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

Fox, Michael D.; Bump, Gregory M.; Butler, Gabriella; Chen, Ling-Wan; Buchert, Andrew R.

doi:10.1097/pts.0000000000000344

Cited by 29 publications

(25 citation statements)

References 6 publications

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“…While the percentage of physicians failing to file incident reports has remained persistently elevated, some researchers have showed pockets of improvement. Fox et al implemented a multidimensional intervention that educated resident physicians regarding patient safety, integrated it into their daily work, and addressed the barriers to incident reporting when serious harm events went down and reporting went up [22]. Gaining a better understanding of the barriers to reporting is the first step in effectively addressing them.…”

Section: Plos Onementioning

confidence: 99%

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

et al. 2022

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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.

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Section: Plos Onementioning

confidence: 99%

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

et al. 2022

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“…Pediatric residents report at higher rates than other trainees in the system, partly because of a concerted effort by hospital leadership to encourage reporting. 21 Residents who rotate at multiple sites anecdotally report differing reporting behaviors at each site. The system, with a single incident reporting system active across many hospitals with varied rates of resident engagement in reporting, provides a unique opportunity to learn more about what aspects of hospital culture affect resident event reporting.…”

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confidence: 99%

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

et al. 2019

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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.

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“…In the absence of findings other than knowledge-based deficits, we agree with the suggestions of Fox., et al, and Louis, et al, and recommend that, in the short-term, programs follow and invest their limited institutional resources for training in case-based educational modules to have the greatest benefit [15,25]. These methodologies have been shown to increase resident participation in event reporting, and, until larger scale multi-center studies are performed, remain the best available evidence for improving resident reporting of patient safety events.…”

Section: Resultsmentioning

confidence: 99%

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

Singal

Zafar

Tbakhi

et al. 2018

Journal of Community Hospital Internal Medicine Perspectives

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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.

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

Cited by 29 publications

References 6 publications

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

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

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

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

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