An Assessment of an Educational Intervention on Resident Physician Attitudes, Knowledge and Skills Related to Adverse Event Reporting
Transparency can be the “Trojan Horse” for Cultural Transformation: Assessment of an Educational Intervention on Resident Physician Attitudes, Knowledge and Skills Related to Patient Safety Event Reporting David Mayer, MD 1,2,4 , Timothy McDonald, MD, JD 1,2,3,4,5 , Barbara G. Jericho, MD 1,2 , Rosalie F. Tassone, MD, MPH 1,2 , Jennifer Clary, MUPP 2 , Crescent Turner, RN, MS 3 ,Michael Sikora, MD 1 , 1 University of Illinois College of Medicine at Chicago Department of Anesthesiology, 2 University of Illinois College of Medicine at Chicago, 3 Safety and Risk Management, University of Illinois at Chicago Medical Center, 4 University of Illinois at Chicago Institute for Patient Safety Excellence, 5 University of Illinois College of Medicine at Chicago Department of Pediatrics Introduction: Reporting and learning from patient safety events (adverse events, near misses and unsafe conditions) and the open and honest communications that can follow are critical to improving patient safety. Programs that engage residents in patient safety event reporting can address all six competencies of the Accreditation Council for Graduate Medical Education. However, fewer than 60% of physicians know how to report adverse events and near misses, and fewer than 40% know what to report 1 . Furthermore, only 31% of residents receive instruction in error disclosure techniques 2 . We aimed to evaluate attitudes, knowledge and skills of anesthesiology residents before and after an educational intervention focused on our “Seven Pillars” comprehensive response to patient safety events. Methods: In a prospective assessor study, anesthesiology residents participated in a training program (intervention) focused on the importance of safety event reporting in patient safety and reporting methods. The educational intervention consisted of a workshop highlighting the importance of safety event reporting in patient safety and the reporting methods used. Quarterly patient safety event reports were analyzed retrospectively for the 2 years prior to the intervention and then prospectively on a quarterly basis. The residents also completed a survey prior to and one year after the intervention. Results: The number of patient safety event reports increased from 0 per quarter in the 2 years pre-intervention to almost 30 per quarter for the 7 quarters post-intervention (see figure to left) . We identified several categories of harm events, near misses, and unsafe conditions, including 19 incidents related to medications, 12 incidents associated with patient transport, and 17 incidents involving invasive procedures. Nine (over half) of the harm events linked to invasive procedures were associated with lack of adequate attending supervision. Comparison of the pre- and post- intervention surveys revealed decreased fear among residents of litigation or disciplinary action after reporting of incidents. The residents also perceived improved support from colleagues and the hospital system in response to adverse events. Furthermore, survey participants reported improved ability to discern which events were appropriate for reporting (see table to left) . Conclusions: An educational intervention increased the number of patient safety event reports by anesthesiology residents, improved their attitudes about the importance of reporting, and produced a source for learning opportunities related to process improvements and open and honest communication in the delivery of care. <ul><li>Kaldjian, LC, Jones EW, WuBJ, Forman-Hoffman VL, Levi BH, Rosenthal GE. Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Arch Intern Med. 2008; 168(1):40-60. </li></ul><ul><li>White AA, Gallagher TH, Krauss MJ, Garbutt J, Waterman Azd, Dunagan WC, Fraser VJ, Levinson W, Larson EB. The attitudes and experiences of trainees regarding disclosing medical errors to patients. Academic Medicine 2008; 83(3): 250-255. </li></ul>Start of occurrence reporting system Anesthesia resident survey and educational intervention Comparison of Pre-intervention and Post-intervention Surveys N Mean SD p value* I don’t report incidents because I am worried about disciplinary action Pre Post 51 45 2.37 1.93 1.131 0.963 0.045 I don’t report incidents because I am worried about litigation Pre Post 51 45 2.49 1.98 1.046 0.812 0.009 I don’t report incidents because my colleagues may be unsupportive Pre Post 51 45 2.73 2.07 1.218 0.963 0.004 I don’t report incidents because I do not know which incidents should be reported Pre Post 50 45 3.14 2.53 1.125 1.120 0.010 Current systems for health care providers to report patient safety problems are adequate Pre Post 50 45 3.24 3.82 1.205 0.684 0.005 Hospitals and health care organizations adequately support providers in coping with stress Pre Post 49 45 2.67 3.22 1.265 1.085 0.027 Pre = response to survey prior to educational intervention All questions answered with following five point scale Post = response to survey after educational intervention 1 = Strongly disagree 2 = Disagree * ANOVA analysis used to compare pre and post 3 = Neither agree nor disagree Intervention data; p <0.05 considered significant; 4 = Agree 5 = Strongly agree
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