Original Article
House Staff Participation in Patient Safety Reporting: Identification of Predominant Barriers and Implementation of a Pilot Program
Abstract
Objectives: Patient safety event (PSE) reporting is a critical element for healthcare organizations that are striving for continuous quality improvement. Although resident physicians routinely provide the majority of direct patient care, the level of their participation in PSE reporting historically has been low. In addition, as part of the Accreditation Council for Graduate Medical Education’s Next Accreditation System, the Clinical Learning Environment Review site visit assesses residents’ engagement in PSE reporting at each accredited academic institution. The objective of this study was to understand the common barriers to PSE reporting and design an intervention to increase the number of PSE reports by resident physicians.Methods: We surveyed 304 residents and fellows to assess attitudes toward the PSE reporting system and identify barriers to submitting online PSE reports. Based on this analysis of barriers, we piloted interventions with the internal medicine residency program and measured their effect on resident PSE reporting.
Results: Of the survey respondents, 58% had never submitted a PSE report. The most commonly identified barriers were too much time required to submit a report (38% of all respondents), lack of education on how or what to report (37%), lack of feedback or change after reporting (19%), and concern for repercussions or lack of anonymity (13%). Based on this analysis of barriers, we piloted interventions with the internal medicine residency program to educate residents about PSE reporting through a reminder message in their orientation e-mail, informational slides at the end of conferences that described what and how to report, a pocket card with reporting instructions, and leadership encouragement during walk rounds by chief medical residents and the program director. Compared with the 10 weeks before the start of the intervention, the number of PSE reports submitted by internal medicine residents more than doubled, from 16 to 37 reports ( P < 0.01). This increase in resident PSE reporting was sustained for 20 weeks despite the interventions lasting only 8 weeks.
Conclusions: A resident-driven intervention that fostered a culture of encouragement for PSE reporting through leadership support and targeted education increased the number of PSE reports submitted by internal medicine residents at our health system. Hospitals and health systems should seek to understand the common barriers to PSE reporting from this important group of direct patient care providers and administer structured educational programs to encourage their participation.
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References
1. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, DC : National Academy of Sciences, 2000.
2. Pronovost PJ, Morlock LL, Sexton JB, et al. Improving the value of patient safety reporting systems. In: Henriksen K, Battles JB, Keyes MA, et al. , eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol 1: Assessment. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
3. Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care 2008;17:416-423.
4. Agency for Healthcare Research and Quality. Voluntary patient safety event reporting (incident reporting). https://psnet.ahrq.gov/primers/primer/13. Accessed January 18, 2016.
5. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 2006;15:39-43.
6. Dollarhide AW, Rutledge T, Weinger MB, et al. Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians. J Gen Intern Med 2008;23:418-422.
7. Milch CE, Salem DN, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med 2006;21:165-170.
8. Taylor JA, Brownstein D, Christakis DA, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics 2004;114:729-735.
9. Weiss KB, Bagian JP, Nasca TJ. The clinical learning environment: the foundation of graduate medical education. JAMA 2013;309:1687-1688.
10. Schectman JM, Plews-Ogan ML. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf 2006;32:337-343.
11. Jericho BG, Tassone RF, Centomani NM, et al. An assessment of an educational intervention on resident physician attitudes, knowledge, and skills related to adverse event reporting. J Grad Med Educ 2010;2:188-194.
12. Scott DR, Weimer M, English C, et al. A novel approach to increase residents’ involvement in reporting adverse events. Acad Med 2011;86:742-746.
13. Welsh CH, Pedot R, Anderson RJ. Use of morning report to enhance adverse event detection. J Gen Intern Med 1996;11:454-460.
14. Williams PM. Techniques for root cause analysis. Proc (Bayl Univ Med Cent) 2001;14:154-157.
15. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med 2003;41:110-120.
