1. Abstract
The institutional evaluation of organizational climate and safety practices has emerged as a cornerstone of quality improvement and clinical risk governance within global healthcare systems. The Agency for Healthcare Research and Quality (AHRQ) established the Hospital Survey on Patient Safety Culture (HSOPSC) as an international benchmark for quantifying systemic vulnerabilities and shared organizational values. Following the release of the updated HSOPSC 2.0—which refined problematic syntax, updated the operational definition of a ‘just culture,’ and streamlined response scales—the cross-cultural adaptation and psychometric validation of the Brazilian version was conducted to equip South American healthcare institutions with an empirically robust diagnostic instrument.
This article provides an in-depth review of the Brazilian adaptation of the HSOPSC 2.0, an organizational survey comprising 40 items (32 core dimension indicators, 2 overall outcome items, and 6 demographic items) designed to assess 10 distinct latent dimensions. Administered across a sample of 2,702 healthcare workers within a tertiary hospital complex during the COVID-19 pandemic, the psychometric structure was examined using Exploratory Structural Equation Modeling within a Confirmatory Factor Analysis framework (ESEM-within-CFA). The measurement model demonstrated strong global fit indices (Comparative Fit Index [CFI] = 0.986; Tucker-Lewis Index [TLI] = 0.968; Root Mean Square Error of Approximation [RMSEA] = 0.045). Dimension-level internal consistency showed acceptable reliability across most factors (α ≥ 0.60), though lower coefficients were observed for Staffing and Work Pace (α = 0.41) and Handoffs and Information Exchange (α = 0.50). The instrument provides hospital administrators and organizational researchers with a standardized metric for monitoring safety culture, guiding targeted interventions, and conducting cross-national comparisons.
2. Keywords
Patient safety culture, Psychometrics, Cross-cultural adaptation, Hospital management, Quality of healthcare, Exploratory Structural Equation Modeling, Just culture, Organizational climate, Healthcare risk management, Factorial validity, Internal consistency, Brazilian Unified Health System
3. Authors
The cross-cultural adaptation and psychometric validation of the Brazilian Hospital Survey on Patient Safety Culture 2.0 was conducted by a multidisciplinary consortium of researchers specializing in epidemiology, public health, and healthcare quality:
- Claudia Tartaglia Reis, Ph.D. — Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca (ENSP), Rio de Janeiro, Brazil. Email: [email protected]
- Josué Laguardia, M.D., Ph.D. — Fundação Oswaldo Cruz (Fiocruz), Instituto de Comunicação e Informação Científica e Tecnológica em Saúde (ICICT), Rio de Janeiro, Brazil. Email: [email protected]
- Paola Bruno de Araújo Andreoli, Ph.D. — Hospital Alemão Oswaldo Cruz, Diretoria de Qualidade e Segurança do Paciente, São Paulo, Brazil. Email: [email protected]
- Cassimiro Nogueira Júnior, M.Sc. — Hospital Alemão Oswaldo Cruz, São Paulo, Brazil. Email: [email protected]
- Mônica Martins, Ph.D. — Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca (ENSP), Rio de Janeiro, Brazil. Email: [email protected]
4. Purpose
The primary objective underlying the cultural adaptation and validation of the Hospital Survey on Patient Safety Culture 2.0 for Brazil is to provide healthcare administrators, quality managers, and health services researchers with a psychometrically rigorous, culturally resonant self-report instrument capable of diagnosing the institutional and unit-level dynamics that govern patient safety. Prior to the institutionalization of targeted safety culture assessments, healthcare organizations predominantly operated under reactive, epidemiological frameworks that relied on post-hoc error counting, sentinel event tracking, and retrospective morbidity and mortality audits. While necessary, retrospective incident reporting often fails to capture the latent systemic hazards, psychological barriers to open communication, and organizational dynamics that precede medical errors.
The theoretical rationale for the Brazilian HSOPSC 2.0 is grounded in the understanding that patient safety culture represents an upstream determinant of clinical outcomes. Within complex adaptive systems such as tertiary hospital wards, adverse outcomes are rarely the byproduct of isolated operator failures; instead, they emerge from systemic vulnerabilities, unmanageable work paces, inadequate handoffs, punitive leadership styles, and fragmented teamwork. By operationalizing these interdependent dimensions, the HSOPSC 2.0 allows clinical governance bodies to transition from punitive blame-centered cultures toward high-reliability organizational paradigms. Specifically, the scale serves three distinct functional purposes in clinical and empirical contexts:
- Diagnostic Baseline and Longitudinal Monitoring: The scale enables hospitals to conduct institutional baseline assessments to detect specific departmental weaknesses (e.g., intensive care units vs. general surgical wards) and evaluate the longitudinal effectiveness of targeted clinical quality improvement initiatives.
- Benchmarking and Cross-Cultural Research: The standardization of items allows for cross-organizational and international benchmarking, aligning Brazilian health institutions with global comparative datasets maintained by the World Health Organization (WHO) and the OECD.
- Policy Alignment with National Safety Agendas: The instrument directly operationalizes the assessment mandates established by Brazil’s Ministério da Saúde through Portaria nº 529/2013, which instituted the Programa Nacional de Segurança do Paciente (PNSP), requiring hospitals across the public (Sistema Único de Saúde – SUS) and private networks to systematically assess and cultivate a proactive safety culture.
5. Psychological Construct
The overarching psychological construct measured by the HSOPSC 2.0 is Patient Safety Culture, conceptualized as a multi-layered, organizational-level construct defined by the shared values, collective perceptions, behavioral norms, and institutional competencies that determine an organization’s commitment to clinical error reduction and continuous quality improvement. Rather than examining transient affective states or idiosyncratic individual differences, the construct captures the collective climate of the work unit and the broader hospital enterprise across ten distinct dimensions:
1. Teamwork (Unit Level)
This subscale evaluates the interpersonal cohesion, mutual respect, and collaborative efficiency among multidisciplinary team members within a clinical unit. It examines the extent to which personnel support each other during volume surges, communicate respectfully across hierarchical boundaries, and operate as an integrated unit rather than siloed practitioners.
2. Staffing and Work Pace
Reflecting systemic resource allocation, this dimension measures the perceived adequacy of staffing ratios, the necessity of working excessive hours beyond clinical guidelines, reliance on temporary or outsourced personnel, and the degree to which rapid task execution compromises clinical protocols.
3. Organizational Learning — Continuous Improvement
This dimension operationalizes the adaptive learning cycle of the work environment. It captures whether clinical teams proactively evaluate the effectiveness of newly introduced changes, systematically examine recurrent operational failures, and continuously adjust care protocols to prevent recurring adverse events.
4. Response to Error
A core element of ‘just culture’ theory, this dimension measures whether error reporting is met with supportive, system-oriented remediation or individual punishment. It assesses the degree to which staff perceive that mistakes are used against them punitively versus utilized as constructive educational events.
5. Supervisor, Manager, or Clinical Leader Support for Patient Safety
This subscale captures frontline leadership behavior. It evaluates whether immediate clinical supervisors and department managers actively prioritize safety over speed, listen attentively to staff safety recommendations, and support staff members when they make decisions grounded in patient welfare.
6. Communication About Error
Distinct from the psychological freedom to speak, this subscale assesses the institutional feedback loop following safety reports. It measures the extent to which staff receive transparent information regarding reported errors, are informed about systemic changes enacted in response, and discuss mitigation strategies.
7. Communication Openness
Reflecting unit-level psychological safety, this dimension measures the degree to which frontline personnel feel empowered to speak up freely when observing conditions that may compromise care, voice questions when procedures seem incorrect, and challenge authority figures without fear of professional marginalization.
8. Reporting Patient Safety Events
This behavioral frequency subscale measures the normative tendency of healthcare workers to formally report near-misses (errors caught before reaching the patient), errors that reach the patient without causing injury, and events that result in tangible patient harm.
9. Hospital Management Support for Patient Safety
This macro-level dimension evaluates frontline perceptions of executive and administrative leadership. It examines whether executive administration demonstrates that safety is an uncompromising institutional priority, provides necessary fiscal and logistical resources, and maintains an active commitment before crises occur.
10. Handoffs and Information Exchange
Focusing on transitional vulnerabilities, this subscale measures the operational fidelity of information transfer across clinical boundaries, including shift-to-shift handoffs and patient transfers between disparate hospital units or service lines.
6. Theoretical Framework
The structural and conceptual foundation of the HSOPSC 2.0 is grounded in several interrelated paradigms from organizational psychology, human factors engineering, and system safety theory:
James Reason’s Swiss Cheese Model and Just Culture Framework
The primary theoretical driver of the instrument is James Reason’s systemic model of accident causation. Reason postulated that complex operational systems fail not because of isolated active errors committed by sharp-end operators, but through the alignment of latent conditions—structural weaknesses in staffing, equipment, communication, and managerial supervision. Parallel to this is Reason’s conceptualization of a ‘Just Culture,’ an atmosphere of trust where personnel are reinforced for providing essential safety-related information, while maintaining clear boundaries between acceptable system variability and deliberate recklessness. HSOPSC 2.0 explicitly reflects this framework in its ‘Response to Error’ and ‘Communication Openness’ subscales.
Edmondson’s Psychological Safety Paradigm
Amy Edmondson’s model of team psychological safety—defined as a shared belief that the team is safe for interpersonal risk-taking—serves as the psychological architecture for measuring communication dynamics. In medical environments characterized by steep hierarchical authority gradients, junior staff and allied health professionals often engage in defensive silence due to perceived threats to their professional standing. The HSOPSC 2.0 operationalizes psychological safety by assessing the degree to which professionals feel uninhibited in questioning senior authority figures and pointing out systemic discrepancies.
High Reliability Organization (HRO) Theory
The conceptual formulation of the scale also integrates principles from High Reliability Organizations (Weick & Sutcliffe), which operate under extreme hazard conditions while sustaining fewer accidents than expected. Key HRO tenets—preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise—are mirrored in the HSOPSC 2.0 dimensions of Continuous Improvement, Teamwork, and Management Support.
7. Validity
The validation of the Brazilian version of the HSOPSC 2.0 adhered to rigorous cross-cultural adaptation guidelines based on the universalist approach described by Herdman, Fox-Rushby, and Badia (1998) and the structural roadmap delineated by Reichenheim et al. (2014):
Conceptual, Semantic, and Operational Equivalence
The cross-cultural adaptation followed a multi-stage protocol: independent forward translations into Brazilian Portuguese, synthesis of translations, blind back-translations into English by independent bilingual translators, expert committee review comprising healthcare quality and psychometric specialists, and pre-testing cognitive debriefing with frontline hospital personnel. A primary challenge was achieving conceptual equivalence for administrative and staffing terminology; for example, the American construct of ‘temporary staff’ was systematically adapted to account for the nuances of Brazilian outsourced contracts (‘funcionários terceirizados ou substitutos’).
Construct and Structural Validity
Construct validity was empirically assessed within a large sample of 2,702 hospital workers (56% response rate) across clinical, nursing, administrative, and allied health support roles. Using Exploratory Structural Equation Modeling within a Confirmatory Factor Analysis framework (ESEM-within-CFA), the theoretical 10-factor model was confirmed. Global model fit statistics met established criteria:
- Comparative Fit Index (CFI): 0.986 (threshold ≥ 0.95 indicating excellent fit)
- Tucker-Lewis Index (TLI): 0.968 (threshold ≥ 0.95 indicating robust fit)
- Root Mean Square Error of Approximation (RMSEA): 0.045 (90% CI: 0.043–0.047), well below the 0.06 cut-off for good fit
Factor Loadings and Measurement Nuances
Despite the excellent global fit, psychometric examination revealed that 10 of the 32 core items demonstrated standardized factor loadings below the conventional 0.40 threshold on their target factors. This suggests that while the broader latent dimensions hold cross-culturally, specific individual items exhibit unique measurement properties within the Brazilian organizational environment. This divergence reflects systemic differences in employment structures, hierarchical communication gradients, and the exceptional contextual stressors imposed by the COVID-19 pandemic during the primary validation period.
8. Reliability
The internal consistency of the Brazilian HSOPSC 2.0 was evaluated using Cronbach’s alpha (α) coefficients across each of the ten latent subscales. In organizational safety culture instruments where subscales often comprise only three or four items, alpha coefficients of 0.60 or greater are widely accepted for aggregate, group-level decision-making:
| Dimension | Number of Items | Cronbach’s α | Reliability Assessment |
|---|---|---|---|
| Teamwork | 3 | ≥ 0.60 | Acceptable for group-level assessment |
| Staffing and Work Pace | 4 | 0.41 | Low; caution advised in isolated use |
| Organizational Learning — Continuous Improvement | 3 | ≥ 0.60 | Acceptable |
| Response to Error | 4 | ≥ 0.60 | Acceptable |
| Supervisor/Manager Support for Safety | 3 | ≥ 0.60 | Acceptable |
| Communication About Error | 3 | ≥ 0.60 | Acceptable |
| Communication Openness | 4 | ≥ 0.60 | Acceptable |
| Reporting Patient Safety Events | 2 | ≥ 0.60 | Acceptable (Spearman-Brown adjusted) |
| Hospital Management Support | 3 | ≥ 0.60 | Acceptable |
| Handoffs and Information Exchange | 3 | 0.50 | Marginal; requires careful interpretation |
The attenuated internal consistency observed in Staffing and Work Pace (α = 0.41) and Handoffs and Information Exchange (α = 0.50) reflects challenges commonly encountered in organizational health psychometrics. In the case of staffing, items capture heterogeneous facets of workload, including work hours, reliance on outsourced personnel, and temporal pressure, which do not necessarily covary linearly. Similarly, data collection occurred amid the operational disruption of the COVID-19 pandemic, during which clinical shift rotations, temporary staffing surges, and emergency infection-control measures altered traditional handoff practices and workload distribution.
9. Factor Analysis
To evaluate the latent dimensionality of the Brazilian HSOPSC 2.0, the investigators employed Exploratory Structural Equation Modeling within a Confirmatory Factor Analysis framework (ESEM-within-CFA) using Mplus software. In complex organizational measurement, conventional Independent Clusters Model Confirmatory Factor Analysis (ICM-CFA) often imposes overly restrictive constraints by fixing all non-target cross-loadings to absolute zero. Such strict zero constraints frequently lead to inflated factor correlations and degraded goodness-of-fit indices when evaluating interrelated social and organizational constructs.
The ESEM approach addresses these limitations by estimating target factor loadings while allowing cross-loadings to be freely estimated under targeted oblique rotation methods (such as Geomin rotation). The analytical model was specified based on polychoric correlation matrices to account for the ordinal categorical nature of the Likert indicators, utilizing Mean- and Variance-adjusted Weighted Least Squares (WLSMV) estimation.
Model Fit Parameters
- Chi-Square Test of Model Fit: Evaluated alongside descriptive approximate fit indices due to the high statistical power of large sample sizes (N = 2,702).
- Comparative Fit Index (CFI): 0.986, indicating that the multi-factor ESEM model reproduced the observed inter-item covariance matrix with high precision.
- Tucker-Lewis Index (TLI): 0.968, reflecting strong parsimony-adjusted model fit.
- Root Mean Square Error of Approximation (RMSEA): 0.045 (90% Confidence Interval: 0.043–0.047), below the 0.05 threshold indicating close approximate fit.
Structural Observations and Residual Covariances
The factor structure affirmed the 10 theoretical dimensions of the original AHRQ HSOPSC 2.0 instrument within the Brazilian hospital context. The empirical factor loadings revealed that unit-level interpersonal constructs (e.g., Teamwork, Supervisor Support, and Response to Error) exhibited well-defined latent clustering. However, cross-loadings were observed among items addressing managerial support at the unit level versus executive hospital-wide leadership, indicating that frontline staff view administrative commitment as a continuous operational hierarchy. The presence of items with lower factor loadings highlights that certain indicators function differently across distinct clinical cadres (e.g., physicians versus nursing assistants), underscoring the value of multigroup invariance testing in future research.
10. Instrument / Measurement Tool
- Instrument Name: Hospital Survey on Patient Safety Culture 2.0 — Brazilian Version (HSOPSC 2.0 Brasil).
- Test Type: Self-administered organizational climate and safety perception questionnaire.
- Target Population: Clinical staff (physicians, registered nurses, nursing technicians, physical therapists, pharmacists) and non-clinical/support personnel within hospital organizations.
- Total Item Count: 40 items total (32 core items, 2 outcome measures, 6 demographic questions).
- Response Scale: 40 items total (32 core items, 2 outcome measures, 6 demographic questions); 5-point Likert scale (agreement/frequency) plus a ‘Does not apply/Don’t know’ option.
- Dimensional Structure: 10 subscales spanning unit-level dynamics, leadership behavior, and hospital-wide organizational systems.
- Scoring and Transformation: Scored on a 5-point Likert scale. Includes multiple reverse-scored items. Dimension scores are typically calculated as percent positive responses or mean scores.
- Reverse-Scored Items: Reverse score items marked with ‘R’ (A2R, A5R, A6R, A7R, A9R, A11R, A13R, A14R, B2R, C7R, F3R, F4R, F5R). For these items, disagreement represents a positive safety perception (e.g., 1 = Strongly Disagree recoded to 5, 2 = Disagree recoded to 4).
- Administration Platform: Self-administered electronic format via REDCap (Research Electronic Data Capture) or paper-based administrative distribution.
11. Permissions & Fee and Test Year
- Development and Validation Year: The original HSOPSC 2.0 was developed by the Agency for Healthcare Research and Quality (AHRQ) in 2019; the Brazilian cultural adaptation and empirical validation study was published in 2023.
- Copyright and Licensing: The original instrument was developed under the auspices of the United States Department of Health and Human Services (AHRQ) and is situated in the public domain. It is authorized to be used freely for clinical, educational, quality improvement, and scientific research purposes without royalty or user licensing fees.
- Usage Conditions: Researchers and healthcare institutions adapting or administering the Brazilian version are requested to cite the primary validation publication (Reis et al., 2023, BMC Health Services Research) and adhere to standardized scoring and reporting guidelines established by AHRQ.
12. References
The academic validation and contextual analysis of the Brazilian HSOPSC 2.0 are grounded in the following foundational literature:
- Agency for Healthcare Research and Quality. (2021). AHRQ Hospital Survey on Patient Safety Culture Version 2.0: User’s guide (AHRQ Publication No. 19(21)-0076). Westat. https://www.ahrq.gov/sops/surveys/hospital/index.html
- Brasil. Ministério da Saúde. (2013). Portaria nº 529, de 1º de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP). Diário Oficial da União. https://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt0529_01_04_2013.html
- Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. https://doi.org/10.2307/2666999
- Herdman, M., Fox-Rushby, J., & Badia, X. (1998). A model of equivalence in the cultural adaptation of HRQoL instruments: The universalist approach. Quality of Life Research, 7(4), 323–335. https://doi.org/10.1023/a:1024985930536
- Marsh, H. W., Morin, A. J., Parker, P. D., & Kaur, G. (2014). Exploratory structural equation modeling: An integration of the best features of exploratory and confirmatory factor analysis. Annual Review of Clinical Psychology, 10, 85–110. https://doi.org/10.1146/annurev-clinpsy-032813-153700
- Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768–770. https://doi.org/10.1136/bmj.320.7237.768
- Reichenheim, M. E., Hökerberg, Y. H. M., & Moraes, C. L. (2014). Assessing construct structural validity of epidemiological measurement tools: A seven-step roadmap. Cadernos de Saúde Pública, 30(5), 927–939. https://doi.org/10.1590/0102-311X00143613
- Reis, C. T., Laguardia, J., Andreoli, P. B. A., Nogueira Júnior, C., & Martins, M. (2023). Hospital Survey on Patient Safety Culture 2.0 – Brazilian version. BMC Health Services Research, 23, Article 18. https://doi.org/10.1186/s12913-022-08890-7
- Sorra, J., Famolaro, T., & Yount, N. (2019). Transitioning to the SOPS® Hospital Survey Version 2.0: What’s different and what to expect. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sops/surveys/hospital/index.html
- Waterson, P., Carman, E. M., Manser, T., & Hammer, A. (2019). Hospital Survey on Patient Safety Culture (HSPSC): A systematic review of the psychometric properties of 62 international studies. BMJ Open, 9(9), Article e026896. https://doi.org/10.1136/bmjopen-2018-026896
13. Items of the Scale
Escala de Resposta: 40 items total (32 core items, 2 outcome measures, 6 demographic questions); 5-point Likert scale (agreement/frequency) plus a ‘Does not apply/Don’t know’ option.
- Nesta unidade, nós trabalhamos juntos como uma equipe eficaz para cuidar dos pacientes.
- Nesta unidade, temos pessoas suficientes para lidar com a carga de trabalho.
- Os profissionais desta unidade tratam-se com respeito mútuo.
- Nesta unidade, a carga de trabalho é excessiva para que o trabalho seja feito com segurança.
- Os profissionais desta unidade apoiam-se mutuamente durante os momentos de maior movimento.
- Nesta unidade, as pessoas frequentemente trabalham mais horas do que o recomendável para cuidar dos pacientes.
- Nesta unidade, nós estamos constantemente procurando maneiras de melhorar a segurança do paciente.
- Nesta unidade, nós dependemos muito de funcionários temporários ou substitutos.
- Nesta unidade, nós fazemos mudanças para evitar que os mesmos problemas aconteçam novamente.
- Nesta unidade, nós nos apressamos para atender os pacientes por falta de tempo.
- Nesta unidade, quando é feita uma mudança para melhorar a segurança do paciente, nós avaliamos sua efetividade.
- Quando um evento de segurança do paciente é relatado nesta unidade, a ênfase é em descobrir quem cometeu o erro em vez de entender por que o erro aconteceu.
- Os profissionais desta unidade sentem que seus erros são usados contra eles.
- Quando ocorre um erro nesta unidade, as pessoas envolvidas recebem apoio.
- Meu(Minha) supervisor(a), gerente ou líder clínico leva em consideração as sugestões da equipe para melhorar a segurança do paciente.
- Meu(Minha) supervisor(a), gerente ou líder clínico não dá a devida atenção aos problemas de segurança do paciente que acontecem com frequência.
- Meu(Minha) supervisor(a), gerente ou líder clínico apoia a equipe quando ela toma decisões baseadas na segurança do paciente.
- Meu(Minha) supervisor(a), gerente ou líder clínico pressiona para que o trabalho seja concluído mais rápido, mesmo que isso signifique contornar etapas de segurança.
- Nesta unidade, os profissionais sentem-se à vontade para falar abertamente se virem algo que possa afetar negativamente o cuidado ao paciente.
- Nesta unidade, os profissionais têm receio de fazer perguntas quando algo parece não estar certo.
- Nesta unidade, os profissionais expressam suas dúvidas se virem alguém com mais autoridade fazer algo que consideram inseguro.
- Quando um erro é identificado antes de atingir o paciente (quase-falha), com que frequência ele é relatado?
- Quando um erro atinge o paciente, mas não causa danos, com que frequência ele é relatado?
- Quando um erro atinge o paciente e causa danos, com que frequência ele é relatado?
- A liderança do hospital demonstra que a segurança do paciente é uma prioridade máxima.
- A liderança do hospital fornece recursos suficientes para melhorar a segurança do paciente.
- A liderança do hospital parece interessada na segurança do paciente somente depois que acontece um evento adverso grave.
- Quando os pacientes são transferidos de uma unidade para outra, informações importantes sobre o cuidado são perdidas com frequência.
- Há uma boa cooperação entre as diferentes unidades deste hospital para fornecer o melhor atendimento aos pacientes.
- As trocas de plantão neste hospital frequentemente apresentam falhas na comunicação de informações clínicas críticas.
- Nesta unidade, nós somos informados sobre as medidas adotadas para prevenir a recorrência dos erros relatados.
- Nesta unidade, nós discutimos maneiras de prevenir erros para que não aconteçam novamente.
- Como você avalia a segurança do paciente na sua unidade/área de trabalho? (1 = Pobre / 5 = Excelente)
- Nos últimos 12 meses, quantos eventos de segurança do paciente você relatou?
- Há quanto tempo você trabalha neste hospital?
- Há quanto tempo você trabalha nesta unidade / área de trabalho?
- Quantas horas por semana você costuma trabalhar neste hospital?
- Qual é o seu cargo / função principal neste hospital?
- Nesta unidade, você tem contato direto com os pacientes?
- Você tem alguma sugestão ou comentário sobre a segurança do paciente neste hospital?