Implementation of an Orthopedic Trauma Program to Safely Promote Resident Autonomy

There is ongoing tension in graduate medical education between progressive resident autonomy with entrustable professional activities and the need for supervision to ensure patient safety.

We implemented a pediatric orthopedic surgical trauma safety program that utilized a postcall review conference to provide residents graduated responsibility learning opportunities during overnight trauma call without compromising patient safety.

In the program, all orthopedic trauma cases seen in our main tertiary hospital emergency department by the overnight orthopedic resident were reviewed in a case conference. For 1 year, we performed an analysis of all fracture patients who were treated in the emergency department by our orthopedic surgery residents. From June 1, 2016, through June 30, 2017, all care delivery encounters were reviewed for decision-making errors, technical errors, and complication rates. Two resident groups rotated through our institution over the course of the study.

During the year of analysis, all 1298 fracture patients seen overnight in the main tertiary hospital emergency department were reviewed. From the first to the second halves of their rotations, the rate of resident decision-making errors (3.1% [12 of 385] to 2.3% [9 of 399]) and technical errors (9.1% [35 of 395] to 7.3% [29 of 399]) decreased. Excluding decision-making and technical errors, the complication rate for patients discharged home was 3.4% (27 of 784).

Residents demonstrated decreased decision-making and technical error rates on overnight call while maintaining low complication rates.