Making Residents Part of the Safety Culture: Improving Error Reporting and Reducing Harms

Medical Error: Using Storytelling and Reflection to Impact Resident Error Response Factors

Introduction

Medical error is common and has a significant impact on physicians, learners, and patients' perception of the medical system; however, residents receive little formal training on this topic. This curriculum aims to foster sharing of personal medical error stories, review and practice error management and coping strategies, and impact error response factors.

Methods

Faculty identified factors related to effective physician error management and recovery in order to develop a targeted curriculum for family medicine residents. The curriculum consisted of three 1-hour didactic sessions in a medium-sized, urban program. Instructional methods included guided reflection after mentor storytelling, small-group discussion, role-play, and self-reflection.

Results

Twenty-two out of 30 (73%) residents completed the premodule survey, and 15 out of 30 (50%) residents completed the post module survey. Fewer than half of residents reported they knew what to do when faced with medical error, but this increased to 93% after curriculum delivery, as did rates of reported error story sharing. Resident reported self-efficacy (I can be honest about the errors I make as a doctor.) and self-awareness (I acknowledge when I am at increased risk for making errors) also increased following the curriculum.

Discussion

Family medicine residents are receptive to learning from peers and mentors about error management and recovery. A brief curriculum can impact the culture around disclosure and support. Future iterations should focus on the impact of targeted curricular interventions on patient-oriented outcomes related to medical error.

Supporting Error Management and Safety Climate in Ambulatory Care Practices: The CIRSforte Study

BACKGROUND

To improve patient safety, it is important that healthcare facilities learn from critical incidents. Tools such as reporting and learning systems and team meetings structure error management and promote learning from incidents. To enhance error management in ambulatory care practices, it is important to promote a climate of safety and ensure personnel share views on safety policies and procedures. In contrast to the hospital sector, little research has been dedicated to developing feasible approaches to supporting error management and safety climate in ambulatory care. In this study, we developed, implemented, and evaluated a multicomponent intervention to address how error management and safety climate can be improved in ambulatory care practices.

METHODS

In a prospective 1-group pretest-posttest implementation study, we sought to encourage teams in German ambulatory practices to use proven methods such as guidelines, workshops, e-learning, (online) meetings, and e-mail newsletters. A pretest-posttest questionnaire was used to evaluate level and strength of safety climate and psychological behavioral determinants for systematic error management. Using 3 short surveys, we also assessed the state of error management in the participating practices. In semistructured interviews, we asked participants for their views on our intervention measures.

RESULTS

Overall, 184 ambulatory care practices nationwide agreed to participate. Level of safety climate and safety climate strength (rwg) improved significantly. Of psychological behavioral determinants, significant improvements could be seen in "action/coping planning" and "action control." Seventy-six percent of practices implemented a new reporting and learning system or modified their existing system. The exchange of information between practices also increased over time. Interviews showed that the introductory workshop and provided materials such as report forms or instructions for team meetings were regarded as helpful.

CONCLUSIONS

A significant improvement in safety climate level and strength, as well as participants' knowledge of how to analyze critical incidents, derive preventive measures and develop concrete plans suggest that it is important to train practice teams, to provide practical tips and tools, and to facilitate the exchange of information between practices. Future randomized and controlled intervention trials should confirm the effectiveness of our multicomponent intervention.Trial registration: Retrospectively registered on 18. November 2019 in German Clinical Trials Register No. DRKS00019053.

Medical Error: Using Storytelling and Reflection to Impact Error Response Factors in Family Medicine Residents

I am a healer, yet sometimes I do more harm than good…David Hilfiker, 1984.

Objectives

Medical error is common and significantly impacts patients, physicians, learners, and public perception of the medical system; however, residents receive little formal training on this topic. Research on error response in practicing physicians is limited, and even more so on medical education interventions to improve this. This study evaluates a curriculum developed to foster the sharing of faculty medical error stories, practice of constructive coping strategies, and growth in resident confidence in managing error.

Methods

Researchers identified factors related to effective physician error management and recovery to develop a targeted intervention for family medicine residents. The intervention consisted of three one hour didactic sessions in a medium-sized midwestern, urban family medicine residency program over the course of 6 months. Instructional methods included guided reflection after mentor storytelling, small group discussion, role play, and self-reflection.

Results

Of the 30 residents, 22 (73%) completed the preintervention survey, and 15 (50%) completed the postintervention survey. While most residents reported having experienced error (55%), fewer than half of the residents reported they knew what to do when faced with medical errors (46%). This increased to 93% after intervention. Personal error stories from mentors were the most desired type of training reported by residents preintervention, but this was surpassed by legal and malpractice concerns in the postintervention survey. Rates of reported error story sharing increased after the intervention. Residents reported self-efficacy (I can be honest about errors) and self-awareness (I acknowledge when I am at increased risk for error) also increased with intervention. However, these changes did not reach statistical significance.

Conclusions

Family medicine residents are receptive to learning from peers and mentors about error management and recovery. A brief intervention can impact the culture around disclosure and support. Future research should focus on the impact of targeted interventions on patient-oriented outcomes related to medical error.

Safety culture survey among medical residents in Japan: a nationwide cross-sectional study

PURPOSE

This study aimed to examine safety culture among Japanese medical residents through a comparative analysis of university and community hospitals and an investigation of the factors related to safety culture.

METHOD

This nationwide cross-sectional study used a survey to assess first and second-year medical residents' perception of safety culture. We adapted nine key items from the Safety Awareness Questionnaire to the Japanese training environment and healthcare system. Additionally, we explored specific factors relevant to safety culture, such as gender, year of graduation, age, number of emergency room duties per month, average number of admissions per day, incident experience, incident reporting experience, barriers to incident reporting and safety culture. We analysed the data using descriptive statistics and multivariate logistic regression analysis.

RESULTS

We included 5289 residents (88.6%) from community training hospitals and 679 residents (11.4%) from university hospitals. A comparative analysis of safety culture between the two groups on nine representative questions revealed that the percentage of residents who reported a positive atmosphere at their institution was significantly lower at university hospitals (81.7%) than at community hospitals (87.8%) (p<0.001). The other items were also significantly lower for university hospital residents. After adjusting for multivariate logistic analysis, university hospital training remained significantly and negatively associated with all nine safety culture items. Furthermore, we also found that university hospital residents perceived a significantly lower level of safety culture than community hospital residents.

IMPLICATIONS

Further research and discussion on medical professionals' perception of safety culture in their institutions as well as other healthcare professionals' experiences are necessary to identify possible explanations for our findings and develop strategies for improvement.

A study of error reporting by nurses: the significant impact of nursing team dynamics

Background

Error reporting is crucial for organisational learning and improving patient safety in hospitals, yet errors are significantly underreported.

Aims

The aim of this study was to understand how the nursing team dynamics of leader inclusiveness, safety climate and psychological safety affected the willingness of hospital nurses to report errors.

Methods

The study was a cross-sectional design. Self-administered surveys were used to collect data from nurses and nurse managers. Data were analysed using linear mixed models. Bootstrap confidence intervals with bias correction were used for mediation analysis.

Results

Leader inclusiveness, safety climate and psychological safety significantly affected willingness to report errors. Psychological safety mediated the relationship between safety climate and error reporting as well as the relationship between leader inclusiveness and error reporting.

Conclusion

The findings of the study emphasise the importance of nursing team dynamics to error reporting and suggest that psychological safety is especially important to error reporting.

The effect of refresher training on fact description in medical incident report writing in the Japanese language

To maintain the effectiveness of the training (1st-Training Session: 1st-TS) to accurate describe facts in the medical incident reports (IRs) in Japanese, a refresher TS was designed and its effectiveness was examined. First, textual analysis showed that IRs' accuracy significantly decreased six months after the 1st-TS. Based on this result, the refresher TS was designed and conducted with 64 residents. To verify the refresher TS' effectiveness, IRs after the 1st-TS, six months later, and after the refresher TS were compared via text analysis. The results showed that the refresher TS restored the description rate of patient's background, safety check procedures, original work procedures, information on equipment used, reporter's actions, and post-incident response. The questionnaire was also administered and showed that the refresher TS contributed to residents' motivation to learn about IRs. In conclusion, the refresher TS contributed to sustaining the effect of the 1st-TS on accurately describing IRs.

Nationwide survey on Japanese residents' experience with and barriers to incident reporting

The ability of any incident reporting system to improve patient care is dependent upon robust reporting practices. However, under-reporting is still a problem worldwide. We aimed to reveal the barriers experienced while reporting an incident through a nationwide survey in Japan. We conducted a cross-sectional survey. All first- and second-year residents who took the General Medicine In-Training Examination (GM-ITE) from February to March 2021 in Japan were selected for the study. The voluntary questionnaire asked participants regarding the number of safety incidents encountered and reported within the previous year and the barriers to reporting incidents. Demographics were obtained from the GM-ITE. The answers of respondents who indicated they had never previously reported an incident (non-reporting group) were compared to those of respondents who had reported at least one incident in the previous year (reporting group). Of 5810 respondents, the vast majority indicated they had encountered at least one safety incident in the past year (n = 4449, 76.5%). However, only 2724 (46.9%) had submitted an incident report. Under-reporting (more safety incidents compared to the number of reports) was evident in 1523 (26.2%) respondents. The most frequently mentioned barrier to reporting an incident was the time required to file the report (n = 2622, 45.1%). The barriers to incident reporting were significantly different between resident physicians who had previously reported and those who had never previously reported an incident. Our study revealed that resident physicians in Japan commonly encounter patient safety incidents but under-report them. Numerous perceived and experienced barriers to reporting remain, which should be addressed if incident reporting systems are to have an optimal impact on improving patient safety. Incident reporting is essential for improving patient safety in an institution, and this study recommends establishing appropriate interventions according to each learner's barriers for reporting.

Strength of Safety Measures Introduced by Medical Practices to Prevent a Recurrence of Patient Safety Incidents: An Observational Study

OBJECTIVE

The aim of this study was to analyze the strength of safety measures described in incident reports in outpatient care.

METHODS

An incident reporting project in German outpatient care included 184 medical practices with differing fields of specialization. The practices were invited to submit anonymous incident reports to the project team 3 times for 17 months. Using a 14-item coding scheme based on international recommendations, we deductively coded the incident reports and safety measures. Safety measures were classified as "strong" (likely to be effective and sustainable), "intermediate" (possibly effective and sustainable), or "weak" (less likely to be effective and sustainable).

RESULTS

The practices submitted 245 incident reports. In 160 of them, 243 preventive measures were described, or an average of 1.5 per report. The number of documented measures varied from 1 in 67% to 4 in 5% of them. Four preventive measures (2%) were classified as strong, 37 (15%) as intermediate, and 202 (83%) as weak. The most frequently mentioned measures were "new procedure/policy" (n = 121) and "information/notification/warning" (n = 45).

CONCLUSIONS

The study provides examples of critical incidents in medical practices and for the first time examines the strength of ensuing measures introduced in outpatient care. Overall, the proportion of weak measures is (too) high, indicating that practices need more support in identifying strong measures.

Training residents in medical incident report writing to improve incident investigation quality and efficiency enables accurate fact gathering

We assessed whether training on writing readable and accurate medical incident reports (IRs) improves the quality of fact description. In this training, 124 residents created fictional IRs. We provided tips, including using When, Where, Who, What, Why, How. We compared the fictional IRs with and without tips, and the trainees' and non-trainees' IRs submitted in the first five months after training. Results indicated that the subject words in IRs were more clarified and the readability was improved. The fictional IRs using tips were more accurate, with increased descriptions of the patient's background, reporter's actions, team members' actions and conversations, safety check procedures, result of the error, and post-incident response. The reporter's actions, work procedures, and environment were more clarified in the trainees' IRs than in the non-trainees' IRs. This training may help analysts comprehend the sequence of and underlying factors for reporter's actions based on IRs.

Increasing Patient Safety Event Reporting Among Pediatric Residents

Background and objective

Despite their role as frontline providers, resident physicians often underreport adverse patient events or safety issues they encounter. The objective of this study was to increase the number of patient safety events (PSE) reported at our institution through the implementation of a longitudinal, multi-pronged approach.

Methods

We designed and implemented a series of interventions focused on increasing patient safety events reported by resident physicians from October 2018 to April 2021. Interventions consisted of formal didactic sessions, increasing awareness among organizational leaders about the integral role of residents, implementing a direct feedback process to residents regarding the events, and encouraging them to develop solutions to their PSE that were associated with a financial incentive. We collected the rates of reports every month to assess the impact of our interventions.

Results

The mean number of PSEs submitted monthly increased from zero to two reports at baseline to 10.4 during the study period. The mean number of PSE increased to 5.8 (range: 2-11) at the end of the first intervention. Following the third intervention, the average number of reported PSE was 12.3 (range: 5-18). There was a continued increase in the number of events reported across the study period, which was sustained. The outcome of interest was not achieved after intervention 1 but was achieved in 27% and 62% of months following interventions two and three. By theend of the study period, our goal of >13 PSEs per month was consistently met. The most significant increase in reporting occurred when residents received positive timely feedback regarding their reports.

Conclusions

The number of patient safety events reported by pediatric residents increased at our institution following the implementation of a multi-pronged approach including enhanced education, recognition of the residents as frontline reporters among institutional stakeholders, and direct feedback regarding submissions. Our strategies may be replicated at other residency programs seeking to establish resident involvement in safety initiatives. Further work is necessary to ensure residents gain an understanding of how patient safety events are addressed and prevented at an organizational level.

Pathology trainees rarely report safety incidents: A review of 13,722 safety reports and a call to action

Reporting and understanding patient safety incidents is a cornerstone of improving patient care quality and safety. The Accreditation Council for Graduate Medical Education specifically mandates that physician trainee education include participation in the recognition, reporting, and root cause analysis of patient safety incidents. Studies on safety event reporting, however, have consistently shown that attending physicians submit few safety reports, and trainees submit even fewer. We undertook a study to assess the rate at which pathology trainees report patient safety events relative to the rates at which trainees in other medical specialties do. We performed a retrospective analysis of 13,722 safety reports submitted to our medium-sized Academic Medical Center’s incident reporting system. We then analyzed those reported by trainees (residents and fellows), and then further drilled down on the subset of trainee-reported safety events reported by pathology trainees. Despite accounting for over 5% of all types of trainees at the enterprise level, pathology trainees accounted for only 0.5% of all trainee safety reports. Our findings represent a call to action for pathology training programs to engage their residents and fellows in quality and safety initiatives, to understand and remove barriers to safety event reporting for vulnerable populations such as trainees, and to empower trainees to confidently report safety risks as valued frontline care providers.

A Quality Improvement Initiative to Improve Patient Safety Event Reporting by Residents

INTRODUCTION

Residents play a key role in patient care at academic medical centers and have unique insights into safety improvement opportunities. At our institution, <1% of safety events were reported by resident trainees. The primary objective of this quality improvement (QI) initiative was to increase the monthly incidence of event reporting by pediatric residents by 20% from baseline within 12 months.

METHODS

A QI team used the model for improvement to identify barriers to submitting safety event reports. The team used multiple intervention cycles to increase knowledge and promote engagement in event reporting. Interventions included educational tip sheets, a hospital-wide Morbidity and Mortality (M&M) conference, peer recognition and acknowledgment by senior leadership for report submission, and an interactive reporting activity. The outcome measure was monthly number of reports filed by residents. The process measure was the number of unique residents submitting a report each month. Time to complete a report was a balancing measure.

RESULTS

The number of reports placed by residents increased significantly, with a centerline shift from 15 to 29 reports per month (statistical process control chart-Fig. 3). The number of unique residents submitting reports increased from 10 to 22 per month. The time to complete a report was unchanged.

CONCLUSIONS

Engaging residents in patient safety initiatives through education, experiential learning, and recognition can increase safety event reporting by residents. Future planned interventions include enhancing safety event reporting technology, developing patient safety faculty and resident champions, and increasing transparency regarding outcomes of safety event reports.

Resident Safety Huddles: Our Department's Experience in Improving Safety Culture

OBJECTIVE/HYPOTHESIS

Our department sought to develop a quality improvement initiative in the interest of promoting resident involvement within the departmental safety culture. Specifically, we aimed to identify any barriers to incident reporting among residents and to create an approach to rectify this problem.

STUDY DESIGN

Patient Safety/Quality Improvement.

METHODS

This is a descriptive, qualitative study taking place at a large teaching hospital. A brief survey was administered to all Otorhinolaryngology residents and based on feedback a two-pronged approach to creating a patient safety and quality improvement curriculum was undertaken. This entailed implementation of 1) a formalized online curriculum and 2) a resident-driven forum for discussion of safety concerns termed a "Resident Safety Huddle."

RESULTS

The survey identified three main barriers to incident reporting among residents, including increased workload, the punitive nature of the system, and fear of retribution. During the study period, the residents completed the curriculum required to obtain the Institute for Healthcare Improvement Basic Certificate of Quality and Safety and participated in 10 Resident Safety Huddles. Each huddle was dedicated to discussion of a unique safety concern and frequently led to sustainable solutions. After implementation of this curriculum, an increase in the number of safety events reported by residents was recognized.

CONCLUSIONS

In building an educational foundation for incident reporting and further bolstering it with a resident-driven forum for discussion of safety concerns, we were able to achieve a recognizable and meaningful impact on our residents and the greater departmental safety culture.

LEVEL OF EVIDENCE

4 (single descriptive or qualitative study) Laryngoscope, 131:E1811-E1815, 2021.

A Narrative Review of Strategies to Increase Patient Safety Event Reporting by Residents

BACKGROUND

Because residents are often on the frontlines of patient care and are likely to witness adverse events firsthand, it is critical they report patient safety events. They may, however, be underreporting.

OBJECTIVE

We examined the current literature to identify strategies to increase patient safety event reporting by residents.

METHODS

We used CINAHL (EBSCO Information Services, Ipswich, MA), EMBASE (Elsevier, Amsterdam, the Netherlands), PsycINFO (APA Publishing, Washington, DC), and PubMed (National Center for Biotechnology Information, Bethesda, MD) databases. The search was limited to English-language articles published in peer-reviewed journals through March 2020. Key terms included "residents, trainees, fellows, interns, graduate medical education, house staff, event reporting, patient safety reporting, incident reporting, adverse event, and medical error." To organize findings, we adapted a published framework of strategies for encouraging self-protective behavior.

RESULTS

We identified 68 articles that described strategies used to increase event reporting. The most sustainable interventions used a combination of 3 of the 5 strategies: behavior modeling, surveys and messaging, and required limited financial support. The survey creates awareness; the behavior modeling is critical for educational purposes, and the reminders help to reinforce the new behavior and embed it into routine patient care activities. We noted a dearth of studies involving trainees in root cause analysis following submission of event reports.

CONCLUSIONS

The most successful sustainable interventions were those that combined strategies that minimized time for busy physicians, incorporated accessible event reporting in already existing medical records, and became part of a normal workflow in patient care.

A resident-led initiative to improve patient safety event reporting in an internal medicine residency program

Background

Despite the Clinical Learning Environment Review's recommendations of their use, patient safety event reporting systems are underutilized by residents.

Objective

We aimed to identify perceived barriers to event reporting amongst internal medicine residents and implement a targeted quality improvement initiative to address the identified barriers and increase overall resident event report rates.

Methods

A total of 94 Internal Medicine (IM) residents participated in the educational intervention in 2018. We measured residents' perception of barriers to event reporting and employed the results of the questionnaire to create a skill-based educational workshop. We conducted the plan-do-study-act model to test a structured educational intervention and its effectiveness on pre-post IM residents' event report rates and compared it to report rates of Non-Internal Medicine (Non-IM) residents. Additionally, we assessed pre-post intervention knowledge, skills, and attitudes in event reporting.

Results

94/94 (100%) of IM residents had a significantly higher median percent of patient safety event reporting when compared to pre-intervention (23.6% compared to 5.88%, p-value = 0.0030) and when compared to Non-IM residents (23.6% compared to 5.31%, p-value = 0.0002). Residents performed better on the post-test compared to the pre-test (90% compared to 30%, p-value = 0.0001) for knowledge. 100% of the critical action items were completed and 90% of participants reported their perception of the event reporting process improved.

Conclusions

By elucidating common reasons why residents are not reporting patient safety events, a specific intervention can be created to target the identified impediments and improve resident event reporting.

Abbreviations

IM: Internal Medicine IM; Non-IM: Non-Internal Medicine; IOM: Institute of Medicine I; ACGME CLER: Accreditation Council for Graduate Medical Education Clinical Learning Environment Review; GME: Graduate Medical Education; IRB: Institutional Review Board; PDSA: Plan, Do, Study, Act.

Development of a patient safety culture scale for maternal and child health institutions in China: a cross-sectional validation study

OBJECTIVE

This study aimed to develop a patient safety culture (PSC) scale for maternal and child healthcare (MCH) institutions in China.

METHODS

A theoretical framework of PSC for MCH institutions was proposed through in-depth interviews with MCH workers and patients and Delphi expert consultations. The reliability and validity of the PSC scale were tested in a cross-sectional survey of 1256 MCH workers from 14 MCH institutions in Zhejiang province of China. The study sample was randomly split into half for exploratory and confirmatory factor analyses, respectively. Test-retest reliability was assessed through a repeated survey of 63 voluntary participants 2 weeks apart.

RESULTS

The exploratory factor analysis extracted 10 components: patient engagement in patient safety (six items), managerial response to patient safety risks (four items), perceived management support (five items), staff empowerment (four items), staffing and workloads (four items), reporting of adverse events (three items), defensive medical practice (three items), work commitment (three items), training (two items) and transfer and handoff (three items). A good model fit was found in the confirmatory factor analysis: χ²/df=1.822, standardised root mean residual=0.048, root mean square error of approximation=0.038, comparative fit index=0.921, Tucker-Lewis index=0.907. The PSC scale had a Cronbach's α coefficient of 0.89 (0.59-0.90 for dimensional scales) and a test-retest reliability of 0.81 (0.63-0.87 for dimensional reliability), respectively. The intracluster correlation coefficients confirmed a hierarchical nature of the data: individual health workers nested within MCH institutions.

CONCLUSION

The PSC scale for MCH institutions has acceptable reliability and validity. Further studies are needed to establish benchmarking in a national representative sample through a multilevel modelling approach.

Teaching medical students to recognise and report errors

Background

Medical student error reporting can potentially be increased through patient safety education, culture change and by teaching students how to report errors. There is scant literature on what kinds of errors students see during clinical rotations. The authors developed an intervention to better understand what kinds of errors students see and to train them to identify and report errors.

Methods

A safety curriculum was delivered during the Medicine clerkship for the academic year 2015-2016. Prior to the workshop, students completed a preintervention survey to determine whether they had reported a clinical error. Subsequently, they participated in an educational workshop. Facilitated discussions about conditions contributing to errors, types of errors, prevention of errors and importance of reporting followed. Students were required to submit a simulated error report about an error they personally observed. An end-of-year survey was sent to students who participated in the curriculum to determine clinical error reporting frequency.

Results

Students submitted 282 reports. Near miss errors were seen in 64% and adverse events in 36%. National Quality Forum serious events were reported in 14%, including one death. Recommendations to prevent similar events were weak (62%). Students correctly categorised 93% near miss, 88% adverse events, 67% diagnostic, 81% treatment and 78% preventative errors. On the preintervention survey, 8.5% stated they submitted an error report to their clinical site. On the end-of-year survey, 18% confirmed submitting a formal error report.

Conclusion

Training students to recognise and report errors can be successfully integrated into a clinical clerkship and impact clinical error reporting.

A Qualitative Analysis of Resident Adverse Event Reporting: What's Holding Us Back

This study utilized focus groups of residents, who report adverse events at differing rates depending on their hospital site, to better understand barriers to residents' reporting and identify modifiable aspects of an institution's culture that could encourage resident event reporting. Focus groups included residents who rotated at 3 hospitals and represented 4 training programs. Focus groups were audio recorded and analyzed using qualitative methods. A total of 64 residents participated in 8 focus groups. Reporting behavior varied by hospital culture. Residents worried about damage to their professional relationships and lacked insight into the benefits of multiple reports of the same event or how human factors engineering can prevent errors. Residents did not understand how reporting affects litigation. Residents at other academic institutions likely experience similar barriers. This study illustrates that resident reporting is modifiable by changing hospital culture, but hospitals have only a few opportunities to mishandle reporting before resident reporting attitudes solidify.

Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines

INTRODUCTION

Little is known about what motivates residents to report adverse events. The goals of the qualitative study were to: (1) better understand facilitators to residents' event reporting and (2) identify effective interventions that encourage residents to report.

METHODS

The authors conducted focus groups of upper-level residents from 4 training programs (2 internal medicine, a pediatric, and a combined medicine-pediatric) who rotated at 3 institutions within a large healthcare system in 2016. Quantitative data on reporting experience were gathered. Focus groups were audio recorded and transcribed. Two coders reviewed transcripts using the editing approach and organized codes into themes.

RESULTS

Sixty-four residents participated in 8 focus groups. Residents were universally exposed to reportable events and knew how to report. Residents' reporting behavior varied by site according to local culture, with residents filing more reports at the pediatric hospital compared to other sites, but all groups expressed similar general views about facilitators to reporting. Facilitators included familiarity with the investigation process, reporting via telephone, and routine safety educational sessions with safety administrators. Residents identified specific interventions that encouraged reporting at the pediatric hospital, including incorporating an attending physician review of events into sign-out and training on error disclosure.

CONCLUSIONS

This study provides insight into what motivates resident event reporting and describes concrete interventions to increase reporting. Our findings are consistent with the Theoretical Domains Framework of behavioral change. These strategies could prove successful at other pediatric hospitals to build a culture that values reporting and prepares residents as patient safety champions.

Assessment of knowledge and attitudes towards safety events reporting among residents in a community health system

Background: Resident physicians are known to be infrequent reporters of patient safety events (PSE). Previous studies assessing barriers to resident PSE reporting have not considered possible cultural barriers faced by international medical graduates (IMG). This study aimed to assess the knowledge and attitudes of residents regarding PSE and possible barriers contributing to poor resident reporting.

Methods: A cross sectional survey of all house staff undergoing post-graduate residency training at two independent community hospital based academic medical centers was conducted through an online questionnaire. Sample case vignettes were created to assess the residents’ ability to identify safety events and classify them as near miss, adverse events or sentinel events and decide whether they were reportable.

Results: The Reporting of PSE increased significantly by year of residency training (p < 0.005), with time taken to file a PSE being the strongest perceived barrier. There was no difference in PSE reporting between IMG’s and non- IMG’s. We identified major knowledge gaps with only 73.9%, 79.6% and 94.3% of respondents correctly identifying sentinel events, adverse events, and near misses, respectively. 58.1% of respondents did not think near misses were reportable.

Conclusions: A lack of knowledge is the most important barrier towards PSE reporting. A different cultural background and lack of previous exposure to patient safety report by IMGs is not a significant barrier towards safety event reporting. In the short-term, it appears that focusing limited institutional resources on education rather than acculturation issues would have the greatest benefit.

Increasing Patient Safety Event Reporting in an Emergency Medicine Residency

Patient safety event reporting is an important component for fostering a culture of safety. Our tertiary care hospital utilizes a computerized patient safety event reporting system that has been historically underutilized by residents and faculty, despite encouragement of its use. The objective of this quality project was to increase patient safety event reporting within our Emergency Medicine residency program. Knowledge of event reporting was evaluated with a survey. Eighteen residents and five faculty participated in a formal educational session on event reporting followed by feedback every two months on events reported and actions taken. The educational session included description of which events to report and the logistics of accessing the reporting system. Participants received a survey after the educational intervention to assess resident familiarity and comfort with using the system. The total number of events reported was obtained before and after the educational session. After the educational session, residents reported being more confident in knowing what to report as a patient safety event, knowing how to report events, how to access the reporting tool, and how to enter a patient safety event. In the 14 months preceding the educational session, an average of 0.4 events were reported per month from the residency. In the nine months following the educational session, an average of 3.7 events were reported per month by the residency. In addition, the reported events resulted in meaningful actions taken by the hospital to improve patient safety, which were shared with the residents. Improvement efforts including an educational session, feedback to the residency of events reported, and communication of improvements resulting from reported events successfully increased the frequency of safety event reporting in an Emergency Medicine residency.