Improving Incident Reporting Among Physician Trainees

Krouss, Mona; Alshaikh, Jumana; Croft, Lindsay; Morgan, Daniel J.

doi:10.1097/pts.0000000000000325

Cited by 25 publications

(28 citation statements)

References 11 publications

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“…For many institutions, particularly large institutions with multiple participating sites, it is not practical to implement and sustain all these strategies. Articles highlighting sustained improvements 6,11,18 used a combination of behavior modeling, coupled with surveys and messaging, and required limited financial support, but some time and dedication by leaders and educators. The survey creates awareness, the behavior modeling is critical for educational purposes, and the reminders help to reinforce the new behavior and embed it into routine patient care activities.…”

Section: Discussionmentioning

confidence: 99%

A Narrative Review of Strategies to Increase Patient Safety Event Reporting by Residents

Aaron

Webb

Luhanga

2020

Journal of Graduate Medical Education

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Background Because residents are often on the frontlines of patient care and are likely to witness adverse events firsthand, it is critical they report patient safety events. They may, however, be underreporting. Objective We examined the current literature to identify strategies to increase patient safety event reporting by residents. Methods We used CINAHL (EBSCO Information Services, Ipswich, MA), EMBASE (Elsevier, Amsterdam, the Netherlands), PsycINFO (APA Publishing, Washington, DC), and PubMed (National Center for Biotechnology Information, Bethesda, MD) databases. The search was limited to English-language articles published in peer-reviewed journals through March 2020. Key terms included “residents, trainees, fellows, interns, graduate medical education, house staff, event reporting, patient safety reporting, incident reporting, adverse event, and medical error.” To organize findings, we adapted a published framework of strategies for encouraging self-protective behavior. Results We identified 68 articles that described strategies used to increase event reporting. The most sustainable interventions used a combination of 3 of the 5 strategies: behavior modeling, surveys and messaging, and required limited financial support. The survey creates awareness; the behavior modeling is critical for educational purposes, and the reminders help to reinforce the new behavior and embed it into routine patient care activities. We noted a dearth of studies involving trainees in root cause analysis following submission of event reports. Conclusions The most successful sustainable interventions were those that combined strategies that minimized time for busy physicians, incorporated accessible event reporting in already existing medical records, and became part of a normal workflow in patient care.

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Section: Discussionmentioning

confidence: 99%

A Narrative Review of Strategies to Increase Patient Safety Event Reporting by Residents

Aaron

Webb

Luhanga

2020

Journal of Graduate Medical Education

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“…In the same study (27), the results of qualitative analysis of the residents' interviews after patient safety education showed that they mentioned that they had found it quite difficult to carry out the course content in practice, the information learned faded away after the course, and it would be helpful to organize refresher courses. In addition, barriers related to behavioral control like high work-pressure might be effective (28).…”

Section: Discussionmentioning

confidence: 94%

“…However, the incident reporting rate decreased from 34 per 100 admissions in the first month after the intervention to 16% in the sixth month in the follow-up phase. In a study (27) in the US, where 63 participants were included in an education program for IRS implementation, the numbers of events reported over the period of six months were 10 in the first month, 6 in the second month, 10 in the third month, 18 in the fourth month, 11 in the fifth month, and 6 in the sixth month. Which in total might be less than in the current study but given the different sites of the studies, as it wasn't in a PICU with all its complex health care disciplines, but was on a whole hospital, with its various departments, whether critical care or not.…”

Section: Discussionmentioning

confidence: 99%

Incident Reporting System in Pediatric Intensive Care Units of Cairo Tertiary Hospital: An Intervention Study

Labib

Elden

Hegazy

et al. 2019

Arch Pediatr Infect Dis

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Background: Incident reporting system (IRS) deepens the understanding of the frequency of adverse events and near misses. Voluntary reporting is an essential step to improve patient safety. Objectives: The study aimed to apply an efficient and reliable system for incident reporting to enhance patient safety practices in pediatric intensive care units (PICUs). Methods: A quasi-experimental pretest-posttest study design was conducted to implement a voluntary anonymous IRS in PICUs. In-depth interviews were conducted with 16 health care personnel. A tailored educational program was provided to 73 health care personnel. A questionnaire was administered before and three months after the intervention to assess their attitude towards incident reporting. Results: The interviewed health care providers highlighted that no IRS was established in the PICUs and most of them never reported any event unless it was a sentinel event. They agreed that an IRS would be beneficial to PICUs. The average percentage of positive responses for "Frequency of error reporting' increased significantly from 23.8% to 42%. Communication problems, hygienic errors, therapeutic errors, and diagnostic errors accounted for 34%, 32%, 29%, and 5% of the reported potential errors, respectively. Conclusions: IRS implementation improves potential error reporting attitude and practice in PICUs.

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“…Describing what could have happened and making suggestions to prevent similar events allowed students to take ownership for improving the healthcare system. This will prepare students for their roles as interns and residents ready to contribute to a culture of safety as mandated by the Accreditation Council for Graduate Medical Education and underscored in the Clinical Learning Environment Review Pathways to Excellence 14 15 37…”

Section: Discussionmentioning

confidence: 99%

“…Reporting can potentially be increased through patient safety education, culture change,12 13 highlighting the importance of medical error reporting,14 15 and teaching how to file incident reports. There is scant literature on what kinds of errors students see during clinical rotations and their reporting behaviours 9 10.…”

Section: Introductionmentioning

confidence: 99%

Teaching medical students to recognise and report errors

2019

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BackgroundMedical student error reporting can potentially be increased through patient safety education, culture change and by teaching students how to report errors. There is scant literature on what kinds of errors students see during clinical rotations. The authors developed an intervention to better understand what kinds of errors students see and to train them to identify and report errors.MethodsA safety curriculum was delivered during the Medicine clerkship for the academic year 2015–2016. Prior to the workshop, students completed a preintervention survey to determine whether they had reported a clinical error. Subsequently, they participated in an educational workshop. Facilitated discussions about conditions contributing to errors, types of errors, prevention of errors and importance of reporting followed. Students were required to submit a simulated error report about an error they personally observed. An end-of-year survey was sent to students who participated in the curriculum to determine clinical error reporting frequency.ResultsStudents submitted 282 reports. Near miss errors were seen in 64% and adverse events in 36%. National Quality Forum serious events were reported in 14%, including one death. Recommendations to prevent similar events were weak (62%). Students correctly categorised 93% near miss, 88% adverse events, 67% diagnostic, 81% treatment and 78% preventative errors. On the preintervention survey, 8.5% stated they submitted an error report to their clinical site. On the end-of-year survey, 18% confirmed submitting a formal error report.ConclusionTraining students to recognise and report errors can be successfully integrated into a clinical clerkship and impact clinical error reporting.

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Improving Incident Reporting Among Physician Trainees

Cited by 25 publications

References 11 publications

A Narrative Review of Strategies to Increase Patient Safety Event Reporting by Residents

A Narrative Review of Strategies to Increase Patient Safety Event Reporting by Residents

Incident Reporting System in Pediatric Intensive Care Units of Cairo Tertiary Hospital: An Intervention Study

Teaching medical students to recognise and report errors

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