APGO

Background: AHRQ culture of safety survey and ACGME CLER visit both evaluate resident participation in event reporting to enhance quality of care and promote a safe environment for patients and providers. At our institution, there were only 33 safety events reported amongst 770 trainees in 2014. Reporting by residents has been hindered by fear of retaliation, inconvenience, uncertainty about which events merit reporting, and lack of follow-up.

Methods: All residents were instructed on three available mechanisms for reporting: a desktop icon, voicemail hotline, and online reporting. Staff and residents were coached about types of events that merit reporting. A financial incentive program was initiated by the institutional GME office to encourage residents to meet a goal.  Outcomes of reports were reviewed at a feedback session.

Results: Among Ob/GYN trainees, there were 65 events reported during a 9-month period in 2015-2016, an increase from a mean of 0 to 7 events per month.  Most events were submitted through the voicemail hotline; residents confirm that the ease of use promoted reporting.  Our trainees met reporting goals and received the financial incentive.  The majority of incidents involved communication errors and equipment shortages, prompting further investigations and action to avoid recurrent events.

Discussions: Increasing resident involvement in quality and safety improvement enhances patient care. Providing an incentive and a convenient way to report patient safety events successfully increased the frequency reporting by Ob/GYN trainees.  Discussing incident follow-up was considered valuable in identifying areas for future quality improvement projects.  

Keywords: Curriculum Development/Evaluation, Healthcare Systems, Interprofessional, Patient Safety/Medical Errors