In the past 6 months, how many adverse event or near-miss reports did you submit? Enter 0 if none.
Accepts a numeric value
Whole numbers only
When a near miss occurs in your work, how often do you report it?
- Always
- Often
- Sometimes
- Rarely
- Never
- Not applicable
Overall, how easy is it to file a report in your primary reporting system?
Range: 1 – 10
Min: Very difficultMid: NeutralMax: Very easy
Typically, how long does it take you to complete one report?
- Under 5 minutes
- 5–10 minutes
- 11–20 minutes
- 21–30 minutes
- More than 30 minutes
The steps to submit a report are clear.
Scale: 10 (star)
Min: Strongly disagreeMax: Strongly agree
Please rate the ease of the following tasks in your reporting system.
| Rows | Very difficult | Difficult | Neutral | Easy | Very easy |
|---|
| Finding the correct form | • | • | • | • | • |
| Selecting event categories | • | • | • | • | • |
| Entering patient/context details | • | • | • | • | • |
| Writing the narrative | • | • | • | • | • |
| Submitting and receiving confirmation | • | • | • | • | • |
How confident are you that your reports capture all required details?
Range: 1 – 10
Min: Not at allMid: SomewhatMax: Completely
The required fields capture the information needed for learning and follow-up.
Scale: 10 (star)
Min: Strongly disagreeMax: Strongly agree
Which factors most hinder reporting or completeness in your setting? Select all that apply.
- Limited time/workload
- Unclear what qualifies as reportable
- System is cumbersome or slow
- Duplicate entry across systems
- Lack of training or guidance
- Concerns about blame or repercussions
- Uncertain where to submit
- Little or no feedback after reporting
- Technical issues or EHR integration
- Other (please specify)
After submitting a report, how often do you receive feedback within 30 days?
- Always
- Often
- Sometimes
- Rarely
- Never
I feel safe reporting adverse events and near misses.
Range: 1 – 10
Min: Strongly disagreeMid: NeutralMax: Strongly agree
Have you received training on adverse event reporting in the last 12 months?
Which training or job aids would help you report more easily and completely? Select all that apply.
- One-page quick guide or checklist
- Short video (3–5 minutes)
- In-system tooltips or prompts
- Live refresher session
- Case-based examples
- None of the above
Attention check: To confirm you’re paying attention, please select “Often” for this item.
- Always
- Often
- Sometimes
- Rarely
- Never
What is your primary role?
- Physician
- Nurse
- Advanced practice provider (NP/PA)
- Pharmacist
- Allied health professional
- Quality/safety professional
- Administrator/manager
- Other
What is your primary clinical setting?
- Inpatient hospital
- Emergency department
- Ambulatory/clinic
- Surgery/perioperative
- Behavioral health
- Long-term care
- Home health
- Other
Years in practice
- 0–2
- 3–5
- 6–10
- 11–20
- 21+
- Prefer not to say
Typical work schedule
- Day
- Evening
- Night
- Rotating
- Varies
- Not applicable
Location
- U.S. Northeast
- U.S. Midwest
- U.S. South
- U.S. West
- Outside the U.S.
- Prefer not to say
Allocate 100 points to show which improvements would most help reporting.
Total must equal 100
Min per option: 0Whole numbers only
What one change would most improve the ease or completeness of reporting in your practice?
Max 600 chars
AI Interview: 2 Follow-up Questions on adverse event reporting
AI InterviewLength: 2Personality: Expert InterviewerMode: Fast Thank you for your time—your input will help improve reporting processes and patient safety.