Association Between Nurse Turnover and Nurses' Perception of Patient Outcomes in Acute Care Hospitals in South Korea: A Cross-Sectional Study.

High nurse turnover during nursing shortages can contribute to missed nursing care. This study investigated the prevalence of missed nursing care and how nurse turnover affects missed nursing care. A cross-sectional design was adopted to collect data from a convenience sample of nurses working in general hospitals in South Korea. Six-month turnover rates (0%, 1-14%, 15-22%, and 23-50%) and 24 missed nursing care activities were measured. A multivariate regression analysis was performed to examine the relationship between nurse turnover and missed nursing care, after controlling for nurse and work-related characteristics. The final sample was 264 nurses. The mean six-month turnover rate was 15.49%. Seven activities (turning patient every 2 h, attending interdisciplinary care conference, ambulation, patient bathing/skin care, emotional support, mouth care, full documentation) had a missed care prevalence of 30% or higher. Nurses in units with moderate turnover rates (15 and 22%) reported more missed nursing care than those in units with zero turnover. Nurse turnover increases missed nursing care, highlighting the adverse effects of nurse turnover on care processes. Consequently, hospitals and governments should implement policy changes and strategies to prevent nurse turnover.

The COVID-19 epidemic has afflicted patients with severe chronic illnesses who need continuous care between home and hospitals. This qualitative study examines the experiences and challenges of healthcare providers around acute care hospitals who have cared for patients with severe chronic illness in non-COVID-19 situations during the pandemic. Eight healthcare providers, who work in various healthcare settings around acute care hospitals and frequently care for non-COVID-19 patients with severe chronic illnesses, were recruited using purposive sampling from September to October 2021 in South Korea. The interviews were subjected to thematic analysis. Four overarching themes were identified: (1) deterioration in the quality of care at various settings; (2) new emerging systemic problems; (3) healthcare providers holding on but reaching their limit; and (4) a decline in the quality of life of patients at the end of their lives, and their caregivers. Healthcare providers of non-COVID-19 patients with severe chronic illnesses reported that the quality of care was declining due to the structural problems of the healthcare system and policies centered solely on the prevention and control of COVID-19. Systematic solutions are needed for appropriate and seamless care for non-infected patients with severe chronic illness in the pandemic.

Background and aimNurse staffing levels are associated with patient mortality, but little is known regarding the association between nurse turnover rate and patient mortality. This study investigated the combined effect of the bed-to-nurse ratio and the nurse turnover rate on in-hospital mortality in patients admitted to Korean acute care hospitals using national administrative data.MethodsThis study analyzed data from the National Health Insurance Service (NHIS) on 459,113 admitted patients and 111,342 employed nurses in 403 hospitals in South Korea from January to December 2016. Differences in in-hospital mortality and nurse turnover among hospital characteristics, including the bed-to-nurse ratio, were explored using the chi-square test. Multilevel, multivariate GEE logistic regression analyses were used to examine the combined effect of the bed-to-nurse ratio and the nurse turnover rate on in-hospital mortality.ResultsDuring the study period, 13,675 (3.0%) patients died during hospitalization, and 13,349 (12.0%) nurses left their jobs. The risk of death among patients admitted to hospitals with a bed-to-nurse ratio of < 2.5 and a nurse turnover rate of ≥ 12% was lower than among patients admitted to hospitals with a bed-to-nurse ratio of ≥ 4.5 and a nurse turnover rate of ≥ 12% (odds ratio [OR] = 0.63; 95% confidence interval [CI], 0.48–0.82). The risk of in-hospital mortality decreased further when the nurse turnover rate was < 12% (OR = 0.59; 95% CI, 0.44–0.79).ConclusionThe bed-to-nurse ratio and nurse turnover rate were jointly associated with patient mortality. When hospitals with a low bed-to-nurse ratio also experienced high nurse turnover, the risk of in-hospital mortality was even greater. The finding of this study will help health policy makers to better understand the importance of both nursing staffing levels and nurse turnover rates. It is necessary to create a comprehensive improvement plan that integrates policies aiming to improve nurse staffing levels and reduce turnover rates into a single strategy.

The clinical relevance and drug resistance patterns of nontuberculous mycobacteria (NTM) vary by species. This study investigated the species distribution of NTM isolated from respiratory specimens at a tertiary care hospital in South Korea from 2017 to 2022. A retrospective analysis was conducted on laboratory data from respiratory specimens submitted for acid-fast bacilli culture. NTM isolates were identified using a line probe assay, and those unidentifiable at the species or complex level underwent multigene sequencing of the 16S rRNA, rpoB, and hsp65 genes. Among all mycobacterial isolates, the proportion of NTM showed an increasing trend, rising from 87.4% in 2017 to 93.3% in 2022. The eight most common species were M. avium complex (61.9%), M. abscessus (14.2%), M. fortuitum complex (8.4%), M. gordonae (5.3%), M. simiae complex (3.4%), M. kansasii complex (1.9%), M. terrae complex (1.5%), and M. chelonae (1.2%), accounting for 97.7% of all NTM isolates. Among the remaining isolates (2.3%, n = 169), 161 were classified into 24 species and groups, the majority with proportions below 0.1%. Two of the eight isolates that could not be identified at the species or group level despite multigene sequencing underwent whole-genome sequencing, which suggested they likely represent novel Mycobacterium species. This study provides valuable insights into the distribution of NTM species, particularly rarely encountered species, isolated from respiratory specimens in South Korea. These findings may aid in optimizing diagnostic strategies and selecting appropriate treatment options.IMPORTANCEGiven the significant variations in clinical relevance and drug resistance patterns among nontuberculous mycobacteria (NTM) species, understanding their geographic distribution is essential for selecting appropriate treatment options and improving patient outcomes. This study investigated the distribution of NTM species isolated from respiratory specimens at a tertiary care hospital in South Korea from 2017 to 2022. Our findings revealed an increasing proportion of NTM, with M. avium complex and M. abscessus remaining predominant. Additionally, we identified 24 rarely encountered species and groups, along with two strains that likely represent novel Mycobacterium species. Our study advances the understanding of the evolving NTM epidemiology in South Korea, contributing to the optimization of diagnostic strategies and improvement of patient management.

Beginning in 2007, 29 hospitals in South Korea have received accreditation from Joint Commission International (JCI). The present study aimed to identify differences in clinical nutrition service provisions between JCI accredited acute care hospitals and non-accredited acute care hospitals. A survey questionnaire was sent to all 43 acute care hospitals in South Korea. A total of 35 sets of clinical nutrition service surveys, 234 sets of clinical dietitian job satisfaction surveys, and five-day daily work logs from 129 clinical dietitians were received. We used Fisher's exact test and independent t-test to analyze differences between acute care hospitals based on JCI accreditation. Nationwide cross-sectional survey. JCI accredited acute care hospitals (N=8) showed a higher, but not significantly higher, nutritional intervention rate of 12.7% among malnourished patients, compared with 7.0% in non-JCI accredited acute care hospitals (N=27). Analysis of work hours of clinical dietitians indicated time spent on direct care was higher (p<0.05), while time spent on outpatient care was lower (p<0.05) among JCI accredited acute care hospitals relative to non-JCI accredited acute care hospitals. Accreditation from JCI has a positive influence in the advancement of not only the hospital services, but also clinical nutrition services.

BackgroundCandidemia continues to contribute to significant morbidity and mortality in the hospital. This study aimed to evaluate the epidemiology and antifungal susceptibility at a tertiary care hospital in South Korea during an 8-year period.MethodsAdult patients ≥19 years with candidemia at a tertiary care hospital in South Korea from 2006 to 2018 were reviewed, and cases of candidemia with antifungal susceptibility data were included for the analysis.ResultsThere were 270 cases of candidemia with fluconazole susceptibility data from 2011 to 2018. Overall, fluconazole resistance rate of candidemia was 8.5%. Between period 1 (2011–2015) and period 2 (2016–2018), fluconazole resistance rate was significantly higher in the period 2 (14.3%) than in the period 1 (0.9%), P < 0.001. Among candidemia caused by different Candida spp., a significant increase of fluconazole-resistant C. parapsilosis candidemia was noted in the period 2 (12 out of 34 cases; 35.3%) when compared with the period 1 (0 out of 17 cases; 0.0%), P = 0.004. Although there was a trend of higher fluconazole resistance rate for candidemia caused by C. albicans (9.1% vs. 1.8%), C. tropicalis (2.7% vs. 0.0%), and C. glabrata (11.1% vs. 0.0%) in the period 2 than in the period 1, no statistical significance was observed. Echinocandin (caspofungin and micafungin) susceptibility data were available for 211 cases of candidemia from 2013 to 2018. There were no cases of caspofungin-resistant candidemia except for 2 cases of C. utilis candidemia. However, there were 9 cases of micafungin-resistant candidemia (1 case of C. tropicalis candidemia out of 51 cases [2.0%], 6 cases of C. glabrata candidemia out of 18 cases [33.3%], and 2 cases of C. utilis candidemia out of 2 cases [100.0%]). Micafungin-resistant C. tropicalis and C. glabrata candidemia cases were susceptible to caspofungin.ConclusionA significant increase of fluconazole-resistant candidemia in recent years was noted, particularly among C. parapsilosis candidemia cases. Echinocandin resistance among candidemia cases is rare. However, close monitoring needs to be considered for the possible emergence of differential echinocandin resistance.DisclosuresAll authors: No reported disclosures.

BackgroundCarbapenemase-producing Enterobacteriaceae (CPE) poses a great challenge in infection control in healthcare settings. A screening and contact precautions are recommended to prevent the spread of CPE among patients. However, screening strategies differ among countries and healthcare facilities. MethodsIn September 2018, we launched a CPE screening program at a 660-bed hospital in South Korea, which targeted previously colonized patients, patients with history of admission < 1 month or transferred patients or ICU-admitted patients. Once patients were identified to have CPE, they were isolated in a single room. After a CPE outbreak in July-Aug 2019, the enhanced screening program was implemented, which included patients with additional risk factors (exposure to hospitals in the past 6 months, receipt of hemodialysis or invasive procedures or rehabilitation) combined with weekly screening in ICU-admitted patients. Screening methods changed from two consecutive rectal screening swabs with chromogenic agar to initial screening with Xpert-Carba-R PCR, followed by one or two consecutive tests with chromogenic agar. We compared the CPE incidence in screening and clinical cultures before and after the enhanced screening program introduction (Sep 2018-Nov 2020). ResultsA total of 14,318 (2,178 vs. 12,140) were screened among 49,980 admitted patients and screening compliance increased from 18.6% to 94.5%. The number of CPE detection increased from 44 to 154 cases and the proportion of CPE-positive screening per 1000 admissions increased 0.6 to 2.2. However, the number of clinical CPE cultures decreased from 11 to 3 (Figure). Among screened patients, time-to-positivity was markedly reduced by 1.9 days (2.96 vs. 1.02 days) during the post-period. Additional 70 patients were detected: 36 due to serial screening in the ICUs and 34 due to enhanced on-admission screening. Factors significantly associated with positive screening were previous exposure to hospital (OR 3.5; 95% CI 1.7-7.1) and receipt of hemodialysis (OR 4.3; 95%CI 1.9-9.2). CPE isolates and carbapenemase genes were diverse (Figure). Trends in CPE detection in screening and clinical samples (upper), and bacterial species with detected carbapenemase genes (lower).ConclusionThe study results showed that the enhanced screening program enabled us to identify the previously undetected CPE colonized patients and to decrease clinical CPE cultures. DisclosuresAll Authors: No reported disclosures

BackgroundCarbapenemase-producing Enterobacterales (CPE) poses a significant challenge to infection control in healthcare settings. Active screening is recommended to prevent intra-hospital CPE transmission.MethodsCPE screening was initiated at a 660-bed hospital in South Korea in September 2018, targeting patients previously colonized/infected or admitted to outside healthcare facilities (HCFs) within 1 month. Universal intensive care unit (ICU) screening was performed at the time of admission. After a hospital-wide CPE outbreak in July-September 2019, the screening program was enhanced by extending the indications (admission to any HCF within 6 months, receipt of hemodialysis) with weekly screening of ICU patients. The initial screening method was changed from screening cultures to the Xpert Carba-R assay. The impact was assessed by comparing the CPE incidence per 1000 admissions before (phase 1, September 2018-August 2019) and after instituting the enhanced screening program (phase 2, September 2019-December 2020).ResultsA total of 13,962 (2,149 and 11,813 in each phase) were screened as indicated, among 49,490 inpatients, and monthly screening compliance increased from 18.3 to 93.5%. Compared to phase 1, the incidence of screening positive patients increased from 1.2 to 2.3 per 1,000 admissions (P = 0.005) during phase 2. The incidence of newly detected CPE patients was similar (3.1 vs. 3.4, P = 0.613) between two phases, but the incidence of hospital-onset CPE patients decreased (1.9 vs. 1.1, P = 0.018). A significant decrease was observed (0.5 to 0.1, P = 0.014) in the incidence of patients who first confirmed CPE positive through clinical cultures without a preceding positive screening. Compared to phase 1, the median exposure duration and number of CPE contacts were also markedly reduced in phase 2: 10.8 days vs. 1 day (P < 0.001) and 11 contacts vs. 1 contact (P < 0.001), respectively. During phase 2, 42 additional patients were identified by extending the admission screening indications (n = 30) and weekly in-ICU screening (n = 12).ConclusionsThe enhanced screening program enabled us to identify previously unrecognized CPE patients in a rapid manner and curtailed a hospital-wide CPE outbreak. As CPE prevalence increases, risk factors for CPE colonization can broaden, and hospital prevention strategies should be tailored to the changing local CPE epidemiology.

Costs for 5-year lung cancer survivors in a tertiary care hospital in South Korea

We investigated the evolution of fluconazole resistance mechanisms and clonal types of Candida parapsilosis isolates from a tertiary care hospital in South Korea. A total of 45 clinical isolates, including 42 collected between 2017 and 2021 and 3 collected between 2012 and 2013, were subjected to antifungal susceptibility testing, sequencing of fluconazole resistance genes (ERG11, CDR1, TAC1, and MRR1), and microsatellite typing. Twenty-two isolates carried Y132F (n = 21; fluconazole MIC = 2 to >256 mg/L) or Y132F+R398I (n = 1; fluconazole MIC = 64 mg/L) in ERG11 and four isolates harbored N1132D in CDR1 (fluconazole MIC = 16 to 64 mg/L). All 21 Y132F isolates exhibited similar microsatellite profiles and formed a distinct group in the dendrogram. All four N1132D isolates displayed identical microsatellite profiles. Fluconazole MIC values of the Y132F isolates varied depending on their MRR1 mutation status (number of isolates, year of isolation, and MIC): K177N (n = 8, 2012 to 2020, 2 to 8 mg/L); K177N + heterozygous G982R (n = 1, 2017, 64 mg/L); K177N + heterozygous S614P (n = 2, 2019 to 2020, 16 mg/L); and K177N + homozygous S614P (n = 10, 2020 to 2021, 64 to > 256 mg/L). Our study revealed that Y132F in ERG11 and N1132D in CDR1 were the major mechanisms of fluconazole resistance in C. parapsilosis isolates. Furthermore, our results suggested that the clonal evolution of Y132F isolates persisting and spreading in hospital settings for several years occurred with the acquisition of heterozygous or homozygous MRR1 mutations associated with a gradual increase in fluconazole resistance.

Evidence-based design (EBD) has traditionally guided health care facility design to improve functional workflow from health care professionals’ perspectives. However, it is hard to apply EBD concepts in a specific hospital, such as a geriatric long-term care hospital in South Korea where there is a need to provide services based on geriatric patients’ characteristics. This study aims to suggest design factors with practical suggestions for inpatient rooms in a geriatric long-term care hospital in South Korea from the user-centred design (UCD) perspective which covers a wider range than EBD by including the patients’ perspective. In order to accomplish the goal, we conducted the following steps using qualitative research methods because geriatric patients have a limited capability to adequately respond to questions. First, evaluation criteria from a UCD perspective were optimized after analysing literature. Second, a field study was conducted, which proposed a case study, expert interviews and user-centred research. Finally, the design factors with practical suggestions were provided after the evaluation.

Background Adverse drug reactions (ADRs) are any unwanted/uncomfortable effects from medication resulting in physical, mental, and functional injuries. Antibiotics account for up to 40.9% of ADRs and are associated with several serious outcomes. However, few reports on ADRs have evaluated only antimicrobial agents. In this study, we investigated antibiotic-related ADRs at a tertiary care hospital in South Korea. Methods This is a retrospective cohort study that evaluated ADRs to antibiotics that were reported at a 2400-bed tertiary care hospital in 2015. ADRs reported by physicians, pharmacists, and nurses were reviewed. Clinical information reported ADRs, type of antibiotic, causality assessment, and complications were evaluated. Results 1,277 (62.8%) patients were considered antibiotic-related ADRs based on the World Health Organization-Uppsala Monitoring Center criteria (certain, 2.2%; probable, 35.7%; and possible, 62.1%). Totally, 44 (3.4%) patients experienced serious ADRs. Penicillin and quinolones were the most common drugs reported to induce ADRs (both 16.0%), followed by third-generation cephalosporins (14.9%). The most frequently experienced side effects were skin manifestations (45.1%) followed by gastrointestinal disorders (32.6%). Conclusion Penicillin and quinolones are the most common causative antibiotics for ADRs and skin manifestations were the most frequently experienced symptom.

BackgroundEndogenous fungal endophthalmitis is one of the critical complications of candidemia in adult patients. We conducted a study to investigate the prevalence and risk factors for endogenous fungal endophthalmitis in adult patients with candidemia.MethodsAdult patients ≥19 years with candidemia who underwent ophthalmological examination after the diagnosis of candidemia at a tertiary care hospital in South Korea from 2006 to 2018 were enrolled, and clinical data were collected.ResultsThere was a total of 152 adult patients with candidemia who underwent an ophthalmological examination. Endogenous fungal endophthalmitis was found in 29 patients (19.1%). Patients were categorized into two groups (Non-endophthalmitis [NE] and endophthalmitis [E]). Between two groups, there was no significant difference in terms of age, sex, underlying comorbidities. Also, no difference in clinical conditions at the diagnosis of candidemia was noted including concomitant bacteremia, presence of septic shock, receipt of recent surgery, presence of neutropenia, total parenteral nutrition, central venous catheter, urinary catheter, ventilator, dialysis, use of antibiotics, and Candida spp. colonization. However, there was a higher rate of abnormal alanine aminotransferase (ALT) in the E (35.7%) than in the NE (14.8%), P = 0.008. Moreover, the proportion of C. albicans candidemia was higher in the E (65.5%) than in the NE (35.8%), P = 0.003. In contrast, C. parapsilosis candidemia was more common in the NE (27.6%) than in the E (6.9%), P = 0.018. Although there was a trend of higher mortality rate in the E (51.7%) than in the NE (35.0%), no statistical significance was observed, P = 0.095. Multivariate logistic analysis showed C. albicans candidemia (odds ratio [OR] 4.122, 95% confidence interval [CI] 1.653–10.280, P = 0.002) and abnormal ALT (OR 3.839, 95% CI 1.427–10.333, P = 0.008) were significantly associated with E cases.ConclusionEndogenous fungal endophthalmitis occurred in 19% of adult patients with candidemia. C. albicans candidemia and abnormal ALT were significantly associated with endophthalmitis. Adult patients with candidemia caused by C. albicans or having abnormal ALT need to be closely monitored for the possibility of endophthalmitis.DisclosuresAll authors: No reported disclosures.

BackgroundThe dissemination of carbapenem-resistant Acinetobacter baumannii (CRAB) became an urgent public health concern. A specific sequence type (ST) of A. bauamannii has been reported to be associated with severity of disease or mortality. This study aimed to determine the genetic relatedness of CRAB blood isolates cultured from patients at a tertiary care hospital and to investigate clinical characteristics and outcome of CRAB bacteremia.MethodsCRAB blood isolates were collected between June 2016 and December 2018, and their clinical data were obtained. Multi-locus sequence test (MLST) was performed using the Oxford scheme, and the STs were assigned using the MLST database.ResultsOf the 126 CRAB blood isolates, 123 isolates which could be typed by MLST all belonged to clonal complex (CC) 92. During the entire period, ST369 (42.3%) was the most dominant, followed by ST191 (32.5%), ST784 (13.8%) and ST451 (4.1%). ST369 was firstly introduced in August 2017. ST191 (61.4%) was the most abundant during June 2016 to July 2017, whereas ST369 (65.8%) replaced ST191 (16.5%) since August 2017. The time interval between intensive care unit admission and bacteremia was shorter in ST369 than ST191 in multivariate analysis (day, median (Q1, Q3), ST369 6 (3, 9.8), ST191 9 (6, 17), Odd Ratio 0.87 (95% CI 0.76–0.99) P = 0.048 logistic regression). According to the ST, the 7-day and 30-day mortality rates were as follows; 46% and 65% in ST191, 50% and 62% in ST369, and 10.7% and 46.4% in the other STs. Patients infected by ST191 or 369 had significant higher 7-day mortality rates (ST191/369, 48.3% vs. the other STs 10.7%, P = 0.001 by log-rank test) and 30-day mortality rates (ST191/369, 63.2% vs. the other STs, 46.4%, P = 0.045 by log-rank test).ConclusionThis study demonstrates the clonal spread of two STs at a tertiary care hospital in South Korea over 2.5 years. After the introduction of ST369, it replaced ST 191 and widely disseminated within a hospital. Two predominant STs were associated with poor outcome. Continuous surveillance are necessary to monitor the dissemination of these strains.DisclosuresAll authors: No reported disclosures.

This section includes detailed findings from the second set of visits (2015–2017) of the Clinical Learning Environment Review (CLER) Program. The findings in the 6 CLER Focus Areas1 are based on site visits to the major participating clinical sites (ie, hospitals and medical centers) for 287 Accreditation Council for Graduate Medical Education (ACGME)-accredited Sponsoring Institutions (SIs) with 3 or more core residency programs.23 These clinical sites serve as clinical learning environments (CLEs) for the SIs.Collectively, the 287 SIs oversee 9167 ACGME-accredited residency and fellowship programs, with a median of 20 programs per SI. These larger SIs account for 87.1% of all residents and fellows in ACGME-accredited programs—with a range of 17 to 2156 trainees per SI (median = 246).Approximately 28% of the CLEs were located in the Northeast region of the United States, 30.3% in the South, 26.5% in the Midwest, and 14.6% in the West. The sites ranged in size from 107 to 2654 acute care beds (median = 528). The majority (67.2%) were nongovernment, not-for-profit organizations; 23.3% were government, nonfederal; 5.9% were investor-owned, for-profit; and 3.5% were government, federal. Although the CLER teams spent the majority of their time at inpatient settings, they also sometimes visited affiliated ambulatory care practices in close proximity.In total, the CLER teams interviewed more than 1600 members of executive leadership (including chief executive officers), 9262 residents and fellows, 8164 core faculty members, and 6034 program directors of ACGME-accredited programs in group meetings. Additionally, the CLER teams interviewed the CLEs' leadership in patient safety and health care quality and thousands of residents, fellows, faculty members, nurses, pharmacists, social workers, and other health care professionals while on walking rounds in the clinical areas.As previously described in the CLER National Report of Findings 2016,4 these findings are based on a mixed methods approach to data gathering and analysis to improve the accuracy of the findings by combining quantitative, descriptive, and qualitative evidence in a complementary manner. As such, some of the findings are represented quantitatively while others are described qualitatively.The combination of methodologies and varied representation of findings should be considered when interpreting the results, making comparisons, or drawing conclusions. Both supporting and conflicting evidence may be presented to explain or qualify findings. For example, results from the group interviews may appear more positive than information gathered on walking rounds. Alternatively, practices reported during group interviews may have been verified on walking rounds.During the group interviews with residents and fellows, faculty members, and program directors, an electronic audience response system (ARS; Keypoint Interactive version 2.6.6, Innovision Inc, Commerce Township, MI) was used to collect anonymous responses to closed-ended questions. The results from the ARS were analyzed at both the individual (eg, residents and fellows) and the CLE levels.At the individual level of analysis, results are presented as percentages of the total number of individuals surveyed. For example:At the CLE level of analysis, individual responses were aggregated at the CLE level and results are presented as median and interquartile range (IQR) percentages. For example:Statistically significant differences (ie, P ≤ .05) in responses due to resident and fellow characteristics (eg, residency year) and CLE characteristics (eg, bed size) are also reported. Of note, statistical significance does not always imply practical significance. For example, differences in responses by residency year may be statistically significant but the differences may not be meaningful or large enough to have practical relevance or implications.As described in the Methodology section,5 this report contains a specific set of descriptive terms that summarize quantitative results from both the ARS and specific findings that were quantified from the site visit reports. These terms and their corresponding quantitative ranges are as follows:Besides the quantitative data, this report contains qualitative data from a number of open-ended questions that CLER Site Visitors asked during group interviews and walking rounds. This information, by design, was not intended to be enumerated. For these questions, the site visit teams made an assessment of the relative magnitude of observations at each individual site. To prevent confusion, these results are presented in the report using a set of descriptive terms different from the previously described terms used for quantitative data. The qualitative descriptive terms, which are intended to approximate the quantitative terms above, are as follows:Finally, this section follows approximately the same structure as the individual CLER Site Visit reports received by participating institutions. This structure is intended to facilitate easy comparison between data from an individual site and that of this report, which aggregates results from all 287 SIs. Those who seek additional detail may consult the Appendices (p. 81–124). Appendix A contains additional information on the SIs, sites visited, and groups interviewed, Appendix B contains selected aggregated quantitative results from the group interviews with residents and fellows, and Appendix C contains qualitative information from the group interviews and walking rounds.The CLER Program explored several aspects of resident and fellow engagement in patient safety with emphasis on 5 major topics: culture of safety, use of the patient safety event reporting system, knowledge of patient safety principles and methods, inclusion in patient safety event investigations, and disclosure of patient safety events. Generally across CLEs, members of the executive leadership team identified patient safety as their highest priority area for improvement.The patient safety and quality leaders in many CLEs indicated that they periodically conduct a culture of safety survey that includes residents, fellows, and faculty members. Overall, 97.7% of the residents and fellows in the group interviews reported that their CLE provides a safe and nonpunitive environment for reporting errors.Across CLEs, physicians and other staff members also reported use of the patient safety event reporting system to report on individual behaviors. This use included reporting on behaviors in a retaliatory fashion or in a manner that could be perceived as punitive.Given this and based on the collective findings from the site visits, it is unclear as to whether residents, fellows, and other staff members perceived a safe and nonpunitive culture for reporting patient safety events.Overall, CLEs had 1 or more mechanisms for reporting patient safety events, including an online or paper-based patient safety event reporting system, a chain-of-command system that allowed events to be reported to an immediate supervisor (eg, a more senior resident or faculty member), and a mechanism to verbally report events to the patient safety staff (eg, hotline).In general, residents and fellows appeared to be aware of their CLE's process for reporting patient safety events such as adverse events, near misses/close calls, and unsafe conditions. During walking rounds, the CLER Site Visit teams also asked nurses about their CLE's patient safety event reporting system. Across nearly all CLEs (97.2%), nurses appeared to be familiar with their CLE's system for reporting patient safety events.Approximately 78% of CLEs were able to provide information on the number of patient safety event reports submitted by residents and fellows (see Appendix C1), and 70.7% were able to provide the number of patient safety event reports submitted by attending physicians. The remaining CLEs indicated that their system did not track such information. Whereas CLEs occasionally provided the Graduate Medical Education Committee and their governing body with information on the number or percentage of patient safety event reports submitted by residents and fellows, it was less common for them to routinely report the number or percentage of patient safety event reports submitted by faculty members to these same groups.Generally across CLEs, the residents and fellows interviewed on walking rounds appeared to lack understanding and awareness of the range of reportable patient safety events, including what defines a near miss/close call. In most CLEs (83.6%), nurses' understanding of reportable patient safety events also varied (see Appendix C2).Across CLEs, residents, fellows, and nurses appeared to focus on reporting sentinel events, medication errors, patient falls, and other events with harm; they did not appear to recognize near misses/close calls, unsafe conditions, events without harm, unexpected deteriorations, or known procedural complications as reportable patient safety events. Residents, fellows, and nurses appeared to have little awareness of the importance of reporting these events and how such reporting can provide valuable information for identifying system failures, addressing vulnerabilities in the system, reducing risks, and improving patient safety.Overall, 72.7% of the residents and fellows in the group interviews indicated that they had experienced an adverse event, near miss/close call, or unsafe condition while at their CLE. This experience varied by gender, year of training, and specialty grouping (see Appendix B1).Of the residents and fellows who reported that they had experienced an adverse event, near miss/close call, or unsafe condition, 49.8% indicated that they had personally reported the patient safety event using the CLE's patient safety event reporting system. Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was 50.0% (37.5%–66.7%) and varied by region, CLE bed size, and type of ownership (see Appendix B2). For those who did not personally enter the patient safety event into the system, 13.6% indicated that they relied on a nurse to submit the patient safety event report, 24.4% indicated that they relied on a physician supervisor, and 12.1% indicated that they cared for the patient and chose not to submit a report.When faculty members and program directors in the group interviews were asked what process residents and fellows most frequently followed when reporting a patient safety event, 57.9% of the faculty members and 53.7% of the program directors indicated that they believed residents and fellows most often reported the event themselves using the CLE's patient safety event reporting system.In a separate query, 23.6% of the residents and fellows in the group interviews indicated that they had reported a near miss/close call event while at the CLE; responses varied by gender, year of training, and specialty grouping (FIGURE 1). Across CLEs, this finding ranged from 0% to 100%, with a median (IQR) of 23.1% (15.2%–33.3%); responses varied by region and type of ownership (see Appendix B3).On walking rounds, residents and fellows in many CLEs mentioned that they often report patient safety events locally or through their chain of command while also indicating familiarity with the patient safety event reporting system and its use. When they delegated or relied on others to report, it was unclear if these reports were formally captured in the CLE's centralized patient safety event reporting system. Residents and fellows mentioned the cumbersome process of submitting a report, the time needed to enter a report, fears of repercussion, and the uncertainty of receiving feedback as reasons for not reporting. The collective information from the site visits indicated that in 70.6% of the CLEs, resident and fellow reporting of patient safety events into the CLE's patient safety event reporting system was varied or infrequent (see Appendix C3).In the group interviews, the CLER teams also explored faculty members' and program directors' use of the CLE's patient safety event reporting system. Approximately 36% of the faculty members reported that they had personally reported an adverse event, near miss/close call, or unsafe condition in the past year (median [IQR], 35.7% [26.0%–46.6%] across CLEs). Among the program directors, 35.9% reported that they had personally reported an adverse event, near miss/close call, or unsafe condition in the past year (5.5% had no clinical responsibilities at the site). Across CLEs, the median (IQR) finding was 36.0% (27.3%–50.0%). In both groups, responses varied by CLE bed size and type of ownership.In the group interviews, the CLER teams asked residents and fellows whether they received feedback on patient safety event reports. Of those who had experienced an adverse event, near miss/close call, or unsafe condition and who had personally submitted a patient safety event report or relied on a nurse or supervisor to submit the report, 46.1% reported that they received feedback on the outcome of the report. Responses varied by gender, specialty grouping, and year of training (FIGURE 2; see also Appendix B4).Residents and fellows often mentioned receiving an e-mail acknowledging receipt of the patient safety event report. They also noted receiving requests for additional information as part of a formal patient safety event investigation. It was uncommon for residents to mention receiving information on the outcome of the investigation, including recommended actions to address vulnerabilities in the system and to improve patient safety. Across CLEs, residents, fellows, nurses, and other clinical staff expressed a strong desire to receive feedback in response to submitting a patient safety event report.Overall, CLEs varied in their processes for reviewing and prioritizing patient safety events. Residents and fellows also varied in their knowledge of these processes and often used the term "black box," indicating that these processes were unclear. Many residents and fellows appeared to be unaware of how their CLEs use the reporting of adverse events, near misses/close calls, or unsafe conditions to improve care both broadly and at the individual departmental level. Residents and fellows were rarely involved in their CLE's process for reviewing and prioritizing patient safety events that required further investigation.On walking rounds, the CLER teams explored resident and fellow participation in the time-out process as part of patient safety practices (eg, ambulatory and bedside procedures). Across many CLEs, residents, fellows, nurses, and other health care professionals interviewed on walking rounds indicated that residents and fellows do not consistently conduct standardized time-outs before performing bedside procedures.Across most CLEs (91.6%), residents and fellows appeared to have limited knowledge of fundamental patient safety principles and methods (eg, Swiss cheese model of system failure, root cause analysis, fishbone diagrams; see Appendix C4).When asked to identify their skills in applying patient safety principles, the majority of the faculty members indicated that they were either proficient or expert (62.7% and 25.1%, respectively) in applying these skills. Similarly, most of the program directors reported themselves as proficient or expert (63.6% and 21.9%, respectively).Of the residents and fellows in the group interviews, 36.3% reported that they had participated in a structured interprofessional simulation activity related to patient safety. Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was 37.1% (26.3%–50.0%), with responses varying by region and type of ownership.In many CLEs, the patient safety and quality leaders indicated that they did not track resident and fellow participation in patient safety event investigations (eg, root cause analysis). A limited number of CLEs provided the Graduate Medical Education Committee and the governing body with information regarding the number of residents and fellows who had participated in formal patient safety event investigations.The CLER teams also asked the program directors in the group interviews if they measured resident and fellow participation in patient safety event investigations. Approximately 42% of the program directors reported tracking resident and fellow involvement (median [IQR], 44.4% [30.0%–66.7%] across CLEs). Responses varied by region, CLE bed size, and type of ownership.In the group interviews, 37.6% of the residents and fellows who were postgraduate year 3 (PGY-3) and higher indicated that they had participated in an interprofessional investigation of a patient safety event that included components such as analysis of system issues, development and implementation of an action plan, and monitoring for continuous improvement. Reponses varied by specialty grouping (FIGURE 3). Across CLEs, the median (IQR) finding was 37.6% (28.6%–50.0%), with responses varying by region, CLE bed size, and type of ownership (see Appendix B5).The CLER teams also asked faculty members about their involvement in interprofessional patient safety event investigations. Approximately 64% of the faculty members in the group interviews reported that they had participated in an investigation of a patient safety event that involved physicians, nurses, administrators, and other health care professionals (median [IQR], 63.3% [53.0%–73.2%] across CLEs).Overall, the format and process of investigating patient safety events varied both across and within CLEs. It was uncommon for residents and fellows to describe involvement in comprehensive systems-based approaches to patient safety event investigations aimed at preventing future adverse events and sustaining improvements in patient safety. In general, residents and fellows described experiences that lacked the attributes of a formal patient safety event investigation with very little or no interprofessional or interdisciplinary engagement. Residents and fellows varied widely in their perceptions of what constituted a formal investigation of a patient safety event. Across many CLEs, case conferences, morbidity and mortality conferences, and grand rounds continued to be the major approach to patient safety event investigations.Faculty members and program directors indicated that departmental mortality conferences, case conferences, and online modules were other informal approaches to model elements of a patient safety event investigation.In the group interviews, 66.0% of the residents and fellows indicated that they had received training on disclosing medical errors to patients and/or families (4.5% reported that such training was not applicable). Responses varied by year of training. Across CLEs, the median (IQR) finding was 68.2% (57.1%–79.3%), with responses varying by region and CLE bed size. Of those who received training, 10.1% indicated that the training was primarily simulation based; 69.8%, didactic and/or online; 15.1%, informal; and 5.0%, other.Approximately 82% of the residents and fellows in the group interviews indicated that they knew of CLE resources to assist them in coping with a major patient safety event that resulted in a patient death (median [IQR], 85.8% [74.7%–93.0%] across CLEs; see Appendix B6 for information on variability). Of those familiar with the resources, most indicated that they would be somewhat (39.8%) or very comfortable (44.7%) in using these resources.The CLER Program explored resident and fellow engagement in improving health care quality within the context of 6 major areas: involvement in developing and implementing the CLE's strategies for health care quality, awareness of the CLE's health care quality priorities, knowledge of health care quality terminology and methods, engagement in quality improvement (QI) projects, access to quality metrics data, and engagement in CLE efforts to address health care disparities.As part of understanding the CLE's approach to improving health care quality, the CLER Site Visit teams reviewed the organization's strategic plan for quality and interviewed both executive and patient safety and quality leaders. Overall, a limited number of CLEs appeared to integrate QI within the organization as part of a system-wide, comprehensive approach to promote experiential learning and to improve quality and safety across the organization.Across CLEs, resident and fellow involvement in strategic planning for QI was uncommon. Residents and fellows often served as implementers of CLE-wide QI activities (eg, hand hygiene, reducing hospital-acquired infections, reducing 30-day readmissions).A limited number of CLEs had instituted resident and fellow committees aimed at increasing resident and fellow engagement in QI; few of these committees were integrated into the CLE's formal QI processes. In many CLEs, resident and fellow participation in institutional QI committees was uncommon; often, roles and expectations for participation were undefined or unclear. The clinical sites also appeared to have insufficient structure to allow residents and fellows to attend committee meetings regularly and to participate in meaningful ways. Additionally, residents and fellows in many CLEs were not included in the governing body's patient safety and quality committees.In general, priorities for improving health care quality varied across CLEs. However, some common themes included alignment with broad national priorities such as Centers for Medicare & Medicaid Services value-based purchasing, Core Measures, or publicly reported performance measures. Many were also highly focused on meeting specific criteria such as reducing 30-day readmissions or improving performance on metrics related to pneumonia, chronic heart failure, and surgical care improvement project measures.In the group interviews, 78.8% of the residents and fellows (PGY-2 and above) reported knowing their CLE's priorities for improving health care quality (see Appendix B7 for additional information on variability). When asked the same question, 84.4% of the faculty members and 86.7% of the program directors reported knowing the priorities. Often, the physician groups focused on departmental activities and did not describe priorities that aligned with those identified by the CLE's executive leadership or the patient safety and quality leaders. When the physicians identified priorities aligned with those of executive leadership, they were most commonly around nationally recognized measures, especially those related to programs with financial incentives such as measures from the Centers for Medicare & Medicaid Services.In 55.1% of the CLEs, the residents and fellows appeared to have limited knowledge or understanding of basic QI terminology and methods such as Lean, Plan-Do-Study-Act, and Six Sigma (FIGURE 4, see also Appendix C5). A limited number of residents and fellows could articulate the QI approach employed by their CLE in designing and implementing QI activities to improve patient care.In general, the approach to educating residents and fellows about health care QI varied both within and between CLEs. Although some type of education was common as part of new resident and fellow orientation, a limited number of CLEs aimed to provide ongoing training for all residents and in health care QI appeared to primarily within or medical education programs, and the methods, and appeared to of the CLEs, the patient safety and quality leaders indicated that they resident and fellow QI the group interviews with residents and fellows (PGY-2 and reported they had participated in a QI project of their design, or by their program or Of this reported that their QI project was to 1 or more of the CLE's 23.3% were Of those who reported their QI were to the CLE's reported their involved interprofessional Appendices and provide detailed information on the group interviews and on walking rounds, the CLER teams asked residents and fellows to describe their QI Overall, residents and fellows varied in their of these It was uncommon for residents and fellows to describe that aligned with their CLE's priorities. In most CLEs few described that included the components of a QI (ie, (FIGURE see also Appendix Often, resident and fellow participation was limited to planning and implementing a QI For many residents and fellows, their QI did not formally and designing actions to and ongoing QI was also uncommon for residents and fellows to describe involvement in interprofessional QI During the interviews on walking rounds, a limited number of nurses and other health care professionals indicated that they were involved in interprofessional QI that included residents and the CLER teams faculty members in the group interviews about their engagement in interprofessional QI projects, 72.7% reported that they had participated in a QI project with nurses, pharmacists, and other members of the health care team (median [IQR], across the group interviews, of the program directors reported that their residents and fellows have access to for and data for the of health clinical and or national quality were often reported as common of QI data. Residents and fellows often mentioned the (eg, in specific reports from these data Many faculty members noted that residents and fellows had limited for data When it was often a departmental The type and of to residents and fellows varied both within and across of the residents and fellows in the group interviews reported receiving aggregated or QI data on their Responses varied by gender, year of training, and specialty grouping. Across CLEs, the median (IQR) finding was with responses varying by region, CLE bed size, and type of ownership (FIGURE see also Appendix the patient safety and quality leaders indicated that residents and fellows receive QI data to the care of their patients with others served by their clinical many CLEs, executive leaders were aware of of health their Many described to improve access to care and or care and for the often by residents and fellows from a few core (eg, and A limited number of residents and fellows from other specialty and programs reported in these limited number of executive leaders to health care within their or medical Overall, less than of executive leaders described a specific set of strategies or a approach to and in the care provided to or the clinical of their patient at for health care In approximately of the CLEs, the executive faculty members, or program directors indicated that some were data or related to health care specific patient many of these efforts were reported as the group interviews, 55.1% of the residents and fellows reported that they knew their CLE's priorities in addressing in health responses varied by year of training and specialty grouping. Across CLEs, this finding ranged from to (median [IQR], Responses varied by region, CLE bed size, and type of ownership (see Appendix In of the faculty members and of the program directors reported that they knew their CLE's priorities with to health care residents, fellows, faculty members, and program directors interviewed in the group interviews were able to describe at for health care at their clinical the group interviews, of the residents and fellows reported that they had received training that was specific to at for health care at their clinical reported receiving training that was not specific to the CLE's patient reported receiving training that was primarily informal while clinical and indicated that they had not received training at their CLEs, a median (IQR) of of the residents and fellows indicated that they had received training that was specific to at for health care at their clinical site. Responses varied by region, CLE bed size, and type of ownership (FIGURE see also Appendix interviews on walking rounds, many residents and fellows described education and training in that was and not specific to the