An Improvement Approach to Integrate Teaching Teams in the Reporting of Safety Events

Area of Science:

• Healthcare Quality Improvement
• Patient Safety Research
• Medical Education

Background:

• Physician underreporting of patient safety events is a significant issue, with baseline data showing only 3% of reports submitted by physicians.
• Low physician reporting rates hinder comprehensive understanding and mitigation of patient safety risks.

Purpose of the Study:

• To increase the proportion of patient safety event reports submitted by physicians (residents and faculty) from 3% to 6% within nine months.
• To identify and implement effective interventions to enhance physician recognition and reporting of patient safety events.

Main Methods:

• Utilized the Model for Improvement framework with iterative Plan, Do, Study-Act (PDSA) cycles.
• Implemented targeted interventions: "patient safety rounds" via text message, an inpatient "superintendent" rotation, and a "QI on the Fly" faculty development program.
• Monitored the percentage of event reports entered by residents or faculty as the primary outcome measure.

Main Results:

• Achieved a sustained monthly average of 24% physician-reported events, a substantial increase from the baseline 3%.
• Resident reporting was the primary driver of the increase in physician-submitted safety events.
• The introduction of the "superintendent" rotation showed a temporal association with increased physician reporting, leading to a rise in total reported events.

Conclusions:

• Integrating patient safety responsibilities into existing teaching team workflows effectively increases physician safety event reporting.
• Further PDSA cycles are planned to scale this approach to other clinical settings.
• Future research will explore the impact of increased reporting on overall patient care outcomes.