Institutional members access full text with Ovid®

A Novel Approach to Increase Residents' Involvement in Reporting Adverse Events

Scott, David R. MD; Weimer, Melissa DO; English, Clea MPH; Shaker, Lynn RN, MPH; Ward, William MD; Choi, Dongseok PhD; Cedfeldt, Andrea MD; Girard, Donald MD

doi: 10.1097/ACM.0b013e318217e12a
Graduate Medical Education

Purpose: In the wake of the Patient Safety and Quality Improvement Act of 2005, national attention has increasingly focused on adverse-event reporting as a means of identifying systems changes to improve patient safety. However, physicians and residents have demonstrated meager involvement in this effort.

Method: In 2008–2009, the authors measured participation in adverse-event reporting by 680 residents at Oregon Health & Science University before and after implementing a quality improvement initiative, which consisted of a financial incentive and multifaceted educational campaign. The primary measure of success was an increase in the average monthly adverse-event reports submitted by residents to greater than 5% of the institution's overall report submissions.

Results: The average number of adverse events reported by residents increased from 1.6% to 9.0% of the institution's overall event reports, representing a 5.6-fold increase during the initiative (P < .001). The relative percentage of resident-submitted reports defined as “near-misses” increased from 6% to 27% during the initiative (P < .001).

Conclusions: The novel approach of integrating a retirement benefit and educational campaign to increase residents' involvement in adverse-event reporting was successful. In addition to increasing residents' contributions to adverse-event reporting to levels higher than any documented in the current literature, there was also a remarkable increase in the relative frequency of near-miss reporting by residents.

Dr. Scott is clinical instructor, Department of Medicine, Portland Veteran Affairs Medical Center and Oregon Health & Science University, Portland, Oregon.

Dr. Weimer is clinical instructor and general internal medicine fellow, Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon.

Ms. English is division manager, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon.

Ms. Shaker is patient safety officer, Oregon Health & Science University, Portland, Oregon.

Dr. Ward is instructor of medicine, Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota.

Dr. Choi is associate professor of biostatistics, Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Oregon.

Dr. Cedfeldt is assistant dean, Department of Graduate Medical Education, Oregon Health & Science University, Portland, Oregon.

Dr. Girard is associate dean, Departments of Graduate and Continuing Medical Education, Oregon Health & Science University, Portland, Oregon.

Please see the end of this article for information about the authors.

Correspondence should be addressed to Dr. Scott, Department of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road OP-30, Portland, OR 97239-3098; e-mail: scottdav@ohsu.edu.

First published online April 20, 2011.

© 2011 Association of American Medical Colleges