Beaumont Health System, Royal Oak, MI
Promoting Medical Error Reporting by Residents

Abstract

Background: We sought to increase resident/fellow involvement in patient safety and healthcare quality improvement initiatives by identifying and reporting opportunities for improvement. We wanted to enhance residents' attention to quality and safety lapses, whether resulting in patient harm or near misses, and to promote collaboration between GME and patient safety/quality improvement personnel.

Methods: The quality improvement team met with all 40 residency and fellowship programs individually to educate them regarding the patient safety/quality improvement reporting process and incident follow-up. Every resident/fellow in each program was then requested to identify a perceived patient safety concern and complete a patient safety/quality improvement report. Patient safety/quality improvement staff reviewed all submitted reports and provided feedback 1 month later at resident meetings.

Results: Prior to the beginning of the educational sessions in January 2014, only 6 patient safety/quality improvement reports were completed by residents and fellows from January–June 2013, and 8 reports were completed from July–December 2013. However, in the January–June 2014 time frame, 55 reports were completed, and the number increased to 117 in the July–December 2014 time frame. The educational intervention yielded a 12-fold increase in medical error reports submitted by residents.

Conclusions: This project encouraged discussion about medical error reporting and resulted in more involvement by residents in quality committees. Also, in cooperation with the quality improvement team, changes were made to the online patient safety/quality improvement reporting form to include an optional data field identifying the status of the individual submitting the report (resident, nurse, etc) so even when reporting anonymously, residents can be identified as residents.