Patient safety stories: a project utilizing narratives in resident training

Incident reports have traditionally been the vehicle for identifying, assessing, and responding to quality gaps in hospitals. Yet because of a variety of barriers, residents often fail to participate in this formal process. The authors created a project to engage residents in incident reporting through the use of an online, anonymous narrative format, faculty-facilitated discussion groups, and involvement of patient safety officers in the educational process. During three months, 36 residents submitted a total of 79 stories about patient care that did not "go as intended." The authors reviewed and scored each story for contributing factors and outcomes. The residents met monthly in small groups with trained faculty facilitators to analyze the stories, which were also shared with the patient safety officers. The stories, narratives of both personal involvement and observed events, ranged from near-misses to sentinel events. Key contributing factors included lapses of professionalism, decision errors, communication/information mishaps, transition mix-ups, and workload difficulties. The narrative format proved a feasible tool for collecting significant, previously unrecognized patient safety issues. Internal medicine residents were willing to discuss gaps in care when given the tools and opportunity for anonymous storytelling and blame-free dialogue.

Medical trainees' formal and informal incident reporting across a five-hospital academic medical center

BACKGROUND

Despite the importance of incident reporting for promoting patient safety, the extent to which residents and fellows (trainees) in graduate medical education (GME) programs report incidents is not well understood. A study was conducted to determine the prevalence of and variations in incident reporting across hospitals in an academic medical center.

METHODS

Trainees enrolled in GME programs sponsored by the Indiana University School of Medicine (IUSM) completed (1) the Behavior Index Survey (BIS), which asked respondents if they knew how to locate incident forms and if they ever submitted an incident form, and (2) the Safety Culture Survey (SCS), which asked about the frequencies of their formal and informal incident reporting behaviors.

RESULTS

Some 443 of 992 invited trainees (45% response rate) participated in the study. Of the 305 BIS respondents who rotated through all five hospitals, varying proportions knew how to locate an incident form (22.3%-31.5%) and had completed an incident form (6.2%-20%) in each hospital. Incident report completion rates were higher (20.1%-81.3%) among trainees who knew how to locate an incident form. Higher proportions of the 443 SCS respondents had informally discussed an incident with other trainees (90%), faculty physicians (70%), and at resident meetings and conferences (73%).

DISCUSSION

The study confirms that GME trainees formally report incidents rarely. The flow of communication to and from trainees about patient safety and incidents is low, despite an organizational focus on safety and quality. Discussion of safety issues among trainees occurs more informally among colleagues and peers than with faculty or through formal reporting mechanisms. The data suggest a number of strategies to increase the culture of safety among GME trainees.

The gap between nurses and residents in a community hospital's error-reporting system

BACKGROUND

Little is known about current attitudes and practices among residents and nurses regarding error reporting. A survey was conducted to suggest differing needs for training and other interventions to enhance reporting.

METHODS

The authors surveyed 24 residents and 60 nursing staff in all inpatient care units at a community hospital from 2001 to 2002. The authors used self-administered questionnaires to assess respondents' knowledge and use of the hospital's error-reporting system, perceptions and attitudes toward error reporting, reported behaviors in hypothetical error scenarios, and conditions that influence error reporting.

RESULTS

Only half of the residents (54%) knew about the hospital's error-reporting system, whereas nearly all nurses did (97%; p = .001). Only 13% of the residents (versus 72% of the nurses) had ever used the reporting system (p = .001). Residents (29%) were less likely than nurses (64%) to report being comfortable discussing mistakes with supervisors (p = .006), and residents (38%) were more likely than nurses (0%) to rate the hospital atmosphere as nonsupportive of error reporting (p = 001).

DISCUSSION

Error-reporting systems may give a biased picture of the true pattern of medical errors, and hospitals may need to initiate other interventions to improve residents' error reporting.