A recent survey explored patient safety culture at 30 Veterans Administration (VA) hospitals and found that most respondents reported a positive safety culture overall. In this study, the authors of the original study report on the difficulties they faced in recruiting hospitals to participate in the survey, and how recruitment difficulties could have biased the study results. Despite efforts to avoid selection bias in recruiting hospitals, hospitals that participated tended to have performed better on Patient Safety Indicators, and many difficulties were encountered in recruiting lower-performing hospitals. This study points out the need to include both high-performing and low-performing hospitals when conducting research into factors affecting patient safety.