Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care.

Katherine Ralston; Samantha Eve Smith; Joanne Kerins; Saskia Clark-Stewart; Victoria R. Tallentire

Study

Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care.

March 20, 2024

Ralston K, Smith SE, Kerins J, et al. BMJ Open Qual. 2024;13(1):e002641.

View more articles from the same authors.

Understanding medical trainees’ experiences with medical errors can offer important learning opportunities. This qualitative study examined 221 patient safety incidents experienced by physician trainees in the United Kingdom. The researchers concluded that incidents could generally be attributed to one of four factors – individual skills, collaboration (e.g., communication, trust), organizational systems, or the training environment – and identified safety-related interventions to improve care.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Systematic review of clinical debriefing tools: attributes and evidence for use.

April 19, 2023

Exploring error in team-based acute care scenarios: an observational study from the United Kingdom.

June 6, 2012

Understanding the behaviour of newly qualified doctors in acute care contexts.

November 2, 2011

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

The contribution of prescription chart design and familiarity to prescribing error: a prospective, randomised, cross-over study.

October 9, 2013

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

September 29, 2010

Engaging patients in medication reconciliation via a patient portal following hospital discharge.

October 2, 2013

Changes in prevalence of health care-associated infections in U.S. hospitals.

November 14, 2018

Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems.

November 29, 2023

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Targeted versus universal decolonization to prevent ICU infection.

May 1, 2013

Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness.

March 4, 2020

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Using social and behavioural science to support COVID-19 pandemic response.

June 3, 2020

Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes.

February 22, 2017

Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).

December 3, 2014

Implementing the Comprehensive Unit-Based Safety Program (CUSP) to improve patient safety in an academic primary care practice.

October 18, 2017

Doctors' stress responses and poor communication performance in simulated bad-news consultations.

December 9, 2009

Why it is so hard to talk about overuse in pediatrics and why it matters.

August 30, 2017

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study.

March 24, 2010

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

July 2, 2014

Interruptions during the delivery of high-risk medications.

June 2, 2010

Nurses' communication of safety events to nursing home residents and families.

November 15, 2017

Developing and implementing a standardized process for Global Trigger Tool application across a large health system.

July 10, 2013

SAFER Care: improving caregiver comprehension of discharge instructions.

March 31, 2021

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

October 16, 2019

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

February 15, 2023

Accuracy in patient understanding of common medical phrases.

December 21, 2022

Pediatric ADHD medication exposures reported to US poison control centers.

June 6, 2018

Assessment of physician sleep and wellness, burnout, and clinically significant medical errors.

January 13, 2021

Automated communication tools and computer-based medication reconciliation to decrease hospital discharge medication errors.

April 8, 2015

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

New solutions to reduce wrong route medication errors.

December 13, 2017

Lessons learned from a systems approach to engaging patients and families in patient safety transformation.

February 12, 2020

Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting.

April 8, 2020

Learning from latent safety threats identified during simulation to improve patient safety.

October 11, 2023

Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human.'

August 12, 2015

The impact of patient–physician alliance on trust following an adverse event.

April 10, 2019

One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety.

November 15, 2017

Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety.

July 19, 2023

Pharmacy e-prescription dispensing before and after CancelRx implementation.

September 20, 2023

American College of Surgeons' Committee on Trauma performance improvement and patient safety program: maximal impact in a mature trauma center.

December 14, 2011

A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events.

November 15, 2017

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship.

June 15, 2016

Crossing to safety: transforming healthcare organizations for patient safety.

April 15, 2005

Strategies to reduce errors associated with 2-component vaccines.

December 2, 2020

Racial and ethnic differences in the experience and treatment of noncancer pain.

May 30, 2019

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

October 5, 2022

Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures.

February 13, 2019

Guideline for opioid therapy and chronic noncancer pain.

May 31, 2017

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.

December 7, 2022

Variation in medication information for elderly patients during initial interventions by emergency department physicians.

January 16, 2008

EACTS guidelines for the use of patient safety checklists.

March 29, 2012

Omissions of care in nursing homes: a uniform definition for research and quality improvement.

November 18, 2020

Vital signs: maternity care experiences — United States, April 2023.

September 6, 2023

Patient safety in inpatient psychiatry: a remaining frontier for health policy.

January 9, 2019

Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial.

March 18, 2015

Trends and patterns in reporting of patient safety situations in transplantation.

February 10, 2016

Excess cost and length of stay associated with voluntary patient safety event reports in hospitals.

January 28, 2009

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study.

December 19, 2018

Testimonial injustice: linguistic bias in the medical records of black patients and women.

June 6, 2021

Time out—charting a path for improving performance measurement.

April 25, 2018

Sins of omission. Getting too little medical care may be the greatest threat to patient safety.

July 6, 2005

Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample.

March 6, 2005

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Association of clinical nursing work environment with quality and safety in maternity care in the United States.

November 11, 2020

Resident fatigue: is there a patient safety issue?

January 6, 2010

Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months.

February 2, 2011

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

June 8, 2011

A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system.

November 14, 2012

Medical emergency team calls in the radiology department: patient characteristics and outcomes.

March 14, 2012

Hospital testing of the effectiveness of co-designed educational materials to improve patient and visitor knowledge and confidence in reporting patient deterioration.

February 14, 2024

ASHP Guidelines on Preventing Diversion of Controlled Substances.

December 14, 2022

Computer based medication error reporting: insights and implications.

June 21, 2006

Decreasing errors in pediatric continuous intravenous infusions.

May 24, 2006

Reconciling medications at admission: safe practice recommendations and implementation strategies.

January 11, 2006

Prescribing errors in a pediatric emergency department.

March 5, 2008

American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology.

December 7, 2005

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

March 6, 2005

Parent participation in morbidity and mortality review: parent and physician perspectives.

June 22, 2022

American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards.

February 10, 2010

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center.

August 12, 2020

Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington.

June 10, 2020

Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center.

December 2, 2009

National trends in patient safety for four common conditions, 2005–2011.

January 29, 2014

Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.

October 3, 2018

Description and factors associated with missed nursing care in an acute care community hospital.

October 17, 2018

Improving sepsis care through systems change: the impact of a medical emergency team.

March 5, 2008

Opportunities for diagnostic improvement among pediatric hospital readmissions.

June 28, 2023

Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.

November 25, 2015

Top 10 patient safety issues: what more can we do?

June 19, 2013

Priority patient safety issues identified by perioperative nurses.

May 8, 2013

What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up.

November 22, 2017

Medical error disclosure among pediatricians: choosing carefully what we might say to parents.

October 15, 2008

Reporting and disclosing medical errors: pediatricians' attitudes and behaviors.

February 7, 2007

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

January 18, 2006

How do hospitalized patients feel about resident work hours, fatigue, and discontinuity of care?

June 4, 2008

Related Resources

Association between sleep health and rates of self-reported medical errors in intern physicians: an ancillary analysis of the Intern Health Study.

February 28, 2024

Factors affecting medical residents' decisions to work after call.

January 10, 2024

Public opinion of resident physician work hours in 2022.

November 29, 2023

Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study.

October 18, 2023

Physician behaviors associated with increased physician and nurse communication during bedside interdisciplinary rounds.

October 18, 2023

Interview

In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing

August 30, 2023

Perspectives on Safety

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

August 30, 2023

Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study.

April 26, 2023

Measuring team hierarchy during high-stakes clinical decision making: development and validation of a new behavioral observation method.

April 12, 2023

Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed at trainees at an academic medical center.

December 21, 2022

Trainees' perceptions of being allowed to fail in clinical training: a sense-making model.

December 14, 2022

Prescribing decision making by medical residents on night shifts: a qualitative study.

November 9, 2022

Trainee perceptions of resident duty hour restrictions: a qualitative study of online discussion forums.

October 19, 2022

Changes in unprofessional behaviour, teamwork, and co-operation among hospital staff during the COVID-19 pandemic.

September 28, 2022

Temporal associations between EHR-derived workload, burnout, and errors: a prospective cohort study.

July 20, 2022

Influence of psychological safety and organizational support on the impact of humiliation on trainee well-being.

June 8, 2022

Medical errors during training: how do residents cope?: a descriptive study.

September 8, 2021

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

August 25, 2021

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.

July 14, 2021

Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation.

June 2, 2021

An act of performance: exploring residents' decision-making processes to seek help.

April 14, 2021

The Collective Leadership for Safety Culture (Co-Lead) team intervention to promote teamwork and patient safety.

February 17, 2021

An in situ simulation program: a quantitative and qualitative prospective study identifying latent safety threats and examining participant experiences.

January 20, 2021

Incoming interns recognize inadequate physical examination as a cause of patient harm.

July 15, 2020

Hacking teamwork in health care: addressing adverse effects of ad hoc team composition in critical care medicine.

January 15, 2020

Multidisciplinary simulation activity effectively prepares residents for participation in patient safety activities.

October 16, 2019

Associations between national board exam performance and residency program emphasis on patient safety and interprofessional teamwork.

September 11, 2019

Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands.

July 31, 2019

Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.

June 12, 2019

Interventions to reduce burnout and improve resilience: impact on a health system's outcomes.

June 12, 2019

See More About The Topic

Hospitals

Medicine

Teamwork

Residents and Fellows

Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site