Cox, LeeAnn M. MD; Logio, Lia S. MD
Although incident reports form the core of patient safety processes in many medical organizations and educational settings, they are inconsistently used and often composed of fragmented details with little explanation or context.1 Nurses, pharmacists, and ancillary staff file most of the reports, which often revolve around adverse events pertaining to the work of these groups.2 Physicians and trainees fail to fully participate in the formal process for a variety of reasons, including fear of appearing incompetent, malpractice risk, lack of follow-up, and cynicism about efforts to fix problems.1–5 When they do submit reports, the reactionary nature of the process can create unnecessary overtones and feelings of blame. These challenges may help explain the apparent lack of significant improvement in patient safety in the decade since the Institute of Medicine's report, To Err Is Human.6,7
In response, medical educators have been advised to focus more closely on patient safety education.7 Residency, a time when physicians develop lifelong skills, habits, and attitudes while participating at the front lines of patient care, is a ripe opportunity for training in patient safety.8 Yet residents often go without this training. For instance, when an adapted form of the Agency for Healthcare Research and Quality's (AHRQ's) patient safety culture survey was conducted within the graduate medical education community at Indiana University School of Medicine (IUSM), many physicians-in-training at the institution's five hospitals admitted not knowing how to report adverse events; even those oriented to the process did so infrequently.9
That survey, while identifying barriers to formal reporting of adverse events, also shed light on a practice of residents informally sharing “stories” about gaps in care.9 We were intrigued by this, and so, as part of the IUSM internal medicine residency's comprehensive patient safety curriculum, we collected those naturally occurring conversations by providing residents an alternative reporting system, one that used a narrative format. This format, with its short descriptive sentences, is easy to use and generates richer detail than does the traditional incident report.10 Our choice to use electronic journaling seemed appropriate given its similarity to blogging, a medium already familiar to many residents.11 In addition to having residents report incidents through storytelling, we enlisted faculty to facilitate residents in small-group discussions to analyze the stories, thus enhancing the residents' learning. We also asked hospital patient safety officers to read summaries of the stories and propose systematic interventions, thereby closing the feedback loop and promoting the project's sustainability. Residents were immersed in learning about patient safety using their own stories to provide timely and relevant discussions about key concepts identified from their experiences.
The institutional review board of Indiana University–Purdue University at Indianapolis approved the project as a component of a larger patient safety curriculum across graduate medical education programs.
Patient Safety Stories Project
IUSM internal medicine residents learn the science and art of medicine through a combination of organized curricular activities and supervised clinical work within four of the five affiliated teaching hospitals (excluding the children's hospital), which include a private community hospital staffed by local physician practices, a university tertiary care referral hospital staffed by academic faculty, a Veterans Administration hospital, and a public county hospital. As residents rotate through these hospitals during their 36 months of training, they are exposed to the differing administrative structures and patient populations.
In late 2007, 12 faculty members volunteered to facilitate the small-group discussions. The three hour-long faculty development sessions they attended were critically important to ensure that the small-group sessions remained “blame free” and focused instead on identifying system failures. The faculty also received binders consisting of key educational information about patient safety, including the executive summary of To Err Is Human, the Quality Grand Rounds Series published in Annals of Internal Medicine, and several other articles on understanding and teaching core concepts of patient safety (see the contents of this faculty facilitator manual in the Appendix).
Appendix Contents of...Image Tools
At the first session, the faculty were introduced to the concepts of error and health care gaps through videos from the AHRQ-sponsored TeamSTEPPS, an evidence-based teamwork system for health care professionals.12 The second session explored the “Five Whys” technique,13 used during root cause analyses, and included a question-and-answer period pertaining to the project's goals and implementation. At the final session, the faculty, using sample cases from AHRQ's Web M&M and role play, practiced their new facilitation skills in a mock discussion.14
We conducted the project during the first three months of 2008. Using a tiered (by postgraduate year) computer randomization, we selected 46 internal medicine residents to participate. Balanced representation of the three years of training included nearly 50% of each class (16 first-year, 15 second-year, and 15 third-year residents). The residents were unaware of their randomization, and involvement was voluntary, based on active participation in the project (i.e., story submission).
To collect the stories, we created the Patient Safety Journal, an electronic journal within the residency program's established learning management system. Aware of concerns about retribution, reprimand, or reprisal, we gave the residents a password-protected, anonymous link, eliminating the need to log into the system. We also worked with risk management and patient safety administrators from each hospital to ensure that the information gathered would remain nondiscoverable.
We asked the residents to record stories of patient care that did not go as intended, sending them weekly e-mail reminders throughout the three months. To preserve the integrity of the story and allow for the most narrative freedom, we gave no directions regarding the content except to indicate whether the scenario had occurred overnight, on a weekend or holiday, during a postcall transition, or during a cross-cover period. We asked that they provide sufficient detail to help others understand the gaps of care and to prompt discussion about improvements in the system, but we discouraged the use of protected health information or any details that could identify the patients, providers, or staff members involved. Journal entries did not replace the formal incident reporting system, so we encouraged the residents to also submit official reports with patient identification to facilitate hospital tracking.
We invited the residents to monthly Safety Story Sessions, small groups of four to six individuals from all levels of training with a faculty facilitator, assigning them based on the location of their monthly rotations. Within these groups, the residents were asked to share and discuss their personal narratives, focusing not on placing blame but, rather, on identifying the contributing system failures and proposing potential improvements. Residents did not have access to others' submissions. The faculty facilitators, however, were provided access to the cumulative journal submissions for review in advance as a means to prompt group discussion if individuals were reluctant to share personal reflections. The faculty members documented the key elements from the conversation and subsequently summarized the discussions.
We shared the summaries with the appropriate hospital patient safety officers, asking them to use a dedicated section of the Patient Safety Journal to post comments and share plans made in response to the residents' suggestions for system improvements.
By the end of the three months, we had collected and reviewed 79 narratives. To better understand the range of patient safety gaps observed by internal medicine residents, we analyzed the stories, using a constant comparative method to create a coding scheme that identified common thematic categories and subcategories.15 All discrepancies were reconciled by consensus.16,17
Of the 46 eligible residents, 3 (6%) submitted five to eight entries, 22 (48%) submitted two to four entries, and 11 (24%) submitted one entry. Ten (22%) of the participants did not submit any stories. This submission rate, markedly higher than the rates in published works on incident reporting by medical trainees,2,9,18,19 may be due in part to the ability of a narrative format similar to blogging to capture discussions already occurring informally among colleagues and peers.3,19 The format's use of short sentences allowed the residents to clearly and comfortably communicate in rich detail the variety of safety gaps they observed. The entries composed a much more diverse collection, as demonstrated in the following three excerpts, than the wrong medications, dosing errors, equipment failures, and falls that often appear in traditional incident reports, as demonstrated in the following three excerpts.
BP [blood pressure] medications were held for a BP of 100–110 when the patient needed good control and had rebound from clonidine since it was held.
Miscommunication with the staff, over the phone, resulted in patient getting unintended fluids. [The] plan was repeated back to the staff [and] confirmed. The intern should have questioned the staff again.
Patient was on morphine PCA [patient-controlled analgesia] and nurse had put the PCA button up and out of reach of the patient after bilateral BKA [below the knee amputation].
On the basis of these submissions, we believe that internal medicine residents not only observe gaps in patient care but are also willing to discuss them and record them in sufficient detail when using an open “storytelling” narrative format (Table 1). Although nearly a fourth of the stories were submitted by only three residents, most residents voiced common experiences during the small-group sessions.
The overwhelming majority of stories, including narratives of both personal involvement and observed events, involved errors, defined by the Institute of Medicine as the “failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”6 A minority of stories described no actual identifiable error but, instead, scenarios or situations that posed a significant potential for error. As seen in Table 2, the stories described a range of outcomes: (1) near-misses, defined as errors that occur but are identified and diverted before affecting a patient, (2) incidents, defined as times when care is not completed as intended (which may or may not affect the clinical outcome), and (3) sentinel events, which the Joint Commission20 defines as “unexpected occurrence[s] involving death or serious physical or psychological injury, or the risk thereof.”
Although 35 (44%) of the 79 stories represented no change in outcome (near-misses and incidents without effect), they nonetheless identified systematic vulnerabilities, such as barriers to timely delivery of care, lack of decision support aids, and limited infrastructure to support effective communication and handoffs. The incidents described ranged widely in severity (from delayed diagnostic testing to extended hospitalization) and outcome (from prolonged pain to severe decline in the patient's health status). Of these, only seven identified a significant delay in care as the isolated adverse outcome. Just six stories revolved around sentinel events.
Timing of errors
Three-quarters of the adverse events occurred during recognized periods of patient vulnerability: overnight; on weekends or holidays; during a postcall transition; or during a time when a provider was cross-covering another provider's patients. (More than one of those factors came into play in some of the stories. We presumed that the 20 unlabeled narratives occurred during regular daytime hours when the primary team was available.) This information highlights the challenges that occur during handoffs, cross-cover transitions, and off-hour care, challenges that clearly call for reinforced teamwork, collective accountability, and robust communication strategies. In the curricular material created for ongoing patient safety education, we incorporated many of these actual stories to emphasize the vulnerability of patients during care transitions.
Our analysis of the stories identified seven key systematic contributors to gaps in care (some of which we divided into subcategories) plus the rare lapse of professionalism. These contributing factors were decision errors, communication/information mishaps, transition of care barriers, environmental obstacles, failures to execute intended care plans, technological problems, and workload challenges (Table 3). From the 79 stories, we identified 257 occurrences of these factors.
The analysis revealed some noteworthy findings about the residents' perspective. Communication/information mishaps were the factors most frequently identified, a confirmation of the importance of information management in safe patient care. The second most common factor was the failed execution of a defined care plan, highlighting a perceived lack of reliability in the care delivery process. Those factors combined accounted for nearly 60% of care gaps in the residents' stories; another 25% related to decision errors and mix-ups during transitions of care (Table 3). Unexpectedly, despite the training setting, misdiagnosis (a subcategory of decision error) was at the core of only three stories. This may have been because the developing physicians were slow to recognize such errors, because they were unwilling to disclose incidents that might be perceived as a lack of competence or skill, or—ideally—because they were well supervised by experienced teaching faculty and, thus, made few errors in diagnosis.2,4,5 Without prompting, the residents recorded lack of professionalism as a contributing factor in some incidents, consistent with evidence correlating disruptive behavior and team management with patient outcomes.21,22 Interestingly, workload challenges, technological problems, and environmental obstacles were minor contributors to the patient safety issues identified by the residents.
The small-group discussions allowed the residents to safely explore system complexity and harm in medicine with personal relevance to their daily work. Discussions were sometimes stalled by overtones of blame directed at other specialties, disciplines, or services, but the trained faculty easily redirected the conversation. With this guidance, the residents actively engaged in productive dialogues about system analysis and improvement.
Forty (87%) of the participating residents attended at least one of the monthly sessions, but attendance declined during the three months. The difficulties (discussed in the next section) in achieving rapid, tangible improvements in response to the residents' concerns and subsequent dissatisfaction with the process may in part explain the decline in attendance. Additionally, coordinating faculty schedules and resident rotations proved challenging, even within our project's limited population. We were able to arrange small-group sessions for the randomized, decentralized project for three months, but a core educational activity that includes all residents and is managed centrally would be more sustainable.
Faculty are key role models and integral to conversations about safety and systems improvement. As facilitators of small-group discussions, they must be trained to avoid the natural tendency to blame and shame. We were fortunate to identify 12 faculty volunteers who were willing to devote the time and effort. Their return on their investment was a broadened ability to meaningfully contribute to quality and safety initiatives, a skill that will be increasingly required at every level in health care.
Closing the Patient Safety Loop
When one of us (L.L.) sat down with the patient safety officers of the participating teaching hospitals to discuss the collection of safety stories and monthly session reports, they all expressed surprise and concern because the problems described in the narratives were markedly different from the issues and events collected through formal incident reports. They welcomed the information and felt compelled to more actively partner with the residency program on patient safety initiatives. Importantly, however, the final feedback loop proved difficult; the participating residents received little information about efforts to fix the problems. Timely feedback was limited by the multifactorial nature of gaps in care, which require layers of interventions that are implemented over time, often extending beyond the assigned rotation for any given resident. Residents' hectic schedules also make it difficult to keep them involved. Improved transparency and increased efforts to close the feedback loop between physicians, trainees, and patient safety administration are imperative to maintain the residents' ongoing sense of value. To foster engagement and sustainability, we are now working to more deliberately and consistently integrate patient safety education with the hospitals' systems improvements.
Assessment of the Project
At the end of the project, in response to a short survey, 39 (85%) of the participants rated the activities a positive learning experience. Although the number of formal incident reports did not concurrently increase, 20 (44%) of the participants reported a change in attitude about gaps in care and better awareness and understanding of medical errors. As one resident reflected,
It helped me to look back to see how we can improve as physicians. In our busy schedules, we do not get any time to look back to see how we can do better. This was an opportunity to discuss our past experiences, [which] will always make you a better physician.
The Patient Safety Stories project uncovered a blind spot in the current reporting practices of our teaching hospitals. Formal reporting processes tend to rely on nurses, pharmacists, and ancillary staff and focus on incidents related to their work. Residents infrequently file formal reports, but, as seen in the 79 collected stories and confirmed by the patient safety officers with whom we spoke, they see gaps in care that are not reported elsewhere.2
This project shows that internal medicine residents are willing to talk about those gaps when given the tools and opportunity for anonymous storytelling and blame-free dialogue. The narrative format can uncover significant, unrecognized patient safety issues. With simple facilitation skills, faculty can encourage active engagement in patient safety conversations. Patient safety officers should regularly engage residents to report and discuss incidents and develop robust mechanisms to close the feedback loop. Finally, these stories of obstacles to delivering consistent, reliable care can help formulate proactive patient safety measures in ways that the current approach, which only reacts to sentinel events and actual harm, cannot.
The authors would like to thank John Black, MD, Ella Bowman, MD, Richard Hellman, MD, Ahdy Helmy, MD, Jennifer Hur, MD, Ziad Jaradat, MD, Richard Kohler, MD, Mark Leutkemeyer, MD, Rakesh Mehta, MD, David Miller, MD, Michael Ober, MD, Jennifer Schwartz, MD, Noelle Sinex, MD, Steve Wilson, MD, Karen Wolf, MD, Curtis Wright, MD, and Syed Zaidi, MD, for their invaluable assistance as faculty facilitators. We are additionally indebted to the patient safety officers who participated in the project, Crissy Lough, Jane Murphy, and Valerie Shariari, and other expert consultants, Richard Frankel, Betsy Lee, and Michael Weiner.
This project was funded by the Clarian Valued Fund for Education and was a key component of the Indiana University Internal Medicine Residency Program's Educational Innovations Project as designated by the Residency Review Committee of Internal Medicine and the Accreditation Council of Graduate Medical Education.
The study was approved by the Indiana University–Purdue University at Indianapolis institutional review board through an expedited and exempted process.
Results of the study were presented at Academic Internal Medicine Week, Alliance for Academic Internal Medicine, October 2008, Orlando, Florida.