Background:
Preventable medical errors are the third leading cause of death in the United States behind heart disease and cancer. In order to decrease the number of medical errors, it is vital to establish a culture of patient safety and encourage incident reporting.
Methods:
We completed a resident-led educational initiative to increase rates of incident reporting among Internal Medicine resident physicians at our institution. During week one of their four-week rotation, residents received individual education about incident reports and completed a pre-education survey about their existing knowledge of incident reports and any barriers to reporting. The education included what an incident report is, when it is appropriate to complete an incident report, demonstration of how to file a report electronically, and what happens to reports that are filed. At the time of education, residents also received a pocket-card of instructions of how to file an incident report. After education was completed, weekly “Patient Safety Rounds” were conducted to inquire about any patient safety events that occurred and reinforce the education they had received. At the end of the rotation, the residents filled out a post-education survey again assessing their knowledge of incident reports and any barriers to reporting. The number of incident reports filed by resident physicians was compared pre and post-intervention.
Results:
A total of 57 residents were included in the intervention over 4 months. Before intervention, 89% knew what an incident report was and 19% knew how to file an incident report. A total of 49 residents completed the post-intervention survey. After education, 100% (p 0.5) of residents knew what an incident report was and 100% (p <0.005) knew how to file an incident report. Four months prior to intervention, there were a total of 3 incident reports entered by resident physicians. This made up 1.6% of all incident reports during that time period. Four months post-intervention, there were a total of 45 incidents reported by resident-physicians, comprising 16.8% of total incidents reported at our institution (p <0.03). Most commonly cited barriers pre-intervention were lack of knowledge of how to file an incident report (68%) and lack of knowledge about what needs to be reported (58%). Post-intervention, the most common barriers reported were lack of time (37%) and unclear outcomes of what happens when incident reports are filed (18%).
Conclusions: Education of incident reporting, along with reinforcement and promotion of filing incident reports through “Patient Safety Rounds” increased rates of resident reporting.