Increasing Patient Safety Event Reporting in an Emergency Medicine Residency

Abstract

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.

Patient safety awareness among postgraduate students and nurses in a tertiary health care facility

“… 7 There is also knowledge gaps on what is considered as reportable patient safety event. 21 Discussing errors with seniors or supervisors had a positive attitude shown by higher mean score in our study. Similar results by various other researches showed that disclosing mistakes may help physicians to learn.…”

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

“…64 Smith et al 63 described how pediatric residents developed a curriculum and led a monthly conference during which they reviewed adverse event reports, identified system vulnerabilities, and designed solutions to address those vulnerabilities. As part of educational programming, morbidity and mortality conferences were used to increase trainee awareness about adverse events and the importance of reporting 31,34,53,57,63,74,[76][77][78][79] ; however, although there were calls for increased trainee participation in RCA), 19 only Murphy and colleagues 60 described an intervention using a mock RCA to increase trainee adverse event reporting, and only the study by Dunbar and colleagues 52 reported increased resident physician involvement in RCA as a result of their intervention.…”

“…59 With regard to reinforcing factors, 22 of those 42 articles (52%)## addressed how programs used feedback or incentives to promote patient safety event reporting. Steen and colleagues 19 developed an educational session on event reporting and followed up by providing feedback every 2 months on events reported and actions taken. Finally, 18 of the 42 articles (43%)*** discussed the use of behavioral modeling or training to address attitudes and beliefs; for example, Boike and colleagues 21 used 1-hour training conferences to educate residents on the types of events that qualify for adverse event reporting.…”

“…References 6,9,11,12,[14][15][16]18,19,21,22,24,30, 41-44, 47-68. †References 6, 18, 44, 51, 56, 57, 62, 69-72.…”

Should Trainees Get Paid to Submit Patient Safety Reports?

“…There is evidence that in US states where reporting of adverse events is mandatory, reports submitted by individuals (contrasted with automated reporting) have improved safety and reduced harm at the institutional level after root cause analysis. 2 However, this positive outcome was found in the context of (1) voluntary reporting and (2) conducting a root cause analysis. We wonder whether voluntary reporting is comparable to incentivized reporting and whether root cause analyses were conducted following the receipt of the incentivized safety reports.…”