Abstract
Objective
Underreporting of adverse events by physicians is a barrier to improving patient safety.
In an effort to increase resident and medical student (hereafter “trainee”) reporting
of adverse events, trainees developed and led a monthly conference during which they
reviewed adverse event reports (AERs), identified system vulnerabilities, and designed
solutions to those vulnerabilities.
Methods
Monthly conferences over the 22-month study period were led by pediatric trainees
and attended by fellow trainees, departmental leadership, and members of the hospital's
quality improvement team. Trainees selected which AERs to review, with a focus on
common near misses. Discussions were directed toward the development of potential
solutions to issues identified in the reports. Trainee submissions of AERs were tracked
monthly.
Results
The mean number of AERs submitted by trainees increased from 6.7 per month during
the baseline period to 14.1 during the study period (P < .001). The average percent of reports submitted by trainees increased from a baseline
of 27.6% to 46.1% during the study period (P = .0059). There was no significant increase in reporting by any other group (attending,
nursing, or pharmacy). Multiple meaningful solutions to identified system vulnerabilities
were developed with trainee input.
Conclusions
Trainee-led monthly adverse event review conferences sustainably increased trainee
reporting of adverse events. These conferences had the additional benefit of having
trainees use their unique perspective as frontline providers to identify important
system vulnerabilities and develop innovative solutions.
Keywords
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Article info
Publication history
Published online: January 16, 2017
Accepted:
January 7,
2017
Received:
May 16,
2016
Footnotes
Conflict of Interest: The authors declare that they have no conflict of interest.
Identification
Copyright
© 2017 by Academic Pediatric Association
