Mona Krouss1, Jumana Alshaikh1, Lindsay Croft2, Daniel J Morgan2,3. 1. From the University of Maryland Medical Center. 2. Department of Epidemiology and Public Health, University of Maryland School of Medicine. 3. VA Maryland Healthcare System, Baltimore, Maryland.
Abstract
BACKGROUND: Preventable medical harm is a leading cause of death in the United States. Incident reporting systems have been identified as the primary method to capture medical error and harm. Incidents are rarely reported, particularly among physician trainees. METHODS: We conducted a single-center, quasi-experimental study to examine the effect of education on the importance of and how to file an incident report for physician trainees on reporting rates. Trainees were provided laminated plastic instructions, and reporting was reinforced with weekly patient safety rounds. In addition, trainees completed anonymous surveys preintervention and postintervention to determine barriers to reporting. A χ test compared the number of reports preintervention and postintervention. RESULTS: For 6 months, 73 resident physicians participated in the study. Median incident reports entered by trainees increased from 1 report per month during the preintervention period to 10 reports per month after the intervention (P = 0.005). The most common barriers to reporting incidents before intervention were not knowing how to report (72.6%), what to report (56.2%), and lack of time (42.5%). A total of 13.7% reported fear of retaliation. Most incident reports were due to delay in patient care (40.9%) and medical errors (33.3%). CONCLUSIONS: Real-time education and regular reinforcement increased incident reporting among resident physicians. This educational approach may increase incidence reporting in other institutions.
BACKGROUND: Preventable medical harm is a leading cause of death in the United States. Incident reporting systems have been identified as the primary method to capture medical error and harm. Incidents are rarely reported, particularly among physician trainees. METHODS: We conducted a single-center, quasi-experimental study to examine the effect of education on the importance of and how to file an incident report for physician trainees on reporting rates. Trainees were provided laminated plastic instructions, and reporting was reinforced with weekly patient safety rounds. In addition, trainees completed anonymous surveys preintervention and postintervention to determine barriers to reporting. A χ test compared the number of reports preintervention and postintervention. RESULTS: For 6 months, 73 resident physicians participated in the study. Median incident reports entered by trainees increased from 1 report per month during the preintervention period to 10 reports per month after the intervention (P = 0.005). The most common barriers to reporting incidents before intervention were not knowing how to report (72.6%), what to report (56.2%), and lack of time (42.5%). A total of 13.7% reported fear of retaliation. Most incident reports were due to delay in patient care (40.9%) and medical errors (33.3%). CONCLUSIONS: Real-time education and regular reinforcement increased incident reporting among resident physicians. This educational approach may increase incidence reporting in other institutions.
Authors: Johanna I Westbrook; Ling Li; Elin C Lehnbom; Melissa T Baysari; Jeffrey Braithwaite; Rosemary Burke; Chris Conn; Richard O Day Journal: Int J Qual Health Care Date: 2015-01-12 Impact factor: 2.038
Authors: John Szymusiak; Thomas J Walk; Maggie Benson; Megan Hamm; Susan Zickmund; Alda Maria Gonzaga; Gregory M Bump Journal: Pediatr Qual Saf Date: 2019-04-12