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

Szymusiak, John; Walk, Thomas J.; Benson, Maggie; Hamm, Megan; Zickmund, Susan; Gonzaga, Alda Maria; Bump, Gregory M.

doi:10.1177/1062860619853878

Cited by 9 publications

(54 citation statements)

References 25 publications

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“…Furthermore, residents may have different perspectives and strategies on addressing a safety issue. Similar to our findings, Szymusiak et al also demonstrated that residents felt that involvement in the post-PSE reporting process reinforced the value of making a report [ 21 ].…”

Section: Discussionsupporting

confidence: 89%

“…Kaldjian et al demonstrated that knowledge deficits were an essential factor in underreporting of PSE [ 14 ]. Similarly, previous studies investigating methods to improve PSE reporting have emphasized the importance of education [ 21 - 23 ]. The modest increase in our PSE rates with educational interventions alone supports the need for supplementary programs in addition to educational seminars when developing safety training programs for graduate medical education.…”

Section: Discussionmentioning

confidence: 98%

“…It is well-known that healthcare personnel fail to obtain timely feedback about PSE reports [ 17 - 20 ]. In a study done by Farley et al, most hospitals surveyed that they do not have robust processes for sharing outcomes of adverse reports, and only 20-21% of hospitals thoroughly distribute and communicate action reports on identified safety events [ 21 ]. This leads to a lack of engagement in reporting safety issues and prevents efficient interactions among providers.…”

Section: Discussionmentioning

confidence: 99%

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Increasing Patient Safety Event Reporting Among Pediatric Residents

Vijayan¹,

Limon²

2022

Cureus

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Background and objective Despite their role as frontline providers, resident physicians often underreport adverse patient events or safety issues they encounter. The objective of this study was to increase the number of patient safety events (PSE) reported at our institution through the implementation of a longitudinal, multi-pronged approach. Methods We designed and implemented a series of interventions focused on increasing patient safety events reported by resident physicians from October 2018 to April 2021. Interventions consisted of formal didactic sessions, increasing awareness among organizational leaders about the integral role of residents, implementing a direct feedback process to residents regarding the events, and encouraging them to develop solutions to their PSE that were associated with a financial incentive. We collected the rates of reports every month to assess the impact of our interventions. Results The mean number of PSEs submitted monthly increased from zero to two reports at baseline to 10.4 during the study period. The mean number of PSE increased to 5.8 (range: 2-11) at the end of the first intervention. Following the third intervention, the average number of reported PSE was 12.3 (range: 5-18). There was a continued increase in the number of events reported across the study period, which was sustained. The outcome of interest was not achieved after intervention 1 but was achieved in 27% and 62% of months following interventions two and three. By theend of the study period, our goal of >13 PSEs per month was consistently met. The most significant increase in reporting occurred when residents received positive timely feedback regarding their reports. Conclusions The number of patient safety events reported by pediatric residents increased at our institution following the implementation of a multi-pronged approach including enhanced education, recognition of the residents as frontline reporters among institutional stakeholders, and direct feedback regarding submissions. Our strategies may be replicated at other residency programs seeking to establish resident involvement in safety initiatives. Further work is necessary to ensure residents gain an understanding of how patient safety events are addressed and prevented at an organizational level.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

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Increasing Patient Safety Event Reporting Among Pediatric Residents

Vijayan¹,

Limon²

2022

Cureus

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“…Salah satu hambatan lainnya adalah belum optimalnya sistem splaporan insiden bahwa sistem pelaporan yang berbasis kertas dianggap sebagai penghalang karena adanya ambiguitas formulir pelaporan, selain itu, fitur atau format pelaporan dianggap terlalu banyak pertanyaan yang harus dijawab. (25) Setiap hambatan pelaporan insiden menjadi penghalang dalam meningkatkan budaya keselamatan pasien. Petugas kesehatan diharapkan memiliki sikap dan perilaku melaporkan insiden yang terjadi dilingkungan perawatan.…”

Section: Pembahasanunclassified

Hambatan Pelaporan Insiden Keselamatan Pasien : A Literature ReviewHambatan Pelaporan Insiden Keselamatan Pasien: A Literature Review

Mursid

Sjattar

Arafat

2021

JPKSF

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Reports of patient safety incidence at health service provider have yet been optimized. Report rates are still low and health service providers were facing obstacles in reporting incidents. Therefore, the purpose of this study was to identify obstacles in reporting patient safety incidents. A literature review was the method of choice in this study. Literature sources were obtained from the Pubmed and Ebsco Medline databases based on inclusion criteria. Based on the literature search results that have been done, we get as many as six (n = 6) articles. The obstacles that were found in reporting incidents are the negatif impact felt by the reporter, the lack of time in reporting incidents, lack of feedback, certain types of incidents reported, lack of knowledge, incidence reports were not considered as obligation, lack of clarity on who should report, lack of anonymity, and reporting system that has yet been optimized. Meanwhile, the ways to overcome these obstacles are improving and increasing report rates, giving feedback, increasing anonymity and secrecy, as well as giving the reward, education, and training for incident reports. As conclusion, obstacles in reporting incidence surely can hinder patient safety and therefore need to be resolved. Commitment from policy maker were necessary in improving patient’s safety incident reporting system. Keywords: obstacles; incidence report; patient safety ABSTRAK Pelaporan insiden keselamatan pasien di pelayanan kesehatan saat ini belum optimal. Tingkat pelaporan masih rendah, petugas kesehatan masih merasakan kendala dalam melaporkan kejadian. Oleh karena itu, tujuan dari penelitian ini adalah untuk mengidentifikasi hambatan dalam pelaporan insiden keselamatan pasien. Metode yang digunakan dalam studi ini adalah literature review. Sumber literatur didapatkan dari basis data Pubmed dan Ebsco Medline berdasarkan kriteria inklusi. Berdasarkan hasil pencarian literatur yang telah dilakukan, kami mendapatkan sebanyak enam (n=6) artikel. Hambatan pelaporan insiden yang ditemukan dalam penelitian ini adalah adanya dampak negatif yang dirasakan oleh pelapor, kurangnya waktu melaporkan insiden, kurangnya umpan balik, jenis insiden tertentu yang dilaporkan, kurangnya pengetahuan, pelaporan tidak dianggap sebagai kewajiban, kurangnya kejelasan tentang siapa yang harus melaporkan, kurangnya anonimitas, dan sistem pelaporan yang belum optimal. Sedangkan cara mengatasi hambatan atau fasilitator pelaporan insiden adalah mengembangkan dan meningkatkan sistem pelaporan, memberikan umpan balik, meningkatkan anonimitas dan kerahasiaan, serta memberikan penghargaan, pendidikan dan pelatihan tentang sistem pelaporan insiden. Sebagai kesimpulan, hambatan dalam melaporkan insiden tentunya menghambat peningkatan keselamatan pasien sehingga diperlukan upaya untuk mengatasinya. Komitmen para pembuat kebijakan memainkan peran penting dalam meningkatkan sistem pelaporan insiden keselamatan pasien. Kata kunci: hambatan; pelaporan insiden; keselamatan pasien

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“…Healthcare organizations have implemented educational initiatives and patient safety (PS) reporting systems ( 4 ) with the goal of transforming the culture and paradigm around PS ( 5 ). Nonetheless, medical trainees underreport PS concerns and are less engaged in PS than are other clinicians ( 6 , 7 ).…”

mentioning

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

Cited by 9 publications

References 25 publications

Increasing Patient Safety Event Reporting Among Pediatric Residents

Increasing Patient Safety Event Reporting Among Pediatric Residents

Hambatan Pelaporan Insiden Keselamatan Pasien : A Literature ReviewHambatan Pelaporan Insiden Keselamatan Pasien: A Literature Review

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

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