Resident reflections on adverse events: a baseline assessment

Abstract

Context and setting Quality of care and patient safety are essential components of optimal health care. In recognition of the need for improved education in these principles, practice-based learning and improvement (PBLI) and systems-based practice (SBP) have been endorsed by the Accreditation Council for Graduate Medical Education (ACGME) as 2 core competencies required for successful graduate medical education in the USA. As a participant in the ACGME Educational Innovations Project, our internal medicine residency programme is developing innovative educational approaches aimed at educating our residents to improve patient care. Why the idea was necessary Implicit in the PBLI and SBP competencies, and a necessary skill for quality improvement, is the ability to identify improvement opportunities within one's individual practice and the health care system. Little is known about residents' ability to identify opportunities for health care improvement. This study was conducted to obtain baseline data at the beginning of residents' postgraduate training on their ability to identify, describe and classify improvement opportunities. What was done The practice-based improvement log (PBIL) was created as a tool to solicit resident reflections on recent patient care events in which they had participated during their medical school training which could have been improved upon. Log completion includes the resident's description of an adverse patient care event and his or her perception of the event's severity and preventability and contributing personal and systems factors. The PBIL was distributed to all incoming categorical and preliminary internal medicine residents at a large academic medical centre during orientation for the 2005–06 academic year. Evaluation of results and impact A total of 73 residents (97%) completed the PBIL. Resident reflections classified 25 (34%) of the reported events as moderately severe or severe; 9 (12%) of the described events resulted in patient death. A total of 68 (93%) of the events described were considered to be preventable. Residents ascribed errors largely to personal factors (41%), team factors (22%), and factors related to the patient's condition (15%), with 8%, 12% and 2% assigned to systems, institutional and regulatory factors, respectively. Resident logs each identified multiple specific personal, team and systems factors that could have prevented or mitigated the described events. Personal factors identified by residents that could have prevented or mitigated the described incidents included more experience (71%), better situational awareness (63%), better judgement (56%) and improved knowledge (52%). Team factors identified included improved communication between doctors (45%), improved communication between doctors and allied health and/or nursing staff (41%), and better transfer of care (27%). Potentially mitigating systems factors identified by residents included better information technology (30%), more workable policy/procedures (27%), better support or supervision (26%), and improved response to early warning signs (25%). This baseline assessment of resident PBIL reflections indicates that entering internal medicine residents can recognise significant improvement opportunities with both personal and systems-level implications. However, our results indicate that residents may attribute errors to personal rather than systems factors. This implies a need for greater attention to systems-based educational initiatives, which are currently underway at our institution.