Document Detail


A novel approach to increase residents' involvement in reporting adverse events.
MedLine Citation:
PMID:  21512369     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
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.
Authors:
David R Scott; Melissa Weimer; Clea English; Lynn Shaker; William Ward; Dongseok Choi; Andrea Cedfeldt; Donald Girard
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Publication Detail:
Type:  Clinical Trial; Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Academic medicine : journal of the Association of American Medical Colleges     Volume:  86     ISSN:  1938-808X     ISO Abbreviation:  Acad Med     Publication Date:  2011 Jun 
Date Detail:
Created Date:  2011-05-26     Completed Date:  2011-08-04     Revised Date:  2012-05-03    
Medline Journal Info:
Nlm Unique ID:  8904605     Medline TA:  Acad Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  742-6     Citation Subset:  AIM; IM    
Affiliation:
Department of Medicine, Portland Veteran Affairs Medical Center and Oregon Health & Science University, 3181 SW Sam Jackson Park Road OP-30, Portland, OR 97239-3098, USA. scottdav@ohsu.edu
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MeSH Terms
Descriptor/Qualifier:
Humans
Internship and Residency*
Linear Models
Oregon
Physician Incentive Plans*
Program Evaluation
Prospective Studies
Quality Improvement*
Risk Management*
Comments/Corrections
Comment In:
Acad Med. 2012 Apr;87(4):389-90; author reply 390   [PMID:  22452909 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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