Q01
Message
All templates
Pharmacy Patient Safety Culture Survey (AHRQ-Aligned)
Assesses teamwork, communication openness, staffing adequacy, and response to mistakes in a pharmacy setting, modeled on AHRQ's patient safety culture framework. Built for pharmacy managers and quality leads, with an AI follow-up interview that reconstructs a specific near-miss or error to surface the real contributing factors behind the ratings.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
14 questions · ~7 min
Q02
MatrixRequired
How much do you agree with the following statements about communication and teamwork in this pharmacy?
4 rows × 5 columns
- Staff freely speak up if they see something that may negatively affect patient care.
- Pharmacy staff work together as an effective team.
- When one area of this pharmacy gets really busy, others help out.
- Staff feel comfortable asking questions when something does not seem right with a prescription.
Columns: Strongly Disagree · Disagree · Neither Agree nor Disagree · Agree · Strongly Agree
Q03
MatrixRequired
How much do you agree with the following statements about staffing and how mistakes are handled here?
4 rows × 5 columns
- Staff are treated fairly when they report a mistake.
- This pharmacy focuses on learning from mistakes rather than placing blame.
- We have enough staff to handle the workload safely.
- Staff feel rushed when processing prescriptions.
Columns: Strongly Disagree · Disagree · Neither Agree nor Disagree · Agree · Strongly Agree
Q04
Opinion ScaleRequired
Overall, how would you rate the patient safety culture in this pharmacy?
Scale: 0 – 10
Min:PoorMax:Excellent
Q05
Multiple ChoiceRequired
In the past 12 months, how many medication errors or near misses have you personally reported?
- None
- 1-2
- 3-5
- 6-10
- More than 10
Q06
Multiple ChoiceRequired
When a near miss occurs (an error caught before it reached the patient), how often is it reported through this pharmacy's formal reporting process?
- Never
- Rarely
- Sometimes
- Most of the time
- Always
Q07
Best–Worst Trade-off (MaxDiff)Required
Which of these changes would do the most to improve patient safety in this pharmacy?
- More staffing during peak hours
- A clearer, simpler error-reporting process
- Regular safety culture training
- Fewer interruptions and distractions during dispensing
- Better communication between shifts
- A non-punitive response when mistakes happen
- Standardized double-check procedures for high-risk prescriptions
Pick best & worst per setBest:Most impactfulWorst:Least impactful
Q08
AI Interview
Ask the respondent to walk through the most recent medication error or near miss they personally witnessed or were involved in: what happened, what contributing factors were present (staffing, distractions, workflow, communication), and whether it was reported. If it wasn't reported, probe specifically why not. If they say they've never experienced one, ask what would make them confident enough to report a hypothetical mistake without fear of blame.
Q09
Short Text
What is one change that would make it easier for staff here to speak up about safety concerns or mistakes?
Q10
Message
Now a few quick questions about your role — these help us compare results across positions and are entirely optional.
Q11
Multiple Choice
What is your primary role in this pharmacy?
- Pharmacist
- Pharmacy Technician
- Pharmacy Manager/Owner
- Intern/Student
- Other
Q12
Multiple Choice
How long have you worked in a pharmacy setting?
- Less than 1 year
- 1-3 years
- 4-9 years
- 10-19 years
- 20+ years
- Prefer not to say
Q13
Multiple Choice
What is your employment status at this pharmacy?
- Full-time
- Part-time
- PRN/On-call
- Prefer not to say
Q14
Message
Thank you for your candor. Responses across the team are combined into an anonymous safety culture report used to guide staffing, training, and reporting-process improvements — no individual answers are shared with management.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Includes an AI follow-up interview that asks respondents to walk through their most recent medication error or near miss, surfacing the real contributing factors behind their ratings rather than stopping at a number.
- Combines AHRQ-aligned matrix questions on teamwork/communication and staffing/response-to-mistakes with a MaxDiff prioritization question, so managers see both attitudes and which fixes matter most.
- Captures concrete incident history (frequency of errors/near-misses, reporting behavior) alongside role, tenure, and employment status for meaningful subgroup comparison.
- Uses transparent prompts and automated per-response quality scoring, then rolls everything into an anonymized, auto-generated report for pharmacy leadership.
SurveyMonkey
Pharmacy Patient Safety Culture Survey Template | AHRQA directly comparable, AHRQ-referenced pharmacy safety culture template from a major survey platform. It's a fielding-ready static questionnaire covering similar culture dimensions, but it stops at collecting ratings rather than exploring the story behind them. Best suited for teams wanting a quick, standard rollout rather than deeper qualitative insight.
What it does well
- Explicitly AHRQ-referenced, matching the same recognized patient safety culture framework
- Backed by SurveyMonkey's established survey distribution and reporting infrastructure
- Likely quick to deploy given SurveyMonkey's template library and simple editing tools
Where it falls short
- Static question set with no adaptive AI follow-up to probe into specific near-miss incidents
- No mention of automated per-response quality scoring or transparent prompt methodology
- No voice AI interview or guided task/screen-share option for richer incident reconstruction
SurveySparrow
Patient Safety Culture Survey TemplateA general healthcare patient safety culture template rather than one built specifically for pharmacy settings, so question wording likely needs adaptation for pharmacy workflows. It appears to be a standard conversational-style survey form, useful for broad culture pulse-checks but not tailored incident analysis.
What it does well
- Conversational survey format may improve completion rates over long grid-style forms
- Positioned within a broader healthcare template category, suggesting some domain familiarity
- Likely supports basic branching logic typical of SurveySparrow's platform
Where it falls short
- Not pharmacy-specific, unlike a template modeled on pharmacy staffing/dispensing realities
- No adaptive AI interview to reconstruct a specific error or near-miss
- No stated automated quality scoring or transparent prompt disclosure for respondent answers
QuestionPro
Employee Concern for Patients Survey TemplateThis template focuses on employee concern for patients broadly, which overlaps only partially with a pharmacy-specific patient safety culture assessment — it's not framed around AHRQ dimensions like staffing adequacy or response to mistakes. It reads as a fielding-ready static form aimed at general employee sentiment rather than incident-level safety culture analysis.
What it does well
- Simple, ready-to-use survey template within an established survey platform
- Framed around employee sentiment toward patients, which could suit general concern tracking
- Likely customizable within QuestionPro's standard survey builder
Where it falls short
- Not aligned to the AHRQ patient safety culture framework or pharmacy-specific staffing/error dynamics
- No adaptive AI or voice interview to dig into a specific near-miss or error narrative
- No automated quality scoring or transparent prompt methodology disclosed
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.