Alla Smith1, Jonathan Hatoun2, James Moses3. 1. Boston Children's Hospital, Boston, Mass. Electronic address: alla.smith@childrens.harvard.edu. 2. Boston Children's Hospital, Boston, Mass. 3. Quality and Patient Safety Department, Boston Medical Center, Boston, Mass.
Abstract
OBJECTIVE: Underreporting of adverse events by physicians is a barrier to improving patient safety. In an effort to increase resident and medical student (hereafter "trainee") reporting of adverse events, trainees developed and led a monthly conference during which they reviewed adverse event reports (AERs), identified system vulnerabilities, and designed solutions to those vulnerabilities. METHODS: Monthly conferences over the 22-month study period were led by pediatric trainees and attended by fellow trainees, departmental leadership, and members of the hospital's quality improvement team. Trainees selected which AERs to review, with a focus on common near misses. Discussions were directed toward the development of potential solutions to issues identified in the reports. Trainee submissions of AERs were tracked monthly. RESULTS: The mean number of AERs submitted by trainees increased from 6.7 per month during the baseline period to 14.1 during the study period (P < .001). The average percent of reports submitted by trainees increased from a baseline of 27.6% to 46.1% during the study period (P = .0059). There was no significant increase in reporting by any other group (attending, nursing, or pharmacy). Multiple meaningful solutions to identified system vulnerabilities were developed with trainee input. CONCLUSIONS: Trainee-led monthly adverse event review conferences sustainably increased trainee reporting of adverse events. These conferences had the additional benefit of having trainees use their unique perspective as frontline providers to identify important system vulnerabilities and develop innovative solutions.
OBJECTIVE: Underreporting of adverse events by physicians is a barrier to improving patient safety. In an effort to increase resident and medical student (hereafter "trainee") reporting of adverse events, trainees developed and led a monthly conference during which they reviewed adverse event reports (AERs), identified system vulnerabilities, and designed solutions to those vulnerabilities. METHODS: Monthly conferences over the 22-month study period were led by pediatric trainees and attended by fellow trainees, departmental leadership, and members of the hospital's quality improvement team. Trainees selected which AERs to review, with a focus on common near misses. Discussions were directed toward the development of potential solutions to issues identified in the reports. Trainee submissions of AERs were tracked monthly. RESULTS: The mean number of AERs submitted by trainees increased from 6.7 per month during the baseline period to 14.1 during the study period (P < .001). The average percent of reports submitted by trainees increased from a baseline of 27.6% to 46.1% during the study period (P = .0059). There was no significant increase in reporting by any other group (attending, nursing, or pharmacy). Multiple meaningful solutions to identified system vulnerabilities were developed with trainee input. CONCLUSIONS: Trainee-led monthly adverse event review conferences sustainably increased trainee reporting of adverse events. These conferences had the additional benefit of having trainees use their unique perspective as frontline providers to identify important system vulnerabilities and develop innovative solutions.
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
Authors: Beate Sigrid Müller; Martin Beyer; Tatjana Blazejewski; Dania Gruber; Hardy Müller; Ferdinand Michael Gerlach Journal: BMJ Open Qual Date: 2019-08-19