A Multicentered Academic Medical Center Experience of a Simulated Root Cause Analysis (RCA) for Hematology/Oncology Fell
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A Multicentered Academic Medical Center Experience of a Simulated Root Cause Analysis (RCA) for Hematology/Oncology Fellows Danielle Wallace 1
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& Denise Cochran & Jennifer Duff & Julia Close & Martina Murphy & Andrea Baran & Arpan Patel
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Accepted: 11 October 2020 # American Association for Cancer Education 2020
Abstract Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Interprofessional clinical patient safety activities, such as root cause analyses (RCA), can be challenging to incorporate into busy schedules. We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. The 2-h module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/ contributing factor statements and proposed a solution. Twenty-three fellows from two institutions completed the experience. There was a significant difference in fellow reported comfort with participating in a live RCA (p = 0.03), and in utilizing the tools of an RCA following the mock RCA experience (p = 0.005). About 70% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event and were more likely to be thorough in their documentation. Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hematology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills. Keywords Graduate medical education . Root cause analysis . Simulation . Quality improvement
Introduction Healthcare quality improvement (QI) initiatives are increasingly implemented as a means to improve the quality of patient care and decrease the occurrence of avoidable outcomes.
* Danielle Wallace [email protected] 1
James P Wilmot Cancer Institute, Division of Hematology/ Oncology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14620, USA
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Patient Safety and Quality North Florida/South Georgia Malcom Randall VA, 1601 SW Archer Road, Gainesville, FL 32608, USA
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Hematology & Oncology, Department of Medicine, University of Florida, 1515 SW Archer Road, Gainesville, FL 32608, USA
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Designated Institutional Official, University of Florida/ South Georgia Malcom Randall VA, 1535 Gale Lemerand Drive, Gainesville, FL 32610-3008, USA
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Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14620, USA
Noting the importance of training physicians to meet this need, the
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