Interventions to improve resident reporting of patient safety events: a quality improvement initiative

Mukul Singal; Manasi Godbole; Aneeqa Zafar; Nagesh Jadhav; Richard Alweis; Hiloni Bhavsar

doi:10.1080/20009666.2020.1799494

Interventions to improve resident reporting of patient safety events: a quality improvement initiative

J Community Hosp Intern Med Perspect. 2020 Sep 3;10(5):431-435. doi: 10.1080/20009666.2020.1799494.

Authors

Mukul Singal^{1

2}, Manasi Godbole², Aneeqa Zafar², Nagesh Jadhav¹, Richard Alweis^{3

4}, Hiloni Bhavsar¹

Affiliations

¹ Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA.
² Internal Medicine Residency Program, Unity Hospital, Rochester, NY, USA.
³ Department of Graduate Medical Education, Rochester Regional Health, Rochester, NY, USA.
⁴ Clinical Associate Professor of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.

Abstract

Background: Patient safety events (PSE) are opportunities to improve patient care but physicians rarely report them. In a previous study, residents identified knowledge regarding what constitutes a PSE, perceived lack of time, complexity of the reporting process, lack of feedback, and perceived failure to resolve the issue despite reporting to be barriers limiting their PSE reporting. The residency programs and system patient safety and quality improvement departments created targeted interventions to address identified barriers.

Objective: Assess effectiveness of targeted interventions on improving PSE reporting rates amongst residents.

Methods: As part of a multi-residency patient safety project, interventions were created to focus on the removal of barriers to reporting PSE identified previously. Post-interventions, an identical cross-sectional survey of the residents at the same two community teaching hospitals was conducted from Sept to Dec 2018 through an online questionnaire tool.

Results: 78 out of 149 residents (52.3%) completed the survey. We found a significant improvement in the number of residents who endorsed reporting a PSE in the past 1 year (51.2% vs 23.5%, p = 0.001), as well as during the course of their training (52.6% vs 26.5%, P = 0.001). There was also a significant decrease in the number of residents who were unsure of how to report a PSE (p = 0.031) as well as those who viewed medical error as a sign of incompetence (p = 0.036).

Conclusion: Our study demonstrates that simplifying the PSE reporting process, improving knowledge and acceptance of patient safety/quality improvement principles and promotion of a just culture improves resident PSE reporting.

Keywords: Patient safety; educational models; general hospitals; graduate medical education; residency; safety culture; voluntary patient safety event reporting.