Background: Voluntary incident reporting systems are an essential component of a high reliability organization (HRO). Historically, housestaff contribute just 1% of all patient safety intelligence (PSI) events reported at our tertiary care academic institution. This is a missed opportunity, as housestaff spend a significant amount of their time in direct patient care and can see [...]

Background: Microaggressions and bias events in the clinical environment are widespread and have both individual and structural consequences. Microaggressions are brief and mundane verbal, environmental, or behavioral slights that communicate bias, hostility, or prejudice toward any group. Microaggressions can occur in a variety of interactions between the physician and patients, learners, colleagues, and staff. Studies [...]

Background: Event reporting has been the cornerstone of patient safety culture since the IOM report “To Err is Human” was published. Over the past 20 years, the medical literature has focused on improving the overall rates, but not the quality, of reporting. To inform change, event reports must have a standard quality of content for [...]

Background: The United States is responsible for 43% of lab expenditures worldwide, and up to 30% of lab tests may be unnecessary.  Purpose: This project aims to determine if a human “best practice alert (BPA)” could decrease the number of unnecessary labs ordered by residents at a major academic medical center.  Description: Three internal medicine [...]

Background: The under-reporting of adverse events has been a significant issue in patient and healthcare staff safety, and prevents improvement of individual and systemic errors in healthcare. As champions for quality and safety in their institutions, it is essential hospitalists who work with housestaff  serve as role models to encourage trainees to report safety issues. [...]