Harms to Patients Survey

Unit or Service*

Other Unit*

Provider Type of Survey Respondent*

Nurse
Advanced Nurse Practitioner
Physician Assistant
Resident Physician
Physician Fellow
Attending Physician
Other

Over the past 7 days, how often did you receive a problematic handoff? (e.g., information that was clinically important was not given to you, or you received inaccurate information)*

Never (0 times)
Rarely (1 or 2 times)
Sometimes (between 3 and 5 times)
Often (more than 5 times)

Please keep these definitions in mind when answering the next set of questions

Minor Harm- Limited clinical consequence—such as a need for more frequent monitoring or transient discomfort, without prolongation of hospitalization, significant organ dysfunction or worsening of clinical condition. Major Harm- Significant clinical consequences such as deterioration in clinical status, organ dysfunction, prolonged hospitalization, disability beyond discharge, or death.

Harms to Patients*

	0	1	2	3	4	>4
Over the past 7 days, please estimate the number of your patients who experienced a MINOR harm as a result of a problematic handoff.
Over the past 7 days, please estimate the number of your patients who experienced a MAJOR harm as a result of a problematic handoff.

Over the past 7 days, how many days did you work?*

Technical Support

Harms to Patients Survey