Background: General wards are high-risk clinical areas, but frontline staff face operational challenges not prioritized in national safety initiatives. Team reporting may identify important risks to patient care, although its impact as a safety strategy is unknown. We developed HEADS-UP (Hospital Event Analysis Describing Significant Unanticipated Problems), a system for prospective clinical team surveillance (PCTS). [...]

Background: Deep vein thrombosis (DVT) is typically diagnosed from ultrasound (US) Doppler evaluation and anticoagulation therapy is the standard treatment to prevent life threatening pulmonary embolism (PE). In our hospital, the treating provider is alerted to the positive test result by phone and/or text in the imaging result. There is an absence of clinical decision [...]

Background: According to AHRQ, patient safety culture refers to the beliefs, values, and norms shared by health care practitioners and other staff throughout the organization that influence their actions and behaviors. Safety reporting (or incident reporting) is an important aspect of safety culture. Safety reporting of adverse events is a valuable epidemiological tool to measure [...]

Background: General wards are high-risk clinical areas, but frontline staff face operational challenges not prioritized in national safety initiatives. Team reporting may identify important risks to patient care, although its impact as a safety strategy is unknown. We developed HEADS-UP (Hospital Event Analysis Describing Significant Unanticipated Problems), a system for prospective clinical team surveillance (PCTS). [...]

Background: Deep vein thrombosis (DVT) is typically diagnosed from ultrasound (US) Doppler evaluation and anticoagulation therapy is the standard treatment to prevent life threatening pulmonary embolism (PE). In our hospital, the treating provider is alerted to the positive test result by phone and/or text in the imaging result. There is an absence of clinical decision [...]

Background: Error reporting is an integral component in the safety program of hospitals. Residents in training programs are encouraged and expected to participate in error reporting as part of the clinical learning environment. Previous studies identified barriers to resident reporting including knowledge of how to submit reports and understanding how reports affect institutional safety culture. [...]

Background: Residents, because they are on the frontlines of the provision of care, are integral to improving care. Yet the Accreditation Council for Graduate Medical Education (ACGME) has reported residents are not as engaged in improving patient safety as they could be, noting, “Though most residents and fellows were aware of their [clinical learning environment]’s [...]

Background: Incident reporting systems are widely utilized to detect adverse events and remain central to many hospital patient safety programs. It is well established that non-physicians file the majority of incident reports, but the barriers to physician reporting are not well understood. Therefore the aims of this study are to understand physicians’ perceived barriers to [...]

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 [...]