Creating a Culture of Physician Event Reporting Through Resident Physician Education and Engagement
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Department of Internal Medicine, Saint Louis University, Saint Louis, MO, USA; 2HealthFirst Bluegrass, Lexington, KY, USA; 3Department of Internal Medicine, Medical College of Wisconsin, Wauwatosa, WI, USA; 4Clement J. Zablocki VAMC, Milwaukee, WI, USA.
J Gen Intern Med DOI: 10.1007/s11606-019-05371-2 © Society of General Internal Medicine 2019
(3) reporting demonstrations, and (4) feedback on reported events.
Data Collection and Analysis BACKGROUND
Adverse event (AE) reporting is an essential part of patient safety. However, physicians are very unlikely to report. The literature suggests that an institutional culture that embraces safety and quality is essential to supporting physician event reporting.1, 2 Additionally, reporting increases when physicians receive feedback on the actions that are taken as a result of their error reports.3 This project sought to increase reporting among internal medicine residents.
We used surveys to collect pre-post knowledge, attitudes, beliefs about barriers to reporting, and VA-specific reporting behavior from the entire residency program. We also used very brief monthly surveys of residents rotating at the VA to assess knowledge of the reporting system and whether or not they reported an event. We used two-tailed chi-square tests (P < 0.05) to analyze our data.
RESULTS METHODS
Study Design This study occurred between September 2015 and March 2016 and was designed with four 1-month-long plan-do-study-act (PDSA) cycles, each introducing a new intervention.4 We continued each intervention in subsequent cycles. While each intervention was tentatively planned at the start of the project, we analyzed the results of each set of short surveys to determine if we needed further interventions, no further need if 2 months of statistically significant changes occurred in at least two questions. Two 1-month-long sustain and spread cycles were completed after the fourth PDSA cycle. This study was deemed an exempt QI project.
Participants/Setting Participants included all house staff rotating on an internal medicine service at the Milwaukee Veterans Administration Hospital (VA) during the study period.
Interventions We implemented four interventions (Table 1) including (1) presentation at the program’s weekly didactic session, (2) informal event reporting discussions led by chief residents, Received May 28, 2019 Revised July 16, 2019 Accepted September 12, 2019
A total of 96 (response rate 77%) and 91 (response rate 73%) residents completed the pre and post surveys, respectively. The monthly survey results as well as the pre/post-project survey results can be seen in Table 2. The number of residents who reported filing an event report statistically significantly increased for both near misses and adverse events in the prepost analysis. The number of residents witnessing both event types was not statistically significantly different.
DISCUSSION
We demonstrated increased self-reported filing of patient safety events at the VA. We also saw increased resident physician knowledge of the
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