Residents Report on Adverse Events and Their Causes

Abstract

These findings support the perception that AEs are commonly encountered by physicians and often associated with errors. Causes of errors in teaching hospitals appear to be multifactorial, and a variety of measures are necessary to improve safety. Eliciting residents' perspectives is important because residents may perceive events, actions, and causal relationships that medical record reviewers or observers cannot.

Supporting involved health care professionals (second victims) following an adverse health event: A literature review

“…Not only managers but also nurses are also concerned about the quality of care they deliver. There is still work on local and national level to change the safety culture (Jagsi et al, 2005). For changing the safety system leadership and culture are important.…”

Residents contributing to inpatient quality: Blending learning and improvement

“…2,3 If medical care is dangerous, then a substantial contributor to the hazard must be the apprentice-style process of physician training and the novice skill set of the trainees. 4,5 Many resident training programs have devised efforts to decrease the errors committed by physicians-in-training, 6 change the culture of residency training, 7 engage residents in quality improvement, 8,9 and improve resident training in quality improvement. 10 Many of the programs devised to teach QI in the residency setting require substantial funding, a large pool of QI experts, or redesign of resident training programs.…”

“…10 Many of the programs devised to teach QI in the residency setting require substantial funding, a large pool of QI experts, or redesign of resident training programs. [4][5][6][7][8][9][10] While effective, these programs are not feasible for many resource-constrained residency programs. A less intense program, using resident-led, hospitalist-facilitated, limited root cause analysis (RCA), has been adopted at the Internal Medicine Residency Program at the Mount Sinai Hospital (MSH).…”

Safe use of symbols in handover documentation for medical teams

“…These transitions cross boundaries of space (as the patient progresses from the care of one team to another) and time (as healthcare professionals change shift) and are important to a safe patient journey: poor transitions have been implicated in incidents of patient harm, poor outcomes and ineffective work practices (Healthcare Commission, 2009, Ye et al, 2007, Petersen et al, 1994, and Jagsi et al, 2005.…”