Increasing Resident Engagement and Reporting of Adverse Events

Michelle Bejar, MD, MPH Department of Family Medicine Mount Sinai Beth Israel [email protected]

Michael R. Berman, MD, MBI Department of Quality and Patient Safety Mount Sinai Beth Israel [email protected]

Background and Rationale

• Physicians have low reporting rates - less than 2% of total adverse event reports nationally.1

• At the Mount Sinai Hospital, there were 10,277 patient safety event reports in the 2017 calendar year. Residents submitted 269 (2.6%) of those reports.2

• Residents are on the frontline of patient care to ‘catch’ adverse events.

• Joint Commission and Accreditation Council for Graduate Medical Education (ACGME) strongly emphasizes “reporting, investigation, and follow-up of adverse events, near misses, and unsafe conditions as pivotal mechanisms for improving patient safety, and are essential for the success of any patient safety program.”3

• ACGME recommends that residents “know their responsibilities in reporting patient safety events and know how to report patient safety events, including near misses, at the clinical site.”3

• Educational interventions have shown to be effective in increasing reporting rates.4,5

Setting

• Mount Sinai Beth Israel Hospital, New York, NY

• December 2017- March 2018

• Participants: Residents from different training programs – Internal Medicine, Psychiatry, Emergency Medicine, Neurology, Surgery Goals

• Address barriers to residents reporting adverse events – specifically, awareness of how to report and reducing time needed to report

• Increase resident engagement in reporting adverse events at the hospital Methodology • Survey of resident reported barriers to reporting adverse events

• Created an online electronic reporting system, ESTER© (Enhancing Safety Through Engagement and Reporting)

• ESTER© is hyperlinked to the hospital’s home webpage where residents can fill out a simple form to report adverse events

• Housestaff encouraged to use ESTER© through emails, demos and flyers in workroom

• Website was presented to different groups of residents, highlighting different features of the portal and emphasizing its non-punitive, accessible and responsive design

Resident Survey of Adverse Event Reporting

Survey Response Rate of 79/323 (24%) Survey of Resident Reported Barriers Introducing ESTER©

• Housestaff was encouraged to use ESTER© through emails, demos and flyers in workroom

• Website was presented to different groups of residents, highlighting different features of the portal and emphasizing its non-punitive, accessible and responsive design

• Established relationships with Chief Residents to encourage them to engage their program’s residents in using ESTER Resident Reporting at Mount Sinai Hospital vs. Mount Sinai Beth Israel from Dec 2017- March 2018

Survey Comparison

Pre-Intervention Post-Intervention Survey Comparison

Pre-Intervention Post-Intervention Discussion • Creating a simple, resident-centered system, and educating residents on how to use it can engage residents in reporting adverse events • Meeting with residents and presenting the ESTER© demo was productive to show all of the website’s features in person and receive instant feedback • Increased resident reporting compared to Mount Sinai Hospital during the same time period • Emergency Medicine department had highest participation in ESTER© usage • Most commonly reported errors were related to transitions of care and communication • More residents knew how to report events after intervention

Example Events Reported

• Stat lab tests delayed

• Mistriaged patient in Emergency Room

• Lack of overhead paging in Emergency Department Limitations

● Created brand new reporting website

● Unable to track resident reports from QI hotline at Mount Sinai Beth Israel for comparison

● Small team

● Feedback system not fully in place

● Family Medicine Residency transferred to Mount Sinai Hospital prior to intervention

Directions for Future Work

● Improving Feedback System

● Incoming intern intervention

● Longitudinal continued education