Footnotes

• Contributors This letter was written by all three contributing authors.

• Disclaimer The authors of this response are solely responsible for its content and the statements in this response should not be construed as being endorsed by or representing the Agency for Healthcare Research and Quality (AHRQ) or the US Department of Health and Human Services.

• Competing interests All contributing authors to this response work at Westat, which is under contract with the Agency for Healthcare Research and Quality (AHRQ), Contract No. HHSA 290201300003C, to develop and support the Surveys on Patient Safety Culture, including the Hospital Survey on Patient Safety Culture. The authors of this response are solely responsible for its content and the statements in this response should not be construed as being endorsed by or representing the Agency for Healthcare Research and Quality (AHRQ) or the US Department of Health and Human Services.

• Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

• Provenance and peer review Not commissioned; internally peer reviewed.