2 Appendix B: Safety Attitude Survey

Appendix B – Safety Attitude Survey

Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20

Safety Attitude Survey – Clinician

MedStar Health Research Institute (MHRI) will conduct interviews with up to twenty (n=20) clinicians to assess perception of safety climate in their current practice settings.

Recruitment Criteria

Any licensed clinician whose scope of practice includes diagnosis.

Location and Schedule

The survey will be completed online. The survey will take approximately 15 minutes to complete.

Informed Consent Procedures

Informed consent will be completed online with a survey cover page.

Safety Attitude Survey

	1	2	3	4		5	N/A
	Disagree Strongly	Disagree Slightly	Neutral	Agree Slightly		Agree Strongly	Not Applicable
I would feel safe being treated here as a patient.					1 2 3 4 5 N/A
Medical errors are handled appropriately in this clinical area.					1 2 3 4 5 N/A
I know the proper channels to direct questions regarding patient safety in this clinical area.					1 2 3 4 5 N/A
I receive appropriate feedback about my performance.					1 2 3 4 5 N/A
In this clinical area, it is difficult to discuss errors.					1 2 3 4 5 N/A
I am encouraged by my colleagues to report any patient safety concerns I may have.					1 2 3 4 5 N/A
The culture in this clinical area makes it easy to learn from the errors of others.					1 2 3 4 5 N/A

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.