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Improving Adverse Patient Safety Event Reporting by Pediatric Residents
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ABSTRACTS
ACADEMIC PEDIATRICS Table 1. Number of Resident Reported Adverse Events per Month from Apr 2014 Aug 2015
collection, and those wait times were likely underestimated compared to post intervention data that used timestamps. Future cycles to sustain our improvement include the participation of ancillary staff as well as broadening our intervention to other resident clinic days. Additional proposed steps include implementation of radio frequency identification (RFID) cards to automate the ability of residents and staff to find attendings without the need to input data manually. 39. IMPROVING ADVERSE PATIENT SAFETY EVENT REPORTING BY PEDIATRIC RESIDENTS David Ashby, DO, Mehgan Teherani, MD, Amanda Kuch, MD, Angela Ibragimov, MD, Richard Engel, MD, Vasudha Bhavaraju, MD, Ann Beasley, MD, Ryan Bode, MD, Phoenix Children’s Hospital, Phoenix, AZ, Lilia Parra-Roide, MD, St. Joseph’s Hospital & Medical Center, Phoenix, AZ, Lindsey Query, MD, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI BACKGROUND: Reporting adverse events is fundamental in identifying patient safety vulnerabilities and improving the culture of safety. Resident house staff across the country under report witnessed adverse events leading to breeches in patient safety. The ACGME initiated CLER program is designed to provide feedback in 6 areas including patient safety. Patient Safety Pathway 1 mandates that residents know their role, responsibility and how to report patient safety events. Our 98 pediatric residents are on the front lines of care at Phoenix Children’s Hospital, but rarely reported patient safety events. AIM STATEMENT: To increase adverse event reporting by at least twenty five percent of house staff (twenty five resident reports) from 10/2014-3/2015. INTERVENTIONS: Cycle 1: Residents educated on adverse events and how to report. Cycle 2: Report data collected and reviewed with residents. Gifts were raffled for residents who submitted reports. Cycle 3: A laminated badge card with instructions on how to report events was created for residents. Cycle 4: Quality Department added a resident field to Event Report Form. Current: Creating a process to provide residents with outcome data and changes made as a result of their reports.
MEASURES: The number of adverse event reports filed by pediatric residents was tracked monthly. RESULTS: Resident adverse event reports increased from 0 per month to an average of 7.5 per month from 10/2014-8/ 2015 and a total of 50 reported events from 10/2014-3/2015 (see TABLE 1). CONCLUSIONS AND NEXT STEPS: Educating Pediatric Residents on their roles and responsibilities to report adverse safety events along with the process of filing reports led to a residency-wide change in the culture of reporting. These reports identified patient safety vulnerabilities and opportunities for change. Offering an incentive initially increased adverse safety event reporting; however, this is not required to create a sustainable event reporting process. Next Steps: 1. Residents will participate in clinical site patient safety investigations to help identify causes of events and institute systems-based changes. 2. Provide feedback to residents on select individual safety reports and system change outcomes. 3. Implement a similar QI project with Fellows and Attending Physicians. 40. IMPROVING ATTENDANCE RECORDING: ELECTRONIC BADGING VERSUS TRADITIONAL SIGN IN SHEET Drew T. Louden, MD, Jaime W. Peterson, MD, Valerie Gribben, MD, Stanford University, Michelle R. Brooks, Palo Alto, CA BACKGROUND: At Lucile Packard Childrens Hospital Stanford, pediatric residents used a traditional sign-in sheet to record attendance at Morning and Noon Conferences. Recorded attendance at these conferences was lower than expected and observed. Morning and Noon Conference average recorded attendance for the 2014-2015 academic year were 5.4 and 7.5, respectively. In addition, residency coordinators were spending significant time entering the data into Medhub for tracking purposes. AIM STATEMENT: Increase recorded conference attendance by 100% in 2015 during 3 month period when compared to the same time period in 2014. INTERVENTIONS: Chief Residents and Residency Coordinators at Stanford evaluated multiple different methods of recording attendance at conferences. Electronic badging was chosen for ease of use and compatibility with MedHub for direct uploading of attendance into MedHub. Each resident was given a specific Quick
ABSTRACTS
ACADEMIC PEDIATRICS Table 1. Number of Resident Reported Adverse Events per Month from Apr 2014 Aug 2015
collection, and those wait times were likely underestimated compared to post intervention data that used timestamps. Future cycles to sustain our improvement include the participation of ancillary staff as well as broadening our intervention to other resident clinic days. Additional proposed steps include implementation of radio frequency identification (RFID) cards to automate the ability of residents and staff to find attendings without the need to input data manually. 39. IMPROVING ADVERSE PATIENT SAFETY EVENT REPORTING BY PEDIATRIC RESIDENTS David Ashby, DO, Mehgan Teherani, MD, Amanda Kuch, MD, Angela Ibragimov, MD, Richard Engel, MD, Vasudha Bhavaraju, MD, Ann Beasley, MD, Ryan Bode, MD, Phoenix Children’s Hospital, Phoenix, AZ, Lilia Parra-Roide, MD, St. Joseph’s Hospital & Medical Center, Phoenix, AZ, Lindsey Query, MD, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI BACKGROUND: Reporting adverse events is fundamental in identifying patient safety vulnerabilities and improving the culture of safety. Resident house staff across the country under report witnessed adverse events leading to breeches in patient safety. The ACGME initiated CLER program is designed to provide feedback in 6 areas including patient safety. Patient Safety Pathway 1 mandates that residents know their role, responsibility and how to report patient safety events. Our 98 pediatric residents are on the front lines of care at Phoenix Children’s Hospital, but rarely reported patient safety events. AIM STATEMENT: To increase adverse event reporting by at least twenty five percent of house staff (twenty five resident reports) from 10/2014-3/2015. INTERVENTIONS: Cycle 1: Residents educated on adverse events and how to report. Cycle 2: Report data collected and reviewed with residents. Gifts were raffled for residents who submitted reports. Cycle 3: A laminated badge card with instructions on how to report events was created for residents. Cycle 4: Quality Department added a resident field to Event Report Form. Current: Creating a process to provide residents with outcome data and changes made as a result of their reports.
MEASURES: The number of adverse event reports filed by pediatric residents was tracked monthly. RESULTS: Resident adverse event reports increased from 0 per month to an average of 7.5 per month from 10/2014-8/ 2015 and a total of 50 reported events from 10/2014-3/2015 (see TABLE 1). CONCLUSIONS AND NEXT STEPS: Educating Pediatric Residents on their roles and responsibilities to report adverse safety events along with the process of filing reports led to a residency-wide change in the culture of reporting. These reports identified patient safety vulnerabilities and opportunities for change. Offering an incentive initially increased adverse safety event reporting; however, this is not required to create a sustainable event reporting process. Next Steps: 1. Residents will participate in clinical site patient safety investigations to help identify causes of events and institute systems-based changes. 2. Provide feedback to residents on select individual safety reports and system change outcomes. 3. Implement a similar QI project with Fellows and Attending Physicians. 40. IMPROVING ATTENDANCE RECORDING: ELECTRONIC BADGING VERSUS TRADITIONAL SIGN IN SHEET Drew T. Louden, MD, Jaime W. Peterson, MD, Valerie Gribben, MD, Stanford University, Michelle R. Brooks, Palo Alto, CA BACKGROUND: At Lucile Packard Childrens Hospital Stanford, pediatric residents used a traditional sign-in sheet to record attendance at Morning and Noon Conferences. Recorded attendance at these conferences was lower than expected and observed. Morning and Noon Conference average recorded attendance for the 2014-2015 academic year were 5.4 and 7.5, respectively. In addition, residency coordinators were spending significant time entering the data into Medhub for tracking purposes. AIM STATEMENT: Increase recorded conference attendance by 100% in 2015 during 3 month period when compared to the same time period in 2014. INTERVENTIONS: Chief Residents and Residency Coordinators at Stanford evaluated multiple different methods of recording attendance at conferences. Electronic badging was chosen for ease of use and compatibility with MedHub for direct uploading of attendance into MedHub. Each resident was given a specific Quick