Using a Root Cause Analysis Curriculum for Practice-Based Learning and Improvement in General Surgery Residency

Ramanathan, R. K.; Duane, Therèse M.; Farquhar, Doris; Kasirajan, Vigneshwar; Ferrada, Paula

doi:10.1016/j.jsurg.2015.05.005

Cited by 16 publications

(21 citation statements)

References 24 publications

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“…Limitations of this institutional curriculum include the small sample size, as well as the timing and continuity, which are common barriers in GME curricula ( 19 , 29 ). Resident attendance was variable because of time off, vacation, and night-shift responsibilities, which also affected curricular evaluations because only those present for the respective session took part in the assessment.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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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.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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“…Many structured exercises such as the Ishikawa fishbone diagram for cause effect analysis exist to facilitate this process (11). Feedback from case simulation-based education for residents on the use of RCA clearly demonstrates their appreciation for the value of the process in reducing medical errors and as a constructive way to analyze medical errors (12). More interestingly, the residents also identified an issue with "buy in" at all levels as a barrier to implementation.…”

Section: Investigating Process Measuresmentioning

confidence: 94%

The critical role of learning from investigating and debriefing adverse events

Raja¹,

Litle²

2021

J Thorac Dis

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“…Prior reports of RCA educational simulations are limited to a single residency program, include small numbers of participants, and/or simulate the adverse event itself, rather than the investigation, analysis, and improvement process. [3][4][5][6][7] None included an interprofessional team of educators and learners. We have addressed these limitations and further this work through developing and implementing an institutionally sponsored, interprofessional RCA investigation and analysis simulation program across all graduate medical education (GME) programs at a large academic medical center.…”

Section: Problemmentioning

confidence: 99%

The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment

et al. 2021

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ProblemThe Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania.

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Using a Root Cause Analysis Curriculum for Practice-Based Learning and Improvement in General Surgery Residency

Cited by 16 publications

References 24 publications

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

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

The critical role of learning from investigating and debriefing adverse events

The RCA ReCAst: A Root Cause Analysis Simulation for the Interprofessional Clinical Learning Environment

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