SECTION D: Near-Miss Documentation When something happens that could harm the patient, but does not, how often is it documented in an ► incident or occurrence report? Most of Does not apply Never Rarely Sometimes the time Always or Don’t know ▼ ▼ ▼ ▼ ▼  1 2 3 4 5 9 SECTION E: Management Support for Patient Safety How much do you agree or disagree with the following state ► Does not Neither apply or nor Strongly Strongly Don’t disagree disagree Disagree Agree agree know       1. Managers encourage everyone to suggest ways to improve patient 1 2 3 4 5 9 safety................................................. 2. Management examines near-miss events that could have harmed patients but did 1 2 3 4 5 9 not................................. 3. Management provides adequate resources to improve patient 1 2 3 4 5 9 safety................................................. SECTION F: Overall Rating Please give your facility an overall rating on patient safety. ► Fair Good Very Poor good ▼ ▼ Excellent ▼ ▼ 2 3 ▼ 1 4 5 SECTION G: Communication in the Surgery/Procedure Room Are you typically in the surgery/procedure room during surgeries, procedures, or treatments? ► Yes Continue No to Section H Go In the past 6 months, how often were the following actions done in your facility? ► Does not or Some- Most of Don’t Never Rarely Always times the time know       1. Just before the of procedures, all team members stopped to discuss the overall plan of what was to be 1 2 3 4 5 9 2. Just before the start of procedures, the doctor encouraged all team members to speak up at any time if they had any concerns. 1 2 3 4 5 9 ......................................
SECTION D: Near-Miss Documentation ► When something happens that could harm the patient, but does not, how often is it documented in an incident or occurrence report? Most of Does not apply Never Rarely Sometimes the time Always or Don’t know ▼ ▼ ▼ ▼ ▼  1 2 3 4 5 9 SECTION E: Management Support for Patient Safety ► How much do you agree or disagree with the following state Strongly disagree  Disagree  Neither nor disagree  Agree  Strongly agree  Does not apply or Don’t know  1. Managers encourage everyone to suggest ways to improve patient safety................................................. 1 2 3 4 5 9 2. Management examines near-miss events that could have harmed patients but did not................................. 1 2 3 4 5 9 3. Management provides adequate resources to improve patient safety................................................. 1 2 3 4 5 9 SECTION F: Overall Rating ► Please give your facility an overall rating on patient safety. Poor ▼ 1 Fair ▼ 2 Good ▼ 3 Very good ▼ 4 Excellent ▼ 5 SECTION G: Communication in the Surgery/Procedure Room ► Are you typically in the surgery/procedure room during surgeries, procedures, or treatments? Yes Continue No Go to Section H ► In the past 6 months, how often were the following actions done in your facility? Never  Rarely  Some- times  Most of the time  Always  Does not or Don’t know  1. Just before the of procedures, all team members stopped to discuss the overall plan of what was to be 1 2 3 4 5 9 2. Just before the start of procedures, the doctor encouraged all team members to speak up at any time if they had any concerns. ...................................... 1 2 3 4 5 9