Regions Hospital¹/HealthPartners Institute for Education and Research,² St. Paul, MN
“Good Catch” Safety Event Reporting

Abstract

Background: One of the 6 focus areas of the CLER program is patient safety, specifically patient error reporting. Teaching institutions need to ensure that residents have the opportunity to report errors, unsafe conditions, and near misses and then participate in safety event analysis, action plan development, and follow-up. Unfortunately, early reports from ACGME CLER visits have shown that many institutions fail to engage residents in this process. At the same time, residents may not be aware of why or how to report patient care errors. Even if they are aware, they may be hesitant to report errors for fear of retribution or because of time constraints.

Methods: We created a multidisciplinary work group involving key Regions Hospital leaders in nursing, quality improvement, patient safety, finance, informatics, GME, and residency programs. We integrated an event reporting system into our EMR. We presurveyed residents to obtain baseline levels of awareness, ease, and comfort with safety event reporting. We developed a 14-minute “Good Catch” event reporting video to explain the need to report, how to report, and what happens after errors are reported. The video was distributed to all 6 primary residency and fellowship programs at our institution and to all 17 affiliated programs. We postsurveyed residents after 3 months to assess their understanding of safety event reporting and to quantify how many times they had reported an event.

Results: Seven percent (8 of 112) of residents had reported an unexpected event at our institution prior to implementation compared with almost 13% after. Fifty-nine percent (66 of 112) were unsure if the reporting process was anonymous prior to implementation compared with 23% after. Seven percent of residents still didn't feel comfortable reporting unexpected events compared with 11% prior to implementation. Ninety-three percent of residents felt good about their ability to report an unexpected event after implementation compared with 41% prior. The most common reasons cited for not reporting were not knowing how to report, not wanting to take the time to report, and uncertainty regarding anonymity.

Conclusions: Resident physicians are more likely to report safety events after integration of reporting systems into the EMR and after being educated about why they need to report, how to report, and what happens after they report errors. Short, online instructional videos can be effective tools for educating residents about event reporting.