Oral Themed Presentation
Context: : Children’s National Health System (CN) was the only children's hospital to be awarded an Accreditation Council on Graduate Medical Education (ACGME) Pursuing Excellence Grant in 2016. The ACGME’s Clinical Learning Environment Report (CLER) identified four themes for this initiative to: 1) align organizational and educational strategies 2) integrate quality, safety, equity and value into workflow 3) develop faculty expertise in quality and safety and 4) expand interprofessional learning. The challenge for each organization was to develop innovative methods to address these themes alongside their own organizational goals.
In 2015, the ACGME CLER specifically revealed that CN residents and nurses were reluctant in using the patient safety event reporting system due to concern about damaging their relationship with fellow staff members; some expressed a preference for addressing patient safety issues locally. Nearly all nurses interviewed were familiar with CN reporting system; however, many had never used it. Unsafe conditions, unexpected deteriorations, and recognized procedural complications were not commonly viewed as reportable events. There was some variability among resident and fellows in their understanding of patient safety concepts and terminology.
Description: : To address this, three online modules were developed focusing on types and reporting of safety events; apparent cause analysis (ACA), root cause analysis and action. Building on this theoretical knowledge, a one hour interprofessional simulation-based class was delivered to 1,000+ clinicians over six months. Participants underwent a simulated ACA followed by a simulated patient event; debriefing focused on teamwork and communication.
Observation/Evaluation: : All participants completed an evaluation at the conclusion of the class about behaviors and reactions. Participants were sent a follow up survey six weeks later to share reporting behaviors, which did not indicate an increase in event reporting (24% response rate). Time was the primary barrier identified followed by knowledge of how to correctly complete an event report and fear of reporting. Enablers to event reporting included leadership support and better understanding of safety culture. Clinicians requested a closed loop for those reporting events on systems improvements. Overall, a positive response to the training was received. Verbatim comments include:
‘Reporting safety events is a learning tool not punitive; we should always remain in a teachable mode’
‘given the importance of teamwork in everything we do, the in-person training really emphasized the need for that’
Discussion: : By ensuring that frontline clinicians have a basic understanding of safety event reporting and the ACA process, we anticipate increased staff engagement in event reporting. This innovation builds on an earlier project and further embeds key concepts such as communication, teamwork, and safety into our clinicians’ practice promoting patient safety.