TriHealth, Cincinnati, OH
Improving Patient Safety Event Reporting Among Residents and Teaching Faculty

Abstract

Background: A June 2012 site visit report from the ACGME CLER revealed residents' and physicians' lack of awareness and understanding of the hospital's system for reporting patient safety concerns in 3 areas: (1) what constitutes a reportable patient safety event, (2) who responsible for reporting, and (3) the current reporting system.

Methods: We conducted a quality improvement study consisting of an educational program (intervention) focusing on the importance of event reporting and a pre/post educational survey to measure attitudes, knowledge, and self-reported behaviors. Following the implementation of a new patient safety event reporting system, we compared the reported events with baseline data to determine improvement in reporting. Subjects included residents and teaching faculty from the internal medicine/family medicine, general surgery, Ob/Gyn-urogynecology, and vascular surgery GME programs.

Results: Among 105 residents, the response rate was 56%–92% for the preintervention survey and 68%–100% for the postintervention survey. Among 78 teaching faculty, the response rate was 43%–67% for the preintervention survey and 33%–92% for the postintervention survey. The majority of respondents agreed that as a healthcare provider, they will be responsible for a medical error at some point, and to improve patient safety, serious events should be reported to hospital administration. Of all respondents, 62% did not have medical error report training in their medical schools; 71% had never used the online error event reporting system in our healthcare organization; 33% indicated that they did not receive education/training on how to disclose medical errors to hospital administration, and 76% indicated that they will likely report medical errors. Most important, the number of reported patient safety events increased. The preintervention average was 1.5 events, while the postintervention average was 4.6 events.

Conclusions: Immediately after the intervention, we achieved an approximately 5-fold increase in the number of reported events by residents and teaching faculty. The educational intervention improved knowledge of which incidents or errors to report. Also, after the intervention, in 3 of the 4 residency programs, more residents responded that they would report an error even if their colleagues or attending physicians disagreed.