Patient Safety Pledge Survey Form
Please complete the Patient Safety Pledge Survey Form to share your perspectives and commitments regarding patient safety. Your feedback helps us strengthen our safety culture.
What is your primary role in the organization?
*
Please Select
Nurse
Physician
Administrator
Support Staff
Other
I understand the importance of patient safety in my daily work.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
I feel empowered to speak up if I notice a safety concern.
*
Strongly Disagree
1
2
3
4
Strongly Agree
5
1 is Strongly Disagree, 5 is Strongly Agree
How confident are you in your knowledge of our safety protocols?
*
1
2
3
4
5
Have you received training on patient safety procedures in the last 12 months?
*
Yes
No
How likely are you to report a near miss or safety incident?
*
Not Likely
1
2
3
4
Very Likely
5
1 is Not Likely, 5 is Very Likely
Please indicate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Patient safety is a shared responsibility.
1
2
3
4
5
Mistakes should be used as learning opportunities.
6
7
8
9
10
Reporting safety concerns is encouraged.
11
12
13
14
15
I am familiar with the process for reporting incidents.
16
17
18
19
20
Which area do you believe needs the most improvement for patient safety?
*
Communication between staff
Training and education
Reporting processes
Equipment and facilities
Other
What motivates you to uphold patient safety standards?
*
Personal values
Organizational policies
Peer influence
Patient feedback
Other
Please share any additional comments or suggestions related to patient safety.
Submit Survey
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