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

Perceptions of U.S. and U.K. Incident Reporting Systems: A Scoping Review

OBJECTIVE

The aim of the study is to evaluate the extent, range, and nature of the literature that concerns healthcare providers' perceptions following the use of incident reporting systems (IRSs) in the United States (U.S.) and the United Kingdom (U.K.). Literature was compared describing providers' perceptions of reporting patient safety incidents using IRSs from healthcare systems built on public, private, for-profit, or nonprofit insurers in the U.S., with providers' perceptions using an IRS within a universal government supported healthcare system in the U.K.

METHODS

This scoping review searched literature from 4 electronic databases, producing 4863 articles between January 2010 to March 2023.

RESULTS

Eleven U.S. and 8 U.K. articles met the inclusion criteria. Providers described system and individual barriers when using IRSs. The U.S. providers described more concerns regarding individual barriers (fear of punitive response or retaliation, feel incapable or shamed, unsure of what constitutes a patient safety incident, and concerned about litigation) than providers in the U.K. Both countries had similar responses regarding system barriers, except for U.K. providers who were more concerned than the U.S. about damage to professional culture. Providers in both countries believed incident reporting was ineffective and time consuming with hospital leaders seldom acknowledging or integrating improvement measures based on reported incidents.

CONCLUSIONS

Sustainable improvements in patient care must be driven by hospital leadership who create just cultures where reporting of safety concerns is encouraged and respected within nonpunitive milieus.

"Near Miss": A Mixed-Methods Analysis of Medical Student Assignments in Patient Safety

The purpose of this study is to inform the curriculum for Entrustable Professional Activity 13 through analysis of fourth year medical student patient safety event assignments. From 2016 to 2021, students were asked to identify a patient safety event and indicate if the event required an incident report. Assignments were reviewed and coded based on Joint Commission incident definitions. Qualitative analysis was performed to evaluate incident report justification. There were 473 student assignments included in the analysis. Assignments reported incidents regarding communication, medical judgment, medication errors, and coordination of care. Students indicated only 18.0% (85/473) would warrant an incident report. Justification for not filing an incident report included lack of harm to the patient or that it was previously reported. Students were able to identify system issues but infrequently felt an incident report was required. Justifications for not filing an incident report suggest a need for a curriculum focused on the value of reporting near misses and hazardous conditions.

A Leadership Pathway in Patient Safety and Quality Improvement for Trainees

Training house staff in patient safety and quality improvement (PSQI) requires multidisciplinary collaboration between program directors, graduate medical education, and hospital safety and quality leadership. A heavy clinical workload and limited protected time hinder trainees from engaging in a meaningful PSQI experience during their years of post-graduate training. This is further exacerbated by the lack of subject experts who are available to mentor young physicians. For pulmonary and critical care trainees who are actively involved in the management and care coordination of high-acuity patients, this lack of experience adds undue burden. The role of house officer for patient safety and quality improvement was implemented to engage those currently in training who have an interest in PSQI. Under the supervision of the hospital PSQI leaders, they are given optimal, purposeful immersion without impacting their primary training specialty. This skill set can then be incorporated into their future careers. In this review, we provide perspective on how this can be accomplished and provide a framework that can be expanded.

Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis

BACKGROUND

The implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems, there is a need to more comprehensively understand critical success factors. This study aims to summarise the barriers and facilitators perceived by hospital staff and physicians to influence the reporting, analysis, learning and feedback within PSLS in hospitals.

METHODS

We performed a systematic review and meta-synthesis by searching MEDLINE (Ovid), EMBASE (Ovid), CINAHL, Scopus and Web of Science. We included English-language manuscripts of qualitative studies evaluating effectiveness of the PSLS and excluded studies evaluating specific individual adverse events, such as systems for tracking only medication side effects, for example. We followed the Joanna Briggs Institute methodology for qualitative systematic reviews.

RESULTS

We extracted data from 22 studies, after screening 2475 for inclusion/exclusion criteria. The included studies focused on reporting aspects of the PSLS, however, there were important barriers and facilitators across the analysis, learning and feedback phases. We identified the following barriers for effective use of PSLS: inadequate organisational support with shortage of resources, lack of training, weak safety culture, lack of accountability, defective policies, blame and a punitive environment, complex system, lack of experience and lack of feedback. We identified the following enabling factors: continuous training, a balance between accountability and responsibility, leaders as role models, anonymous reporting, user-friendly systems, well-structured analysis teams, tangible improvement.

CONCLUSION

Multiple barriers and facilitators to uptake of PSLS exist. These factors should be considered by decision makers seeking to enhance the impact of PSLS.

ETHICS AND DISSEMINATION

No formal ethical approval or consent were required as no primary data were collected.

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.

Effect of Patient Safety Curriculum for Internal Medicine Residents on a Health Care System

Background

Healthcare organizations seeking to promote a safety culture depend on engaged clinicians. Academic medical centers include a community of physicians-in-training; however, medical residents and fellows are historically less engaged in patient safety (PS) than are other clinicians. Increased attention has been focused on integrating PS into graduate medical education. Nonetheless, developing curricula that result in real-world system changes is difficult.

Objective

To develop an interactive PS curriculum for internal medicine (IM) residents that analyzes real-word PS problems.

Methods

A multidisciplinary group developed a five-session, case-based PS curriculum for IM residents in the context of a 3-year, longitudinal quality-improvement, PS, and high-value-care curriculum. The curriculum was facilitated by a PS analyst and incorporated mock root cause analysis (RCA) based on actual resident-reported PS events. Each mock RCA developed an action plan, and outcomes were tracked. Pre- and postcurriculum assessments with participating residents were conducted to evaluate the curriculum.

Results

Twenty-eight IM residents completed the curriculum during four iterations from 2017 to 2020. The curriculum identified multiple potential PS risks, led to tangible changes in clinical processes, and enhanced resident confidence in improving systems of care.

Conclusions

We describe an active-learning PS curriculum for IM residents that addressed actual resident-reported PS problems. Through RCA, action items were identified and meaningful system changes were made. Leveraging the expertise of local PS experts in the design and delivery of PS curricula may improve the translation of learner recommendations into real system changes and cultivate a positive PS culture.

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.