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pdfHospital Survey on Patient Safety Culture:
2012 User 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
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
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.
Dawn Nelson
Scott Alan Smith, Ph.D.
AHRQ Publication No. 12-0017
January 2012
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, et al. Hospital Survey on Patient Safety Culture 2012 comparative
database report, appendixes, parts II and III (Appendixes for AHRQ Publication No. 12-0017).
(Prepared by Westat, Rockville, MD, under contract No. HHSA 290200710024C). Rockville,
MD: Agency for Healthcare Research and Quality; January 2012.
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.
ii
Contents
Executive Summary ...................................................................................................................... vii
Part II—Appendixes A & B: Overall Results by Hospital and Respondent Characteristics .. vii
Part III—Appendixes C & D: Trending Results by Hospital and Respondent
Characteristics ......................................................................................................................x
Part II ...............................................................................................................................................1
Appendix A: Overall Results by Hospital Characteristics ...............................................................1
(1) Bed Size................................................................................................................................1
(2) Teaching Status and (3) Ownership and Control .................................................................9
(4) Geographic Region .............................................................................................................17
Appendix B: Overall Results by Respondent Characteristics........................................................25
(1) Work Area/Unit ..................................................................................................................25
(2) Staff Position ......................................................................................................................33
(3) Interaction With Patients ....................................................................................................41
Part III ............................................................................................................................................48
Appendix C: Trending Results by Hospital Characteristics ..........................................................49
Characteristics of the Trending Hospitals ................................................................................49
(1) Bed Size..............................................................................................................................52
(2) Teaching Status and (3) Ownership and Control ...............................................................63
(4) Geographic Region .............................................................................................................74
Appendix D: Trending Results by Respondent Characteristics .....................................................85
(1) Work Area/Unit ..................................................................................................................85
(2) Staff Position ......................................................................................................................96
(3) Interaction With Patients ..................................................................................................107
Tables
Table 1. Example of Decrease in Average Score Over Time (Negative Change) ...........................x
Table 2. Example of Increase in Average Score Over Time (Positive Change) ..............................x
Table A-1. Composite-Level Average Percent Positive Response by Bed Size .............................2
Table A-2. Item-Level Average Percent Positive Response by Bed Size .......................................3
Table A-3. Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Bed Size ..............................................................................................7
Table A-4. Average Percentage of Respondents Reporting Events in the Past 12 Months
by Bed Size ................................................................................................................................7
Table A-5. Composite-Level Average Percent Positive Response by Teaching Status and
Ownership and Control ............................................................................................................10
Table A-6. Item-Level Average Percent Positive Response by Teaching Status and Ownership
and Control...............................................................................................................................11
Table A-7. Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety
Grade by Teaching Status and Ownership and Control ...........................................................15
Table A-8. Average Percentage of Respondents Reporting Events in the Past 12 Months by
Teaching Status and Ownership and Control...........................................................................16
Table A-9. Composite-Level Average Percent Positive Response by Geographic Region ..........18
Table A-10. Item-Level Average Percent Positive Response by Geographic Region ..................19
Table A-11. Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Geographic Region ...........................................................................23
Table A-12. Average Percentage of Respondents Reporting Events in the Past 12 Months by
Geographic Region ..................................................................................................................24
iii
Table B-1. Composite-Level Average Percent Positive Response by Work Area/Unit ................26
Table B-2. Item-Level Average Percent Positive Response by Work Area/Unit ..........................27
Table B-3. Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Work Area/Unit ................................................................................31
Table B-4. Average Percentage of Respondents Reporting Events in the Past 12 Months
by Work Area/Unit ..................................................................................................................31
Table B-5. Composite-Level Average Percent Positive Response by Staff Position ....................34
Table B-6. Item-Level Average Percent Positive Response by Staff Position ..............................35
Table B-7. Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Staff Position.....................................................................................39
Table B-8. Average Percentage of Respondents Reporting Events in the Past 12 Months
by Staff Position .......................................................................................................................39
Table B-9. Composite-Level Average Percent Positive Response by Interaction With
Patients .....................................................................................................................................42
Table B-10. Item-Level Average Percent Positive Response by Interaction With
Patients .....................................................................................................................................43
Table B-11. Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Interaction With Patients ..................................................................47
Table B-12. Average Percentage of Respondents Reporting Events in the Past 12 Months by
Interaction With Patients..........................................................................................................47
Table C-1. Distribution of 650 Trending Hospitals by Bed Size ...................................................50
Table C-2. Distribution of 650 Trending Hospitals by Teaching Status .......................................50
Table C-3. Distribution of 650 Trending Hospitals by Ownership and Control ...........................50
Table C-4. Distribution of 650 Trending Hospitals by Geographic Region ..................................51
Table C-5. Trending: Composite-Level Average Percent Positive Response by Bed Size ...........54
Table C-6. Trending: Item-Level Average Percent Positive Response by Bed Size .....................55
Table C-7. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Bed Size ............................................................................................61
Table C-8. Trending: Average Percentage of Respondents Reporting Events in the Past 12
Months by Bed Size .................................................................................................................62
Table C-9. Trending: Composite-Level Average Percent Positive Response by Teaching
Status and Ownership and Control ..........................................................................................64
Table C-10. Trending: Item-Level Average Percent Positive Response by Teaching
Status and Ownership and Control ..........................................................................................66
Table C-11. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Teaching Status and Ownership and Control ...................................72
Table C-12. Trending: Average Percentage of Respondents Reporting Events in the Past 12
Months by Teaching Status and Ownership and Control ........................................................73
Table C-13. Trending: Composite-Level Average Percent Positive Response by Geographic
Region ......................................................................................................................................75
Table C-14. Trending: Item-Level Average Percent Positive Response by Geographic
Region ......................................................................................................................................77
Table C-15. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Geographic Region ...........................................................................83
Table C-16. Trending: Average Percentage of Respondents Reporting Events in the Past 12
Months by Geographic Region ................................................................................................84
iv
Table D-1. Trending: Composite-Level Average Percent Positive Response by
Work Area/Unit ......................................................................................................................86
Table D-2. Trending: Item-Level Average Percent Positive Response by
Work Area/Unit .......................................................................................................................88
Table D-3. Trending: Average Percentage of Respondents Giving Their Work
Area/Unit a Patient Safety Grade by Work Area/Unit.............................................................94
Table D-4. Trending: Average Percentage of Respondents Reporting Events in the Past 12
Months by Work Area/Unit .....................................................................................................95
Table D-5. Trending: Composite-Level Average Percent Positive Response by
Staff Position............................................................................................................................97
Table D-6. Trending: Item-Level Average Percent Positive Response by
Staff Position............................................................................................................................99
Table D-7. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a
Patient Safety Grade by Staff Position...................................................................................105
Table D-8. Trending: Average Percentage of Respondents Reporting Events in the Past 12
Months by Staff Position .......................................................................................................106
Table D-9. Trending: Composite-Level Average Percent Positive Response by
Interaction With Patients........................................................................................................108
Table D-10. Trending: Item-Level Average Percent Positive Response by Interaction With
Patients ...................................................................................................................................110
Table D-11. Trending: Average Percentage of Respondents Giving Their Work Area/Unit
a Patient Safety Grade by Interaction With Patients ..............................................................116
Table D-12. Trending: Average Percentage of Respondents Reporting Events in the Past 12
Months by Interaction With Patients .....................................................................................117
v
vi
Executive Summary
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, 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.
Comparing Your Results
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 percentage point
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 can then compare your hospital’s
percent positive scores against the averages shown in the tables. Again, you can use a 5
percentage point difference as a rule of thumb.
vii
Highlights From Appendix A: Overall Results by
Hospital Characteristics
Bed Size (Tables A-1, A-3)
The smallest hospitals (6-24 beds) had the highest percent positive average
across all patient safety culture composites (68 percent); larger hospitals (400
beds or more) had the lowest (60 percent).
Smaller hospitals (49 beds or fewer) had the highest percentage of respondents
who gave their work area/unit a patient safety grade of “Excellent” or “Very
Good” (80 percent); larger hospitals (400 beds or more) had the lowest (71
percent).
Teaching Status and Ownership and Control (Tables A-5, A-8)
Nonteaching hospitals on average scored higher than teaching hospitals by 5
percentage points on Teamwork Across Units (60 percent positive compared with
55 percent positive) and Handoffs and Transitions (47 percent positive compared
with 42 percent).
Non-government-owned hospitals reported more events (47 percent) than
government-owned hospitals (41 percent).
Geographic Region (Tables A-9, A-11, A-12)
East South Central, West South Central, and South Atlantic/Associated
Territories hospitals had the highest average percent positive response across all
composites (65 percent positive); New England hospitals had the lowest (60
percent positive).
West North Central hospitals had the highest percentage of respondents who
gave their work area/unit a patient safety grade of “Excellent” or “Very Good”
(78 percent); New England hospitals had the lowest (69 percent).
Pacific/Associated Territories hospitals had the highest percentage of
respondents who reported one or more events in the past year (50 percent); the
lowest percentage of respondents reporting events was in the West South Central
region (41 percent).
viii
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
across the composites (69 percent positive); Emergency had the lowest (57 percent
positive).
Rehabilitation had the highest percentage of respondents who gave their work
area/unit a patient safety grade of “Excellent” or “Very Good” (85 percent);
Emergency had the lowest (64 percent).
ICU (Any Type) had the highest percentage of respondents reporting one or more
events in the past year (64 percent); Rehabilitation had the lowest (39 percent).
Staff Position (Tables B-5, B-7, B-8)
Respondents in Administration/Management had the highest average percent
positive response across the composites (74 percent positive); Pharmacists had the
lowest (60 percent positive).
Administration/Management had the highest percentage of respondents who gave
their work area/unit a patient safety grade of “Excellent” or “Very Good” (86
percent); Pharmacists had the lowest (68 percent).
Pharmacists had the highest percentage of respondents reporting one or more
events in the past year (71 percent); Unit Assistants/Clerks/Secretaries had the
lowest (16 percent).
Interaction With Patients (Tables B-9, B-11, B-12)
Respondents with direct patient interaction were more positive on Handoffs and
Transitions compared with those without direct patient interaction (47 percent
positive compared with 39 percent).
Respondents without direct patient interaction were more positive than those with
direct patient interaction on Management Support for Patient Safety (77 percent
positive compared with 71 percent).
Respondents without direct patient interaction had a higher percentage of
respondents who gave their work area/unit a patient safety grade of “Excellent” or
“Very Good” (80 percent) than respondents with direct patient interaction (75
percent).
More respondents with direct patient interaction reported one or more events in the
past year (50 percent) than respondents without direct patient interaction (30
percent).
ix
Part III—Appendixes C & D: Trending Results by Hospital and
Respondent Characteristics
Appendixes C and D show trends over time for the 650 hospitals (of the 1,128 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 for 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
Geographic region
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. Therefore, in
Appendix C, two of the standard American Hospital Association geographic regions (MidAtlantic and New England) have been combined.
Tables 1 and 2 below show examples of the statistics in this appendix. The tables show the
average percentage 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 a positive number if the most recent administration showed
an increase. Changes in scores of 5 percentage points or more, whether positive or negative, are
shown in bold in the tables.
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.
x
Highlights From Appendix C: Trending Results by
Hospital Characteristics
Bed Size (Tables C-5, C-7)
Hospitals with 50-99 beds had the greatest increases in percent positive response
over time on all 12 composites (an average increase of 2 percentage points).
Hospitals with 50-99 beds had the greatest increase in the percentage of
respondents who gave their work area/unit a patient safety grade of “Excellent”
or “Very Good” (a 3 percentage point increase, from 75 percent to 78 percent).
Teaching Status and Ownership and Control (Table C-9)
Nonteaching hospitals showed increases up to 2 percentage points on all 12
patient safety composites; teaching hospitals showed increases of 1 percentage
point on half of the composites and decreased by 1 percentage point on
Supervisor/Manager Expectations.
Government-owned hospitals showed increases up to 2 percentage points across
11 composites; non-government-owned hospitals showed increases of 1
percentage point on 9 composites.
Geographic Region (Tables C-13, C-15)
West North Central hospitals had the greatest increases in percent positive
response over time on 6 of the 12 composites (average increase of 2 percentage
points).
West North Central hospitals had the greatest increase in the percentage of
respondents who gave their work area/unit a patient safety grade of “Excellent”
or “Very Good” (a 3 percentage point increase, from 75 percent to 78 percent).
xi
Highlights From Appendix D: Trending Results by
Respondent Characteristics
Work Area/Unit (Tables D-1, D-3, D-4)
Rehabilitation had the greatest increase in percent positive response on 10
patient safety culture composites (average increases of 3 percentage points).
Emergency, Radiology, and Rehabilitation had the greatest increases over time in
the average percentage of respondents giving their work area/unit a patient safety
grade of “Excellent” or “Very Good” (3 percentage point increases, from 62
percent to 65 percent, 79 percent to 82 percent, and 82 percent to 85 percent,
respectively).
Anesthesiology and Lab had the greatest increases in the average percentage of
respondents reporting one or more events in the past year (3 percentage point
increases). The largest decrease was in Psychiatry/Mental Health (a 4 percentage
point decrease).
Staff Position (Tables D-5, D-7, D-8)
Patient Care Asst./Aide/Care Partner had the greatest increase in positive
response over time on 5 of the 12 patient safety composites (average increase of
2 percentage points).
Pharmacists had the greatest increase over time in the average percentage of
respondents giving their work area/unit a patient safety grade of “Excellent” or
“Very Good” (a 3 percentage point increase).
Dietitians had the greatest decrease over time in the average percentage of
respondents reporting one or more events in the past year (an 11 percentage
point decrease).
Interaction With Patients (Table D-9)
Respondents with direct interaction with patients showed an increase of 1
percentage point across 11 patient safety culture composites; respondents
without direct interaction showed an increase of 1 percentage point across 10
composites.
xii
Part II
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.
1
Table A-1. Composite-Level Average Percent Positive Response by Bed Size
Bed Size
Patient Safety Culture Composites
# Hospitals
# Respondents
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
74
165
196
250
192
94
63
94
7,322
22,687
47,914
94,361
120,566
72,147
68,752
133,954
1.
Teamwork Within Units
82%
82%
81%
80%
79%
78%
78%
78%
2.
Supervisor/Manager Expectations & Actions Promoting Patient Safety
78%
78%
77%
75%
73%
73%
72%
72%
3.
Org Learning--Continuous Improvement
74%
74%
73%
72%
71%
72%
71%
71%
4.
Management Support for Patient Safety
77%
76%
74%
71%
69%
70%
69%
68%
5.
Overall Perceptions of Patient Safety
72%
71%
68%
65%
63%
63%
61%
61%
6.
Feedback & Communication About Error
66%
66%
66%
64%
63%
64%
63%
62%
7.
Frequency of Events Reported
65%
66%
65%
64%
62%
63%
61%
60%
8.
Communication Openness
64%
63%
63%
61%
60%
60%
60%
59%
9.
Teamwork Across Units
66%
64%
61%
57%
55%
55%
54%
53%
10.
Staffing
63%
61%
58%
56%
53%
53%
53%
53%
11.
Handoffs & Transitions
56%
52%
48%
43%
41%
42%
40%
40%
12.
Nonpunitive Response to Error
50%
48%
46%
43%
42%
41%
40%
39%
68%
67%
65%
63%
61%
61%
60%
60%
Average Across Composites
2
Table A-2. Item-Level Average Percent Positive Response by Bed Size (Page 1 of 4)
Bed Size
Survey Items by Composite
# Hospitals
# Respondents
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
74
165
196
250
192
94
63
94
7,322
22,687
47,914
94,361
120,566
72,147
68,752
133,954
Teamwork Within Units
A1.
People support one another in this unit.
87%
87%
86%
86%
85%
85%
85%
84%
A3.
When a lot of work needs to be done quickly, we work together as a
team to get the work done.
89%
88%
87%
86%
85%
84%
85%
84%
A4.
In this unit, people treat each other with respect.
80%
80%
79%
78%
77%
77%
76%
76%
A11.
When one area in this unit gets really busy, others help out.
72%
72%
71%
69%
68%
68%
68%
68%
Supervisor/Manager Expectations & Actions Promoting Patient
Safety
B1.
My supv/mgr says a good word when he/she sees a job done according
to established patient safety procedures.
75%
75%
76%
73%
72%
72%
71%
71%
B2.
My supv/mgr seriously considers staff suggestions for improving patient
safety.
78%
78%
78%
76%
75%
75%
74%
74%
B3R.
Whenever pressure builds up, my supv/mgr wants us to work faster,
even if it means taking shortcuts.
79%
78%
75%
73%
70%
71%
71%
70%
B4R.
My supv/mgr overlooks patient safety problems that happen over and
over.
78%
79%
78%
76%
74%
74%
74%
74%
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve patient safety.
84%
85%
84%
83%
82%
83%
83%
82%
A9.
Mistakes have led to positive changes here.
67%
66%
64%
63%
63%
63%
63%
63%
A13.
After we make changes to improve patient safety, we evaluate their
effectiveness.
70%
71%
70%
69%
68%
69%
68%
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).
3
Table A-2. Item-Level Average Percent Positive Response by Bed Size (Page 2 of 4)
Bed Size
Survey Items by Composite
# Hospitals
# Respondents
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
74
165
196
250
192
94
63
94
7,322
22,687
47,914
94,361
120,566
72,147
68,752
133,954
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient safety.
85%
85%
83%
80%
78%
78%
78%
78%
F8.
The actions of hospital mgmt show that patient safety is a top priority.
78%
78%
76%
74%
73%
73%
73%
72%
F9R.
Hospital mgmt seems interested in patient safety only after an adverse
event happens.
66%
66%
63%
60%
57%
58%
56%
55%
Overall Perceptions of Patient Safety
A10R.
It is just by chance that more serious mistakes don’t happen around
here.
69%
67%
64%
61%
59%
59%
59%
58%
A15.
Patient safety is never sacrificed to get more work done.
74%
70%
67%
63%
61%
60%
59%
59%
71%
70%
67%
64%
61%
60%
58%
58%
74%
75%
73%
72%
71%
71%
70%
69%
A17R. We have patient safety problems in this unit.
A18.
Our procedures and systems are good at preventing errors from
happening.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on event
reports.
55%
56%
58%
57%
56%
57%
57%
56%
C3.
We are informed about errors that happen in this unit.
69%
68%
67%
65%
63%
64%
63%
62%
C5.
In this unit, we discuss ways to prevent errors from happening again.
74%
74%
74%
71%
70%
71%
70%
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).
4
Table A-2. Item-Level Average Percent Positive Response by Bed Size (Page 3 of 4)
Bed Size
Survey Items by Composite
# Hospitals
# Respondents
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
74
165
196
250
192
94
63
94
7,322
22,687
47,914
94,361
120,566
72,147
68,752
133,954
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before affecting
the patient, how often is this reported?
58%
58%
58%
57%
56%
57%
55%
54%
D2.
When a mistake is made, but has no potential to harm the patient, how
often is this reported?
61%
62%
61%
60%
58%
58%
56%
55%
D3.
When a mistake is made that could harm the patient, but does not, how
often is this reported?
76%
76%
76%
74%
73%
72%
70%
70%
Communication Openness
C2.
Staff will freely speak up if they see something that may negatively
affect patient care.
78%
77%
77%
75%
74%
73%
73%
72%
C4.
Staff feel free to question the decisions or actions of those with more
authority.
49%
47%
48%
46%
46%
46%
46%
45%
C6R.
Staff are afraid to ask questions when something does not seem right.
66%
64%
64%
62%
61%
60%
61%
60%
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
53%
53%
48%
45%
42%
42%
41%
40%
F4.
There is good cooperation among hospital units that need to work
together.
67%
66%
62%
59%
56%
57%
56%
54%
F6R.
It is often unpleasant to work with staff from other hospital units.
66%
64%
61%
58%
56%
57%
56%
55%
F10.
Hospital units work well together to provide the best care for patients.
76%
74%
71%
68%
65%
66%
65%
64%
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 4 of 4)
Bed Size
Survey Items by Composite
# Hospitals
# Respondents
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
74
165
196
250
192
94
63
94
7,322
22,687
47,914
94,361
120,566
72,147
68,752
133,954
Staffing
A2.
We have enough staff to handle the workload.
65%
62%
58%
55%
51%
52%
52%
50%
A5R.
Staff in this unit work longer hours than is best for patient care.
59%
56%
54%
52%
50%
50%
50%
50%
A7R.
We use more agency/temporary staff than is best for patient care.
71%
70%
68%
68%
67%
66%
66%
66%
59%
57%
53%
48%
45%
45%
45%
44%
A14R. We work in “crisis mode” trying to do too much, too quickly.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients from one
unit to another.
54%
50%
45%
39%
36%
37%
34%
34%
F5R.
Important patient care information is often lost during shift changes.
58%
55%
53%
49%
48%
49%
47%
48%
F7R.
Problems often occur in the exchange of information across hospital
units.
54%
51%
47%
42%
39%
40%
38%
38%
57%
52%
47%
43%
41%
42%
39%
40%
F11R. Shift changes are problematic for patients in this hospital.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held against them.
56%
54%
53%
49%
48%
46%
46%
45%
A12R.
When an event is reported, it feels like the person is being written up,
not the problem.
51%
49%
49%
45%
45%
44%
44%
43%
42%
40%
38%
34%
33%
31%
31%
30%
A16R. 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).
6
Table A-3. Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Bed Size
Bed Size
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
74
165
196
250
192
94
63
94
7,322
22,687
47,914
94,361
120,566
72,147
68,752
133,954
A.
Excellent
32%
33%
32%
30%
28%
27%
27%
26%
B.
Very Good
48%
47%
46%
45%
45%
45%
44%
45%
C.
Acceptable
17%
17%
18%
20%
22%
23%
23%
23%
D.
Poor
3%
3%
3%
4%
5%
5%
5%
5%
E.
Failing
0%
0%
0%
1%
1%
1%
1%
1%
Note: Percentages may not add to 100 due to rounding.
7
Table A-4. Average Percentage of Respondents Reporting Events in the Past 12 Months by Bed Size
Bed Size
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
74
165
196
250
192
94
63
94
7,322
22,687
47,914
94,361
120,566
72,147
68,752
133,954
No events
54%
55%
56%
54%
54%
54%
56%
54%
1 to 2 events
28%
27%
26%
27%
27%
27%
26%
27%
3 to 5 events
12%
12%
11%
12%
12%
12%
11%
12%
6 to 10 events
4%
4%
4%
4%
4%
4%
4%
4%
11 to 20 events
1%
2%
2%
2%
2%
2%
2%
2%
21 events or more
1%
1%
1%
1%
1%
1%
1%
1%
Number of Events Reported by Respondents
# Hospitals
# Respondents
Note: Percentages may not add to 100 due to rounding.
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
nonresponse/missing data.
9
Table A-5. Composite-Level Average Percent Positive Response by Teaching Status and Ownership and Control
Teaching Status and Ownership and Control
Patient Safety Culture Composites
# Hospitals
# Respondents
Teaching
Nonteaching
Govt
Nongovt
386
742
229
899
322,030
245,673
109,656
458,047
1.
Teamwork Within Units
78%
81%
78%
80%
2.
Supervisor/Manager Expectations & Actions Promoting Patient Safety
73%
76%
74%
75%
3.
Org Learning--Continuous Improvement
71%
73%
72%
72%
4.
Management Support for Patient Safety
70%
73%
73%
72%
5.
Overall Perceptions of Patient Safety
63%
67%
66%
66%
6.
Feedback & Communication About Error
63%
66%
64%
65%
7.
Frequency of Events Reported
61%
65%
63%
63%
8.
Communication Openness
60%
62%
60%
62%
9.
Teamwork Across Units
55%
60%
58%
58%
10.
Staffing
54%
58%
55%
57%
11.
Handoffs & Transitions
42%
47%
46%
45%
12.
Nonpunitive Response to Error
41%
45%
42%
44%
61%
64%
63%
63%
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 and Ownership and Control
Survey Items by Composite
# Hospitals
# Respondents
Teaching
Nonteaching
Govt
Nongovt
386
742
229
899
322,030
245,673
109,656
458,047
Teamwork Within Units
A1.
People support one another in this unit.
85%
86%
83%
86%
A3.
When a lot of work needs to be done quickly, we work together as a team to get the work
done.
85%
87%
84%
87%
A4.
In this unit, people treat each other with respect.
77%
79%
76%
79%
A11.
When one area in this unit gets really busy, others help out.
68%
70%
67%
70%
Supervisor/Manager Expectations & Actions Promoting Patient Safety
B1.
My supv/mgr says a good word when he/she sees a job done according to established
patient safety procedures.
71%
74%
72%
74%
B2.
My supv/mgr seriously considers staff suggestions for improving patient safety.
74%
77%
75%
76%
B3R.
Whenever pressure builds up, my supv/mgr wants us to work faster, even if it means
taking shortcuts.
71%
75%
75%
73%
B4R.
My supv/mgr overlooks patient safety problems that happen over and over.
75%
77%
76%
76%
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve patient safety.
83%
84%
83%
84%
A9.
Mistakes have led to positive changes here.
63%
64%
64%
64%
A13.
After we make changes to improve patient safety, we evaluate their effectiveness.
67%
70%
69%
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).
11
Table A-6. Item-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 2 of 4)
Teaching Status and Ownership and Control
Survey Items by Composite
# Hospitals
# Respondents
Teaching
Nonteaching
Govt
Nongovt
386
742
229
899
322,030
245,673
109,656
458,047
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient safety.
79%
82%
82%
80%
F8.
The actions of hospital mgmt show that patient safety is a top priority.
73%
76%
75%
75%
F9R.
Hospital mgmt seems interested in patient safety only after an adverse event happens.
57%
62%
61%
61%
A10R. It is just by chance that more serious mistakes don’t happen around here.
60%
63%
61%
62%
A15.
61%
66%
67%
64%
A17R. We have patient safety problems in this unit.
61%
66%
65%
64%
A18.
70%
73%
71%
72%
Overall Perceptions of Patient Safety
Patient safety is never sacrificed to get more work done.
Our procedures and systems are good at preventing errors from happening.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on event reports.
55%
57%
54%
57%
C3.
We are informed about errors that happen in this unit.
63%
67%
67%
65%
C5.
In this unit, we discuss ways to prevent errors from happening again.
70%
73%
71%
72%
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 and Ownership and Control
Survey Items by Composite
# Hospitals
# Respondents
Teaching
Nonteaching
Govt
Nongovt
386
742
229
899
322,030
245,673
109,656
458,047
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before affecting the patient, how
often is this reported?
55%
58%
57%
57%
D2.
When a mistake is made, but has no potential to harm the patient, how often is this
reported?
56%
61%
59%
60%
D3.
When a mistake is made that could harm the patient, but does not, how often is this
reported?
71%
75%
73%
74%
Communication Openness
C2.
Staff will freely speak up if they see something that may negatively affect patient care.
74%
76%
74%
76%
C4.
Staff feel free to question the decisions or actions of those with more authority.
46%
47%
46%
47%
C6R.
Staff are afraid to ask questions when something does not seem right.
61%
63%
62%
63%
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
42%
48%
45%
46%
F4.
There is good cooperation among hospital units that need to work together.
56%
62%
60%
60%
F6R.
It is often unpleasant to work with staff from other hospital units.
57%
61%
58%
60%
F10.
Hospital units work well together to provide the best care for patients.
65%
70%
69%
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).
13
Table A-6. Item-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 4 of 4)
Teaching Status and Ownership and Control
Survey Items by Composite
# Hospitals
# Respondents
Teaching
Nonteaching
Govt
Nongovt
386
742
229
899
322,030
245,673
109,656
458,047
Staffing
A2.
We have enough staff to handle the workload.
53%
57%
56%
55%
A5R.
Staff in this unit work longer hours than is best for patient care.
50%
54%
50%
53%
A7R.
We use more agency/temporary staff than is best for patient care.
66%
69%
65%
69%
46%
52%
50%
50%
A14R. We work in “crisis mode” trying to do too much, too quickly.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients from one unit to another.
36%
43%
44%
40%
F5R.
Important patient care information is often lost during shift changes.
49%
52%
51%
51%
F7R.
Problems often occur in the exchange of information across hospital units.
39%
46%
44%
44%
42%
47%
46%
45%
47%
51%
48%
50%
A12R. When an event is reported, it feels like the person is being written up, not the problem.
45%
47%
44%
47%
A16R. Staff worry that mistakes they make are kept in their personnel file.
33%
36%
35%
35%
F11R. Shift changes are problematic for patients in this hospital.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held against them.
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 Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Teaching Status and Ownership
and Control
Teaching Status and Ownership and Control
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
Teaching
Nonteaching
Govt
Nongovt
386
742
229
899
322,030
245,673
109,656
458,047
A.
Excellent
27%
31%
29%
30%
B.
Very Good
46%
45%
47%
45%
C.
Acceptable
22%
19%
20%
20%
D.
Poor
4%
4%
4%
4%
E.
Failing
1%
1%
1%
1%
Note: Percentages may not add to 100 due to rounding.
15
Table A-8. Average Percentage of Respondents Reporting Events in the Past 12 Months by Teaching Status and Ownership and Control
Teaching Status and Ownership and Control
Number of Events Reported by Respondents
Teaching
Nonteaching
Govt
Nongovt
386
742
229
899
322,030
245,673
109,656
458,047
No events
55%
55%
59%
54%
1 to 2 events
27%
27%
24%
28%
3 to 5 events
12%
11%
10%
12%
6 to 10 events
4%
4%
4%
4%
11 to 20 events
2%
2%
2%
2%
21 events or more
1%
1%
1%
1%
# Hospitals
# Respondents
Note: Percentages may not add to 100 due to rounding.
16
Appendix A: Overall Results by Hospital Characteristics
(4) Geographic Region
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 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 nonresponse/missing data.
NOTE 2: States and territories are categorized into regions defined by the American Hospital Association (AHA) as follows:
New England: CT, MA, ME, NH, RI, VT
Mid-Atlantic: NJ, NY, PA
South Atlantic/Associated Territories: DC, DE, FL, GA,
MD, NC, SC, VA, WV, Puerto Rico, Virgin Islands
East North Central: IL, IN, MI, OH, WI
East South Central: AL, KY, MS, TN
West North Central: IA, KS, MN, MO, ND, NE, SD
West South Central: AR, LA, OK, TX
Mountain: AZ, CO, ID, MT, NM, NV, UT, WY
Pacific/Associated Territories: AK, CA, HI, OR, WA,
American Samoa, Guam, Marshall Islands, Northern
Mariana Islands
17
Table A-9. Composite-Level Average Percent Positive Response by Geographic Region
Geographic Region
Patient Safety Culture Composites
# Hospitals
# Respondents
MidAtlantic
New
England
South
Atlantic*
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific*
30
82
182
279
110
142
139
73
91
23,838
70,275
101,597
142,124
36,841
47,469
56,740
39,543
49,276
1.
Teamwork Within Units
79%
76%
80%
80%
80%
81%
81%
79%
80%
2.
Supervisor/Manager Expectations & Actions Promoting Patient
Safety
72%
71%
77%
74%
78%
75%
77%
73%
74%
3.
Org Learning--Continuous Improvement
69%
71%
75%
71%
74%
72%
74%
69%
71%
4.
Management Support for Patient Safety
70%
69%
75%
71%
74%
74%
74%
69%
70%
5.
Overall Perceptions of Patient Safety
63%
62%
67%
65%
68%
68%
68%
65%
63%
6.
Feedback & Communication About Error
61%
62%
67%
63%
67%
63%
67%
63%
63%
7.
Frequency of Events Reported
61%
62%
66%
61%
67%
61%
67%
62%
63%
8.
Communication Openness
61%
60%
62%
60%
62%
61%
64%
62%
61%
9.
Teamwork Across Units
53%
55%
60%
56%
61%
60%
61%
57%
57%
10. Staffing
54%
50%
56%
57%
58%
61%
57%
56%
53%
11. Handoffs & Transitions
41%
43%
46%
43%
50%
47%
49%
43%
42%
12. Nonpunitive Response to Error
44%
39%
44%
42%
45%
47%
45%
46%
42%
61%
60%
65%
62%
65%
64%
65%
62%
62%
Average Across Composites
* Includes associated territories.
18
Table A-10. Item-Level Average Percent Positive Response by Geographic Region (Page 1 of 4)
Geographic Region
Survey Items by Composite
# Hospitals
# Respondents
MidAtlantic
New
England
South
Atlantic*
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific*
30
82
182
279
110
142
139
73
91
23,838
70,275
101,597
142,124
36,841
47,469
56,740
39,543
49,276
Teamwork Within Units
A1.
People support one another in this unit.
86%
83%
86%
86%
85%
86%
87%
84%
87%
A3.
When a lot of work needs to be done quickly, we work together
as a team to get the work done.
86%
83%
86%
86%
86%
88%
87%
85%
85%
A4.
In this unit, people treat each other with respect.
76%
75%
79%
77%
79%
78%
80%
77%
80%
A11.
When one area in this unit gets really busy, others help out.
66%
65%
70%
69%
70%
70%
71%
69%
70%
My supv/mgr says a good word when he/she sees a job done
according to established patient safety procedures.
My supv/mgr seriously considers staff suggestions for
improving patient safety.
Whenever pressure builds up, my supv/mgr wants us to work
faster, even if it means taking shortcuts.
My supv/mgr overlooks patient safety problems that happen
over and over.
Org Learning--Continuous Improvement
69%
70%
76%
72%
76%
71%
77%
72%
73%
74%
73%
78%
75%
78%
76%
78%
74%
76%
73%
69%
76%
71%
76%
76%
75%
74%
72%
73%
73%
79%
75%
80%
77%
77%
73%
73%
A6.
We are actively doing things to improve patient safety.
81%
82%
86%
83%
85%
83%
84%
80%
82%
A9.
Mistakes have led to positive changes here.
62%
61%
66%
62%
64%
65%
65%
62%
64%
A13.
After we make changes to improve patient safety, we evaluate
their effectiveness.
64%
68%
73%
67%
74%
68%
71%
65%
65%
Supervisor/Manager Expectations & Actions Promoting
Patient Safety
B1.
B2.
B3R.
B4R.
* Includes associated territories.
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 2 of 4)
Geographic Region
Survey Items by Composite
# Hospitals
# Respondents
MidAtlantic
New
England
South
Atlantic
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific
30
82
182
279
110
142
139
73
91
23,838
70,275
101,597
142,124
36,841
47,469
56,740
39,543
49,276
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient
safety.
78%
77%
83%
79%
83%
83%
83%
78%
79%
F8.
The actions of hospital mgmt show that patient safety is a top
priority.
73%
73%
78%
73%
76%
76%
77%
70%
73%
F9R.
Hospital mgmt seems interested in patient safety only after an
adverse event happens.
58%
57%
63%
59%
63%
63%
62%
58%
57%
Overall Perceptions of Patient Safety
A10R.
It is just by chance that more serious mistakes don’t happen
around here.
60%
57%
62%
62%
63%
66%
62%
63%
60%
A15.
Patient safety is never sacrificed to get more work done.
63%
62%
66%
62%
67%
65%
68%
64%
63%
60%
58%
65%
64%
67%
67%
67%
64%
61%
70%
70%
74%
71%
74%
73%
74%
69%
70%
A17R. We have patient safety problems in this unit.
A18.
Our procedures and systems are good at preventing errors
from happening.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on
event reports.
52%
53%
60%
56%
59%
54%
59%
53%
55%
C3.
We are informed about errors that happen in this unit.
61%
64%
68%
64%
70%
63%
69%
63%
63%
C5.
In this unit, we discuss ways to prevent errors from happening
again.
68%
68%
73%
70%
73%
71%
74%
71%
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).
20
Table A-10. Item-Level Average Percent Positive Response by Geographic Region (Page 3 of 4)
Geographic Region
Survey Items by Composite
# Hospitals
# Respondents
MidAtlantic
New
England
South
Atlantic
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific
30
82
182
279
110
142
139
73
91
23,838
70,275
101,597
142,124
36,841
47,469
56,740
39,543
49,276
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before
affecting the patient, how often is this reported?
54%
56%
60%
53%
61%
53%
62%
56%
57%
D2.
When a mistake is made, but has no potential to harm the
patient, how often is this reported?
56%
59%
62%
57%
63%
57%
63%
58%
59%
D3.
When a mistake is made that could harm the patient, but does
not, how often is this reported?
72%
72%
75%
73%
76%
73%
76%
72%
74%
Communication Openness
C2.
Staff will freely speak up if they see something that may
negatively affect patient care.
75%
74%
75%
75%
75%
75%
77%
76%
74%
C4.
Staff feel free to question the decisions or actions of those with
more authority.
46%
46%
48%
45%
47%
46%
50%
47%
48%
C6R.
Staff are afraid to ask questions when something does not
seem right.
63%
61%
63%
61%
64%
62%
65%
63%
62%
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
37%
41%
48%
44%
50%
47%
50%
43%
42%
F4.
There is good cooperation among hospital units that need to
work together.
53%
56%
62%
57%
63%
61%
63%
58%
58%
F6R.
It is often unpleasant to work with staff from other hospital
units.
57%
56%
61%
57%
60%
61%
60%
59%
60%
F10.
Hospital units work well together to provide the best care for
patients.
63%
65%
71%
66%
70%
71%
72%
66%
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).
21
Table A-10. Item-Level Average Percent Positive Response by Geographic Region (Page 4 of 4)
Geographic Region
Survey Items by Composite
# Hospitals
# Respondents
MidAtlantic
New
England
South
Atlantic
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific
30
82
182
279
110
142
139
73
91
23,838
70,275
101,597
142,124
36,841
47,469
56,740
39,543
49,276
Staffing
A2.
We have enough staff to handle the workload.
52%
47%
55%
55%
55%
63%
58%
55%
55%
A5R.
Staff in this unit work longer hours than is best for patient care.
50%
47%
53%
53%
56%
56%
52%
53%
49%
A7R.
We use more agency/temporary staff than is best for patient
care.
67%
64%
68%
70%
71%
69%
66%
65%
62%
46%
43%
51%
48%
52%
54%
53%
52%
46%
A14R. We work in “crisis mode” trying to do too much, too quickly.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients
from one unit to another.
35%
38%
43%
38%
47%
42%
46%
40%
37%
F5R.
Important patient care information is often lost during shift
changes.
48%
51%
52%
48%
55%
51%
54%
48%
47%
F7R.
Problems often occur in the exchange of information across
hospital units.
40%
41%
45%
41%
48%
44%
48%
42%
41%
39%
42%
46%
43%
49%
49%
49%
43%
41%
Staff feel like their mistakes are held against them.
50%
44%
50%
48%
52%
54%
52%
51%
48%
A12R. When an event is reported, it feels like the person is being
written up, not the problem.
47%
43%
47%
45%
48%
49%
47%
48%
45%
A16R. Staff worry that mistakes they make are kept in their personnel
file.
35%
30%
35%
33%
37%
39%
37%
38%
33%
F11R. Shift changes are problematic for patients in this hospital.
Nonpunitive Response to Error
A8R.
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).
22
Table A-11. Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Geographic Region
Geographic Region
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
MidAtlantic
New
England
South
Atlantic*
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific*
30
82
182
279
110
142
139
73
91
23,838
70,275
101,597
142,124
36,841
47,469
56,740
39,543
49,276
A.
Excellent
29%
25%
34%
28%
32%
28%
33%
29%
30%
B.
Very Good
45%
44%
43%
47%
45%
50%
44%
44%
46%
C.
Acceptable
21%
25%
19%
20%
19%
18%
19%
22%
20%
D.
Poor
5%
5%
4%
4%
3%
4%
3%
5%
4%
E.
Failing
1%
1%
1%
1%
1%
1%
1%
1%
1%
* Includes associated territories.
Note: Percentages may not add to 100 due to rounding.
23
Table A-12. Average Percentage of Respondents Reporting Events in the Past 12 Months by Geographic Region
Geographic Region
MidAtlantic
New
England
South
Atlantic*
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific*
30
82
182
279
110
142
139
73
91
23,838
70,275
101,597
142,124
36,841
47,469
56,740
39,543
49,276
No events
54%
56%
56%
54%
56%
51%
59%
55%
51%
1 to 2 events
27%
25%
26%
29%
26%
28%
25%
27%
28%
3 to 5 events
12%
11%
11%
11%
11%
13%
10%
11%
14%
6 to 10 events
4%
4%
4%
4%
4%
5%
4%
4%
5%
11 to 20 events
1%
2%
2%
2%
2%
2%
1%
1%
2%
21 events or more
1%
1%
1%
1%
1%
1%
1%
1%
1%
Number of Events Reported by Respondents
# Hospitals
# Respondents
* Includes associated territories.
Note: Percentages may not add to 100 due to rounding.
24
Part II
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” or “Other” or who 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
five respondents in a particular work area/unit and at least three respondents to a particular question. 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.
25
Table B-1. Composite-Level Average Percent Positive Response by Work Area/Unit
Work Area/Unit
Patient Safety Culture Composites
# Hospitals
# Respondents
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
174
842
723
823
884
635
332
706
402
868
727
888
3,086
29,862
36,120
25,391
62,449
23,709
16,602
15,154
15,393
29,929
17,863
51,857
1.
Teamwork Within Units
82%
78%
84%
76%
77%
81%
83%
75%
78%
79%
87%
77%
2.
Supervisor/Manager Expectations & Actions Promoting
Patient Safety
76%
70%
73%
75%
73%
73%
74%
75%
74%
75%
81%
73%
3.
Org Learning--Continuous Improvement
74%
66%
72%
72%
72%
72%
74%
75%
71%
71%
76%
73%
4.
Management Support for Patient Safety
67%
62%
64%
74%
67%
69%
71%
71%
69%
74%
77%
70%
5.
Overall Perceptions of Patient Safety
67%
55%
60%
70%
58%
64%
68%
64%
61%
74%
77%
66%
6.
Feedback & Communication About Error
66%
57%
60%
63%
60%
62%
63%
67%
65%
64%
71%
63%
7.
Frequency of Events Reported
57%
57%
59%
69%
62%
63%
64%
58%
66%
60%
65%
65%
8.
Communication Openness
68%
58%
61%
60%
57%
61%
64%
65%
60%
62%
71%
62%
9.
Teamwork Across Units
53%
48%
57%
55%
57%
58%
59%
54%
53%
56%
62%
54%
10. Staffing
58%
50%
58%
56%
52%
61%
61%
56%
55%
64%
63%
56%
11. Handoffs & Transitions
39%
48%
51%
37%
46%
56%
51%
30%
42%
43%
41%
43%
12. Nonpunitive Response to Error
43%
36%
40%
39%
41%
41%
45%
51%
45%
43%
59%
43%
63%
57%
62%
62%
60%
63%
65%
62%
62%
64%
69%
62%
Average Across Composites
26
Table B-2. Item-Level Average Percent Positive Response by Work Area/Unit (Page 1 of 4)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
174
842
723
823
884
635
332
706
402
868
727
888
3,086
29,862
36,120
25,391
62,449
23,709
16,602
15,154
15,393
29,929
17,863
51,857
Teamwork Within Units
A1.
People support one another in this unit.
89%
84%
89%
82%
85%
87%
88%
81%
83%
86%
92%
83%
A3.
When a lot of work needs to be done quickly, we work
together as a team to get the work done.
88%
86%
90%
83%
81%
90%
89%
81%
83%
88%
90%
86%
A4.
In this unit, people treat each other with respect.
81%
74%
80%
73%
77%
78%
81%
72%
77%
78%
88%
73%
A11.
When one area in this unit gets really busy, others help out.
69%
67%
77%
67%
64%
71%
74%
67%
69%
66%
77%
65%
Supervisor/Manager Expectations & Actions
Promoting Patient Safety
B1.
My supv/mgr says a good word when he/she sees a job
done according to established patient safety procedures.
74%
69%
71%
69%
71%
71%
71%
71%
74%
70%
77%
70%
B2.
My supv/mgr seriously considers staff suggestions for
improving patient safety.
78%
71%
74%
74%
74%
73%
75%
77%
76%
75%
84%
75%
B3R.
Whenever pressure builds up, my supv/mgr wants us to
work faster, even if it means taking shortcuts.
74%
67%
72%
79%
71%
71%
74%
77%
72%
75%
80%
70%
B4R.
My supv/mgr overlooks patient safety problems that
happen over and over.
79%
72%
75%
77%
74%
75%
76%
77%
75%
78%
83%
75%
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve patient safety.
86%
79%
84%
82%
84%
83%
86%
87%
82%
84%
89%
85%
A9.
Mistakes have led to positive changes here.
67%
57%
61%
67%
61%
63%
64%
74%
61%
63%
63%
64%
A13.
After we make changes to improve patient safety, we
evaluate their effectiveness.
68%
62%
69%
66%
70%
69%
71%
66%
69%
66%
74%
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).
27
Table B-2. Item-Level Average Percent Positive Response by Work Area/Unit (Page 2 of 4)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
174
842
723
823
884
635
332
706
402
868
727
888
3,086
29,862
36,120
25,391
62,449
23,709
16,602
15,154
15,393
29,929
17,863
51,857
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes
patient safety.
78%
72%
72%
82%
75%
78%
80%
78%
76%
84%
86%
79%
F8.
The actions of hospital mgmt show that patient safety is a
top priority.
70%
65%
67%
77%
70%
72%
73%
75%
72%
76%
80%
72%
F9R.
Hospital mgmt seems interested in patient safety only after
an adverse event happens.
55%
50%
53%
62%
57%
58%
58%
60%
59%
61%
66%
58%
Overall Perceptions of Patient Safety
A10R.
It is just by chance that more serious mistakes don’t
happen around here.
67%
54%
60%
63%
57%
62%
66%
61%
59%
69%
74%
63%
A15.
Patient safety is never sacrificed to get more work done.
62%
53%
54%
70%
55%
57%
63%
62%
63%
73%
78%
62%
64%
51%
58%
70%
54%
63%
66%
61%
53%
75%
76%
65%
75%
63%
69%
77%
67%
72%
76%
73%
68%
77%
80%
74%
A17R. We have patient safety problems in this unit.
A18.
Our procedures and systems are good at preventing errors
from happening.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place
based on event reports.
56%
51%
54%
54%
54%
56%
56%
56%
58%
55%
63%
53%
C3.
We are informed about errors that happen in this unit.
68%
57%
58%
67%
60%
60%
61%
70%
65%
67%
71%
64%
C5.
In this unit, we discuss ways to prevent errors from
happening again.
74%
62%
68%
70%
67%
71%
72%
74%
71%
71%
79%
72%
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 3 of 4)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
174
842
723
823
884
635
332
706
402
868
727
888
3,086
29,862
36,120
25,391
62,449
23,709
16,602
15,154
15,393
29,929
17,863
51,857
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected
before affecting the patient, how often is this reported?
53%
48%
50%
63%
54%
54%
56%
47%
61%
52%
61%
59%
D2.
When a mistake is made, but has no potential to harm the
patient, how often is this reported?
51%
54%
56%
63%
59%
59%
61%
55%
61%
55%
60%
62%
D3.
When a mistake is made that could harm the patient, but
does not, how often is this reported?
67%
69%
72%
80%
73%
74%
77%
73%
75%
72%
75%
75%
Communication Openness
C2.
Staff will freely speak up if they see something that may
negatively affect patient care.
79%
70%
75%
73%
71%
77%
77%
74%
74%
77%
84%
77%
C4.
Staff feel free to question the decisions or actions of those
with more authority.
56%
44%
45%
44%
42%
46%
48%
52%
46%
45%
56%
46%
C6R.
Staff are afraid to ask questions when something does not
seem right.
69%
59%
63%
63%
59%
62%
65%
68%
60%
64%
73%
62%
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
39%
36%
43%
42%
44%
45%
46%
42%
39%
44%
48%
41%
F4.
There is good cooperation among hospital units that need
to work together.
54%
48%
57%
57%
58%
60%
61%
55%
53%
58%
63%
55%
F6R.
It is often unpleasant to work with staff from other hospital
units.
55%
50%
63%
54%
61%
60%
61%
57%
59%
55%
64%
56%
F10.
Hospital units work well together to provide the best care
for patients.
63%
58%
66%
66%
66%
68%
68%
64%
61%
67%
71%
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).
29
Table B-2. Item-Level Average Percent Positive Response by Work Area/Unit (Page 4 of 4)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
174
842
723
823
884
635
332
706
402
868
727
888
3,086
29,862
36,120
25,391
62,449
23,709
16,602
15,154
15,393
29,929
17,863
51,857
Staffing
A2.
We have enough staff to handle the workload.
61%
44%
56%
51%
47%
58%
59%
51%
49%
62%
59%
55%
A5R.
Staff in this unit work longer hours than is best for patient
care.
47%
50%
54%
58%
50%
56%
57%
57%
54%
62%
59%
48%
A7R.
We use more agency/temporary staff than is best for
patient care.
70%
67%
73%
68%
69%
78%
74%
69%
69%
75%
72%
72%
54%
38%
49%
47%
44%
52%
56%
47%
49%
57%
63%
48%
A14R. We work in “crisis mode” trying to do too much, too quickly.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients
from one unit to another.
36%
45%
41%
28%
41%
48%
45%
22%
35%
41%
38%
40%
F5R.
Important patient care information is often lost during shift
changes.
45%
58%
61%
45%
51%
65%
60%
36%
50%
48%
45%
49%
F7R.
Problems often occur in the exchange of information
across hospital units.
38%
45%
46%
36%
44%
51%
46%
30%
39%
42%
43%
42%
35%
45%
58%
40%
46%
61%
53%
33%
43%
42%
39%
39%
Staff feel like their mistakes are held against them.
50%
43%
46%
45%
46%
48%
51%
56%
50%
49%
64%
48%
A12R. When an event is reported, it feels like the person is being
written up, not the problem.
43%
38%
43%
42%
44%
44%
48%
54%
50%
45%
62%
46%
37%
28%
31%
29%
32%
31%
35%
44%
37%
34%
52%
35%
F11R. Shift changes are problematic for patients in this hospital.
Nonpunitive Response to Error
A8R.
A16R.
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).
30
Table B-3. Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Work Area/Unit
Work Area/Unit
Work Area/Unit Patient Safety Grade
Anesthesiology
Emergency
ICU
(any
type)
174
842
3,086
# Hospitals
# Respondents
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
723
823
884
635
332
706
402
868
727
888
29,862
36,120
25,391
62,449
23,709
16,602
15,154
15,393
29,929
17,863
51,857
A.
Excellent
36%
20%
24%
30%
20%
29%
29%
25%
25%
34%
40%
32%
B.
Very Good
43%
44%
48%
47%
47%
46%
49%
47%
43%
46%
45%
44%
C.
Acceptable
17%
26%
22%
20%
26%
20%
18%
22%
23%
16%
12%
19%
D.
Poor
3%
8%
5%
3%
6%
4%
4%
5%
7%
3%
2%
4%
E.
Failing
0%
2%
1%
0%
1%
1%
1%
1%
1%
0%
0%
1%
Note: Percentages may not add to 100 due to rounding.
31
Table B-4. Average Percentage of Respondents Reporting Events in the Past 12 Months by Work Area/Unit
Work Area/Unit
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
174
842
723
823
884
635
332
706
402
868
727
888
3,086
29,862
36,120
25,391
62,449
23,709
16,602
15,154
15,393
29,929
17,863
51,857
No events
56%
48%
36%
46%
42%
46%
45%
46%
51%
56%
60%
47%
1 to 2 events
31%
31%
39%
26%
32%
35%
35%
20%
26%
32%
30%
32%
3 to 5 events
10%
13%
17%
14%
18%
13%
14%
15%
15%
9%
7%
14%
6 to 10 events
3%
5%
5%
7%
6%
4%
4%
9%
6%
3%
2%
5%
11 to 20 events
1%
2%
2%
4%
2%
1%
1%
6%
2%
1%
0%
2%
21 events or more
0%
1%
1%
3%
1%
0%
0%
5%
1%
0%
0%
1%
Number of Events Reported by
Respondents
# Hospitals
# Respondents
Note: Percentages may not add to 100 due to rounding.
32
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 who 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
five respondents in a particular staff position and at least three respondents to a particular question. 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.
33
Table B-5. Composite-Level Average Percent Positive Response by Staff Position
Staff Position
Attending/
Physician/
Resident/
Admin/
PA or
Mgmt
NP
Dietitian
Patient Safety Culture Composites
# Hospitals
975
# Respondents 41,700
Pat. Care
Asst/
Aide/
Care
PharmPartner
acist
RN/
LVN/
LPN
Therapist
(Respir,
Unit
Tech
Phys,
Asst/
(EKG, Lab, Occup,
Clerk/
Radiol)
Speech) Secretary
543
227
842
541
1,109
971
897
928
29,162
2,334
29,213
9,454
191,381
58,335
24,776
34,414
1.
Teamwork Within Units
89%
83%
81%
73%
77%
80%
76%
85%
78%
2.
Supervisor/Manager Expectations & Actions Promoting Patient
Safety
86%
71%
76%
74%
75%
73%
73%
77%
76%
3.
Org Learning--Continuous Improvement
83%
70%
71%
74%
75%
72%
71%
71%
72%
4.
Management Support for Patient Safety
85%
70%
75%
73%
67%
67%
73%
73%
76%
5.
Overall Perceptions of Patient Safety
75%
64%
66%
63%
60%
61%
70%
72%
67%
6.
Feedback & Communication About Error
78%
59%
66%
67%
62%
61%
64%
66%
68%
7.
Frequency of Events Reported
70%
54%
56%
67%
52%
63%
63%
58%
68%
8.
Communication Openness
77%
64%
65%
57%
64%
60%
60%
66%
60%
9.
Teamwork Across Units
67%
58%
60%
59%
51%
56%
55%
62%
58%
10. Staffing
64%
54%
55%
50%
54%
58%
58%
61%
54%
11. Handoffs & Transitions
47%
42%
36%
50%
28%
48%
41%
43%
45%
12. Nonpunitive Response to Error
63%
40%
44%
35%
52%
43%
41%
50%
39%
74%
61%
63%
62%
60%
62%
62%
65%
63%
Average Across Composites
34
Table B-6. Item-Level Average Percent Positive Response by Staff Position (Page 1 of 4)
Staff Position
Admin/
Mgmt
Survey Items by Composite
# Hospitals
# Respondents
Attending/
Pat. Care
Physician/
Asst/
Resident/
Aide/
PA or
Care
PharmNP
Dietitian Partner
acist
RN/
LVN/
LPN
Therapist
(Respir,
Unit
Tech
Phys,
Asst/
(EKG, Lab, Occup,
Clerk/
Radiol)
Speech) Secretary
975
543
227
842
541
1,109
971
897
928
41,700
29,162
2,334
29,213
9,454
191,381
58,335
24,776
34,414
Teamwork Within Units
A1.
People support one another in this unit.
94%
89%
85%
79%
84%
87%
82%
90%
84%
A3.
When a lot of work needs to be done quickly, we work together as
a team to get the work done.
93%
86%
86%
78%
82%
87%
84%
89%
85%
A4.
In this unit, people treat each other with respect.
89%
86%
80%
71%
75%
78%
73%
83%
75%
A11.
When one area in this unit gets really busy, others help out.
79%
70%
75%
64%
66%
69%
66%
76%
69%
My supv/mgr says a good word when he/she sees a job done
according to established patient safety procedures.
My supv/mgr seriously considers staff suggestions for improving
patient safety.
Whenever pressure builds up, my supv/mgr wants us to work
faster, even if it means taking shortcuts.
My supv/mgr overlooks patient safety problems that happen over
and over.
Org Learning--Continuous Improvement
85%
68%
78%
72%
69%
71%
69%
75%
76%
89%
75%
80%
75%
76%
74%
73%
80%
77%
84%
67%
70%
73%
76%
72%
75%
75%
76%
85%
73%
76%
74%
76%
75%
76%
79%
77%
A6.
We are actively doing things to improve patient safety.
89%
83%
82%
86%
87%
84%
83%
84%
83%
A9.
Mistakes have led to positive changes here.
81%
67%
62%
61%
76%
62%
63%
60%
63%
A13.
After we make changes to improve patient safety, we evaluate
their effectiveness.
79%
61%
69%
74%
61%
70%
66%
69%
70%
Supervisor/Manager Expectations & Actions Promoting
Patient Safety
B1.
B2.
B3R.
B4R.
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 2 of 4)
Staff Position
Admin/
Mgmt
Survey Items by Composite
# Hospitals
# Respondents
Attending/
Pat. Care
Physician/
Asst/
Resident/
Aide/
PA or
Care
PharmNP
Dietitian Partner
acist
RN/
LVN/
LPN
Therapist
(Respir,
Unit
Tech
Phys,
Asst/
(EKG, Lab, Occup,
Clerk/
Radiol)
Speech) Secretary
975
543
227
842
541
1,109
971
897
928
41,700
29,162
2,334
29,213
9,454
191,381
58,335
24,776
34,414
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient
safety.
91%
79%
86%
82%
73%
75%
82%
82%
85%
F8.
The actions of hospital mgmt show that patient safety is a top
priority.
88%
73%
79%
78%
70%
69%
75%
75%
79%
F9R.
Hospital mgmt seems interested in patient safety only after an
adverse event happens.
77%
59%
60%
59%
57%
56%
60%
61%
63%
A10R. It is just by chance that more serious mistakes don’t happen
around here.
74%
65%
61%
53%
59%
61%
65%
69%
59%
A15.
74%
60%
65%
65%
54%
56%
70%
69%
70%
74%
62%
64%
62%
56%
58%
71%
72%
68%
80%
70%
73%
72%
69%
69%
76%
76%
73%
Overall Perceptions of Patient Safety
Patient safety is never sacrificed to get more work done.
A17R. We have patient safety problems in this unit.
A18.
Our procedures and systems are good at preventing errors from
happening.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on
event reports.
71%
52%
58%
60%
52%
54%
54%
58%
60%
C3.
We are informed about errors that happen in this unit.
79%
58%
67%
68%
65%
59%
67%
67%
71%
C5.
In this unit, we discuss ways to prevent errors from happening
again.
85%
68%
75%
71%
70%
68%
70%
73%
73%
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-6. Item-Level Average Percent Positive Response by Staff Position (Page 3 of 4)
Staff Position
Admin/
Mgmt
Survey Items by Composite
# Hospitals
# Respondents
Attending/
Pat. Care
Physician/
Asst/
Resident/
Aide/
PA or
Care
PharmNP
Dietitian Partner
acist
RN/
LVN/
LPN
Therapist
(Respir,
Unit
Tech
Phys,
Asst/
(EKG, Lab, Occup,
Clerk/
Radiol)
Speech) Secretary
975
543
227
842
541
1,109
971
897
928
41,700
29,162
2,334
29,213
9,454
191,381
58,335
24,776
34,414
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before
affecting the patient, how often is this reported?
64%
48%
53%
64%
39%
53%
57%
53%
64%
D2.
When a mistake is made, but has no potential to harm the patient,
how often is this reported?
65%
48%
49%
63%
48%
61%
58%
53%
63%
D3.
When a mistake is made that could harm the patient, but does not,
how often is this reported?
80%
67%
67%
73%
71%
75%
74%
70%
76%
Communication Openness
C2.
Staff will freely speak up if they see something that may negatively
affect patient care.
85%
73%
78%
73%
73%
74%
74%
80%
76%
C4.
Staff feel free to question the decisions or actions of those with
more authority.
70%
55%
53%
40%
52%
44%
43%
51%
43%
C6R.
Staff are afraid to ask questions when something does not seem
right.
75%
64%
64%
57%
69%
62%
62%
68%
61%
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
56%
45%
47%
46%
39%
43%
43%
49%
46%
F4.
There is good cooperation among hospital units that need to work
together.
70%
60%
61%
61%
50%
56%
58%
64%
60%
F6R.
It is often unpleasant to work with staff from other hospital units.
66%
63%
62%
59%
56%
60%
54%
66%
57%
F10.
Hospital units work well together to provide the best care for
patients.
76%
66%
71%
70%
60%
65%
67%
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).
37
Table B-6. Item-Level Average Percent Positive Response by Staff Position (Page 4 of 4)
Staff Position
Admin/
Mgmt
Survey Items by Composite
# Hospitals
# Respondents
Attending/
Pat. Care
Physician/
Asst/
Resident/
Aide/
PA or
Care
PharmNP
Dietitian Partner
acist
RN/
LVN/
LPN
Therapist
(Respir,
Unit
Tech
Phys,
Asst/
(EKG, Lab, Occup,
Clerk/
Radiol)
Speech) Secretary
975
543
227
842
541
1,109
971
897
928
41,700
29,162
2,334
29,213
9,454
191,381
58,335
24,776
34,414
Staffing
A2.
We have enough staff to handle the workload.
69%
56%
57%
46%
47%
55%
55%
56%
53%
A5R.
Staff in this unit work longer hours than is best for patient care.
59%
49%
49%
45%
57%
55%
57%
58%
49%
A7R.
We use more agency/temporary staff than is best for patient care.
72%
61%
62%
64%
70%
75%
70%
73%
64%
58%
51%
52%
46%
42%
48%
51%
56%
52%
43%
40%
33%
47%
19%
43%
35%
38%
43%
52%
46%
39%
57%
33%
55%
47%
47%
51%
46%
42%
36%
46%
28%
46%
39%
44%
45%
47%
39%
36%
49%
30%
49%
41%
42%
43%
68%
46%
51%
41%
57%
49%
47%
55%
45%
A12R. When an event is reported, it feels like the person is being written
up, not the problem.
69%
43%
44%
36%
56%
47%
42%
51%
41%
A16R. Staff worry that mistakes they make are kept in their personnel file.
50%
31%
37%
27%
43%
34%
33%
43%
31%
A14R. We work in “crisis mode” trying to do too much, too quickly.
Handoffs & Transitions
F3R.
F5R.
F7R.
Things “fall between the cracks” when transferring patients from
one unit to another.
Important patient care information is often lost during shift
changes.
Problems often occur in the exchange of information across
hospital units.
F11R. Shift changes are problematic for patients in this hospital.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held against them.
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).
38
Table B-7. Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Staff Position
Staff Position
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
975
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
543
227
842
541
1,109
971
897
928
41,700
29,162
2,334
29,213
9,454
191,381
58,335
24,776
34,414
Unit
Asst/
Clerk/
Secretary
A.
Excellent
40%
29%
27%
29%
21%
24%
32%
33%
33%
B.
Very Good
46%
45%
49%
44%
47%
46%
45%
46%
46%
C.
Acceptable
13%
21%
20%
22%
25%
23%
18%
17%
18%
D.
Poor
1%
4%
3%
4%
6%
5%
4%
3%
3%
E.
Failing
0%
1%
1%
1%
1%
1%
1%
1%
1%
Note: Percentages may not add to 100 due to rounding.
39
Table B-8. Average Percentage of Respondents Reporting Events in the Past 12 Months by Staff Position
Staff Position
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
543
227
842
541
1,109
971
897
928
41,700
29,162
2,334
29,213
9,454
191,381
58,335
24,776
34,414
No events
49%
63%
79%
77%
29%
32%
59%
61%
83%
1 to 2 events
21%
26%
14%
18%
24%
39%
27%
30%
12%
3 to 5 events
15%
8%
4%
3%
20%
20%
9%
6%
3%
6 to 10 events
8%
2%
2%
1%
13%
6%
3%
2%
1%
11 to 20 events
4%
1%
1%
0%
8%
2%
1%
1%
0%
21 events or more
3%
0%
0%
0%
6%
1%
1%
0%
0%
Number of Events Reported by
Respondents
# Hospitals
# Respondents
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
975
Note: Percentages may not add to 100 due to rounding.
40
Unit
Asst/
Clerk/
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 five respondents in the response categories and at least three respondents to a particular question. 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.
41
Table B-9. Composite-Level Average Percent Positive Response by Interaction With Patients
Interaction With Patients
Patient Safety Culture Composites
# Hospitals
# Respondents
WITH
direct interaction
WITHOUT
direct interaction
1,113
1,054
407,880
130,006
1.
Teamwork Within Units
80%
81%
2.
Supervisor/Manager Expectations & Actions Promoting Patient Safety
75%
77%
3.
Org Learning--Continuous Improvement
72%
73%
4.
Management Support for Patient Safety
71%
77%
5.
Overall Perceptions of Patient Safety
66%
68%
6.
Feedback & Communication About Error
64%
68%
7.
Frequency of Events Reported
63%
65%
8.
Communication Openness
61%
64%
9.
Teamwork Across Units
58%
59%
10.
Staffing
58%
54%
11.
Handoffs & Transitions
47%
39%
12.
Nonpunitive Response to Error
44%
46%
63%
64%
Average Across Composites
42
Table B-10. Item-Level Average Percent Positive Response by Interaction With Patients (Page 1 of 4)
Interaction With Patients
Survey Items by Composite
# Hospitals
# Respondents
WITH
direct interaction
WITHOUT
direct interaction
1,113
1,054
407,880
130,006
Teamwork Within Units
A1.
People support one another in this unit.
86%
86%
A3.
When a lot of work needs to be done quickly, we work together as a team to get the work done.
86%
87%
A4.
In this unit, people treat each other with respect.
78%
80%
A11.
When one area in this unit gets really busy, others help out.
69%
70%
Supervisor/Manager Expectations & Actions Promoting Patient Safety
B1.
My supv/mgr says a good word when he/she sees a job done according to established patient safety
procedures.
72%
77%
B2.
My supv/mgr seriously considers staff suggestions for improving patient safety.
76%
79%
B3R.
Whenever pressure builds up, my supv/mgr wants us to work faster, even if it means taking shortcuts.
73%
76%
B4R.
My supv/mgr overlooks patient safety problems that happen over and over.
76%
77%
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve patient safety.
84%
82%
A9.
Mistakes have led to positive changes here.
63%
69%
A13.
After we make changes to improve patient safety, we evaluate their effectiveness.
70%
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).
43
Table B-10. Item-Level Average Percent Positive Response by Interaction With Patients (Page 2 of 4)
Interaction With Patients
Survey Items by Composite
# Hospitals
# Respondents
WITH
direct interaction
WITHOUT
direct interaction
1,113
1,054
407,880
130,006
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient safety.
80%
86%
F8.
The actions of hospital mgmt show that patient safety is a top priority.
73%
80%
F9R.
Hospital mgmt seems interested in patient safety only after an adverse event happens.
60%
66%
A10R. It is just by chance that more serious mistakes don’t happen around here.
63%
62%
A15.
64%
68%
A17R. We have patient safety problems in this unit.
64%
67%
A18.
72%
74%
Overall Perceptions of Patient Safety
Patient safety is never sacrificed to get more work done.
Our procedures and systems are good at preventing errors from happening.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on event reports.
56%
60%
C3.
We are informed about errors that happen in this unit.
64%
70%
C5.
In this unit, we discuss ways to prevent errors from happening again.
71%
75%
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).
44
Table B-10. Item-Level Average Percent Positive Response by Interaction With Patients (Page 3 of 4)
Interaction With Patients
Survey Items by Composite
# Hospitals
# Respondents
WITH
direct interaction
WITHOUT
direct interaction
1,113
1,054
407,880
130,006
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before affecting the patient, how often is this
reported?
56%
61%
D2.
When a mistake is made, but has no potential to harm the patient, how often is this reported?
59%
61%
D3.
When a mistake is made that could harm the patient, but does not, how often is this reported?
74%
74%
Communication Openness
C2.
Staff will freely speak up if they see something that may negatively affect patient care.
75%
76%
C4.
Staff feel free to question the decisions or actions of those with more authority.
46%
52%
C6R.
Staff are afraid to ask questions when something does not seem right.
63%
64%
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
45%
48%
F4.
There is good cooperation among hospital units that need to work together.
59%
62%
F6R.
It is often unpleasant to work with staff from other hospital units.
60%
57%
F10.
Hospital units work well together to provide the best care for patients.
68%
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).
45
Table B-10. Item-Level Average Percent Positive Response by Interaction With Patients (Page 4 of 4)
Interaction With Patients
Survey Items by Composite
# Hospitals
# Respondents
WITH
direct interaction
WITHOUT
direct interaction
1,113
1,054
407,880
130,006
Staffing
A2.
We have enough staff to handle the workload.
55%
58%
A5R.
Staff in this unit work longer hours than is best for patient care.
54%
49%
A7R.
We use more agency/temporary staff than is best for patient care.
71%
59%
51%
49%
A14R. We work in “crisis mode” trying to do too much, too quickly.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients from one unit to another.
43%
35%
F5R.
Important patient care information is often lost during shift changes.
53%
44%
F7R.
Problems often occur in the exchange of information across hospital units.
45%
39%
47%
40%
49%
53%
A12R. When an event is reported, it feels like the person is being written up, not the problem.
46%
49%
A16R. Staff worry that mistakes they make are kept in their personnel file.
35%
37%
F11R. Shift changes are problematic for patients in this hospital.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held against them.
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).
46
Table B-11. Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Interaction With Patients
Interaction With Patients
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
WITH
direct interaction
WITHOUT
direct interaction
1,113
1,054
407,880
130,006
A.
Excellent
29%
34%
B.
Very Good
46%
46%
C.
Acceptable
20%
18%
D.
Poor
4%
2%
E.
Failing
1%
0%
Note: Percentages may not add to 100 due to rounding.
47
Table B-12. Average Percentage of Respondents Reporting Events in the Past 12 Months by Interaction With Patients
Interaction With Patients
WITH
direct interaction
WITHOUT
direct interaction
1,113
1,054
407,880
130,006
No events
50%
70%
1 to 2 events
30%
15%
3 to 5 events
13%
7%
6 to 10 events
4%
4%
11 to 20 events
2%
2%
21 events or more
1%
2%
Number of Events Reported by Respondents
# Hospitals
# Respondents
Note: Percentages may not add to 100 due to rounding.
48
Part III
Appendix C: Trending Results by Hospital Characteristics
Characteristics of the Trending Hospitals
The tables below display the distribution of trending hospitals by bed size, teaching status, and ownership and control. Alongside the
distribution of the 650 trending hospitals, the tables show the distributions of all 1,128 hospitals in the 2012 database and of all U.S.
hospitals registered with the American Hospital Association (AHA) for comparison purposes.i
As shown in Table C-1, the distribution of trending hospitals by bed size is similar to the distribution of AHA-registered U.S.
hospitals, as well as the distribution of database hospitals.
Tables C-2 and C-3 show that most of the 650 trending hospitals were nonteaching (65 percent) and non-government owned and
controlled (78 percent).
Table C-4 shows the distribution of trending hospitals by geographic region.
States and territories are categorized into AHA-defined regions as follows:
New England: CT, MA, ME, NH, RI, VT
Mid-Atlantic: NJ, NY, PA
South Atlantic/Associated Territories: DC, DE, FL, GA,
MD, NC, SC, VA, WV, Puerto Rico, Virgin Islands
East North Central: IL, IN, MI, OH, WI
East South Central: AL, KY, MS, TN
West North Central: IA, KS, MN, MO, ND, NE, SD
West South Central: AR, LA, OK, TX
Mountain: AZ, CO, ID, MT, NM, NV, UT, WY
Pacific/Associated Territories: AK, CA, HI, OR, WA,
American Samoa, Guam, Marshall Islands, Northern
Mariana Islands
i
Data for AHA-registered hospitals were obtained from the 2006 or 2010 AHA Annual Survey of Hospitals Database, © 2010 Health Forum, LLC, an affiliate of
the American Hospital Association. Hospitals not registered with AHA were asked to provide information on their hospital’s characteristics, such as bed size and
teaching status.
49
Table C-1. Distribution of 650 Trending Hospitals by Bed Size
Bed Size
2012 Trending Hospitals
2012 Database Hospitals
Number
Number
Percent
AHA-Registered U.S. Hospitals
Percent
Number
Percent
6-24 beds
52
8%
74
7%
657
10%
25-49 beds
87
13%
165
15%
1,418
22%
50-99 beds
107
16%
196
17%
1,347
21%
100-199 beds
148
23%
250
22%
1,326
21%
200-299 beds
112
17%
192
17%
709
11%
300-399 beds
54
8%
94
8%
409
6%
400-499 beds
33
5%
63
6%
218
3%
500 or more beds
TOTAL
57
9%
94
8%
323
5%
650
99%
1,128
100%
6,407
99%
Note: Percentages may not add to 100 due to rounding.
Table C-2. Distribution of 650 Trending Hospitals by Teaching Status
2012 Trending Hospitals
2012 Database Hospitals
Number
Percent
Number
Percent
Number
Percent
Teaching
227
35%
386
34%
1,516
24%
Nonteaching
423
65%
742
66%
4,891
76%
TOTAL
650
100%
1,128
100%
6,407
100%
Teaching Status
AHA-Registered U.S. Hospitals
Note: Percentages may not add to 100 due to rounding.
Table C-3. Distribution of 650 Trending Hospitals by Ownership and Control
2012 Trending Hospitals
Ownership and Control
2012 Database Hospitals
AHA-Registered U.S.
Hospitals
Number
Percent
Number
Percent
Number
Percent
Government (Federal or non-Federal)
140
22%
229
20%
1,645
26%
Nongovernment (voluntary/nonprofit or
proprietary/investor owned)
510
78%
899
80%
4,762
74%
TOTAL
650
100%
1,128
100%
6,407
100%
Note: Percentages may not add to 100 due to rounding.
50
Table C-4. Distribution of 650 Trending Hospitals by Geographic Region
2012 Trending Hospitals
Region
2012 Database Hospitals
AHA-Registered U.S.
Hospitals
Number
Percent
Number
Percent
Number
Percent
Mid-Atlantic/New England
51
8%
112
10%
873
14%
South Atlantic/Associated Territories
112
17%
182
16%
1,016
16%
East North Central
167
26%
279
25%
925
14%
East South Central
53
8%
110
10%
533
8%
West North Central
70
11%
142
13%
803
13%
West South Central
88
14%
139
12%
1,089
17%
Mountain
52
8%
73
6%
509
8%
Pacific/Associated Territories
57
9%
91
8%
659
10%
TOTAL
650
101%
1,128
100%
6,407
100%
Note: Percentages may not add to 100 due to rounding.
51
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.
52
Table C-5. Trending: Composite-Level Average Percent Positive Response by Bed Size (Page 1 of 2)
Bed Size
Patient Safety Culture Composites
# Hospitals
# Respondents
1.
2.
3.
4.
5.
6.
Teamwork Within Units
Supervisor/Manager Expectations & Actions Promoting Patient Safety
Org Learning--Continuous Improvement
Management Support for Patient Safety
Overall Perceptions of Patient Safety
Feedback & Communication About Error
Database
Year
6-24
beds
25-49
beds
50-99
beds
Both Years
52
87
107
148
112
54
33
57
Most Recent
5,175
13,066
30,508
60,134
77,867
39,462
39,711
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
83%
81%
80%
80%
80%
80%
79%
78%
Previous
83%
81%
79%
79%
79%
79%
78%
78%
Change
0%
0%
1%
1%
1%
1%
1%
0%
Most Recent
78%
77%
77%
75%
73%
74%
73%
73%
Previous
77%
78%
75%
75%
73%
73%
72%
72%
Change
1%
-1%
2%
0%
0%
1%
1%
1%
Most Recent
74%
75%
73%
72%
72%
73%
72%
71%
Previous
74%
74%
72%
72%
72%
72%
71%
71%
Change
0%
1%
1%
0%
0%
1%
1%
0%
Most Recent
78%
77%
74%
72%
71%
72%
70%
68%
Previous
77%
76%
72%
71%
70%
70%
68%
68%
Change
1%
1%
2%
1%
1%
2%
2%
0%
Most Recent
73%
71%
68%
65%
64%
64%
62%
62%
Previous
71%
71%
66%
65%
63%
63%
62%
61%
Change
2%
0%
2%
0%
1%
1%
0%
1%
Most Recent
67%
66%
67%
65%
64%
65%
65%
63%
Previous
68%
65%
64%
65%
62%
63%
63%
62%
Change
-1%
1%
3%
0%
2%
2%
2%
1%
53
100-199 200-299 300-399 400-499
beds
beds
beds
beds
500+
beds
Table C-5. Trending: Composite-Level Average Percent Positive Response by Bed Size (Page 2 of 2)
Bed Size
Patient Safety Culture Composites
# Hospitals
# Respondents
7.
8.
9.
Frequency of Events Reported
Communication Openness
Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to Error
Database
Year
6-24
beds
25-49
beds
50-99
beds
Both Years
52
87
107
148
112
54
33
57
Most Recent
5,175
13,066
30,508
60,134
77,867
39,462
39,711
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
65%
67%
65%
64%
63%
64%
62%
60%
Previous
65%
65%
63%
63%
62%
62%
60%
59%
Change
0%
2%
2%
1%
1%
2%
2%
1%
Most Recent
64%
63%
64%
62%
61%
61%
61%
60%
Previous
65%
64%
62%
62%
60%
60%
60%
60%
Change
-1%
-1%
2%
0%
1%
1%
1%
0%
Most Recent
66%
64%
61%
58%
56%
57%
55%
53%
Previous
67%
64%
59%
57%
55%
55%
53%
52%
Change
-1%
0%
2%
1%
1%
2%
2%
1%
Most Recent
64%
61%
58%
56%
54%
55%
54%
53%
Previous
62%
61%
55%
56%
53%
55%
53%
53%
Change
2%
0%
3%
0%
1%
0%
1%
0%
Most Recent
56%
52%
49%
44%
42%
43%
40%
40%
Previous
56%
52%
47%
43%
41%
41%
38%
39%
Change
0%
0%
2%
1%
1%
2%
2%
1%
Most Recent
50%
48%
47%
43%
42%
43%
41%
40%
Previous
50%
48%
46%
43%
41%
42%
40%
39%
Change
0%
0%
1%
0%
1%
1%
1%
1%
54
100-199 200-299 300-399 400-499
beds
beds
beds
beds
500+
beds
Table C-6. Trending: Item-Level Average Percent Positive Response by Bed Size (Page 1 of 6)
Bed Size
Survey Items by Composite
# Hospitals
# Respondents
1.
Teamwork Within Units
A1.
People support one another in this unit.
Database
Year
6-24
beds
25-49
beds
50-99
beds
Both Years
Most Recent
52
5,175
87
13,066
107
30,508
148
60,134
112
77,867
54
39,462
33
39,711
57
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
88%
88%
0%
90%
89%
1%
81%
81%
0%
72%
72%
0%
87%
87%
0%
88%
88%
0%
79%
80%
-1%
71%
71%
0%
86%
84%
2%
86%
85%
1%
79%
78%
1%
70%
68%
2%
86%
85%
1%
86%
85%
1%
78%
77%
1%
69%
68%
1%
85%
85%
0%
86%
85%
1%
78%
78%
0%
69%
68%
1%
86%
85%
1%
86%
85%
1%
79%
78%
1%
70%
68%
2%
84%
84%
0%
85%
85%
0%
76%
76%
0%
69%
67%
2%
85%
84%
1%
84%
84%
0%
76%
76%
0%
68%
68%
0%
75%
73%
2%
79%
78%
1%
79%
78%
1%
79%
75%
75%
0%
78%
79%
-1%
78%
78%
0%
79%
76%
73%
3%
79%
77%
2%
77%
75%
2%
78%
74%
73%
1%
76%
76%
0%
74%
74%
0%
76%
72%
72%
0%
75%
75%
0%
72%
71%
1%
75%
73%
72%
1%
76%
76%
0%
72%
71%
1%
76%
71%
71%
0%
74%
74%
0%
71%
70%
1%
74%
71%
70%
1%
74%
74%
0%
71%
71%
0%
75%
78%
1%
79%
0%
77%
1%
76%
0%
75%
0%
74%
2%
73%
1%
74%
1%
Previous
Change
A3.
When a lot of work needs to be done quickly, we work together as a team
to get the work done.
Most Recent
In this unit, people treat each other with respect.
Most Recent
Previous
Change
A4.
Previous
Change
A11.
When one area in this unit gets really busy, others help out.
Most Recent
Previous
Change
2.
Supervisor/Manager Expectations & Actions Promoting Patient Safety
B1.
My supv/mgr says a good word when he/she sees a job done according to
established patient safety procedures.
Most Recent
My supv/mgr seriously considers staff suggestions for improving patient
safety.
Most Recent
Whenever pressure builds up, my supv/mgr wants us to work faster, even if
it means taking shortcuts.
Most Recent
Previous
Change
B2.
Previous
Change
B3R.
Previous
Change
B4R.
My supv/mgr overlooks patient safety problems that happen over and over.
Most Recent
Previous
Change
100-199 200-299 300-399 400-499
beds
beds
beds
beds
500+
beds
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).
55
Table C-6. Trending: Item-Level Average Percent Positive Response by Bed Size (Page 2 of 6)
Bed Size
Survey Items by Composite
# Hospitals
# Respondents
3.
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve patient safety.
A9.
A13.
Mistakes have led to positive changes here.
After we make changes to improve patient safety, we evaluate their
effectiveness.
4.
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient safety.
F8.
F9R.
The actions of hospital mgmt show that patient safety is a top priority.
Hospital mgmt seems interested in patient safety only after an adverse
event happens.
Database
Year
6-24
beds
25-49
beds
50-99
beds
100-199 200-299 300-399 400-499
beds
beds
beds
beds
500+
beds
Both Years
52
87
107
148
112
54
33
57
Most Recent
5,175
13,066
30,508
60,134
77,867
39,462
39,711
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
85%
86%
85%
83%
83%
84%
83%
83%
Previous
84%
85%
83%
83%
83%
84%
82%
82%
Change
1%
1%
2%
0%
0%
0%
1%
1%
Most Recent
68%
66%
64%
64%
64%
65%
63%
63%
Previous
67%
65%
63%
64%
63%
64%
63%
63%
Change
1%
1%
1%
0%
1%
1%
0%
0%
Most Recent
71%
73%
71%
70%
69%
71%
70%
68%
Previous
71%
72%
69%
70%
69%
69%
68%
68%
Change
0%
1%
2%
0%
0%
2%
2%
0%
Most Recent
86%
85%
83%
80%
80%
80%
79%
78%
Previous
86%
85%
81%
80%
79%
79%
77%
77%
Change
0%
0%
2%
0%
1%
1%
2%
1%
Most Recent
79%
78%
77%
75%
74%
75%
74%
72%
Previous
78%
78%
74%
74%
73%
73%
72%
71%
Change
1%
0%
3%
1%
1%
2%
2%
1%
Most Recent
68%
67%
63%
61%
59%
60%
57%
55%
Previous
67%
66%
62%
60%
59%
58%
56%
54%
Change
1%
1%
1%
1%
0%
2%
1%
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).
56
Table C-6. Trending: Item-Level Average Percent Positive Response by Bed Size (Page 3 of 6)
Bed Size
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
5.
Patient safety is never sacrificed to get more work done.
A17R. We have patient safety problems in this unit.
A18.
Our procedures and systems are good at preventing errors from happening
.
6.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on event
reports.
C3.
C5.
25-49
beds
50-99
beds
100-199 200-299 300-399 400-499
beds
beds
beds
beds
500+
beds
Both Years
52
87
107
148
112
54
33
57
Most Recent
5,175
13,066
30,508
60,134
77,867
39,462
39,711
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
70%
67%
64%
62%
60%
61%
60%
59%
Previous
67%
67%
62%
61%
60%
59%
58%
58%
Change
3%
0%
2%
1%
0%
2%
2%
1%
Most Recent
75%
71%
68%
64%
62%
61%
60%
59%
Previous
74%
70%
66%
63%
62%
60%
59%
59%
Overall Perceptions of Patient Safety
A10R. It is just by chance that more serious mistakes don’t happen around here.
A15.
6-24
beds
We are informed about errors that happen in this unit.
In this unit, we discuss ways to prevent errors from happening again.
Change
1%
1%
2%
1%
0%
1%
1%
0%
Most Recent
72%
71%
68%
64%
62%
62%
59%
59%
Previous
71%
71%
65%
64%
61%
60%
59%
58%
Change
1%
0%
3%
0%
1%
2%
0%
1%
Most Recent
75%
75%
73%
72%
72%
73%
71%
70%
Previous
73%
75%
72%
71%
71%
71%
70%
69%
Change
2%
0%
1%
1%
1%
2%
1%
1%
Most Recent
56%
57%
59%
58%
56%
59%
59%
57%
Previous
57%
56%
56%
58%
55%
57%
57%
56%
Change
-1%
1%
3%
0%
1%
2%
2%
1%
Most Recent
69%
69%
68%
66%
64%
64%
65%
62%
Previous
71%
66%
66%
66%
63%
62%
63%
62%
Change
-2%
3%
2%
0%
1%
2%
2%
0%
Most Recent
75%
74%
74%
72%
71%
73%
71%
69%
Previous
76%
74%
71%
72%
69%
71%
69%
69%
Change
-1%
0%
3%
0%
2%
2%
2%
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).
57
Table C-6. Trending: Item-Level Average Percent Positive Response by Bed Size (Page 4 of 6)
Bed Size
Survey Items by Composite
# Hospitals
# Respondents
7.
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before affecting the
patient, how often is this reported?
D2.
D3.
When a mistake is made, but has no potential to harm the patient, how
often is this reported?
When a mistake is made that could harm the patient, but does not, how
often is this reported?
8.
Communication Openness
C2.
Staff will freely speak up if they see something that may negatively affect
patient care.
C4.
C6R.
Staff feel free to question the decisions or actions of those with more
authority.
Staff are afraid to ask questions when something does not seem right.
Database
Year
6-24
beds
25-49
beds
50-99
beds
100-199 200-299 300-399 400-499
beds
beds
beds
beds
500+
beds
Both Years
52
87
107
148
112
54
33
57
Most Recent
5,175
13,066
30,508
60,134
77,867
39,462
39,711
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
58%
60%
59%
58%
57%
58%
56%
54%
Previous
57%
58%
56%
57%
55%
56%
55%
53%
Change
1%
2%
3%
1%
2%
2%
1%
1%
Most Recent
61%
63%
61%
60%
59%
60%
58%
56%
Previous
61%
62%
58%
59%
57%
58%
56%
55%
Change
0%
1%
3%
1%
2%
2%
2%
1%
Most Recent
76%
77%
76%
75%
74%
74%
71%
70%
Previous
77%
76%
75%
74%
73%
73%
70%
70%
Change
-1%
1%
1%
1%
1%
1%
1%
0%
Most Recent
78%
77%
77%
75%
74%
74%
74%
72%
Previous
79%
77%
75%
76%
74%
74%
73%
72%
Change
-1%
0%
2%
-1%
0%
0%
1%
0%
Most Recent
49%
48%
49%
47%
46%
47%
47%
46%
Previous
50%
49%
47%
48%
46%
46%
46%
46%
Change
-1%
-1%
2%
-1%
0%
1%
1%
0%
Most Recent
66%
65%
65%
63%
62%
62%
61%
61%
Previous
67%
66%
64%
63%
62%
61%
60%
60%
Change
-1%
-1%
1%
0%
0%
1%
1%
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).
58
Table C-6. Trending: Item-Level Average Percent Positive Response by Bed Size (Page 5 of 6)
Bed Size
Survey Items by Composite
# Hospitals
# Respondents
9.
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
Database
Year
6-24
beds
25-49
beds
50-99
beds
Both Years
Most Recent
52
5,175
87
13,066
107
30,508
148
60,134
112
77,867
54
39,462
33
39,711
57
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
53%
56%
-3%
68%
69%
-1%
66%
65%
1%
76%
77%
-1%
53%
52%
1%
65%
65%
0%
63%
62%
1%
74%
74%
0%
49%
47%
2%
62%
60%
2%
61%
60%
1%
71%
68%
3%
45%
45%
0%
59%
58%
1%
59%
58%
1%
68%
67%
1%
43%
42%
1%
58%
56%
2%
57%
57%
0%
66%
66%
0%
44%
42%
2%
58%
56%
2%
60%
58%
2%
68%
65%
3%
42%
40%
2%
56%
54%
2%
56%
55%
1%
65%
63%
2%
40%
38%
2%
54%
53%
1%
55%
53%
2%
64%
62%
2%
66%
66%
0%
59%
57%
2%
71%
68%
3%
61%
61%
61%
0%
56%
56%
0%
70%
69%
1%
57%
58%
55%
3%
54%
53%
1%
67%
64%
3%
54%
55%
54%
1%
53%
53%
0%
68%
67%
1%
49%
52%
52%
0%
50%
50%
0%
67%
65%
2%
46%
55%
55%
0%
52%
51%
1%
67%
68%
-1%
46%
53%
51%
2%
51%
50%
1%
67%
67%
0%
45%
50%
51%
-1%
51%
51%
0%
67%
66%
1%
45%
59%
2%
57%
0%
50%
4%
48%
1%
45%
1%
45%
1%
44%
1%
44%
1%
Previous
Change
F4.
There is good cooperation among hospital units that need to work together.
Most Recent
Previous
Change
F6R.
It is often unpleasant to work with staff from other hospital units.
Most Recent
Previous
Change
F10.
Hospital units work well together to provide the best care for patients.
Most Recent
Previous
Change
10.
Staffing
A2.
We have enough staff to handle the workload.
Most Recent
Previous
Change
A5R.
Staff in this unit work longer hours than is best for patient care.
Most Recent
Previous
Change
A7R.
We use more agency/temporary staff than is best for patient care.
Most Recent
Previous
Change
A14R. We work in “crisis mode” trying to do too much, too quickly.
Most Recent
Previous
Change
100-199 200-299 300-399 400-499
beds
beds
beds
beds
500+
beds
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).
59
Table C-6. Trending: Item-Level Average Percent Positive Response by Bed Size (Page 6 of 6)
Bed Size
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
11.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients from one unit to
another.
F5R.
F7R.
Important patient care information is often lost during shift changes.
Problems often occur in the exchange of information across hospital units.
F11R. Shift changes are problematic for patients in this hospital.
12.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held against them.
A12R. When an event is reported, it feels like the person is being written up, not
the problem.
A16R. Staff worry that mistakes they make are kept in their personnel file.
6-24
beds
25-49
beds
50-99
beds
100-199 200-299 300-399 400-499
beds
beds
beds
beds
500+
beds
Both Years
52
87
107
148
112
54
33
57
Most Recent
5,175
13,066
30,508
60,134
77,867
39,462
39,711
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
54%
50%
46%
40%
37%
37%
35%
34%
Previous
55%
51%
44%
39%
36%
35%
33%
33%
Change
-1%
-1%
2%
1%
1%
2%
2%
1%
Most Recent
58%
55%
54%
50%
49%
50%
47%
49%
Previous
60%
54%
51%
49%
48%
48%
45%
48%
Change
-2%
1%
3%
1%
1%
2%
2%
1%
Most Recent
54%
51%
47%
42%
41%
42%
39%
38%
Previous
53%
50%
45%
41%
39%
39%
37%
37%
Change
1%
1%
2%
1%
2%
3%
2%
1%
Most Recent
58%
52%
48%
43%
42%
44%
40%
40%
Previous
56%
52%
46%
43%
41%
41%
38%
39%
Change
2%
0%
2%
0%
1%
3%
2%
1%
Most Recent
55%
54%
53%
49%
48%
49%
48%
45%
Previous
57%
55%
53%
49%
48%
48%
47%
45%
Change
-2%
-1%
0%
0%
0%
1%
1%
0%
Most Recent
51%
50%
49%
46%
46%
47%
45%
44%
Previous
51%
50%
47%
45%
44%
45%
43%
42%
Change
0%
0%
2%
1%
2%
2%
2%
2%
Most Recent
43%
41%
39%
34%
33%
33%
32%
30%
Previous
44%
40%
37%
34%
32%
32%
31%
30%
Change
-1%
1%
2%
0%
1%
1%
1%
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).
60
Table C-7. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade 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
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
Both Years
52
87
107
148
112
54
33
57
Most Recent
5,175
13,066
30,508
60,134
77,867
39,462
39,711
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
32%
33%
32%
31%
29%
29%
29%
26%
Previous
32%
32%
29%
30%
28%
27%
27%
25%
Change
0%
1%
3%
1%
1%
2%
2%
1%
Most Recent
49%
47%
46%
44%
45%
45%
43%
44%
Previous
48%
48%
46%
44%
45%
45%
44%
45%
Change
1%
-1%
0%
0%
0%
0%
-1%
-1%
Most Recent
16%
17%
18%
20%
21%
21%
23%
23%
Previous
18%
17%
20%
21%
22%
23%
24%
24%
Change
-2%
0%
-2%
-1%
-1%
-2%
-1%
-1%
Most Recent
3%
3%
3%
4%
4%
4%
5%
5%
Previous
2%
2%
4%
4%
5%
4%
5%
5%
Change
1%
1%
-1%
0%
-1%
0%
0%
0%
Most Recent
0%
0%
0%
1%
1%
1%
1%
1%
Previous
0%
0%
1%
1%
1%
1%
1%
1%
Change
0%
0%
-1%
0%
0%
0%
0%
0%
Note: Percentages may not add to 100 due to rounding.
61
Table C-8. Trending: Average Percentage of Respondents Reporting Events in the Past 12 Months by 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 events or more
Database
Year
6-24
beds
25-49
beds
50-99
beds
100-199
beds
200-299
beds
300-399
beds
400-499
beds
500+
beds
Both Years
52
87
107
148
112
54
33
57
Most Recent
5,175
13,066
30,508
60,134
77,867
39,462
39,711
83,613
Previous
5,241
12,128
27,527
52,312
72,069
33,578
33,799
70,210
Most Recent
55%
57%
57%
55%
54%
53%
57%
54%
Previous
55%
55%
56%
54%
53%
51%
55%
54%
Change
0%
2%
1%
1%
1%
2%
2%
0%
Most Recent
28%
26%
26%
27%
27%
29%
26%
28%
Previous
27%
27%
26%
27%
27%
30%
26%
28%
Change
1%
-1%
0%
0%
0%
-1%
0%
0%
Most Recent
11%
11%
11%
11%
12%
12%
11%
12%
Previous
12%
11%
12%
12%
12%
13%
12%
12%
Change
-1%
0%
-1%
-1%
0%
-1%
-1%
0%
Most Recent
4%
4%
4%
4%
4%
4%
4%
4%
Previous
4%
4%
4%
4%
5%
4%
4%
4%
Change
0%
0%
0%
0%
-1%
0%
0%
0%
Most Recent
1%
1%
1%
2%
2%
1%
2%
1%
Previous
1%
2%
2%
2%
2%
2%
2%
1%
Change
0%
-1%
-1%
0%
0%
-1%
0%
0%
Most Recent
1%
1%
1%
1%
1%
1%
1%
1%
Previous
1%
1%
1%
1%
1%
1%
1%
1%
Change
0%
0%
0%
0%
0%
0%
0%
0%
Note: Percentages may not add to 100 due to rounding.
62
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
nonresponse/missing data.
63
Table C-9. Trending: Composite-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 1 of 2)
Teaching Status and Ownership and Control
Patient Safety Culture Composites
# Hospitals
# Respondents
1.
2.
3.
4.
5.
6.
Teamwork Within Units
Supervisor/Manager Expectations & Actions Promoting Patient Safety
Org Learning--Continuous Improvement
Management Support for Patient Safety
Overall Perceptions of Patient Safety
Feedback & Communication About Error
64
Database
Year
Teaching
Nonteaching
Govt
Nongovt
Both Years
227
423
140
510
Most Recent
194,831
154,705
65,752
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
79%
81%
78%
81%
Previous
78%
80%
77%
80%
Change
1%
1%
1%
1%
Most Recent
73%
76%
75%
75%
Previous
74%
75%
74%
75%
Change
-1%
1%
1%
0%
Most Recent
72%
74%
72%
73%
Previous
71%
73%
71%
73%
Change
1%
1%
1%
0%
Most Recent
70%
74%
74%
73%
Previous
70%
73%
72%
72%
Change
0%
1%
2%
1%
Most Recent
64%
68%
67%
66%
Previous
63%
67%
66%
65%
Change
1%
1%
1%
1%
Most Recent
63%
66%
65%
65%
Previous
62%
65%
64%
64%
Change
1%
1%
1%
1%
Table C-9. Trending: Composite-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 2 of 2)
Teaching Status and Ownership and Control
Patient Safety Culture Composites
# Hospitals
# Respondents
7.
8.
9.
Frequency of Events Reported
Communication Openness
Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to Error
65
Database
Year
Teaching
Nonteaching
Govt
Nongovt
Both Years
227
423
140
510
Most Recent
194,831
154,705
65,752
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
61%
65%
63%
64%
Previous
61%
64%
62%
63%
Change
0%
1%
1%
1%
Most Recent
61%
63%
61%
62%
Previous
61%
62%
61%
62%
Change
0%
1%
0%
0%
Most Recent
56%
61%
59%
59%
Previous
55%
59%
58%
58%
Change
1%
2%
1%
1%
Most Recent
54%
59%
56%
57%
Previous
54%
57%
54%
56%
Change
0%
2%
2%
1%
Most Recent
43%
47%
47%
45%
Previous
42%
46%
46%
44%
Change
1%
1%
1%
1%
Most Recent
42%
46%
44%
45%
Previous
42%
45%
43%
44%
Change
0%
1%
1%
1%
Table C-10. Trending: Item-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 1 of 6)
Teaching Status and Ownership and Control
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
1.
Teamwork Within Units
A1.
People support one another in this unit.
Teaching
Nonteaching
Govt
Nongovt
Most Recent
227
194,831
423
154,705
140
65,752
510
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
85%
85%
0%
85%
84%
1%
77%
77%
0%
68%
68%
0%
87%
86%
1%
87%
86%
1%
79%
79%
0%
71%
69%
2%
84%
83%
1%
84%
84%
0%
77%
76%
1%
67%
65%
2%
86%
86%
0%
87%
86%
1%
79%
79%
0%
71%
69%
2%
71%
71%
0%
75%
75%
0%
72%
72%
0%
75%
75%
73%
2%
77%
77%
0%
76%
74%
2%
77%
73%
71%
2%
76%
75%
1%
75%
74%
1%
76%
74%
73%
1%
77%
77%
0%
74%
74%
0%
77%
75%
0%
77%
0%
75%
1%
77%
0%
Both Years
Previous
Change
A3.
When a lot of work needs to be done quickly, we work together as a team to get the work
done.
Most Recent
In this unit, people treat each other with respect.
Most Recent
Previous
Change
A4.
Previous
Change
A11.
Most Recent
When one area in this unit gets really busy, others help out.
Previous
Change
2.
Supervisor/Manager Expectations & Actions Promoting Patient Safety
B1.
My supv/mgr says a good word when he/she sees a job done according to established patient
safety procedures.
Most Recent
My supv/mgr seriously considers staff suggestions for improving patient safety.
Most Recent
Previous
Change
B2.
Previous
Change
B3R.
Whenever pressure builds up, my supv/mgr wants us to work faster, even if it means taking
shortcuts.
Most Recent
Previous
Change
B4R.
Most Recent
My supv/mgr overlooks patient safety problems that happen over and over.
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).
66
Table C-10. Trending: Item-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 2 of 6)
Teaching Status and Ownership and Control
Survey Items by Composite
# Hospitals
# Respondents
3.
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve patient safety.
A9.
A13.
Mistakes have led to positive changes here.
After we make changes to improve patient safety, we evaluate their effectiveness.
4.
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient safety.
F8.
F9R.
The actions of hospital mgmt show that patient safety is a top priority.
Hospital mgmt seems interested in patient safety only after an adverse event happens.
Database
Year
Teaching
Nonteaching
Govt
Nongovt
Both Years
227
423
140
510
Most Recent
194,831
154,705
65,752
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
83%
85%
83%
84%
Previous
83%
84%
82%
84%
Change
0%
1%
1%
0%
Most Recent
63%
65%
64%
65%
Previous
63%
64%
62%
64%
Change
0%
1%
2%
1%
Most Recent
68%
71%
69%
70%
Previous
68%
70%
68%
70%
Change
0%
1%
1%
0%
Most Recent
79%
82%
83%
81%
Previous
79%
81%
81%
81%
Change
0%
1%
2%
0%
Most Recent
74%
77%
76%
75%
Previous
73%
75%
74%
74%
Change
1%
2%
2%
1%
Most Recent
58%
63%
62%
61%
Previous
58%
62%
60%
61%
Change
0%
1%
2%
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).
67
Table C-10. Trending: Item-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 3 of 6)
Teaching Status and Ownership and Control
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
5.
Patient safety is never sacrificed to get more work done.
A17R. We have patient safety problems in this unit.
A18.
Our procedures and systems are good at preventing errors from happening.
6.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on event reports.
C3.
C5.
Nonteaching
Govt
Nongovt
Both Years
227
423
140
510
Most Recent
194,831
154,705
65,752
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
60%
64%
62%
63%
Previous
60%
63%
60%
62%
Change
0%
1%
2%
1%
Most Recent
63%
67%
69%
64%
Previous
62%
66%
67%
64%
Overall Perceptions of Patient Safety
A10R. It is just by chance that more serious mistakes don’t happen around here.
A15.
Teaching
We are informed about errors that happen in this unit.
In this unit, we discuss ways to prevent errors from happening again.
Change
1%
1%
2%
0%
Most Recent
62%
67%
66%
65%
Previous
61%
65%
65%
64%
Change
1%
2%
1%
1%
Most Recent
71%
74%
72%
73%
Previous
70%
73%
70%
72%
Change
1%
1%
2%
1%
Most Recent
56%
58%
55%
58%
Previous
55%
57%
53%
57%
Change
1%
1%
2%
1%
Most Recent
64%
67%
68%
66%
Previous
62%
66%
67%
64%
Change
2%
1%
1%
2%
Most Recent
70%
73%
72%
72%
Previous
70%
72%
71%
71%
Change
0%
1%
1%
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).
68
Table C-10. Trending: Item-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 4 of 6)
Teaching Status and Ownership and Control
Survey Items by Composite
# Hospitals
# Respondents
7.
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before affecting the patient, how often
is this reported?
D2.
D3.
When a mistake is made, but has no potential to harm the patient, how often is this reported?
When a mistake is made that could harm the patient, but does not, how often is this reported?
8.
Communication Openness
C2.
Staff will freely speak up if they see something that may negatively affect patient care.
C4.
C6R.
Staff feel free to question the decisions or actions of those with more authority.
Staff are afraid to ask questions when something does not seem right.
Database
Year
Teaching
Nonteaching
Govt
Nongovt
Both Years
227
423
140
510
Most Recent
194,831
154,705
65,752
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
55%
59%
57%
58%
Previous
54%
57%
55%
56%
Change
1%
2%
2%
2%
Most Recent
57%
62%
59%
60%
Previous
56%
60%
58%
59%
Change
1%
2%
1%
1%
Most Recent
72%
76%
74%
75%
Previous
72%
75%
73%
74%
Change
0%
1%
1%
1%
Most Recent
74%
76%
74%
76%
Previous
74%
76%
74%
76%
Change
0%
0%
0%
0%
Most Recent
47%
48%
47%
47%
Previous
47%
47%
47%
47%
Change
0%
1%
0%
0%
Most Recent
62%
64%
63%
63%
Previous
62%
63%
63%
63%
Change
0%
1%
0%
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).
69
Table C-10. Trending: Item-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 5 of 6)
Teaching Status and Ownership and Control
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
9.
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
Teaching
Nonteaching
Govt
Nongovt
Most Recent
227
194,831
423
154,705
140
65,752
510
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
42%
42%
0%
57%
56%
1%
57%
57%
0%
66%
65%
1%
48%
47%
1%
62%
61%
1%
61%
60%
1%
71%
69%
2%
46%
45%
1%
61%
60%
1%
57%
57%
0%
69%
68%
1%
46%
45%
1%
60%
59%
1%
60%
59%
1%
69%
68%
1%
53%
52%
1%
50%
50%
0%
66%
66%
0%
47%
58%
57%
1%
55%
54%
1%
69%
67%
2%
52%
57%
54%
3%
51%
49%
2%
65%
63%
2%
52%
56%
56%
0%
54%
54%
0%
69%
68%
1%
50%
46%
1%
51%
1%
50%
2%
49%
1%
Both Years
Previous
Change
F4.
Most Recent
There is good cooperation among hospital units that need to work together.
Previous
Change
F6R.
Most Recent
It is often unpleasant to work with staff from other hospital units.
Previous
Change
F10.
Most Recent
Hospital units work well together to provide the best care for patients.
Previous
Change
10.
Staffing
A2.
We have enough staff to handle the workload.
Most Recent
Previous
Change
A5R.
Most Recent
Staff in this unit work longer hours than is best for patient care.
Previous
Change
A7R.
Most Recent
We use more agency/temporary staff than is best for patient care.
Previous
Change
A14R. We work in “crisis mode” trying to do too much, too quickly.
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).
70
Table C-10. Trending: Item-Level Average Percent Positive Response by Teaching Status and Ownership and Control (Page 6 of 6)
Teaching Status and Ownership and Control
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
11.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients from one unit to another.
F5R.
F7R.
Important patient care information is often lost during shift changes.
Problems often occur in the exchange of information across hospital units.
F11R. Shift changes are problematic for patients in this hospital.
12.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held against them.
A12R. When an event is reported, it feels like the person is being written up, not the problem.
A16R. Staff worry that mistakes they make are kept in their personnel file.
Teaching
Nonteaching
Govt
Nongovt
Both Years
227
423
140
510
Most Recent
194,831
154,705
65,752
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
38%
44%
45%
41%
Previous
37%
43%
44%
40%
Change
1%
1%
1%
1%
Most Recent
50%
52%
51%
51%
Previous
49%
51%
51%
50%
Change
1%
1%
0%
1%
Most Recent
40%
46%
45%
44%
Previous
40%
45%
44%
43%
Change
0%
1%
1%
1%
Most Recent
43%
48%
47%
46%
Previous
42%
46%
46%
44%
Change
1%
2%
1%
2%
Most Recent
48%
52%
49%
51%
Previous
48%
52%
49%
51%
Change
0%
0%
0%
0%
Most Recent
45%
48%
45%
48%
Previous
44%
47%
44%
46%
Change
1%
1%
1%
2%
Most Recent
34%
37%
37%
35%
Previous
33%
36%
37%
35%
Change
1%
1%
0%
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).
71
Table C-11. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Teaching Status and
Ownership and Control
Teaching Status and Ownership and Control
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
A.
B.
C.
D.
E.
Excellent
Very Good
Acceptable
Poor
Failing
Database
Year
Teaching
Nonteaching
Govt
Nongovt
Both Years
227
423
140
510
Most Recent
194,831
154,705
65,752
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
28%
32%
31%
31%
Previous
27%
30%
29%
29%
Change
1%
2%
2%
2%
Most Recent
46%
45%
47%
45%
Previous
46%
45%
47%
45%
Change
0%
0%
0%
0%
Most Recent
21%
19%
19%
20%
Previous
22%
20%
21%
21%
Change
-1%
-1%
-2%
-1%
Most Recent
4%
4%
3%
4%
Previous
4%
4%
3%
4%
Change
0%
0%
0%
0%
Most Recent
1%
1%
1%
1%
Previous
1%
1%
1%
1%
Change
0%
0%
0%
0%
Note: Percentages may not add to 100 due to rounding.
72
Table C-12. Trending: Average Percentage of Respondents Reporting Events in the Past 12 Months by Teaching Status and Ownership
and Control
Teaching Status and Ownership and Control
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 or more
Database
Year
Teaching
Nonteaching
Govt
Nongovt
Both Years
227
423
140
510
Most Recent
194,831
154,705
65,752
283,784
Previous
165,377
141,487
60,126
246,738
Most Recent
56%
55%
60%
54%
Previous
54%
54%
60%
53%
Change
2%
1%
0%
1%
Most Recent
27%
27%
24%
28%
Previous
27%
27%
24%
28%
Change
0%
0%
0%
0%
Most Recent
11%
11%
10%
12%
Previous
12%
12%
10%
12%
Change
-1%
-1%
0%
0%
Most Recent
4%
4%
4%
4%
Previous
4%
4%
4%
4%
Change
0%
0%
0%
0%
Most Recent
1%
2%
1%
2%
Previous
1%
2%
1%
2%
Change
0%
0%
0%
0%
Most Recent
1%
1%
1%
1%
Previous
1%
1%
1%
1%
Change
0%
0%
0%
0%
Note: Percentages may not add to 100 due to rounding.
73
Appendix C: Trending Results by Hospital Characteristics
(4) Geographic Region
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 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 nonresponse/missing data.
NOTE 2: States and territories are categorized into AHA-defined regions as follows:
New England: CT, MA, ME, NH, RI, VT
Mid-Atlantic: NJ, NY, PA
South Atlantic/Associated Territories: DC, DE, FL, GA,
MD, NC, SC, VA, WV, Puerto Rico, Virgin Islands
East North Central: IL, IN, MI, OH, WI
East South Central: AL, KY, MS, TN
West North Central: IA, KS, MN, MO, ND, NE, SD
West South Central: AR, LA, OK, TX
Mountain: AZ, CO, ID, MT, NM, NV, UT, WY
Pacific/Associated Territories: AK, CA, HI, OR, WA,
American Samoa, Guam, Marshall Islands, Northern
Mariana Islands
74
Table C-13. Trending: Composite-Level Average Percent Positive Response by Geographic Region (Page 1 of 2)
Geographic Region
Database
Year
Patient Safety Culture Composites
# Hospitals
# Respondents
1.
2.
3.
4.
5.
6.
Teamwork Within Units
Supervisor/Manager Expectations & Actions Promoting Patient Safety
Org Learning--Continuous Improvement
Management Support for Patient Safety
Overall Perceptions of Patient Safety
Feedback & Communication About Error
MidAtlantic/
East
East
West
West
New
South
North
South
North
South
England Atlantic* Central Central Central Central
Mountain Pacific*
Both Years
51
112
167
53
70
88
52
57
Most Recent
43,442
71,398
86,939
19,668
20,073
39,079
31,247
37,690
Previous
33,197
63,782
77,128
20,033
18,212
36,698
25,235
32,579
Most Recent
78%
80%
80%
82%
81%
81%
79%
79%
Previous
78%
78%
79%
81%
79%
80%
80%
79%
Change
0%
2%
1%
1%
2%
1%
-1%
0%
Most Recent
72%
76%
74%
79%
76%
77%
74%
73%
Previous
73%
76%
73%
78%
74%
77%
75%
72%
Change
-1%
0%
1%
1%
2%
0%
-1%
1%
Most Recent
70%
75%
72%
76%
74%
74%
70%
71%
Previous
71%
73%
71%
76%
72%
74%
71%
70%
Change
-1%
2%
1%
0%
2%
0%
-1%
1%
Most Recent
69%
74%
72%
76%
76%
74%
70%
71%
Previous
69%
72%
70%
75%
73%
74%
72%
70%
Change
0%
2%
2%
1%
3%
0%
-2%
1%
Most Recent
63%
65%
66%
70%
70%
69%
66%
64%
Previous
62%
65%
64%
69%
69%
67%
67%
63%
Change
1%
0%
2%
1%
1%
2%
-1%
1%
Most Recent
62%
66%
64%
69%
65%
68%
64%
64%
Previous
62%
67%
62%
67%
62%
67%
65%
62%
Change
0%
-1%
2%
2%
3%
1%
-1%
2%
* Includes associated territories.
75
Table C-13. Trending: Composite-Level Average Percent Positive Response by Geographic Region (Page 2 of 2)
Geographic Region
Patient Safety Culture Composites
# Hospitals
# Respondents
7.
8.
9.
Frequency of Events Reported
Communication Openness
Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to Error
Database
Year
MidAtlantic/
New
England
Both Years
51
112
167
53
70
Most Recent
43,442
71,398
86,939
19,668
Previous
33,197
63,782
77,128
Most Recent
63%
65%
Previous
62%
Change
East
East
West
West
South
North
South
North
South
Atlantic Central Central Central Central
Mountain
Pacific
88
52
57
20,073
39,079
31,247
37,690
20,033
18,212
36,698
25,235
32,579
62%
69%
63%
67%
64%
64%
63%
60%
67%
62%
66%
63%
62%
1%
2%
2%
2%
1%
1%
1%
2%
Most Recent
62%
61%
61%
63%
62%
65%
63%
61%
Previous
62%
62%
60%
63%
61%
65%
63%
62%
Change
0%
-1%
1%
0%
1%
0%
0%
-1%
Most Recent
54%
60%
57%
64%
61%
61%
58%
57%
Previous
53%
57%
56%
63%
59%
61%
59%
55%
Change
1%
3%
1%
1%
2%
0%
-1%
2%
Most Recent
53%
55%
57%
61%
62%
58%
56%
52%
Previous
52%
54%
56%
60%
62%
56%
56%
51%
Change
1%
1%
1%
1%
0%
2%
0%
1%
Most Recent
42%
46%
44%
53%
48%
48%
45%
42%
Previous
41%
44%
43%
51%
47%
48%
45%
40%
Change
1%
2%
1%
2%
1%
0%
0%
2%
Most Recent
41%
43%
43%
48%
48%
47%
48%
42%
Previous
42%
42%
41%
47%
48%
46%
47%
41%
Change
-1%
1%
2%
1%
0%
1%
1%
1%
76
Table C-14. Trending: Item-Level Average Percent Positive Response by Geographic Region (Page 1 of 6)
Geographic Region
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
Both Years
Most Recent
Previous
1.
Teamwork Within Units
A1.
People support one another in this unit.
Most Recent
Previous
Change
A3.
When a lot of work needs to be done quickly, we work together as a
team to get the work done.
Most Recent
In this unit, people treat each other with respect.
Most Recent
Previous
Change
A4.
Previous
Change
A11.
When one area in this unit gets really busy, others help out.
Most Recent
Previous
Change
2.
B1.
My supv/mgr says a good word when he/she sees a job done according
to established patient safety procedures.
Most Recent
My supv/mgr seriously considers staff suggestions for improving patient
safety.
Most Recent
Whenever pressure builds up, my supv/mgr wants us to work faster,
even if it means taking shortcuts.
Most Recent
My supv/mgr overlooks patient safety problems that happen over and
over.
Most Recent
Previous
Previous
Change
B3R.
Previous
Change
B4R.
South
Atlantic*
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific*
51
43,442
33,197
112
71,398
63,782
167
86,939
77,128
53
19,668
20,033
70
20,073
18,212
88
39,079
36,698
52
31,247
25,235
57
37,690
32,579
84%
85%
-1%
85%
85%
0%
76%
76%
0%
67%
66%
1%
85%
84%
1%
85%
84%
1%
78%
77%
1%
69%
68%
1%
86%
86%
0%
87%
86%
1%
78%
78%
0%
70%
68%
2%
87%
86%
1%
88%
88%
0%
81%
79%
2%
73%
72%
1%
87%
85%
2%
88%
87%
1%
79%
77%
2%
70%
68%
2%
87%
86%
1%
87%
86%
1%
80%
79%
1%
71%
69%
2%
84%
85%
-1%
85%
86%
-1%
77%
78%
-1%
70%
70%
0%
86%
86%
0%
84%
84%
0%
79%
79%
0%
69%
68%
1%
70%
72%
-2%
73%
75%
-2%
71%
72%
-1%
74%
75%
-1%
75%
74%
1%
77%
77%
0%
75%
74%
1%
78%
78%
0%
73%
71%
2%
76%
75%
1%
73%
72%
1%
76%
75%
1%
77%
75%
2%
79%
78%
1%
77%
76%
1%
81%
82%
-1%
71%
69%
2%
77%
75%
2%
78%
75%
3%
78%
77%
1%
77%
76%
1%
79%
78%
1%
76%
75%
1%
77%
78%
-1%
72%
74%
-2%
75%
77%
-2%
75%
75%
0%
74%
74%
0%
73%
71%
2%
75%
75%
0%
72%
71%
1%
73%
72%
1%
Supervisor/Manager Expectations & Actions Promoting Patient
Safety
Change
B2.
MidAtlantic/
New
England
Previous
Change
* Includes associated territories.
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 C-14. Trending: Item-Level Average Percent Positive Response by Geographic Region (Page 2 of 6)
Geographic Region
Survey Items by Composite
# Hospitals
# Respondents
3.
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve patient safety.
A9.
A13.
Mistakes have led to positive changes here.
After we make changes to improve patient safety, we evaluate their
effectiveness.
4.
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient safety.
F8.
F9R.
The actions of hospital mgmt show that patient safety is a top priority.
Hospital mgmt seems interested in patient safety only after an adverse
event happens.
Database
Year
MidAtlantic/
New
England
South
Atlantic
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific
Both Years
51
112
167
53
70
88
52
57
Most Recent
43,442
71,398
86,939
19,668
20,073
39,079
31,247
37,690
Previous
33,197
63,782
77,128
20,033
18,212
36,698
25,235
32,579
Most Recent
82%
85%
84%
86%
85%
84%
81%
82%
Previous
82%
84%
82%
85%
84%
85%
83%
82%
Change
0%
1%
2%
1%
1%
-1%
-2%
0%
Most Recent
62%
66%
63%
67%
67%
65%
63%
64%
Previous
62%
65%
62%
67%
65%
65%
64%
62%
Change
0%
1%
1%
0%
2%
0%
-1%
2%
Most Recent
68%
73%
69%
76%
70%
71%
66%
67%
Previous
68%
71%
68%
75%
69%
72%
67%
66%
Change
0%
2%
1%
1%
1%
-1%
-1%
1%
Most Recent
77%
82%
80%
85%
85%
83%
79%
79%
Previous
78%
80%
79%
84%
82%
84%
82%
79%
Change
-1%
2%
1%
1%
3%
-1%
-3%
0%
Most Recent
72%
77%
74%
79%
79%
77%
72%
74%
Previous
72%
75%
72%
77%
75%
77%
74%
73%
Change
0%
2%
2%
2%
4%
0%
-2%
1%
Most Recent
57%
62%
60%
65%
66%
63%
59%
58%
Previous
58%
61%
59%
65%
63%
62%
60%
56%
Change
-1%
1%
1%
0%
3%
1%
-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).
78
Table C-14. Trending: Item-Level Average Percent Positive Response by Geographic Region (Page 3 of 6)
Geographic Region
# Hospitals
# Respondents
Patient safety is never sacrificed to get more work done.
A17R. We have patient safety problems in this unit.
A18.
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific
Most Recent
51
43,442
112
71,398
167
86,939
53
19,668
70
20,073
88
39,079
52
31,247
57
37,690
Previous
33,197
63,782
77,128
20,033
18,212
36,698
25,235
32,579
Most Recent
59%
60%
63%
66%
68%
64%
64%
59%
Previous
59%
60%
61%
65%
66%
63%
64%
57%
Both Years
Overall Perceptions of Patient Safety
A10R. It is just by chance that more serious mistakes don’t happen around
here.
A15.
South
Atlantic
Database
Year
Survey Items by Composite
5.
MidAtlantic/
New
England
Our procedures and systems are good at preventing errors from
happening.
Change
0%
0%
2%
1%
2%
1%
0%
2%
Most Recent
63%
64%
63%
69%
67%
69%
65%
64%
Previous
62%
64%
62%
68%
66%
67%
66%
64%
Change
1%
0%
1%
1%
1%
2%
-1%
0%
Most Recent
60%
64%
65%
69%
69%
68%
65%
62%
Previous
59%
63%
63%
69%
68%
66%
66%
60%
Change
1%
1%
2%
0%
1%
2%
-1%
2%
Most Recent
70%
73%
73%
75%
75%
75%
70%
69%
Previous
70%
72%
71%
75%
72%
73%
71%
69%
Change
0%
1%
2%
0%
3%
2%
-1%
0%
6.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on event
reports.
Most Recent
54%
59%
57%
62%
55%
60%
54%
56%
Previous
54%
60%
55%
60%
51%
60%
57%
54%
Change
0%
-1%
2%
2%
4%
0%
-3%
2%
We are informed about errors that happen in this unit.
Most Recent
64%
67%
64%
72%
65%
69%
64%
64%
Previous
64%
67%
62%
69%
63%
69%
65%
63%
Change
0%
0%
2%
3%
2%
0%
-1%
1%
Most Recent
69%
72%
71%
74%
73%
74%
73%
71%
Previous
70%
73%
69%
73%
70%
74%
73%
70%
Change
-1%
-1%
2%
1%
3%
0%
0%
1%
C3.
C5.
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).
79
Table C-14. Trending: Item-Level Average Percent Positive Response by Geographic Region (Page 4 of 6)
Geographic Region
Survey Items by Composite
# Hospitals
# Respondents
7.
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before affecting
the patient, how often is this reported?
D2.
D3.
When a mistake is made, but has no potential to harm the patient, how
often is this reported?
When a mistake is made that could harm the patient, but does not, how
often is this reported?
8.
Communication Openness
C2.
Staff will freely speak up if they see something that may negatively
affect patient care.
C4.
C6R.
Staff feel free to question the decisions or actions of those with more
authority.
Staff are afraid to ask questions when something does not seem right.
Database
Year
MidAtlantic/
New
England
South
Atlantic
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific
Both Years
51
112
167
53
70
88
52
57
Most Recent
43,442
71,398
86,939
19,668
20,073
39,079
31,247
37,690
Previous
33,197
63,782
77,128
20,033
18,212
36,698
25,235
32,579
Most Recent
56%
60%
54%
63%
55%
62%
58%
58%
Previous
55%
58%
53%
61%
52%
61%
57%
56%
Change
1%
2%
1%
2%
3%
1%
1%
2%
Most Recent
59%
61%
57%
65%
58%
63%
60%
59%
Previous
58%
59%
56%
63%
58%
62%
60%
57%
Change
1%
2%
1%
2%
0%
1%
0%
2%
Most Recent
74%
74%
73%
79%
75%
76%
73%
74%
Previous
73%
74%
72%
78%
75%
75%
73%
73%
Change
1%
0%
1%
1%
0%
1%
0%
1%
Most Recent
75%
74%
75%
77%
76%
77%
77%
74%
Previous
75%
76%
74%
77%
74%
77%
76%
74%
Change
0%
-2%
1%
0%
2%
0%
1%
0%
Most Recent
48%
47%
45%
49%
46%
51%
48%
48%
Previous
48%
47%
45%
48%
45%
51%
49%
48%
Change
0%
0%
0%
1%
1%
0%
-1%
0%
Most Recent
63%
62%
62%
65%
63%
66%
64%
61%
Previous
64%
63%
61%
64%
63%
66%
63%
62%
Change
-1%
-1%
1%
1%
0%
0%
1%
-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).
80
Table C-14. Trending: Item-Level Average Percent Positive Response by Geographic Region (Page 5 of 6)
Geographic Region
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
Both Years
Most Recent
Previous
9.
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
Most Recent
Previous
Change
F4.
There is good cooperation among hospital units that need to work
together.
Most Recent
It is often unpleasant to work with staff from other hospital units.
Most Recent
Previous
Change
F6R.
Previous
Change
F10.
Hospital units work well together to provide the best care for patients.
Most Recent
Previous
Change
10.
Staffing
A2.
We have enough staff to handle the workload.
Most Recent
Previous
Change
A5R.
Staff in this unit work longer hours than is best for patient care.
Most Recent
Previous
Change
A7R.
We use more agency/temporary staff than is best for patient care.
Most Recent
Previous
Change
A14R. We work in “crisis mode” trying to do too much, too quickly.
Most Recent
Previous
Change
MidAtlantic/
New
England
South
Atlantic
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific
51
43,442
33,197
112
71,398
63,782
167
86,939
77,128
53
19,668
20,033
70
20,073
18,212
88
39,079
36,698
52
31,247
25,235
57
37,690
32,579
40%
40%
0%
55%
54%
1%
56%
57%
-1%
64%
63%
1%
47%
45%
2%
61%
59%
2%
61%
58%
3%
70%
67%
3%
45%
44%
1%
58%
57%
1%
59%
57%
2%
67%
66%
1%
53%
54%
-1%
66%
66%
0%
63%
61%
2%
74%
74%
0%
48%
45%
3%
62%
60%
2%
62%
60%
2%
72%
69%
3%
49%
50%
-1%
63%
62%
1%
60%
60%
0%
72%
71%
1%
45%
46%
-1%
59%
61%
-2%
60%
61%
-1%
68%
69%
-1%
42%
41%
1%
59%
57%
2%
58%
57%
1%
67%
66%
1%
49%
50%
-1%
50%
49%
1%
66%
65%
1%
45%
45%
0%
53%
51%
2%
51%
52%
-1%
67%
67%
0%
49%
48%
1%
56%
55%
1%
53%
53%
0%
71%
69%
2%
48%
47%
1%
58%
57%
1%
59%
58%
1%
73%
71%
2%
55%
54%
1%
65%
64%
1%
58%
58%
0%
70%
71%
-1%
56%
54%
2%
59%
57%
2%
54%
52%
2%
67%
65%
2%
54%
52%
2%
55%
57%
-2%
53%
53%
0%
65%
63%
2%
52%
52%
0%
53%
54%
-1%
47%
46%
1%
61%
58%
3%
46%
45%
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).
81
Table C-14. Trending: Item-Level Average Percent Positive Response by Geographic Region (Page 6 of 6)
Geographic Region
# Hospitals
# Respondents
11.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients from one
unit to another.
F7R.
Important patient care information is often lost during shift changes.
Problems often occur in the exchange of information across hospital
units.
F11R. Shift changes are problematic for patients in this hospital.
12.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held against them.
South
Atlantic
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific
Most Recent
51
43,442
112
71,398
167
86,939
53
19,668
70
20,073
88
39,079
52
31,247
57
37,690
Previous
33,197
63,782
77,128
20,033
18,212
36,698
25,235
32,579
Most Recent
36%
43%
39%
50%
44%
45%
42%
38%
Previous
36%
41%
38%
49%
44%
45%
42%
36%
Change
0%
2%
1%
1%
0%
0%
0%
2%
Most Recent
50%
53%
50%
58%
52%
53%
49%
48%
Previous
49%
51%
49%
56%
52%
52%
49%
46%
Database
Year
Survey Items by Composite
F5R.
MidAtlantic/
New
England
A12R. When an event is reported, it feels like the person is being written up,
not the problem.
A16R. Staff worry that mistakes they make are kept in their personnel file.
Both Years
Change
1%
2%
1%
2%
0%
1%
0%
2%
Most Recent
40%
45%
43%
51%
45%
47%
43%
40%
Previous
39%
42%
41%
50%
44%
47%
44%
38%
Change
1%
3%
2%
1%
1%
0%
-1%
2%
Most Recent
42%
46%
44%
52%
51%
48%
44%
41%
Previous
41%
44%
42%
51%
49%
47%
45%
40%
Change
1%
2%
2%
1%
2%
1%
-1%
1%
Most Recent
47%
48%
49%
55%
54%
53%
53%
48%
Previous
48%
49%
48%
54%
54%
52%
54%
47%
Change
-1%
-1%
1%
1%
0%
1%
-1%
1%
Most Recent
45%
45%
46%
51%
50%
49%
50%
45%
Previous
45%
45%
44%
49%
49%
48%
49%
43%
Change
0%
0%
2%
2%
1%
1%
1%
2%
Most Recent
32%
34%
33%
39%
40%
38%
40%
33%
Previous
32%
33%
32%
39%
40%
38%
39%
33%
Change
0%
1%
1%
0%
0%
0%
1%
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).
82
Table C-15. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Geographic Region
Geographic Region
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
A.
B.
C.
D.
E.
Excellent
Very Good
Acceptable
Poor
Failing
MidAtlantic/
New
England
South
Atlantic*
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific*
Most Recent
51
43,442
112
71,398
167
86,939
53
19,668
70
20,073
88
39,079
52
31,247
57
37,690
Previous
33,197
63,782
77,128
20,033
18,212
36,698
25,235
32,579
Most Recent
Previous
27%
25%
33%
30%
29%
27%
35%
33%
28%
26%
33%
32%
29%
30%
31%
29%
Database
Year
Both Years
Change
2%
3%
2%
2%
2%
1%
-1%
2%
Most Recent
44%
43%
46%
44%
50%
44%
44%
45%
Previous
46%
44%
46%
45%
49%
45%
45%
46%
Change
-2%
-1%
0%
-1%
1%
-1%
-1%
-1%
Most Recent
23%
20%
20%
17%
18%
19%
21%
20%
Previous
23%
21%
22%
18%
21%
19%
20%
20%
Change
0%
-1%
-2%
-1%
-3%
0%
1%
0%
Most Recent
5%
4%
4%
3%
3%
3%
5%
4%
Previous
5%
4%
4%
3%
4%
3%
4%
4%
Change
0%
0%
0%
0%
-1%
0%
1%
0%
Most Recent
1%
1%
1%
1%
0%
1%
1%
1%
Previous
1%
1%
1%
1%
1%
1%
1%
1%
Change
0%
0%
0%
0%
-1%
0%
0%
0%
* Includes associated territories.
Note: Percentages may not add to 100 due to rounding.
83
Table C-16. Trending: Average Percentage of Respondents Reporting Events in the Past 12 Months by Geographic Region
Geographic Region
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 or more
MidAtlantic/
New
England
South
Atlantic*
East
North
Central
East
South
Central
West
North
Central
West
South
Central
Mountain
Pacific*
Most Recent
51
43,442
112
71,398
167
86,939
53
19,668
70
20,073
88
39,079
52
31,247
57
37,690
Previous
33,197
63,782
77,128
20,033
18,212
36,698
25,235
32,579
Most Recent
Previous
55%
53%
57%
57%
54%
52%
56%
54%
51%
49%
59%
58%
55%
56%
55%
53%
Database
Year
Both Years
Change
2%
0%
2%
2%
2%
1%
-1%
2%
Most Recent
26%
26%
28%
26%
28%
25%
28%
27%
Previous
26%
26%
29%
27%
28%
26%
26%
28%
Change
0%
0%
-1%
-1%
0%
-1%
2%
-1%
Most Recent
12%
11%
11%
11%
13%
10%
12%
12%
Previous
12%
11%
12%
12%
14%
11%
12%
11%
Change
0%
0%
-1%
-1%
-1%
-1%
0%
1%
Most Recent
4%
3%
4%
4%
5%
4%
4%
4%
Previous
5%
4%
4%
4%
6%
4%
4%
5%
Change
-1%
-1%
0%
0%
-1%
0%
0%
-1%
Most Recent
2%
1%
1%
2%
2%
1%
1%
1%
Previous
2%
1%
1%
2%
2%
1%
1%
2%
Change
0%
0%
0%
0%
0%
0%
0%
-1%
Most Recent
1%
1%
1%
1%
1%
1%
1%
1%
Previous
2%
1%
1%
1%
1%
1%
1%
1%
Change
-1%
0%
0%
0%
0%
0%
0%
0%
* Includes associated territories.
Note: Percentages may not add to 100 due to rounding.
84
Part III
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 five respondents in the particular work area/unit and at least three respondents to a particular
question for both the previous and most recent administrations of the survey are included.
NOTE 3: Respondents who selected “Many different work areas/No specific work area” or “Other” or who did not answer (missing)
are not included.
85
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.
2.
3.
4.
5.
6.
Teamwork Within Units
Supervisor/Manager Expectations &
Actions Promoting Patient Safety
Org Learning--Continuous
Improvement
Management Support for Patient
Safety
Overall Perceptions of Patient Safety
Feedback & Communication About
Error
Database
Year
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
Both Years
75
446
392
415
476
315
176
345
180
434
353
455
Most Recent
1,646
17,629
22,370
14,201
38,021
13,427
10,501
8,204
6,817
16,255
9,750
28,433
Previous
2,721
14,486
19,550
12,177
28,629
11,708
9,623
7,263
5,536
14,735
9,192
24,749
Most Recent
80%
78%
84%
76%
78%
81%
83%
76%
79%
79%
87%
78%
Previous
80%
77%
84%
76%
76%
80%
82%
75%
79%
78%
85%
77%
Change
0%
1%
0%
0%
2%
1%
1%
1%
0%
1%
2%
1%
Most Recent
76%
70%
73%
75%
74%
72%
75%
76%
76%
76%
82%
73%
Previous
76%
69%
73%
75%
73%
72%
75%
75%
76%
75%
81%
73%
Change
0%
1%
0%
0%
1%
0%
0%
1%
0%
1%
1%
0%
Most Recent
74%
68%
73%
72%
73%
72%
75%
76%
73%
73%
78%
74%
Previous
73%
66%
73%
72%
73%
73%
74%
75%
72%
71%
74%
74%
Change
1%
2%
0%
0%
0%
-1%
1%
1%
1%
2%
4%
0%
Most Recent
68%
64%
65%
74%
69%
70%
72%
71%
71%
75%
79%
70%
Previous
68%
62%
65%
75%
68%
69%
72%
70%
69%
74%
77%
69%
Change
0%
2%
0%
-1%
1%
1%
0%
1%
2%
1%
2%
1%
Most Recent
66%
57%
61%
70%
60%
64%
69%
64%
62%
75%
78%
66%
Previous
65%
55%
60%
70%
59%
63%
69%
64%
62%
73%
75%
66%
Change
1%
2%
1%
0%
1%
1%
0%
0%
0%
2%
3%
0%
Most Recent
66%
58%
61%
64%
62%
63%
64%
68%
67%
65%
73%
65%
Previous
65%
57%
60%
63%
61%
62%
62%
65%
67%
65%
70%
64%
Change
1%
1%
1%
1%
1%
1%
2%
3%
0%
0%
3%
1%
86
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.
8.
9.
Frequency of Events Reported
Communication Openness
Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to Error
Database
Year
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
Both Years
75
446
392
415
476
315
176
345
180
434
353
455
Most Recent
1,646
17,629
22,370
14,201
38,021
13,427
10,501
8,204
6,817
16,255
9,750
28,433
Previous
2,721
14,486
19,550
12,177
28,629
11,708
9,623
7,263
5,536
14,735
9,192
24,749
Most Recent
56%
58%
60%
70%
64%
63%
65%
60%
67%
61%
67%
66%
Previous
57%
57%
60%
69%
62%
64%
66%
57%
64%
59%
63%
64%
Change
-1%
1%
0%
1%
2%
-1%
-1%
3%
3%
2%
4%
2%
Most Recent
66%
58%
61%
60%
58%
61%
65%
65%
62%
62%
72%
61%
Previous
66%
58%
62%
60%
58%
61%
62%
64%
63%
63%
69%
61%
Change
0%
0%
-1%
0%
0%
0%
3%
1%
-1%
-1%
3%
0%
Most Recent
52%
49%
58%
55%
58%
58%
59%
54%
56%
57%
63%
55%
Previous
53%
47%
56%
55%
57%
56%
58%
54%
55%
56%
60%
54%
Change
-1%
2%
2%
0%
1%
2%
1%
0%
1%
1%
3%
1%
Most Recent
56%
50%
58%
56%
53%
62%
61%
54%
56%
64%
64%
56%
Previous
54%
48%
58%
55%
52%
58%
60%
54%
58%
63%
62%
55%
Change
2%
2%
0%
1%
1%
4%
1%
0%
-2%
1%
2%
1%
Most Recent
39%
49%
52%
37%
46%
57%
52%
31%
43%
45%
42%
43%
Previous
40%
48%
51%
37%
45%
52%
50%
31%
43%
42%
40%
41%
Change
-1%
1%
1%
0%
1%
5%
2%
0%
0%
3%
2%
2%
Most Recent
44%
38%
40%
39%
41%
41%
47%
50%
47%
43%
61%
43%
Previous
44%
35%
39%
39%
41%
42%
43%
51%
47%
43%
57%
43%
Change
0%
3%
1%
0%
0%
-1%
4%
-1%
0%
0%
4%
0%
87
Table D-2. Trending: Item-Level Average Percent Positive Response by Work Area/Unit (Page 1 of 6)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Both Years
Most Recent
Previous
1.
Teamwork Within Units
A1.
People support one another in this
unit.
Most Recent
When a lot of work needs to be done
quickly, we work together as a team
to get the work done.
Most Recent
In this unit, people treat each other
with respect.
Most Recent
When one area in this unit gets really
busy, others help out.
Most Recent
Previous
Change
A3.
A4.
Previous
Change
Previous
Change
A11.
Previous
Change
2.
B1.
B2.
B3R.
B4R.
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
75
1,646
2,721
446
17,629
14,486
392
22,370
19,550
415
14,201
12,177
476
38,021
28,629
315
13,427
11,708
176
10,501
9,623
345
8,204
7,263
180
6,817
5,536
434
16,255
14,735
353
9,750
9,192
455
28,433
24,749
87%
87%
0%
87%
86%
1%
78%
79%
-1%
69%
67%
2%
84%
83%
1%
86%
86%
0%
73%
73%
0%
68%
68%
0%
89%
89%
0%
90%
90%
0%
80%
80%
0%
78%
77%
1%
82%
82%
0%
83%
84%
-1%
73%
74%
-1%
65%
67%
-2%
85%
84%
1%
82%
80%
2%
78%
78%
0%
66%
63%
3%
87%
86%
1%
89%
87%
2%
77%
78%
-1%
70%
69%
1%
88%
88%
0%
88%
87%
1%
82%
80%
2%
74%
72%
2%
81%
81%
0%
81%
81%
0%
73%
74%
-1%
68%
65%
3%
84%
83%
1%
84%
85%
-1%
78%
78%
0%
71%
70%
1%
85%
85%
0%
87%
87%
0%
77%
77%
0%
66%
64%
2%
92%
90%
2%
90%
89%
1%
88%
85%
3%
78%
75%
3%
84%
83%
1%
86%
86%
0%
74%
73%
1%
67%
65%
2%
72%
72%
0%
77%
79%
-2%
76%
74%
2%
80%
78%
2%
69%
68%
1%
71%
71%
0%
68%
67%
1%
72%
71%
1%
71%
71%
0%
74%
75%
-1%
73%
73%
0%
75%
74%
1%
69%
70%
-1%
74%
74%
0%
79%
79%
0%
77%
77%
0%
73%
71%
2%
75%
75%
0%
73%
72%
1%
75%
75%
0%
70%
70%
0%
72%
72%
0%
71%
71%
0%
74%
75%
-1%
70%
71%
-1%
76%
75%
1%
75%
76%
-1%
77%
78%
-1%
71%
70%
1%
76%
75%
1%
78%
76%
2%
77%
77%
0%
77%
75%
2%
77%
77%
0%
73%
75%
-2%
77%
77%
0%
71%
70%
1%
76%
76%
0%
76%
75%
1%
79%
78%
1%
79%
78%
1%
85%
84%
1%
81%
79%
2%
84%
82%
2%
70%
70%
0%
74%
75%
-1%
70%
70%
0%
75%
76%
-1%
Supervisor/Manager Expectations
& Actions Promoting Patient Safety
My supv/mgr says a good word when
he/she sees a job done according to
established patient safety procedures.
Most Recent
My supv/mgr seriously considers staff
suggestions for improving patient
safety.
Most Recent
Whenever pressure builds up, my
supv/mgr wants us to work faster,
even if it means taking shortcuts.
Most Recent
My supv/mgr overlooks patient safety
problems that happen over and over.
Most Recent
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).
88
Table D-2. Trending: Item-Level Average Percent Positive Response by Work Area/Unit (Page 2 of 6)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
3.
A6.
A9.
A13.
4.
F1.
F8.
F9R.
Database
Year
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
Both Years
75
446
392
415
476
315
176
345
180
434
353
455
Most Recent
1,646
17,629
22,370
14,201
38,021
13,427
10,501
8,204
6,817
16,255
9,750
28,433
Previous
2,721
14,486
19,550
12,177
28,629
11,708
9,623
7,263
5,536
14,735
9,192
24,749
Most Recent
87%
80%
85%
83%
85%
83%
87%
87%
84%
85%
90%
86%
Previous
85%
79%
85%
82%
85%
84%
87%
86%
83%
84%
88%
86%
Change
2%
1%
0%
1%
0%
-1%
0%
1%
1%
1%
2%
0%
Most Recent
66%
58%
62%
67%
63%
64%
65%
75%
64%
64%
66%
65%
Previous
67%
56%
62%
67%
61%
65%
64%
73%
64%
63%
62%
65%
Change
-1%
2%
0%
0%
2%
-1%
1%
2%
0%
1%
4%
0%
Most Recent
70%
64%
71%
67%
72%
70%
72%
67%
71%
69%
77%
71%
Previous
66%
63%
71%
67%
71%
70%
71%
65%
69%
67%
74%
70%
Change
4%
1%
0%
0%
1%
0%
1%
2%
2%
2%
3%
1%
Most Recent
79%
73%
73%
82%
77%
78%
82%
78%
78%
85%
87%
80%
Previous
76%
72%
73%
83%
76%
77%
81%
77%
77%
83%
86%
79%
Change
3%
1%
0%
-1%
1%
1%
1%
1%
1%
2%
1%
1%
Most Recent
71%
67%
68%
78%
73%
73%
75%
74%
74%
78%
81%
73%
Previous
72%
65%
67%
77%
71%
71%
75%
75%
72%
76%
79%
72%
Change
-1%
2%
1%
1%
2%
2%
0%
-1%
2%
2%
2%
1%
Most Recent
55%
51%
54%
63%
58%
59%
60%
60%
61%
63%
69%
58%
Previous
55%
50%
53%
63%
57%
58%
59%
58%
58%
61%
66%
57%
Change
0%
1%
1%
0%
1%
1%
1%
2%
3%
2%
3%
1%
Org Learning--Continuous
Improvement
We are actively doing things to
improve patient safety.
Mistakes have led to positive changes
here.
After we make changes to improve
patient safety, we evaluate their
effectiveness.
Management Support for Patient
Safety
Hospital mgmt provides a work
climate that promotes patient safety.
The actions of hospital mgmt show
that patient safety is a top priority.
Hospital mgmt seems interested in
patient safety only after an adverse
event happens.
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).
89
Table D-2. Trending: Item-Level Average Percent Positive Response by Work Area/Unit (Page 3 of 6)
Work Area/Unit
Anesthesiology
Emergency
ICU
(any
type)
Most Recent
75
1,646
446
17,629
Previous
2,721
A10R. It is just by chance that more serious
mistakes don’t happen around here.
Most Recent
A15.
Patient safety is never sacrificed to
get more work done.
Most Recent
A17R. We have patient safety problems in
this unit.
Most Recent
A18.
Most Recent
Survey Items by Composite
# Hospitals
# Respondents
5.
Database
Year
Both Years
Previous
Previous
Change
Previous
Change
C1.
C3.
Our procedures and systems are
good at preventing errors from
happening.
Previous
Change
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
392
22,370
415
14,201
476
38,021
315
13,427
176
10,501
345
8,204
180
6,817
434
16,255
353
9,750
455
28,433
14,486
19,550
12,177
28,629
11,708
9,623
7,263
5,536
14,735
9,192
24,749
66%
62%
4%
62%
62%
0%
61%
62%
-1%
74%
73%
1%
55%
52%
3%
54%
54%
0%
52%
50%
2%
65%
62%
3%
61%
59%
2%
56%
55%
1%
58%
58%
0%
70%
68%
2%
62%
64%
-2%
71%
70%
1%
69%
69%
0%
78%
77%
1%
58%
58%
0%
57%
56%
1%
55%
54%
1%
68%
67%
1%
63%
61%
2%
58%
58%
0%
63%
62%
1%
72%
73%
-1%
68%
64%
4%
66%
67%
-1%
67%
68%
-1%
77%
76%
1%
60%
60%
0%
62%
62%
0%
61%
61%
0%
73%
72%
1%
61%
62%
-1%
64%
64%
0%
54%
54%
0%
70%
69%
1%
71%
68%
3%
75%
73%
2%
76%
74%
2%
78%
76%
2%
75%
72%
3%
78%
75%
3%
76%
74%
2%
82%
78%
4%
63%
62%
1%
62%
62%
0%
66%
66%
0%
75%
74%
1%
56%
54%
2%
67%
66%
1%
74%
53%
51%
2%
58%
56%
2%
63%
56%
55%
1%
59%
57%
2%
69%
54%
54%
0%
67%
66%
1%
70%
57%
55%
2%
62%
61%
1%
69%
57%
55%
2%
61%
61%
0%
71%
57%
53%
4%
63%
62%
1%
74%
57%
54%
3%
71%
70%
1%
74%
61%
61%
0%
67%
67%
0%
73%
56%
55%
1%
68%
68%
0%
72%
66%
63%
3%
72%
70%
2%
81%
55%
55%
0%
66%
65%
1%
73%
76%
-2%
63%
0%
68%
1%
70%
0%
68%
1%
70%
1%
71%
3%
72%
2%
73%
0%
71%
1%
78%
3%
72%
1%
Feedback & Communication About
Error
We are given feedback about
changes put into place based on
event reports.
Most Recent
We are informed about errors that
happen in this unit.
Most Recent
Previous
Change
Previous
Change
C5.
Obstetrics
Overall Perceptions of Patient
Safety
Change
6.
Lab
Medicine
In this unit, we discuss ways to
prevent errors from happening again.
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).
90
Table D-2. Trending: Item-Level Average Percent Positive Response by Work Area/Unit (Page 4 of 6)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
Both Years
75
446
392
415
476
315
176
345
180
434
353
455
Most Recent
1,646
17,629
22,370
14,201
38,021
13,427
10,501
8,204
6,817
16,255
9,750
28,433
Previous
2,721
14,486
19,550
12,177
28,629
11,708
9,623
7,263
5,536
14,735
9,192
24,749
7.
Frequency of Events Reported
D1.
When a mistake is made, but is
caught and corrected before affecting
the patient, how often is this
reported?
Most Recent
52%
49%
52%
64%
56%
55%
57%
49%
61%
54%
63%
60%
Previous
52%
48%
51%
63%
55%
55%
57%
47%
60%
52%
58%
58%
Change
0%
1%
1%
1%
1%
0%
0%
2%
1%
2%
5%
2%
When a mistake is made, but has no
potential to harm the patient, how
often is this reported?
Most Recent
51%
55%
57%
64%
61%
60%
61%
56%
62%
56%
61%
62%
Previous
49%
54%
56%
63%
59%
60%
62%
52%
60%
54%
58%
60%
Change
2%
1%
1%
1%
2%
0%
-1%
4%
2%
2%
3%
2%
Most Recent
67%
70%
72%
82%
75%
75%
78%
75%
77%
73%
77%
75%
Previous
69%
68%
72%
80%
73%
76%
78%
72%
73%
72%
74%
74%
Change
-2%
2%
0%
2%
2%
-1%
0%
3%
4%
1%
3%
1%
Most Recent
77%
70%
75%
73%
72%
76%
78%
74%
76%
77%
85%
78%
Previous
78%
70%
76%
74%
72%
75%
75%
74%
76%
77%
82%
77%
D2.
D3.
When a mistake is made that could
harm the patient, but does not, how
often is this reported?
8.
Communication Openness
C2.
Staff will freely speak up if they see
something that may negatively affect
patient care.
C4.
C6R.
Staff feel free to question the
decisions or actions of those with
more authority.
Staff are afraid to ask questions when
something does not seem right.
Change
-1%
0%
-1%
-1%
0%
1%
3%
0%
0%
0%
3%
1%
Most Recent
55%
45%
46%
43%
43%
45%
49%
52%
48%
45%
57%
46%
Previous
54%
45%
46%
43%
43%
46%
46%
52%
49%
46%
54%
46%
Change
1%
0%
0%
0%
0%
-1%
3%
0%
-1%
-1%
3%
0%
Most Recent
67%
59%
63%
63%
61%
61%
66%
67%
62%
65%
74%
61%
Previous
65%
59%
64%
64%
60%
61%
64%
67%
64%
64%
71%
61%
Change
2%
0%
-1%
-1%
1%
0%
2%
0%
-2%
1%
3%
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).
91
Table D-2. Trending: Item-Level Average Percent Positive Response by Work Area/Unit (Page 5 of 6)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Both Years
Most Recent
Previous
9.
Teamwork Across Units
F2R.
Hospital units do not coordinate well
with each other.
Most Recent
There is good cooperation among
hospital units that need to work
together.
Most Recent
It is often unpleasant to work with
staff from other hospital units.
Most Recent
Hospital units work well together to
provide the best care for patients.
Most Recent
Previous
Change
F4.
F6R.
Previous
Change
Previous
Change
F10.
Previous
Change
10.
Staffing
A2.
We have enough staff to handle the
workload.
Most Recent
Staff in this unit work longer hours
than is best for patient care.
Most Recent
We use more agency/temporary staff
than is best for patient care.
Most Recent
A14R. We work in “crisis mode” trying to do
too much, too quickly.
Most Recent
Previous
Change
A5R.
Previous
Change
A7R.
Previous
Change
Previous
Change
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
75
1,646
2,721
446
17,629
14,486
392
22,370
19,550
415
14,201
12,177
476
38,021
28,629
315
13,427
11,708
176
10,501
9,623
345
8,204
7,263
180
6,817
5,536
434
16,255
14,735
353
9,750
9,192
455
28,433
24,749
38%
40%
-2%
56%
54%
2%
53%
52%
1%
61%
64%
-3%
37%
36%
1%
48%
46%
2%
51%
49%
2%
58%
57%
1%
44%
42%
2%
58%
56%
2%
63%
63%
0%
66%
65%
1%
42%
42%
0%
57%
57%
0%
54%
54%
0%
67%
67%
0%
45%
43%
2%
59%
57%
2%
62%
61%
1%
67%
66%
1%
46%
42%
4%
59%
58%
1%
60%
57%
3%
68%
67%
1%
46%
45%
1%
61%
60%
1%
62%
58%
4%
69%
69%
0%
42%
42%
0%
55%
54%
1%
57%
56%
1%
65%
64%
1%
42%
40%
2%
55%
55%
0%
62%
60%
2%
64%
62%
2%
45%
43%
2%
60%
58%
2%
57%
55%
2%
68%
66%
2%
49%
47%
2%
64%
61%
3%
66%
63%
3%
73%
70%
3%
42%
40%
2%
56%
56%
0%
56%
56%
0%
66%
65%
1%
58%
55%
3%
44%
45%
-1%
69%
67%
2%
52%
50%
2%
44%
42%
2%
50%
48%
2%
67%
64%
3%
39%
37%
2%
57%
58%
-1%
54%
55%
-1%
73%
71%
2%
50%
49%
1%
52%
50%
2%
58%
56%
2%
68%
68%
0%
47%
47%
0%
47%
46%
1%
50%
50%
0%
69%
68%
1%
45%
43%
2%
58%
55%
3%
58%
55%
3%
78%
75%
3%
53%
48%
5%
59%
60%
-1%
57%
55%
2%
73%
74%
-1%
57%
53%
4%
49%
47%
2%
56%
55%
1%
68%
69%
-1%
45%
45%
0%
49%
51%
-2%
54%
56%
-2%
70%
71%
-1%
49%
52%
-3%
63%
61%
2%
61%
61%
0%
75%
74%
1%
58%
55%
3%
59%
57%
2%
60%
60%
0%
73%
70%
3%
64%
60%
4%
55%
54%
1%
48%
48%
0%
73%
72%
1%
47%
46%
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).
92
Table D-2. Trending: Item-Level Average Percent Positive Response by Work Area/Unit (Page 6 of 6)
Work Area/Unit
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
Both Years
75
446
392
415
476
315
176
345
180
434
353
455
Most Recent
1,646
Previous
17,629
22,370
14,201
38,021
13,427
10,501
8,204
6,817
16,255
9,750
28,433
2,721
14,486
19,550
12,177
28,629
11,708
9,623
7,263
5,536
14,735
9,192
24,749
11.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when
transferring patients from one unit to
another.
Most Recent
37%
46%
41%
28%
41%
49%
46%
22%
37%
42%
39%
40%
Previous
37%
44%
40%
29%
41%
44%
43%
23%
36%
40%
37%
39%
Change
0%
2%
1%
-1%
0%
5%
3%
-1%
1%
2%
2%
1%
Important patient care information is
often lost during shift changes.
Most Recent
46%
59%
61%
45%
51%
65%
61%
38%
52%
50%
47%
50%
Previous
49%
58%
61%
45%
52%
61%
59%
37%
52%
47%
45%
48%
F5R.
F7R.
Problems often occur in the exchange
of information across hospital units.
Change
-3%
1%
0%
0%
-1%
4%
2%
1%
0%
3%
2%
2%
Most Recent
37%
46%
46%
37%
45%
50%
47%
31%
41%
44%
44%
43%
Previous
38%
44%
45%
36%
43%
46%
44%
31%
40%
41%
42%
41%
Change
-1%
2%
1%
1%
2%
4%
3%
0%
1%
3%
2%
2%
Most Recent
34%
46%
58%
40%
46%
62%
54%
34%
44%
44%
40%
39%
Previous
37%
45%
58%
39%
43%
57%
53%
34%
44%
40%
38%
37%
Change
-3%
1%
0%
1%
3%
5%
1%
0%
0%
4%
2%
2%
Most Recent
48%
44%
45%
45%
47%
48%
52%
55%
52%
49%
65%
48%
Previous
49%
42%
46%
46%
47%
48%
49%
57%
52%
50%
63%
49%
Change
-1%
2%
-1%
-1%
0%
0%
3%
-2%
0%
-1%
2%
-1%
A12R. When an event is reported, it feels
like the person is being written up, not
the problem.
Most Recent
43%
40%
43%
42%
45%
45%
50%
54%
51%
46%
64%
47%
Previous
44%
37%
42%
43%
44%
45%
46%
53%
51%
45%
60%
46%
Change
-1%
3%
1%
-1%
1%
0%
4%
1%
0%
1%
4%
1%
A16R. Staff worry that mistakes they make
are kept in their personnel file.
Most Recent
40%
29%
31%
30%
33%
32%
37%
42%
38%
35%
54%
34%
Previous
39%
27%
31%
29%
32%
33%
33%
43%
39%
35%
50%
33%
Change
1%
2%
0%
1%
1%
-1%
4%
-1%
-1%
0%
4%
1%
F11R. Shift changes are problematic for
patients in this hospital.
12.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held
against them.
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).
93
Table D-3. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade 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
Database
Year
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
Both Years
75
446
392
415
476
315
176
345
180
434
353
455
Most Recent
1,646
Previous
17,629
22,370
14,201
38,021
13,427
10,501
8,204
6,817
16,255
9,750
28,433
Most Recent
2,721
14,486
19,550
12,177
28,629
11,708
9,623
7,263
5,536
14,735
9,192
24,749
38%
21%
25%
30%
21%
29%
30%
26%
26%
36%
41%
33%
Previous
35%
18%
24%
29%
20%
27%
29%
25%
26%
33%
37%
32%
Change
3%
3%
1%
1%
1%
2%
1%
1%
0%
3%
4%
1%
Most Recent
41%
44%
46%
46%
47%
45%
50%
46%
43%
46%
44%
43%
Previous
43%
44%
47%
48%
46%
46%
50%
47%
43%
46%
45%
44%
Change
-2%
0%
-1%
-2%
1%
-1%
0%
-1%
0%
0%
-1%
-1%
Most Recent
16%
26%
22%
20%
25%
20%
16%
23%
22%
16%
12%
19%
Previous
19%
28%
23%
19%
27%
21%
18%
22%
22%
18%
15%
20%
Change
-3%
-2%
-1%
1%
-2%
-1%
-2%
1%
0%
-2%
-3%
-1%
Most Recent
4%
7%
5%
3%
6%
4%
3%
5%
7%
2%
2%
4%
Previous
3%
8%
5%
3%
6%
5%
2%
5%
7%
3%
2%
4%
Change
1%
-1%
0%
0%
0%
-1%
1%
0%
0%
-1%
0%
0%
Most Recent
1%
1%
1%
0%
1%
1%
1%
1%
1%
1%
0%
1%
Previous
0%
1%
1%
1%
1%
1%
0%
1%
1%
0%
0%
1%
Change
1%
0%
0%
-1%
0%
0%
1%
0%
0%
1%
0%
0%
Note: Percentages may not add to 100 due to rounding.
94
Table D-4. Trending: Average Percentage of Respondents Reporting Events 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 events or more
Database
Year
Anesthesiology
Emergency
ICU
(any
type)
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mentl
Hlth
Radiology
Rehabilitation
Surgery
Both Years
75
446
392
415
476
315
176
345
180
434
353
455
Most Recent
1,646
Previous
17,629
22,370
14,201
38,021
13,427
10,501
8,204
6,817
16,255
9,750
28,433
Most Recent
2,721
14,486
19,550
12,177
28,629
11,708
9,623
7,263
5,536
14,735
9,192
24,749
54%
49%
36%
46%
43%
45%
47%
45%
51%
56%
61%
47%
Previous
57%
48%
37%
49%
41%
42%
46%
47%
47%
56%
58%
47%
Change
-3%
1%
-1%
-3%
2%
3%
1%
-2%
4%
0%
3%
0%
Most Recent
31%
30%
39%
26%
32%
36%
33%
20%
26%
31%
30%
32%
Previous
28%
31%
37%
26%
32%
36%
32%
20%
29%
31%
31%
31%
Change
3%
-1%
2%
0%
0%
0%
1%
0%
-3%
0%
-1%
1%
Most Recent
11%
13%
17%
14%
18%
14%
14%
16%
15%
9%
7%
14%
Previous
11%
13%
17%
13%
18%
15%
16%
15%
16%
10%
8%
15%
Change
0%
0%
0%
1%
0%
-1%
-2%
1%
-1%
-1%
-1%
-1%
Most Recent
3%
5%
5%
7%
5%
4%
4%
9%
6%
3%
2%
5%
Previous
2%
5%
6%
6%
6%
5%
4%
8%
6%
3%
2%
5%
Change
1%
0%
-1%
1%
-1%
-1%
0%
1%
0%
0%
0%
0%
Most Recent
1%
2%
2%
4%
2%
1%
1%
5%
2%
1%
0%
2%
Previous
1%
2%
2%
3%
2%
2%
1%
5%
2%
1%
1%
2%
Change
0%
0%
0%
1%
0%
-1%
0%
0%
0%
0%
-1%
0%
Most Recent
0%
1%
1%
3%
1%
0%
0%
5%
1%
0%
0%
1%
Previous
0%
1%
1%
3%
1%
1%
1%
4%
0%
1%
0%
1%
Change
0%
0%
0%
0%
0%
-1%
-1%
1%
1%
-1%
0%
0%
Note: Percentages may not add to 100 due to rounding.
95
Appendix D: Trending Results by Respondent Characteristics
(2) Staff Position
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 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 five respondents in the particular staff position and at least three respondents to a particular
question for both the previous and most recent administrations of the survey are included.
NOTE 3: Respondents who selected “Other” or did not answer (missing) are not included.
96
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.
2.
3.
4.
5.
6.
Teamwork Within Units
Supervisor/Manager Expectations & Actions
Promoting Patient Safety
Org Learning--Continuous Improvement
Management Support for Patient Safety
Overall Perceptions of Patient Safety
Feedback & Communication About Error
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Both Years
539
259
82
430
239
637
504
447
504
Most Recent
26,025
17,836
942
16,746
4,525
116,413
33,120
14,089
20,964
Previous
23,291
17,287
972
16,268
3,727
102,902
27,402
12,509
16,846
Most Recent
89%
84%
83%
74%
78%
81%
77%
85%
78%
Previous
88%
81%
84%
72%
77%
80%
76%
84%
77%
Change
1%
3%
-1%
2%
1%
1%
1%
1%
1%
Most Recent
86%
73%
79%
74%
75%
74%
74%
78%
77%
Previous
86%
71%
78%
73%
74%
73%
74%
78%
76%
Change
0%
2%
1%
1%
1%
1%
0%
0%
1%
Most Recent
84%
72%
73%
75%
75%
73%
72%
73%
72%
Previous
83%
71%
73%
73%
73%
72%
71%
71%
72%
Change
1%
1%
0%
2%
2%
1%
1%
2%
0%
Most Recent
86%
71%
78%
74%
67%
67%
73%
74%
77%
Previous
84%
70%
77%
72%
67%
67%
72%
72%
75%
Change
2%
1%
1%
2%
0%
0%
1%
2%
2%
Most Recent
76%
66%
69%
64%
60%
62%
72%
72%
68%
Previous
74%
65%
65%
63%
58%
61%
70%
70%
67%
Change
2%
1%
4%
1%
2%
1%
2%
2%
1%
Most Recent
79%
60%
67%
69%
64%
61%
64%
67%
69%
Previous
77%
60%
66%
66%
62%
60%
63%
66%
67%
Change
2%
0%
1%
3%
2%
1%
1%
1%
2%
97
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
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.
8.
9.
Frequency of Events Reported
Communication Openness
Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to Error
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Both Years
539
259
82
430
239
637
504
447
504
Most Recent
26,025
17,836
942
16,746
4,525
116,413
33,120
14,089
20,964
Previous
23,291
17,287
972
16,268
3,727
102,902
27,402
12,509
16,846
Most Recent
71%
55%
56%
68%
52%
64%
64%
60%
69%
Previous
70%
55%
58%
67%
50%
63%
63%
57%
66%
Change
1%
0%
-2%
1%
2%
1%
1%
3%
3%
Most Recent
77%
65%
65%
58%
64%
61%
60%
67%
60%
Previous
76%
63%
63%
57%
64%
60%
59%
67%
61%
Change
1%
2%
2%
1%
0%
1%
1%
0%
-1%
Most Recent
68%
60%
62%
60%
52%
57%
56%
62%
59%
Previous
65%
58%
62%
57%
51%
56%
54%
61%
58%
Change
3%
2%
0%
3%
1%
1%
2%
1%
1%
Most Recent
64%
54%
57%
50%
55%
59%
59%
62%
55%
Previous
64%
54%
51%
49%
54%
57%
57%
60%
54%
Change
0%
0%
6%
1%
1%
2%
2%
2%
1%
Most Recent
48%
43%
38%
50%
28%
48%
41%
42%
46%
Previous
47%
42%
35%
47%
27%
47%
39%
41%
45%
Change
1%
1%
3%
3%
1%
1%
2%
1%
1%
Most Recent
63%
41%
46%
36%
52%
44%
41%
51%
40%
Previous
61%
40%
49%
35%
52%
44%
40%
51%
40%
Change
2%
1%
-3%
1%
0%
0%
1%
0%
0%
98
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
Table D-6. Trending: Item-Level Average Percent Positive Response by Staff Position (Page 1 of 6)
Staff Position
Survey Items by Composite
# Hospitals
# Respondents
1.
Teamwork Within Units
A1.
People support one another in this unit.
A3.
When a lot of work needs to be done
quickly, we work together as a team to get
the work done.
A4.
In this unit, people treat each other with
respect.
A11.
When one area in this unit gets really busy,
others help out.
2.
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Both Years
Most Recent
Previous
539
26,025
23,291
259
17,836
17,287
82
942
972
430
16,746
16,268
239
4,525
3,727
637
116,413
102,902
504
33,120
27,402
447
14,089
12,509
504
20,964
16,846
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
94%
93%
1%
94%
93%
1%
89%
88%
1%
79%
78%
1%
90%
86%
4%
86%
85%
1%
87%
83%
4%
71%
68%
3%
87%
89%
-2%
88%
87%
1%
82%
83%
-1%
77%
75%
2%
80%
79%
1%
78%
77%
1%
72%
71%
1%
66%
63%
3%
84%
84%
0%
82%
82%
0%
78%
77%
1%
66%
67%
-1%
87%
87%
0%
87%
86%
1%
79%
79%
0%
69%
68%
1%
82%
82%
0%
85%
84%
1%
74%
73%
1%
66%
65%
1%
90%
89%
1%
89%
88%
1%
84%
83%
1%
77%
75%
2%
83%
83%
0%
84%
84%
0%
75%
75%
0%
70%
67%
3%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
86%
85%
1%
89%
89%
0%
84%
84%
0%
85%
85%
0%
70%
69%
1%
77%
75%
2%
69%
68%
1%
74%
74%
0%
79%
78%
1%
83%
84%
-1%
73%
73%
0%
79%
79%
0%
73%
71%
2%
76%
73%
3%
75%
72%
3%
74%
73%
1%
69%
69%
0%
77%
76%
1%
76%
75%
1%
77%
76%
1%
72%
71%
1%
75%
74%
1%
72%
72%
0%
76%
75%
1%
70%
69%
1%
74%
74%
0%
76%
75%
1%
76%
76%
0%
76%
76%
0%
81%
81%
0%
77%
76%
1%
80%
79%
1%
76%
74%
2%
77%
77%
0%
76%
75%
1%
78%
76%
2%
Unit
Asst/
Clerk/
Secretary
Supervisor/Manager Expectations &
Actions Promoting Patient Safety
B1.
My supv/mgr says a good word when
he/she sees a job done according to
established patient safety procedures.
B2.
My supv/mgr seriously considers staff
suggestions for improving patient safety.
B3R.
Whenever pressure builds up, my supv/mgr
wants us to work faster, even if it means
taking shortcuts.
B4R.
My supv/mgr overlooks patient safety
problems that happen over and over.
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).
99
Table D-6. Trending: Item-Level Average Percent Positive Response by Staff Position (Page 2 of 6)
Staff Position
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Both Years
539
259
82
430
239
637
504
447
504
Most Recent
26,025
17,836
942
16,746
4,525
116,413
33,120
14,089
20,964
Previous
23,291
17,287
972
16,268
3,727
102,902
27,402
12,509
16,846
Unit
Asst/
Clerk/
Secretary
3.
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve
patient safety.
Most Recent
90%
84%
85%
87%
87%
85%
83%
86%
83%
Previous
90%
84%
85%
85%
85%
84%
83%
84%
83%
Change
0%
0%
0%
2%
2%
1%
0%
2%
0%
Mistakes have led to positive changes
here.
Most Recent
81%
68%
63%
63%
77%
63%
64%
62%
63%
Previous
80%
67%
63%
60%
76%
62%
63%
59%
61%
Change
1%
1%
0%
3%
1%
1%
1%
3%
2%
Most Recent
80%
63%
71%
76%
62%
71%
67%
71%
71%
Previous
78%
63%
70%
74%
59%
70%
66%
69%
70%
Change
2%
0%
1%
2%
3%
1%
1%
2%
1%
A9.
A13.
After we make changes to improve patient
safety, we evaluate their effectiveness.
4.
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that
promotes patient safety.
Most Recent
91%
79%
87%
83%
73%
75%
83%
84%
85%
Previous
90%
80%
86%
82%
73%
75%
82%
83%
84%
Change
1%
-1%
1%
1%
0%
0%
1%
1%
1%
The actions of hospital mgmt show that
patient safety is a top priority.
Most Recent
88%
74%
82%
79%
71%
70%
76%
77%
80%
Previous
86%
73%
82%
76%
72%
69%
75%
74%
77%
Change
2%
1%
0%
3%
-1%
1%
1%
3%
3%
Most Recent
78%
61%
64%
60%
58%
57%
61%
62%
65%
Previous
75%
58%
62%
59%
55%
57%
59%
61%
63%
Change
3%
3%
2%
1%
3%
0%
2%
1%
2%
F8.
F9R.
Hospital mgmt seems interested in patient
safety only after an adverse event
happens.
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).
100
Table D-6. Trending: Item-Level Average Percent Positive Response by Staff Position (Page 3 of 6)
Staff Position
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Both Years
Most Recent
539
26,025
259
17,836
82
942
430
16,746
239
4,525
637
116,413
504
33,120
447
14,089
504
20,964
Previous
23,291
17,287
972
16,268
3,727
102,902
27,402
12,509
16,846
A10R. It is just by chance that more serious
mistakes don’t happen around here.
Most Recent
A15.
Most Recent
74%
73%
1%
75%
73%
2%
75%
72%
3%
80%
79%
1%
67%
64%
3%
62%
64%
-2%
63%
61%
2%
72%
71%
1%
65%
63%
2%
69%
62%
7%
68%
62%
6%
73%
71%
2%
54%
53%
1%
66%
65%
1%
63%
61%
2%
74%
72%
2%
59%
58%
1%
54%
52%
2%
56%
53%
3%
69%
68%
1%
62%
61%
1%
57%
57%
0%
58%
58%
0%
70%
69%
1%
66%
64%
2%
71%
70%
1%
72%
70%
2%
77%
76%
1%
71%
69%
2%
70%
67%
3%
73%
70%
3%
77%
74%
3%
60%
60%
0%
71%
70%
1%
69%
67%
2%
74%
73%
1%
72%
70%
2%
80%
78%
2%
86%
52%
52%
0%
59%
59%
0%
70%
59%
61%
-2%
67%
66%
1%
75%
63%
58%
5%
71%
67%
4%
74%
55%
52%
3%
65%
64%
1%
71%
55%
54%
1%
60%
59%
1%
69%
55%
54%
1%
67%
67%
0%
71%
60%
59%
1%
67%
66%
1%
74%
61%
59%
2%
71%
69%
2%
74%
85%
1%
69%
1%
72%
3%
71%
3%
69%
2%
68%
1%
70%
1%
73%
1%
73%
1%
Survey Items by Composite
# Hospitals
# Respondents
5.
Previous
Patient safety is never sacrificed to get
more work done.
Previous
Change
A17R. We have patient safety problems in this
unit.
Most Recent
A18.
Most Recent
Previous
Change
Our procedures and systems are good at
preventing errors from happening.
Previous
Change
C1.
We are given feedback about changes put
into place based on event reports.
Most Recent
We are informed about errors that happen
in this unit.
Most Recent
In this unit, we discuss ways to prevent
errors from happening again.
Most Recent
Previous
Previous
Change
C5.
Tech
(EKG, Lab,
Radiol)
Unit
Asst/
Clerk/
Secretary
Feedback & Communication About
Error
Change
C3.
Pharmacist
RN/
LVN/
LPN
Therapist
(Respir,
Phys,
Occup,
Speech)
Overall Perceptions of Patient Safety
Change
6.
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
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).
101
Table D-6. Trending: Item-Level Average Percent Positive Response by Staff Position (Page 4 of 6)
Staff Position
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Both Years
539
259
82
430
239
637
504
447
504
Most Recent
26,025
17,836
942
16,746
4,525
116,413
33,120
14,089
20,964
Previous
23,291
17,287
972
16,268
3,727
102,902
27,402
12,509
16,846
Unit
Asst/
Clerk/
Secretary
7.
Frequency of Events Reported
D1.
When a mistake is made, but is caught and
corrected before affecting the patient, how
often is this reported?
Most Recent
66%
49%
51%
66%
39%
54%
58%
54%
65%
Previous
63%
49%
54%
65%
35%
53%
57%
52%
62%
Change
3%
0%
-3%
1%
4%
1%
1%
2%
3%
When a mistake is made, but has no
potential to harm the patient, how often is
this reported?
Most Recent
66%
48%
49%
64%
47%
61%
59%
53%
64%
Previous
66%
48%
51%
62%
45%
60%
57%
51%
61%
Change
0%
0%
-2%
2%
2%
1%
2%
2%
3%
Most Recent
81%
68%
67%
75%
70%
76%
75%
71%
76%
Previous
81%
67%
70%
73%
68%
75%
74%
68%
75%
Change
0%
1%
-3%
2%
2%
1%
1%
3%
1%
D2.
D3.
When a mistake is made that could harm
the patient, but does not, how often is this
reported?
8.
Communication Openness
C2.
Staff will freely speak up if they see
something that may negatively affect
patient care.
Most Recent
85%
73%
78%
73%
73%
75%
75%
81%
76%
Previous
84%
73%
74%
73%
73%
74%
75%
80%
76%
Change
1%
0%
4%
0%
0%
1%
0%
1%
0%
Staff feel free to question the decisions or
actions of those with more authority.
Most Recent
70%
57%
51%
42%
51%
45%
43%
52%
44%
Previous
69%
54%
50%
40%
52%
45%
43%
52%
44%
Change
1%
3%
1%
2%
-1%
0%
0%
0%
0%
Most Recent
75%
64%
65%
58%
68%
62%
63%
68%
61%
Previous
74%
63%
65%
57%
66%
62%
61%
68%
63%
Change
1%
1%
0%
1%
2%
0%
2%
0%
-2%
C4.
C6R.
Staff are afraid to ask questions when
something does not seem right.
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).
102
Table D-6. Trending: Item-Level Average Percent Positive Response by Staff Position (Page 5 of 6)
Staff Position
Survey Items by Composite
# Hospitals
# Respondents
9.
Teamwork Across Units
F2R.
Hospital units do not coordinate well with
each other.
F4.
There is good cooperation among hospital
units that need to work together.
F6R.
It is often unpleasant to work with staff from
other hospital units.
F10.
Hospital units work well together to provide
the best care for patients.
10.
Staffing
A2.
We have enough staff to handle the
workload.
A5R.
Staff in this unit work longer hours than is
best for patient care.
A7R.
We use more agency/temporary staff than
is best for patient care.
A14R. We work in “crisis mode” trying to do too
much, too quickly.
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Both Years
Most Recent
Previous
539
26,025
23,291
259
17,836
17,287
82
942
972
430
16,746
16,268
239
4,525
3,727
637
116,413
102,902
504
33,120
27,402
447
14,089
12,509
504
20,964
16,846
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
58%
54%
4%
71%
67%
4%
67%
64%
3%
77%
75%
2%
46%
44%
2%
62%
59%
3%
64%
61%
3%
68%
66%
2%
50%
47%
3%
65%
67%
-2%
62%
64%
-2%
73%
71%
2%
47%
44%
3%
62%
58%
4%
59%
56%
3%
72%
69%
3%
38%
38%
0%
50%
49%
1%
58%
56%
2%
60%
60%
0%
44%
43%
1%
57%
56%
1%
60%
59%
1%
66%
65%
1%
43%
41%
2%
58%
56%
2%
55%
53%
2%
67%
66%
1%
48%
48%
0%
63%
61%
2%
66%
64%
2%
72%
69%
3%
47%
47%
0%
61%
60%
1%
58%
58%
0%
71%
70%
1%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
69%
69%
0%
59%
59%
0%
72%
72%
0%
58%
57%
1%
55%
55%
0%
49%
49%
0%
62%
59%
3%
52%
51%
1%
58%
51%
7%
52%
48%
4%
65%
58%
7%
53%
49%
4%
46%
44%
2%
45%
45%
0%
63%
62%
1%
47%
46%
1%
47%
47%
0%
59%
59%
0%
72%
72%
0%
42%
41%
1%
56%
54%
2%
56%
55%
1%
75%
72%
3%
49%
46%
3%
56%
54%
2%
58%
56%
2%
71%
69%
2%
51%
49%
2%
57%
56%
1%
59%
58%
1%
74%
71%
3%
57%
56%
1%
54%
53%
1%
50%
50%
0%
64%
63%
1%
52%
50%
2%
Previous
Change
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
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).
103
Table D-6. Trending: Item-Level Average Percent Positive Response by Staff Position (Page 6 of 6)
Staff Position
Survey Items by Composite
# Hospitals
# Respondents
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Both Years
Most Recent
539
26,025
259
17,836
82
942
430
16,746
239
4,525
637
116,413
504
33,120
447
14,089
504
20,964
Previous
23,291
17,287
972
16,268
3,727
102,902
27,402
12,509
16,846
44%
43%
1%
53%
52%
1%
47%
46%
1%
48%
46%
2%
40%
39%
1%
47%
47%
0%
44%
42%
2%
40%
39%
1%
36%
32%
4%
40%
36%
4%
36%
37%
-1%
38%
33%
5%
47%
45%
2%
58%
56%
2%
47%
43%
4%
49%
45%
4%
19%
17%
2%
33%
33%
0%
28%
27%
1%
30%
31%
-1%
43%
42%
1%
55%
54%
1%
46%
45%
1%
49%
48%
1%
36%
34%
2%
47%
45%
2%
40%
37%
3%
41%
39%
2%
37%
35%
2%
47%
45%
2%
43%
41%
2%
42%
41%
1%
44%
43%
1%
51%
51%
0%
45%
45%
0%
44%
42%
2%
69%
68%
1%
70%
67%
3%
51%
47%
47%
0%
45%
43%
2%
33%
55%
57%
-2%
47%
49%
-2%
37%
43%
41%
2%
37%
36%
1%
28%
57%
58%
-1%
57%
57%
0%
43%
50%
50%
0%
48%
47%
1%
35%
47%
46%
1%
44%
41%
3%
33%
57%
57%
0%
53%
52%
1%
44%
46%
47%
-1%
42%
41%
1%
32%
48%
3%
31%
2%
42%
-5%
27%
1%
41%
2%
34%
1%
31%
2%
44%
0%
31%
1%
11.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when
transferring patients from one unit to
another.
Most Recent
Important patient care information is often
lost during shift changes.
Most Recent
F5R.
Previous
Change
Previous
Change
F7R.
Problems often occur in the exchange of
information across hospital units.
Most Recent
Previous
Change
F11R. Shift changes are problematic for patients
in this hospital.
Most Recent
Previous
Change
12.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held
against them.
Most Recent
A12R. When an event is reported, it feels like the
person is being written up, not the problem.
Most Recent
Previous
Change
Previous
Change
A16R. Staff worry that mistakes they make are
kept in their personnel file.
Most Recent
Previous
Change
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
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).
104
Table D-7. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Staff Position
Staff Position
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
A. Excellent
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Both Years
539
26,025
259
17,836
82
942
430
16,746
239
4,525
637
116,413
504
33,120
447
14,089
504
20,964
23,291
43%
38%
5%
44%
47%
-3%
12%
13%
-1%
1%
2%
-1%
0%
17,287
30%
29%
1%
46%
45%
1%
19%
22%
-3%
4%
4%
0%
1%
972
28%
24%
4%
50%
53%
-3%
18%
20%
-2%
3%
3%
0%
1%
16,268
30%
28%
2%
44%
44%
0%
21%
22%
-1%
4%
5%
-1%
1%
3,727
22%
18%
4%
47%
48%
-1%
25%
26%
-1%
5%
6%
-1%
2%
102,902
25%
24%
1%
46%
46%
0%
23%
24%
-1%
5%
5%
0%
1%
27,402
32%
31%
1%
45%
45%
0%
19%
20%
-1%
3%
3%
0%
1%
12,509
34%
33%
1%
45%
45%
0%
17%
18%
-1%
3%
4%
-1%
0%
16,846
34%
31%
3%
45%
46%
-1%
18%
20%
-2%
3%
3%
0%
1%
0%
0%
1%
0%
0%
1%
1%
0%
1%
1%
1%
0%
1%
0%
1%
-1%
1%
0%
Most Recent
Previous
Most Recent
Previous
Change
B. Very Good
Most Recent
Previous
Change
C. Acceptable
Most Recent
Previous
Change
D. Poor
Most Recent
Previous
Change
E.
Failing
Most Recent
Previous
Change
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Note: Percentages may not add to 100 due to rounding.
105
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
Table D-8. Trending: Average Percentage of Respondents Reporting Events in the Past 12 Months by Staff Position
Staff Position
Number of Events Reported by
Respondents
# Hospitals
# Respondents
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or
NP
Both Years
539
26,025
259
17,836
82
942
430
16,746
239
4,525
637
116,413
504
33,120
447
14,089
504
20,964
23,291
51%
46%
5%
21%
23%
-2%
15%
16%
-1%
8%
8%
0%
3%
4%
-1%
3%
17,287
64%
65%
-1%
25%
24%
1%
8%
8%
0%
2%
2%
0%
1%
1%
0%
0%
972
79%
68%
11%
15%
16%
-1%
4%
6%
-2%
1%
5%
-4%
0%
2%
-2%
0%
16,268
79%
78%
1%
17%
17%
0%
3%
3%
0%
1%
1%
0%
0%
0%
0%
0%
3,727
28%
28%
0%
24%
24%
0%
22%
21%
1%
13%
14%
-1%
8%
7%
1%
6%
102,902
32%
33%
-1%
39%
37%
2%
19%
20%
-1%
6%
7%
-1%
2%
2%
0%
1%
27,402
58%
58%
0%
28%
27%
1%
9%
9%
0%
3%
3%
0%
1%
1%
0%
1%
12,509
62%
59%
3%
30%
31%
-1%
6%
7%
-1%
2%
2%
0%
1%
1%
0%
0%
16,846
84%
81%
3%
11%
14%
-3%
3%
3%
0%
1%
1%
0%
0%
0%
0%
0%
3%
0%
1%
-1%
2%
-2%
0%
0%
6%
0%
1%
0%
1%
0%
0%
0%
0%
0%
Most Recent
Previous
No events
Most Recent
Previous
Change
1 to 2 events
Most Recent
Previous
Change
3 to 5 events
Most Recent
Previous
Change
6 to 10 events
Most Recent
Previous
Change
11 to 20 events
Most Recent
Previous
Change
21 events or more
Most Recent
Previous
Change
Dietitian
Pat. Care
Asst/
Aide/
Care
Partner
Note: Percentages may not add to 100 due to rounding.
106
Pharmacist
RN/
LVN/
LPN
Tech
(EKG, Lab,
Radiol)
Therapist
(Respir,
Phys,
Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
Appendix D: Trending Results by Respondent Characteristics
(3) Interaction With Patients
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 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 nonresponse/missing data.
NOTE 2: Only hospitals that had at least five respondents in the response categories (WITH or WITHOUT direct interaction with
patients) and at least three respondents to a particular question for both the previous and most recent administrations of the survey are
included.
NOTE 3: Respondents who did not answer (missing) are not included.
107
Table D-9. Trending: Composite-Level Average Percent Positive Response by Interaction With Patients (Page 1 of 2)
Interaction With Patients
Patient Safety Culture Composites
# Hospitals
# Respondents
1.
2.
3.
4.
5.
6.
Teamwork Within Units
Supervisor/Manager Expectations & Actions Promoting Patient Safety
Org Learning--Continuous Improvement
Management Support for Patient Safety
Overall Perceptions of Patient Safety
Feedback & Communication About Error
108
Database
Year
WITH
direct interaction
WITHOUT
direct interaction
Both Years
641
600
Most Recent
247,970
80,019
Previous
219,148
71,777
Most Recent
80%
81%
Previous
79%
80%
Change
1%
1%
Most Recent
75%
77%
Previous
75%
77%
Change
0%
0%
Most Recent
73%
74%
Previous
72%
73%
Change
1%
1%
Most Recent
72%
78%
Previous
71%
77%
Change
1%
1%
Most Recent
66%
68%
Previous
65%
67%
Change
1%
1%
Most Recent
64%
69%
Previous
63%
68%
Change
1%
1%
Table D-9. Trending: Composite-Level Average Percent Positive Response by Interaction With Patients (Page 2 of 2)
Interaction With Patients
Patient Safety Culture Composites
# Hospitals
# Respondents
7.
8.
9.
10.
11.
12.
Frequency of Events Reported
Communication Openness
Teamwork Across Units
Staffing
Handoffs & Transitions
Nonpunitive Response to Error
109
Database
Year
WITH
direct interaction
WITHOUT
direct interaction
Both Years
641
600
Most Recent
247,970
80,019
Previous
219,148
71,777
Most Recent
64%
66%
Previous
63%
65%
Change
1%
1%
Most Recent
62%
64%
Previous
61%
64%
Change
1%
0%
Most Recent
59%
60%
Previous
58%
59%
Change
1%
1%
Most Recent
58%
54%
Previous
57%
53%
Change
1%
1%
Most Recent
47%
40%
Previous
46%
39%
Change
1%
1%
Most Recent
44%
47%
Previous
43%
46%
Change
1%
1%
Table D-10. Trending: Item-Level Average Percent Positive Response by Interaction With Patients (Page 1 of 6)
Interaction With Patients
Survey Items by Composite
# Hospitals
# Respondents
1.
Teamwork Within Units
A1.
People support one another in this unit.
Database
Year
WITH
direct interaction
WITHOUT
direct interaction
Both Years
Most Recent
641
247,970
600
80,019
Previous
219,148
71,777
Most Recent
86%
85%
1%
86%
85%
1%
78%
78%
0%
70%
69%
1%
86%
86%
0%
87%
87%
0%
80%
79%
1%
71%
70%
1%
73%
72%
1%
76%
76%
0%
74%
74%
0%
77%
77%
76%
1%
79%
78%
1%
77%
75%
2%
77%
77%
0%
77%
0%
Previous
Change
A3.
When a lot of work needs to be done quickly, we work together as a team to get the work
done.
Most Recent
In this unit, people treat each other with respect.
Most Recent
Previous
Change
A4.
Previous
Change
A11.
Most Recent
When one area in this unit gets really busy, others help out.
Previous
Change
2.
Supervisor/Manager Expectations & Actions Promoting Patient Safety
B1.
My supv/mgr says a good word when he/she sees a job done according to established
patient safety procedures.
Most Recent
My supv/mgr seriously considers staff suggestions for improving patient safety.
Most Recent
Previous
Change
B2.
Previous
Change
B3R.
Whenever pressure builds up, my supv/mgr wants us to work faster, even if it means taking
shortcuts.
Most Recent
Previous
Change
B4R.
Most Recent
My supv/mgr overlooks patient safety problems that happen over and over.
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).
110
Table D-10. Trending: Item-Level Average Percent Positive Response by Interaction With Patients (Page 2 of 6)
Interaction With Patients
Survey Items by Composite
# Hospitals
# Respondents
3.
Org Learning--Continuous Improvement
A6.
We are actively doing things to improve patient safety.
A9.
A13.
Mistakes have led to positive changes here.
After we make changes to improve patient safety, we evaluate their effectiveness.
4.
Management Support for Patient Safety
F1.
Hospital mgmt provides a work climate that promotes patient safety.
F8.
F9R.
The actions of hospital mgmt show that patient safety is a top priority.
Hospital mgmt seems interested in patient safety only after an adverse event happens.
Database
Year
WITH
direct interaction
WITHOUT
direct interaction
Both Years
641
600
Most Recent
247,970
80,019
Previous
219,148
71,777
Most Recent
85%
82%
Previous
84%
82%
Change
1%
0%
Most Recent
63%
69%
Previous
63%
69%
Change
0%
0%
Most Recent
71%
69%
Previous
70%
69%
Change
1%
0%
Most Recent
80%
86%
Previous
80%
86%
Change
0%
0%
Most Recent
74%
81%
Previous
73%
80%
Change
1%
1%
Most Recent
60%
67%
Previous
59%
65%
Change
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).
111
Table D-10. Trending: Item-Level Average Percent Positive Response by Interaction With Patients (Page 3 of 6)
Interaction With Patients
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
5.
Patient safety is never sacrificed to get more work done.
A17R. We have patient safety problems in this unit.
A18.
Our procedures and systems are good at preventing errors from happening.
6.
Feedback & Communication About Error
C1.
We are given feedback about changes put into place based on event reports.
C3.
C5.
WITHOUT
direct interaction
Both Years
641
600
Most Recent
247,970
80,019
Previous
219,148
71,777
Most Recent
63%
62%
Previous
62%
61%
Change
1%
1%
Most Recent
65%
68%
Previous
64%
67%
Change
1%
1%
Most Recent
65%
68%
Previous
64%
66%
Change
1%
2%
Most Recent
73%
74%
Previous
72%
73%
Change
1%
1%
Most Recent
57%
61%
Previous
56%
60%
Change
1%
1%
Most Recent
65%
71%
Previous
64%
70%
Overall Perceptions of Patient Safety
A10R. It is just by chance that more serious mistakes don’t happen around here.
A15.
WITH
direct interaction
We are informed about errors that happen in this unit.
In this unit, we discuss ways to prevent errors from happening again.
Change
1%
1%
Most Recent
72%
76%
Previous
71%
75%
Change
1%
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).
112
Table D-10. Trending: Item-Level Average Percent Positive Response by Interaction With Patients (Page 4 of 6)
Interaction With Patients
Survey Items by Composite
# Hospitals
# Respondents
7.
Frequency of Events Reported
D1.
When a mistake is made, but is caught and corrected before affecting the patient, how often
is this reported?
D2.
D3.
When a mistake is made, but has no potential to harm the patient, how often is this reported?
When a mistake is made that could harm the patient, but does not, how often is this
reported?
8.
Communication Openness
C2.
Staff will freely speak up if they see something that may negatively affect patient care.
C4.
C6R.
Staff feel free to question the decisions or actions of those with more authority.
Staff are afraid to ask questions when something does not seem right.
Database
Year
WITH
direct interaction
WITHOUT
direct interaction
Both Years
641
600
Most Recent
247,970
80,019
Previous
219,148
71,777
Most Recent
57%
62%
Previous
55%
60%
Change
2%
2%
Most Recent
60%
61%
Previous
59%
60%
Change
1%
1%
Most Recent
75%
75%
Previous
74%
74%
Change
1%
1%
Most Recent
76%
76%
Previous
75%
75%
Change
1%
1%
Most Recent
46%
52%
Previous
46%
51%
Change
0%
1%
Most Recent
63%
65%
Previous
63%
65%
Change
0%
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).
113
Table D-10. Trending: Item-Level Average Percent Positive Response by Interaction With Patients (Page 5 of 6)
Interaction With Patients
Survey Items by Composite
# Hospitals
# Respondents
9.
Teamwork Across Units
F2R.
Hospital units do not coordinate well with each other.
Database
Year
WITH
direct interaction
WITHOUT
direct interaction
Both Years
Most Recent
641
247,970
600
80,019
Previous
219,148
71,777
Most Recent
46%
45%
1%
60%
59%
1%
60%
59%
1%
69%
67%
2%
48%
47%
1%
62%
60%
2%
58%
57%
1%
71%
70%
1%
56%
55%
1%
54%
54%
0%
71%
69%
2%
51%
58%
57%
1%
50%
49%
1%
60%
59%
1%
49%
50%
1%
48%
1%
Previous
Change
F4.
Most Recent
There is good cooperation among hospital units that need to work together.
Previous
Change
F6R.
Most Recent
It is often unpleasant to work with staff from other hospital units.
Previous
Change
F10.
Most Recent
Hospital units work well together to provide the best care for patients.
Previous
Change
10.
Staffing
A2.
We have enough staff to handle the workload.
Most Recent
Previous
Change
A5R.
Most Recent
Staff in this unit work longer hours than is best for patient care.
Previous
Change
A7R.
Most Recent
We use more agency/temporary staff than is best for patient care.
Previous
Change
A14R. We work in “crisis mode” trying to do too much, too quickly.
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).
114
Table D-10. Trending: Item-Level Average Percent Positive Response by Interaction With Patients (Page 6 of 6)
Interaction With Patients
Database
Year
Survey Items by Composite
# Hospitals
# Respondents
11.
Handoffs & Transitions
F3R.
Things “fall between the cracks” when transferring patients from one unit to another.
F5R.
F7R.
Important patient care information is often lost during shift changes.
Problems often occur in the exchange of information across hospital units.
F11R. Shift changes are problematic for patients in this hospital.
12.
Nonpunitive Response to Error
A8R.
Staff feel like their mistakes are held against them.
A12R. When an event is reported, it feels like the person is being written up, not the problem.
A16R. Staff worry that mistakes they make are kept in their personnel file.
WITH
direct interaction
WITHOUT
direct interaction
Both Years
641
600
Most Recent
247,970
80,019
Previous
219,148
71,777
Most Recent
43%
36%
Previous
42%
35%
Change
1%
1%
Most Recent
53%
45%
Previous
52%
43%
Change
1%
2%
Most Recent
46%
40%
Previous
44%
38%
Change
2%
2%
Most Recent
47%
40%
Previous
46%
39%
Change
1%
1%
Most Recent
50%
53%
Previous
50%
53%
Change
0%
0%
Most Recent
47%
50%
Previous
46%
48%
Change
1%
2%
Most Recent
36%
37%
Previous
35%
37%
Change
1%
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).
115
Table D-11. Trending: Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety Grade by Interaction With
Patients
Interaction With Patients
Database
Year
Work Area/Unit Patient Safety Grade
# Hospitals
# Respondents
A.
B.
C.
D.
E.
Excellent
Very Good
Acceptable
Poor
Failing
WITH
direct interaction
WITHOUT
direct interaction
Both Years
641
600
Most Recent
247,970
80,019
Previous
219,148
71,777
Most Recent
30%
35%
Previous
28%
33%
Change
2%
2%
Most Recent
45%
45%
Previous
46%
46%
Change
-1%
-1%
Most Recent
20%
17%
Previous
21%
19%
Change
-1%
-2%
Most Recent
4%
2%
Previous
4%
2%
Change
0%
0%
Most Recent
1%
0%
Previous
1%
1%
Change
0%
-1%
Note: Percentages may not add to 100 due to rounding.
116
Table D-12. Trending: Average Percentage of Respondents Reporting Events 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 events or more
Database
Year
WITH
direct interaction
WITHOUT
direct interaction
Both Years
641
600
Most Recent
247,970
80,019
Previous
219,148
71,777
Most Recent
51%
71%
Previous
50%
70%
Change
1%
1%
Most Recent
30%
15%
Previous
30%
16%
Change
0%
-1%
Most Recent
12%
7%
Previous
13%
8%
Change
-1%
-1%
Most Recent
4%
3%
Previous
4%
4%
Change
0%
-1%
Most Recent
1%
2%
Previous
2%
2%
Change
-1%
0%
Most Recent
1%
2%
Previous
1%
2%
Change
0%
0%
Note: Percentages may not add to 100 due to rounding.
117
| File Type | application/pdf |
| File Title | Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report, Appendixes |
| Author | Agency for Healthcare Research and Quality (AHRQ) |
| File Modified | 2012-01-24 |
| File Created | 2012-01-06 |