Lastly, resident and fellow physician education curricula were developed to instruct on the need to report patient safety events. Time is allotted at every monthly resident business meeting to discuss reportable patient safety events and offer feedback about concerns. In addition, the director of patient safety sends weekly safety updates, which are emailed to all faculty, residents, and fellows. These include de-identified safety event reports and any organizational and system improvements made in response to these events. Additionally, a mock root analysis takes place each quarter in which the patient safety director reviews a mock case with trainees to identify root causes and system failures. The committee has committed to transparency of reporting patient safety events as means to track the results of our efforts and interventions [17].
We plan to resurvey the resident and fellow physicians to reassess stability or changes in attitudes as a result of these physician-focused improvements. A more systematic analysis of temporal trends in reporting and comparisons across residency programs within our health system is being designed.
Conclusion
Reporting patient safety events should not be seen as a cumbersome task in an already busy clinical workday. We intend to develop scalable solutions that take into account the challenges faced by physicians in training. As the institution strives to become a high-reliability organization with a goal of zero serious patient safety events by 2020, we hope to share the lessons from our quality improvement efforts with other learning organizations.
Acknowledgements: The authors thank Suela Sulo, PhD, for manuscript review and editing.
Corresponding author: Jill Patton, DO, Advocate Lutheran General Hospital, 1775 Dempster St., Park Ridge, IL 60068, jill.patton@advocatehealth.com.
Financial disclosures: None.