Letters to the Editor
We thank Ms. Kelaart for her thoughtful response. We agree with her emphases that health care organizations must engineer a culture of safety, and that true cultural change requires support from stakeholders at all levels of the organizational hierarchy. We believe our intervention succeeded because of close collaboration among leaders from multiple stations: the chief operational and medical officers atop the organizational hierarchy, the director of the Office of Graduate Medical Education, the director of our institution's safety office, and residents. This union represented a melding of “top-down” and “bottom-up” approaches for quality improvement, as outlined by the Accreditation Council for Graduate Medical Education and the Institute for Health care Improvement.1
We also agree that, ideally, research on an organization's safety performance should include senior mangers' attitudes and behaviors. However, we limited the intervention's focus to residents, largely because the project's conception and enthusiasm developed among resident leaders. Also, resident physicians have a marginalized status, incomplete cultural indoctrination, and a transitional role between care delivery and care leadership. These features make residents particularly important targets for education to develop new leaders in a culture of safety, where reporting would be viewed as simple, common, and nonpunitive. We did not offer attending physicians the financial incentive or education that we offered the residents and, instead, chose to report their behavior as a contemporaneous control, noting their incident reporting did not change during the study period. This was done primarily to demonstrate the absence of confounding factors. However, senior professionals represent vital role models, and we recommend their inclusion in future research on and implementation of comprehensive safety initiatives.
We acknowledge that voluntary incident reporting systems often have weaknesses. Without a linked system to exploit those reports for improvement, they lack evidence for improving patient-level outcomes. However, incident reporting fulfills an essential and expanding role when used within a multimodal system to identify events and threats and to target interventions and monitor results.2 We acknowledge that augmenting incident reports with other safety monitoring systems provides a more comprehensive risk profile, the tradeoff being greater costs. Housestaff physician reporting, as compared to records review, is less costly and detects more preventable events, which can serve as targets for quality improvement.3 Resident participation in event reporting is valuable, and should be included as part of a multifaceted approach to both study and improve patient safety.
William J. Ward, MD
Instructor, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; firstname.lastname@example.org.
David Scott, MD
Fellow, Allergy and Immunology, Scripps Clinic, San Diego, California.
Clea English, MPH
Division manager, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon.
2. O'Neil AC, Petersen LA, Cook EF, et al.. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med 1993;119:370–376.
3. Leape LL. Reporting of adverse events. N Engl J Med 2002;347:1633–1638.