Increasing Trainee Reporting of Adverse Events With Monthly Trainee-Directed Review of Adverse Events

Smith, Alla; Hatoun, Jonathan; Moses, James

doi:10.1016/j.acap.2017.01.004

Cited by 10 publications

(14 citation statements)

References 23 publications

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“…22 Furthermore, consistent with our finding about training, participation in monthly quality or safety conferences in US hospitals has increased the reporting rate of trainees from 27.6% to 46.1%. 23 Second, the quantitative and qualitative analyses both revealed that deficient knowledge was a major practical barrier to reporting incidents. This was consistent with a previous study noting that despite staff being aware of a reporting system in their hospital, they did not know how to access an incident form or what to do with it once it was completed.…”

Section: Discussionmentioning

confidence: 99%

<p>Practical and Cultural Barriers to Reporting Incidents Among Health Workers in Indonesian Public Hospitals</p>

Dhamanti¹,

Leggat²,

Barraclough³

2020

JMDH

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This study investigated the practical and cultural barriers of reporting patient safety incidents in three accredited public hospitals in East Java, Indonesia. Methods: This study employed a mixed methods approach using a convergent parallel design. We surveyed 1121 health workers and interviewed 27 managerial staff members from the sampled hospitals. A chi-square analysis was performed to evaluate differences in demographic factors, barriers to reporting, and practices of reporting between those who had reported an incident and those who had witnessed an incident but had not reported it. NVivo 11 software was used to perform the qualitative data analysis. Results: This study had a 76.53% response rate. The quantitative evaluation identified significant differences in professions and work units and in participation in quality and safety training between the reporting group and the non-reporting group. The analysis of practical barriers displayed significant differences between the groups with the following responses: "did not know how to report," "did not know where to report," and "lack of feedback". For cultural barriers, a significant difference was shown only for the response "did not want conflict." In the qualitative assessment, most of the interview participants reported lack of knowledge and lack of socialization or training as practical barriers in reporting incidents. Furthermore, reluctance and fear to report were mentioned as cultural barriers by most of the interviewees. Conclusion: Because there were conflicting findings in the barriers of reporting incidents, these barriers must be identified, discussed, and resolved by health workers and their managers or supervisors to improve incident reporting. Managers must foster open communication and build positive connections with health workers. Further research is necessary to focus on possible ways of addressing the barriers to reporting.

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Section: Discussionmentioning

confidence: 99%

<p>Practical and Cultural Barriers to Reporting Incidents Among Health Workers in Indonesian Public Hospitals</p>

Dhamanti¹,

Leggat²,

Barraclough³

2020

JMDH

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“…Most educational programs were led by a team of faculty and residents; however, 2 articles (3%) described resident-led curricula. 59,63 Tevis and colleagues, 64 for example, developed an annual patient safety orientation of first-year students. The 4-hour event was developed by a multidisciplinary team, including faculty, residents, and experts in quality improvement and patient safety.…”

Section: Figurementioning

confidence: 99%

“…Discussions covered topics such as just culture, definitions of adverse events and near misses, the importance of reporting, instructions about how to submit event reports, and a summary of how reports are processed and how institutional processes are changed based on reports. 64 Smith et al 63 described how pediatric residents developed a curriculum and led a monthly conference during which they reviewed adverse event reports, identified system vulnerabilities, and designed solutions to address those vulnerabilities. As part of educational programming, morbidity and mortality conferences were used to increase trainee awareness about adverse events and the importance of reporting 31,34,53,57,63,74,[76][77][78][79] ; however, although there were calls for increased trainee participation in RCA), 19 only Murphy and colleagues 60 described an intervention using a mock RCA to increase trainee adverse event reporting, and only the study by Dunbar and colleagues 52 reported increased resident physician involvement in RCA as a result of their intervention.…”

Section: Figurementioning

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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“…Previous research suggests that formal safety education encourages reporting. 7,29 Our study illustrates that engaging administrators and patient safety staff in educational sessions provides psychological safety to residents and decreases power distance between reporters and administrators, both of which should increase reporting. 30,31 Providing feedback on reporting outcomes in this forum is simple to do and reinforces future reporting.…”

Section: Discussionmentioning

confidence: 76%

Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines

Szymusiak

Walk

Benson

et al. 2019

Pediatric Quality &Amp; Safety

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Increasing Trainee Reporting of Adverse Events With Monthly Trainee-Directed Review of Adverse Events

Cited by 10 publications

References 23 publications

<p>Practical and Cultural Barriers to Reporting Incidents Among Health Workers in Indonesian Public Hospitals</p>

<p>Practical and Cultural Barriers to Reporting Incidents Among Health Workers in Indonesian Public Hospitals</p>

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

Encouraging Resident Adverse Event Reporting: A Qualitative Study of Suggestions from the Front Lines

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