Facil Scan Form
Facil Scan Form
Facil Scan Form
Instructions
This survey asks for your opinions about patient safety issues, medical error, and event reporting in your facility
and will take about 10 to 15 minutes to complete.
If you do not wish to answer a question, or if a question does not apply to you, you may leave your answer blank.
What is your primary work area or unit in your facility? Select ONE answer.
1
SECTION A: Your Work Area/Unit (continued)
Strongly Strongly
Disagree Disagree Neither Agree Agree
Think about your work area/unit
2
SECTION C: Communications
How often do the following things happen in your work area/unit?
Some- Most of
Never Rarely times the time Always
Think about your work area/unit
1. We are given feedback about changes put into place based on event
reports....................................................................................................... 1 2 3 4 5
2. Staff will freely speak up if they see something that may negatively
affect patient care...................................................................................... 1 2 3 4 5
3. We are informed about errors that happen in this unit............................... 1 2 3 4 5
4. Staff feel free to question the decisions or actions of those with more
authority..................................................................................................... 1 2 3 4 5
5. In this unit, we discuss ways to prevent errors from happening again........ 1 2 3 4 5
6. Staff are afraid to ask questions when something does not seem right..... 1 2 3 4 5
SECTION D: Frequency of Events Reported
In your work area/unit, when the following mistakes happen, how often are they reported?
Some- Most of
Never Rarely times the time Always
1. When a mistake is made, but is caught and corrected before affecting
the patient, how often is this reported?...................................................... 1 2 3 4 5
2. When a mistake is made, but has no potential to harm the patient, how
often is this reported?.................................................................................. 1 2 3 4 5
3. When a mistake is made that could harm the patient, but does not,
how often is this reported?.......................................................................... 1 2 3 4 5
A B C D E
Excellent Very Good Acceptable Poor Failing
3
SECTION F: Your Facility (continued)
Strongly Strongly
Disagree Disagree Neither Agree Agree
Think about your facility
4
b. 20 to 39 hours per week e. 80 to 99 hours per week
5
SECTION H: Background Information (continued)
4. What is your staff position in this facility? Select ONE answer that best describes your staff position.
g. Pharmacist
h. Dietician
i. Unit Assistant/Clerk/Secretary
5. In your staff position, do you typically have direct interaction or contact with patients?
b. 1 to 5 years e. 16 to 20 years
6
THANK YOU FOR COMPLETING THIS SURVEY.