Problem Addressed

Evidence has pointed to a general lack of patient safety educational offerings in graduate medical education.¹⁵ The 2016 Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review (CLER) National Report of Findings stated that few residents had experiential learning opportunities in patient safety.¹³ As an example, the ACGME found that around half of trainees did not have experience submitting a safety event report, and residents were often not taught the link between safety reports and process improvements.¹⁶ This context was striking, as reporting of safety errors is considered an essential component of mitigating patient safety events.^12,17

Description of the Innovative Activity

The Duke Pediatric Residency Safety Council was founded in 2012 by residents in the Department of Pediatrics at the Duke University School of Medicine and is one of several resident-led councils at the school. Past leaders say that the group was formed to increase the residents’ exposure to patient safety training and include their input in discussions and decisions about safety practices in the clinical environment.

Each year since inception, the council has been led by two to three senior residents with a total of seven to 10 resident members. The group is also supported by a chief resident and one or more faculty mentors.⁹ The group meets once a month and participation is voluntary.

The council’s regular activities include participating in and supporting departmental and institutional safety efforts, holding morbidity and mortality conferences, and reviewing and discussing safety event reports. The safety report reviews are discussions of each report and whether the council should create any action items from each report. The morbidity and mortality conferences are larger discussions with the pediatric resident body and with invited representation from various areas of the hospital. The council selects a safety report that highlights a particularly important issue and presents it in detail as a conference using the Agency for Healthcare Research and Quality’s (AHRQ) Learning from Defects tool.¹⁸ The council usually invites nursing representation, pharmacy, and others depending on the case – for example, representatives from occupational therapy, Child Life, Transfer Center Management, Phlebotomy etc.

Resident council members have also developed and implemented their own ideas, such as running mock codes during night shifts; developing a handoff tool to collect information from referring outside hospitals for inter-hospital transfers; developing a handoff tool to collect information from surgical teams after a patient operation or procedure; and holding a scavenger hunt for residents to find their way to different patient destinations in the hospital in case of a patient emergency.

Leaders say that the council’s success lies in the fact that it allows residents to take ownership of their learning and their use of safety practices. They emphasize a systems-approach to safety and say that by helping to initiate small changes, the residents can make an important impact on patient safety.

Context of the Innovation

The work of the Pediatric Residency Safety Council at Duke exists within a larger movement to increase safety training and focuses on graduate residency programs. Previous studies have shown that training residents in patient safety can improve resident knowledge, improve safety in the clinical training environment, and increase reports of patient safety incidents.^5,19 However, the 2016 CLER National Report of Findings from site visits revealed that few trainees were actively involved in efforts to improve patient safety. Additionally, ACGME found that residents generally did not feel that safety reporting was connected to process improvements.¹³

As a result of findings from an initial round of site visits, the AGCME CLER Pathways to Excellence program began focusing in six educational areas, one of which is patient safety. Within the patient safety focus area, CLER defines seven key safety and safety education practices on which to assess medical school programs: (1) reporting of adverse events, close calls (near misses), and unsafe conditions; (2) education on patient safety; (3) culture of safety; (4) resident/fellow experience in patient safety investigations and follow-up; (5) clinical site monitoring of resident/fellow engagement in patient safety; (6) clinical site monitoring of faculty member engagement in patient safety; and (7) resident/fellow education and experience in disclosure of events.¹³

To improve patient safety education, some medical schools have created safety specialty tracks.^20,21,22 Others have increased safety training opportunities across specialties.²³ Additionally, many medical schools have safety councils that cover the entire institution and are not led specifically by residents.⁹ The Duke Pediatric Residency Safety Council is an example of a resident-driven specialty-focused patient safety group.

Results

One study of data from 2014 to 2017 reviewed resident safety attitudes and safety event reporting by residents from multiple specialties at Duke. Safety attitudes were determined by an annual survey overseen by Duke’s patient safety center and the Pediatric Residency Safety Council. ⁹ The study found that the percentage of residents who strongly agreed that they could submit a safety report increased from 35% (6 of 17) to 73% (22 of 30). The average number of safety reports submitted by a pediatrics resident per year did not significantly change during this period. Pediatric residents submitted nearly three times as many reports as residents from other specialties.⁹

The same study found that the Duke Pediatric Residency Safety Council addressed five of the seven practices identified as part of the patient safety focus area of the CLER Pathways to Excellence Program.⁹

Planning and Development Process

For the pre-implementation planning phase, council leaders say facility efforts should focus on getting institutional support while maintaining the resident oversight of the initiative. Other important activities at this stage include:

• Making connections with other safety groups and department leadership
• Acquiring faculty mentors to support the initiative as needed
• Creating regular meeting times and distribution lists
• Discussing the mission of the council and important references such as institutional mission and the AGCME patient safety processes
• Discussing barriers to resident ownership of safety efforts
• Collecting baseline data and discussing measures of progress
• Identifying areas of need.

Resources Used and Skills Needed

According to council leaders, the Duke Pediatric Resident Safety Council requires the following resources, activities, and skill/knowledge areas:

• A faculty mentor or mentors
• Resident leadership
• Institutional support
• Regularly scheduled meetings
• Support of, and collaboration with, other safety groups at the institution
• Regular morbidity and mortality conferences and reviews of safety event reports
• Aims that align with the goals of the Duke residency program and quality system, as well as national accreditation requirements
• Processes and procedures to support the implementation of action items
• Understanding and promotion of a systems-based approach to patient safety

Funding Sources

The council does not receive or require any financial or administrative support.

Getting Started with This Innovation

When starting a resident-led patient safety council, it is important to establish council leaders, begin data collection, test meeting routines and communication channels, discuss areas of need, and promote participation. The assembled council can start to plan and implement activities like morbidity and mortality conferences, safety event report reviews, and training residents on how to submit safety event reports.

Sustaining This Innovation

To sustain the innovation, council leaders suggest the following:

• Remember that not every project has to be big; small steps can be taken to improve safety.
• The council benefits from the participation of a wide group of residents.
• Exposure to the hospital’s safety council, which incorporates safety leaders from various departments and clinical leadership, is an important draw and learning component of the group.
• The council functions best as a resident-led group.
  • While mentors can say what has worked in the past, the residents are often the ones engaged directly in patient care, and therefore their perspective should be centered.  
• Recognize that the structure and processes of the group may evolve over time.
• Sharing the positive impact of the group with peers and colleagues helps elevate the council and encourages participation.

References/Related Articles

Accreditation Council for Graduate Medical Education CLER Evaluation Committee. CLER Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, Version 2.0. Chicago, IL: Accreditation Council for Graduate Medical Education; 2019. doi:10.35425/ACGME.0003.

Cohen SP, Pelletier JH, Ladd JM, Feeney C, Parente V, Shaikh SK. Success of a resident-led safety council: a model for satisfying CLER Pathways to Excellence patient safety goals. J Grad Med Educ. 2019;11(2):226-230. doi:10.4300/JGME-D-18-00459.1.

Kirkman MA, Sevdalis N, Arora S, Baker P, Vincent C, Ahmed M. The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review. BMJ Open. 2015;5:e007705. doi:10.1136/bmjopen-2015-007705.

Parente V, Feeney C, Page L, Johnson S, Porada K, Cheifetz I, Stephany A. Sustained impact of a pediatric resident-led patient safety council. J Patient Saf. 2021 Dec 1;17(8):e1346-e1351. doi:10.1097/PTS.0000000000000495. PMID: 29781977.

Zarrabi K, Cummings K, Lum N, Taub E, Goolsarran N. A resident-led initiative to improve patient safety event reporting in an internal medicine residency program. Journal of Community Hospital Internal Medicine Perspectives. 2020;10(2):111-116.

Footnotes

1. Voogt JJ, Kars MC, van Rensen EL, Schneider MM, Noordegraaf M, van der Schaaf MF. Why medical residents do (and don’t) speak up about organizational barriers and opportunities to improve the quality of care. Academic Medicine. 2020 Apr 1;95(4):574-81.
2. Williams MD. Improving Patient Safety and Quality of Care: What Can Residents Do? https://www.wolterskluwer.com/en/expert-insights/improving-patient-safety-and-quality-of-care-what-can-residents-do. June 17, 2020. Accessed March 10, 2022.
3. Smith A, Hatoun J, Moses J. Increasing trainee reporting of adverse events with monthly trainee-directed review of adverse events. Academic Pediatrics. 2017 Nov 1;17(8):902-6.
4. Stueven J, Sklar DP, Kaloostian P, et al. A resident-led institutional patient safety and quality improvement process. American Journal of Medical Quality. 2012 Sep;27(5):369-76.
5. Wong BM, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Academic Medicine. 2010;85(9):1425-1439.
6. Wagner R, Koh NJ, Patow C, et al. Detailed findings from the CLER National Report of Findings 2016. J Grad Med Educ. 2016;8(2 Suppl 1):35-54. doi:10.4300/1949-8349.8.2s1.35.
7. James M. Naessens, Claudia R. Campbell, Jeanne M. Huddleston, Bjorn P. Berg, John J. Lefante, Arthur R. Williams, Richard A. Culbertson, A comparison of hospital adverse events identified by three widely used detection methods, International Journal for Quality in Health Care, Volume 21, Issue 4, August 2009, Pages 301–307, https://doi.org/10.1093/intqhc/mzp027
8. Herchline D, Rojas C, Shah AA, Fairchild V, Mehta S, Hart J. A Quality Improvement Initiative to Improve Patient Safety Event Reporting by Residents. Pediatric Quality & Safety. 2022 Jan;7(1).
9. Cohen SP, Pelletier JH, Ladd JM, Feeney C, Parente V, Shaikh SK. Success of a resident-led safety council: a model for satisfying CLER Pathways to Excellence patient safety goals. J Grad Med Educ. 2019;11(2):226-230. doi:10.4300/JGME-D-18-00459.1.
10. Turner DA, et al. Improving resident and fellow engagement in patient safety through a graduate medical education incentive program. Journal of Graduate Medical Education. 2018;10(6):671-675
11. Stanford Medicine. The Stanford Resident Safety Council. https://med.stanford.edu/rsc.html. Accessed March 10, 2022.
12. Zarrabi K, Cummings K, Lum N, Taub E, Goolsarran N. A resident-led initiative to improve patient safety event reporting in an internal medicine residency program. Journal of Community Hospital Internal Medicine Perspectives. 2020 Mar 3;10(2):111-6.
13. Smith A, Hatoun J, Moses J. Increasing trainee reporting of adverse events with monthly trainee-directed review of adverse events. Academic Pediatrics. 2017;17(8):902-906.
14. University of Washington Housestaff Quality and Safety Committee. https://sites.uw.edu/uwhqsc/. Accessed March 10, 2022.
15. Mate KS, Johnson MB. Designing for the future: quality and safety education at US teaching hospitals. J Grad Med Educ. 2015;7(2):158-159. doi:10.4300/JGME-D-14-00199.1.
16. Wagner R, Koh NJ, Patow C, et al. Detailed findings from the CLER National Report of Findings 2016. J Grad Med Educ. 2016;8(2 Suppl 1):35-54. doi:10.4300/1949-8349.8.2s1.35.
17. Pronovost PJ, Morlock LL, Sexton JB, et al. Improving the value of patient safety reporting systems. In: Henriksen K, Battles JB, Keyes MA, et al., eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville, MD: Agency for Healthcare Research and Quality; 2008 Aug. https://www.ncbi.nlm.nih.gov/books/NBK43621/. Accessed March 10, 2022.
18. Learn from Defects Tool. Content last reviewed December 2012. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
19. Jansma, JD, Wagner C, ten Kate RW, et al. Effects on incident reporting after educating residents in patient safety: a controlled study. BMC Health Serv Res. 2011;11:335. doi:10.1186/1472-6963-11-335.
20. Murphy TJ, Saldivar BN, Holland CK, Lossius MN. A quality education: a comprehensive review of a combined longitudinal and specialty track quality improvement and patient safety medical school curriculum. American Journal of Medical Quality. 2022 Jan 1;37(1):32-38.
21. University of Virginia School of Medicine. Leadership in Patient Safety and QI Track. https://med.virginia.edu/internal-medicine-residency/training-tracks/specialized/psqi/. Accessed March 10, 2022.
22. Emory University School of Medicine. Quality Improvement Safety Track Goals, Learning Objectives, & Outcome. https://med.emory.edu/education/gme/housestaff/residency-tracks/quality-patient-safety.html. Accessed March 10, 2022.
23. Neumeier A, Levy AE, Gottenborg E, Anstett T, Pierce RG, Tad-Y D. Expanding training in quality improvement and patient safety through a multispecialty graduate medical education curriculum designed for fellows. MedEdPORTAL. 2020;16:11064. Published 2020 Dec 30. doi:10.15766/mep_2374-8265.11064.