
1%
69%
65%
4%
67%
60%
7%
71%
66%
5%
57%
57%
0%
66%
65%
1%
68%
66%
2%
69%
67%
2%
65%
62%
3%
73%
72%
1%
69%
69%
0%
73%
72%
1%
C3
C5
Previous
Change
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
85
Table D-6. Trending: Item-level Average Percent Positive Response by Staff Position (Page 4 of 6)
Staff Position
Item
Database
Year
Both Years
Most Recent
Previous
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
187
4,881
4,608
120
2,869
2,492
80
365
371
158
3,755
3,512
116
985
909
201
22,584
20,928
165
5,948
5,322
162
2,831
2,675
179
3,700
3,741
Most Recent
84%
72%
75%
71%
78%
75%
76%
80%
75%
Previous
81%
72%
77%
73%
76%
74%
73%
80%
74%
Change
3%
0%
-2%
-2%
2%
1%
3%
0%
1%
2. Staff feel free to question
the decisions or actions of
those with more authority.
Most Recent
3. Staff are afraid to ask
questions when something
does not seem right.
Most Recent
69%
65%
4%
75%
70%
5%
56%
53%
3%
64%
61%
3%
56%
56%
0%
62%
58%
4%
40%
39%
1%
56%
55%
1%
60%
57%
3%
71%
69%
2%
44%
45%
-1%
61%
61%
0%
45%
42%
3%
63%
61%
2%
52%
50%
2%
67%
65%
2%
43%
47%
-4%
61%
61%
0%
59%
48%
57%
63%
37%
49%
52%
48%
64%
55%
46%
58%
5%
32%
5%
46%
51%
48%
60%
Patient Safety Culture
Composites
# Hospitals
# Respondents
7.
C2
C4
C6R
8.
D1
D2
D3
Communication Openness
1. Staff will freely speak up
if they see something that
may negatively affect
patient care.
Previous
Change
Previous
Change
Frequency of Events Reported
1. When a mistake is made,
Most Recent
but is caught and corrected
Previous
before affecting the patient,
Change
how often is this reported?
2. When a mistake is made,
Most Recent
but has no potential to harm
Previous
the patient, how often is this
Change
reported?
3. When a mistake is made
Most Recent
that could harm the patient,
Previous
but does not, how often is
Change
this reported?
Pharmacist
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
4%
2%
47%
10%
3%
1%
0%
4%
64%
49%
52%
60%
50%
60%
54%
47%
62%
59%
5%
50%
-1%
46%
6%
56%
4%
41%
9%
57%
3%
54%
0%
48%
-1%
58%
4%
79%
75%
70%
65%
69%
64%
73%
69%
69%
67%
76%
75%
74%
71%
66%
68%
75%
72%
4%
5%
5%
4%
2%
1%
3%
-2%
3%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
86
Table D-6. Trending: Item-level Average Percent Positive Response by Staff Position (Page 5 of 6)
Staff Position
Item
Patient Safety Culture
Composites
# Hospitals
# Respondents
Database
Year
Both Years
Most Recent
Previous
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
187
4,881
4,608
120
2,869
2,492
80
365
371
158
3,755
3,512
116
985
909
201
22,584
20,928
165
5,948
5,322
162
2,831
2,675
179
3,700
3,741
Previous
53%
50%
3%
66%
61%
46%
42%
4%
57%
55%
49%
51%
-2%
61%
64%
44%
47%
-3%
60%
60%
42%
39%
3%
53%
53%
43%
42%
1%
56%
54%
42%
42%
0%
56%
56%
50%
47%
3%
64%
58%
47%
45%
2%
61%
60%
Pharmacist
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
9.
Teamwork Across Units
Most Recent
F2R
1. Hospital units do not
coordinate well with each
other.
Most Recent
F4
2. There is good
cooperation among hospital
units that need to work
together.
Change
5%
2%
-3%
0%
0%
2%
0%
6%
1%
3. It is often unpleasant to
work with staff from other
hospital units.
Most Recent
4. Hospital units work well
together to provide the best
care for patients.
Most Recent
F10
Change
63%
59%
4%
75%
72%
3%
61%
59%
2%
65%
65%
0%
61%
65%
-4%
70%
72%
-2%
57%
58%
-1%
71%
69%
2%
57%
55%
2%
63%
57%
6%
59%
57%
2%
64%
62%
2%
53%
53%
0%
66%
64%
2%
65%
59%
6%
69%
64%
5%
56%
56%
0%
72%
70%
2%
10.
Staffing
A2
1. We have enough staff to
handle the workload.
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
68%
67%
1%
60%
54%
6%
69%
65%
4%
59%
54%
5%
54%
53%
1%
50%
49%
1%
61%
58%
3%
51%
53%
-2%
60%
63%
-3%
53%
53%
0%
55%
59%
-4%
55%
54%
1%
43%
42%
1%
45%
44%
1%
61%
58%
3%
49%
44%
5%
48%
44%
4%
58%
57%
1%
69%
57%
12%
47%
43%
4%
53%
52%
1%
54%
54%
0%
69%
67%
2%
47%
47%
0%
54%
53%
1%
54%
53%
1%
68%
64%
4%
51%
47%
4%
55%
52%
3%
57%
55%
2%
71%
69%
2%
56%
54%
2%
49%
48%
1%
48%
51%
-3%
60%
59%
1%
53%
51%
2%
F6R
2. Staff in this unit work
longer hours than is best for
patient care.
3. We use more
A7R agency/temporary staff than
is best for patient care.
4. We work in “crisis mode”
A14R trying to do too much, too
quickly.
A5R
Previous
Change
Previous
Change
Previous
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
87
Table D-6. Trending: Item-level Average Percent Positive Response by Staff Position (Page 6 of 6)
Staff Position
Item
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
187
4,881
4,608
120
2,869
2,492
Previous
43%
41%
Change
2. Important patient care
information is often lost
during shift changes.
Most Recent
3. Problems often occur in
the exchange of
information across hospital
units.
Most Recent
4. Shift changes are
problematic for patients in
this hospital.
Patient Safety Culture
Composites
# Hospitals
# Respondents
11.
F3R
F5R
F7R
F11R
Handoffs & Transitions
1. Things “fall between the
cracks” when transferring
patients from one unit to
another.
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
80
365
371
158
3,755
3,512
116
985
909
201
22,584
20,928
165
5,948
5,322
162
2,831
2,675
179
3,700
3,741
43%
38%
34%
37%
47%
48%
25%
23%
45%
42%
34%
35%
36%
38%
47%
45%
2%
5%
-3%
-1%
2%
3%
-1%
-2%
2%
Previous
50%
47%
3%
46%
45%
47%
45%
2%
43%
38%
44%
47%
-3%
41%
45%
55%
55%
0%
43%
44%
30%
33%
-3%
27%
26%
55%
53%
2%
46%
44%
44%
44%
0%
38%
37%
44%
46%
-2%
43%
41%
53%
50%
3%
46%
42%
Change
1%
5%
-4%
-1%
1%
2%
1%
2%
4%
Most Recent
49%
49%
0%
41%
37%
4%
38%
43%
-5%
51%
48%
3%
29%
30%
-1%
51%
49%
2%
40%
41%
-1%
40%
38%
2%
48%
47%
1%
Previous
68%
65%
3%
69%
65%
47%
49%
-2%
43%
43%
53%
50%
3%
50%
43%
44%
41%
3%
38%
34%
63%
58%
5%
64%
58%
51%
49%
2%
47%
44%
50%
46%
4%
43%
41%
59%
58%
1%
53%
47%
45%
50%
-5%
37%
40%
Database
Year
Both Years
Most Recent
Previous
Most Recent
Previous
Change
Previous
Change
12.
Nonpunitive Response to Error
Most Recent
A8R
1. Staff feel like their
mistakes are held against
them.
2. When an event is
reported, it feels like the
person is being written up,
not the problem.
Most Recent
Change
4%
0%
7%
4%
6%
3%
2%
6%
-3%
3. Staff worry that mistakes
they make are kept in their
personnel file.
Most Recent
52%
47%
5%
30%
31%
-1%
37%
38%
-1%
28%
26%
2%
53%
47%
6%
35%
33%
2%
35%
33%
2%
44%
41%
3%
33%
32%
1%
A12R
A16R
Previous
Change
Previous
Change
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree” or
“Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
88
Table D-7. Trending: Average Percent Distribution of Work Area/Unit Patient Safety Grades by Staff Position
Staff Position
Work Area/Unit
Patient Safety
Grade
# Hospitals
# Respondents
A
B
C
D
E
Excellent
Very Good
Acceptable
Poor
Failing
Dietician
80
Pat Care
Asst/Aide/
Care
Partner
158
Pharmacist
116
RN/LVN/LPN
201
Technician
(EKG, Lab,
Radiology)
165
Therapist
(Respiratory,
Phys,
Occup,
Speech)
162
Unit
Asst/
Clerk/
Secretary
179
Database
Year
Both Years
Admin/
Mgmt
187
Attending/
Physician/
Resident/
PA or NP
120
Most Recent
4,881
2,869
365
3,755
985
22,584
5,948
2,831
3,700
Previous
4,608
2,492
371
3,512
909
20,928
5,322
2,675
3,741
Most Recent
32%
24%
27%
24%
24%
20%
26%
28%
28%
Previous
28%
19%
28%
20%
19%
17%
26%
25%
24%
Change
4%
5%
-1%
4%
5%
3%
0%
3%
4%
Most Recent
51%
44%
50%
44%
42%
47%
50%
46%
47%
Previous
50%
45%
46%
48%
44%
45%
45%
48%
50%
Change
1%
-1%
4%
-4%
-2%
2%
5%
-2%
-3%
Most Recent
15%
26%
21%
24%
24%
26%
21%
21%
21%
Previous
18%
27%
22%
26%
27%
28%
22%
22%
22%
Change
-3%
-1%
-1%
-2%
-3%
-2%
-1%
-1%
-1%
Most Recent
2%
6%
2%
6%
8%
6%
3%
4%
3%
Previous
3%
7%
3%
5%
8%
8%
6%
4%
4%
Change
-1%
-1%
-1%
1%
0%
-2%
-3%
0%
-1%
Most Recent
0%
0%
0%
2%
1%
1%
0%
1%
1%
Previous
1%
2%
1%
1%
2%
2%
1%
1%
1%
Change
-1%
-2%
-1%
1%
-1%
-1%
-1%
0%
0%
89
Table D-8. Trending: Average Percent Distribution of Number of Events Reported in the Past 12 Months by Staff Position
Staff Position
Number of Events
Reported
by Respondents
# Hospitals
# Respondents
No events
Most Recent
4,881
2,869
365
3,755
985
22,584
5,948
2,831
3,700
Previous
4,608
2,492
371
3,512
909
20,928
5,322
2,675
3,741
Most Recent
46%
48%
-2%
24%
23%
1%
15%
15%
0%
9%
7%
2%
4%
5%
-1%
3%
2%
1%
61%
65%
-4%
26%
23%
3%
8%
7%
1%
3%
2%
1%
0%
2%
-2%
2%
1%
1%
78%
79%
-1%
16%
16%
0%
3%
4%
-1%
2%
2%
0%
1%
0%
1%
0%
0%
0%
75%
73%
2%
18%
20%
-2%
5%
5%
0%
2%
1%
1%
0%
0%
0%
0%
0%
0%
21%
24%
-3%
22%
18%
4%
20%
21%
-1%
12%
15%
-3%
13%
10%
3%
12%
13%
-1%
29%
30%
-1%
38%
37%
1%
21%
21%
0%
7%
8%
-1%
3%
3%
0%
1%
1%
0%
54%
56%
-2%
31%
27%
4%
11%
11%
0%
3%
4%
-1%
1%
2%
-1%
1%
1%
0%
58%
58%
0%
30%
31%
-1%
8%
8%
0%
3%
2%
1%
1%
0%
1%
1%
0%
1%
77%
79%
-2%
18%
16%
2%
4%
3%
1%
1%
1%
0%
0%
0%
0%
0%
0%
0%
Most Recent
1 to 2 events
Previous
Change
Most Recent
3 to 5 events
Previous
Change
Most Recent
6 to 10 events
Previous
Change
Most Recent
11 to 20 events
Previous
Change
21 event reports
or more
RN/LVN/LPN
201
Unit
Asst/
Clerk/
Secretary
179
Admin/
Mgmt
187
Change
Most Recent
Previous
Change
Pharmacist
116
Technician
(EKG, Lab,
Radiology)
165
Database
Year
Both Years
Previous
Dietician
80
Pat Care
Asst/Aide/
Care
Partner
158
Therapist
(Respiratory,
Phys,
Occup,
Speech)
162
Attending/
Physician/
Resident/
PA or NP
120
90
Appendix D: Trending Results by Respondent Characteristics
(3) Interaction with Patients
NOTE: The number of hospitals and respondents in each breakout category is shown in each table (e.g., the number of
hospitals and respondents by interaction with patients). However, the precise number of hospitals and respondents
corresponding to each data cell in a table will vary because hospitals may have omitted a specific survey item and because
of individual non-response/missing data.
NOTE 2: Only hospitals that had at least 1 respondent in the response categories (WITH or WITHOUT direct interaction
with patients) for both their previous and most recent administrations of the survey are included.
NOTE 3: Respondents who did not answer (missing) are not included.
91
Table D-9. Trending: Composite-level Average Percent Positive Response by Interaction with Patients (Page 1 of 2)
Patient Safety Culture Composites
# Hospitals
# Respondents
1. Teamwork Within Units
2. Supervisor/Manager Expectations & Actions
Promoting Patient Safety
3. Org Learning--Continuous Improvement
4. Management Support for Patient Safety
5. Overall Perceptions of Patient Safety
6. Feedback & Communication About Error
Database Year
Both Years
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
203
198
48,941
15,100
7,300
2,079
Most Recent
79%
81%
Previous
77%
78%
Change
2%
3%
Most Recent
75%
77%
Previous
74%
76%
Change
1%
1%
Most Recent
72%
73%
Previous
69%
71%
Change
3%
2%
Most Recent
70%
76%
Previous
67%
74%
Change
3%
2%
Most Recent
65%
66%
Previous
62%
64%
Change
3%
2%
Most Recent
62%
67%
Previous
60%
65%
Change
2%
2%
92
Table D-9. Trending: Composite-level Average Percent Positive Response by Interaction with Patients (Page 2 of 2)
Patient Safety Culture Composites
# Hospitals
# Respondents
7. Communication Openness
8. Frequency of Events Reported
9. Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to Error
Database Year
Both Years
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
203
198
48,941
15,100
7,300
2,079
Most Recent
61%
64%
Previous
60%
63%
Change
1%
1%
Most Recent
61%
62%
Previous
59%
60%
Change
2%
2%
Most Recent
57%
59%
Previous
56%
57%
Change
1%
2%
Most Recent
56%
54%
Previous
55%
50%
Change
1%
4%
Most Recent
47%
40%
Previous
46%
38%
Change
1%
2%
Most Recent
44%
49%
Previous
42%
45%
Change
2%
4%
93
Table D-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 1 of 6)
Interaction with Patients
WITH
WITHOUT
Item
Survey Items By Composite
Database Year
direct interaction
direct interaction
# Hospitals
Both Years
203
198
Most Recent
48,941
15,100
# Respondents
Previous
7,300
2,079
1.
Teamwork Within Units
Most Recent
85%
87%
A1
1. People support one another in this unit.
Previous
82%
83%
Change
3%
4%
Most Recent
86%
87%
2. When a lot of work needs to be done quickly, we work
A3
Previous
84%
84%
together as a team to get the work done.
Change
2%
3%
Most Recent
77%
81%
A4
3. In this unit, people treat each other with respect.
Previous
75%
77%
Change
2%
4%
Most Recent
69%
71%
A11 4. When one area in this unit gets really busy, others help out.
Previous
66%
67%
Change
3%
4%
2.
Supervisor/Manager Expectations & Actions Promoting Patient Safety
Most Recent
71%
75%
1. My supv/mgr says a good word when he/she sees a job
B1
Previous
69%
72%
done according to established patient safety procedures.
Change
2%
3%
Most Recent
76%
79%
2. My supv/mgr seriously considers staff suggestions for
B2
Previous
74%
76%
improving patient safety.
Change
2%
3%
Most Recent
75%
77%
3. Whenever pressure builds up, my supv/mgr wants us to work
B3R
Previous
73%
75%
faster, even if it means taking shortcuts.
Change
2%
2%
Most Recent
77%
78%
4. My supv/mgr overlooks patient safety problems that happen
B4R
Previous
75%
74%
over and over.
Change
2%
4%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
94
Table D-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 2 of 6)
Item
Survey Items By Composite
# Hospitals
# Respondents
3.
Organizational Learning— Continuous Improvement
A6
1. We are actively doing things to improve patient safety.
A9
2. Mistakes have led to positive changes here.
A13
3. After we make changes to improve patient safety, we
evaluate their effectiveness.
4.
Management Support for Patient Safety
F1
1. Hospital mgmt provides a work climate that promotes patient
safety.
F8
2. The actions of hospital mgmt show that patient safety is a top
priority.
F9R
3. Hospital mgmt seems interested in patient safety only after
an adverse event happens.
Database Year
Both Years
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
203
198
48,941
15,100
7,300
2,079
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
83%
80%
3%
63%
60%
3%
69%
66%
3%
81%
79%
2%
68%
67%
1%
69%
66%
3%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
79%
77%
2%
71%
68%
3%
59%
57%
2%
85%
84%
1%
79%
76%
3%
66%
63%
3%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
95
Table D-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 3 of 6)
Item
Survey Items By Composite
# Hospitals
# Respondents
5.
Overall Perceptions of Patient Safety
A10R
1. It is just by chance that more serious mistakes don’t happen
around here.
A15
2. Patient safety is never sacrificed to get more work done.
A17R
3. We have patient safety problems in this unit.
A18
4. Our procedures and systems are good at preventing errors
from happening.
6.
Feedback and Communication About Error
C1
1. We are given feedback about changes put into place based
on event reports.
C3
2. We are informed about errors that happen in this unit.
C5
3. In this unit, we discuss ways to prevent errors from
happening again.
Database Year
Both Years
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
203
198
48,941
15,100
7,300
2,079
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
61%
59%
2%
65%
62%
3%
62%
61%
1%
71%
67%
4%
60%
59%
1%
68%
65%
3%
64%
62%
2%
74%
69%
5%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
52%
51%
1%
63%
62%
1%
70%
68%
2%
56%
54%
2%
70%
68%
2%
75%
73%
2%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
96
Table D-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 4 of 6)
Item
Survey Items By Composite
# Hospitals
# Respondents
7.
Communication Openness
C2
1. Staff will freely speak up if they see something that may
negatively affect patient care.
C4
2. Staff feel free to question the decisions or actions of those
with more authority.
C6R
3. Staff are afraid to ask questions when something does not
seem right.
8.
Frequency of Events Reported
D1
1. When a mistake is made, but is caught and corrected before
affecting the patient, how often is this reported?
D2
2. When a mistake is made, but has no potential to harm the
patient, how often is this reported?
D3
3. When a mistake is made that could harm the patient, but
does not, how often is this reported?
Database Year
Both Years
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
203
198
48,941
15,100
7,300
2,079
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
75%
74%
1%
46%
46%
0%
62%
61%
1%
76%
74%
2%
51%
50%
1%
65%
63%
2%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
53%
51%
2%
57%
55%
2%
74%
72%
2%
57%
55%
2%
56%
55%
1%
73%
70%
3%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
97
Table D-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 5 of 6)
Interaction with Patients
WITH
WITHOUT
Item
Survey Items By Composite
Database Year
direct interaction
direct interaction
# Hospitals
Both Years
203
198
Most Recent
48,941
15,100
# Respondents
Previous
7,300
2,079
9.
Teamwork Across Units
F2R
1. Hospital units do not coordinate well with each other.
F4
2. There is good cooperation among hospital units that need to
work together.
F6R
3. It is often unpleasant to work with staff from other hospital
units.
F10
4. Hospital units work well together to provide the best care for
patients.
10.
Staffing
A2
1. We have enough staff to handle the workload.
A5R
2. Staff in this unit work longer hours than is best for patient
care.
A7R
3. We use more agency/temporary staff than is best for patient
care.
A14R
4. We work in “crisis mode” trying to do too much, too quickly.
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
45%
44%
1%
59%
57%
2%
59%
57%
2%
67%
65%
2%
49%
46%
3%
60%
59%
1%
58%
54%
4%
71%
68%
3%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
53%
52%
1%
53%
52%
1%
67%
65%
2%
50%
49%
1%
57%
55%
2%
50%
46%
4%
58%
54%
4%
51%
45%
6%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
98
Table D-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 6 of 6)
Item
Survey Items By Composite
# Hospitals
#Respondents
11.
Handoffs & Transitions
F3R
1. Things “fall between the cracks” when transferring patients
from one unit to another.
F5R
2. Important patient care information is often lost during shift
changes.
F7R
3. Problems often occur in the exchange of information across
hospital units.
F11R
4. Shift changes are problematic for patients in this hospital.
12.
Nonpunitive Response to Error
A8R
1. Staff feel like their mistakes are held against them.
A12R
2. When an event is reported, it feels like the person is being
written up, not the problem.
A16R
3. Staff worry that mistakes they make are kept in their
personnel file.
Database Year
Both Years
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
203
198
48,941
15,100
7,300
2,079
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
44%
43%
1%
52%
51%
1%
44%
43%
1%
47%
46%
1%
37%
35%
2%
44%
41%
3%
41%
36%
5%
40%
39%
1%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
51%
50%
1%
46%
43%
3%
36%
34%
2%
56%
52%
4%
51%
48%
3%
39%
35%
4%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
99
Table D-11. Trending: Average Percent Distribution of Work Area/Unit Patient Safety Grade by
Interaction with Patients
Interaction with Patients
Work Area/Unit
Patient Safety Grade
# Hospitals
# Respondents
A
B
C
D
E
Excellent
Very Good
Acceptable
Poor
Failing
Database Year
Both Years
Most Recent
Previous
WITH
direct interaction
203
48,941
7,300
WITHOUT
direct interaction
198
15,100
2,079
Most Recent
24%
29%
Previous
22%
25%
Change
2%
4%
Most Recent
47%
48%
Previous
46%
48%
Change
1%
0%
Most Recent
23%
20%
Previous
25%
22%
Change
-2%
-2%
Most Recent
5%
3%
Previous
6%
4%
Change
-1%
-1%
Most Recent
1%
1%
Previous
1%
1%
Change
0%
0%
100
Table D-12. Trending: Average Percent Distribution of Number of Events Reported in the Past 12
Months by Interaction with Patients
Interaction with Patients
Number of Events
Reported by Respondents
# Hospitals
# Respondents
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 event reports or more
Database Year
Both Years
Most Recent
Previous
WITH
direct interaction
203
48,941
7,300
WITHOUT
direct interaction
198
15,100
2,079
Most Recent
48%
69%
Previous
49%
71%
Change
-1%
-2%
Most Recent
31%
16%
Previous
29%
15%
Change
2%
1%
Most Recent
14%
7%
Previous
14%
7%
Change
0%
0%
Most Recent
5%
3%
Previous
5%
4%
Change
0%
-1%
Most Recent
2%
2%
Previous
2%
2%
Change
0%
0%
Most Recent
1%
2%
Previous
1%
2%
Change
0%
0%
101
| File Type | application/pdf |
| Author | sorra_j |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |