SHINING LIGHT ON THE BLACK BOX OF ERROR REPORTING: DEVELOPMENT OF AN INTERPROFESSIONAL SAFETY HUDDLE

Jeff Greenblatt, MD1, Emmanuel King, MD2, 1Perelman School of Medicine at the University of Pennsylvania, Media, PA; 2Hospital of the University of Pennsylvania

Meeting: Hospital Medicine 2018; April 8-11; Orlando, Fla.

Abstract number: 161

Categories: Hospital Medicine 2018, Innovations, Patient Safety

Keywords: , , , ,

Background: New ACGME Core requirements require active resident engagement in patient safety. Our institution’s most recent AHRQ Culture of Safety survey revealed poor ratings from residents for closed-loop feedback on event reports they had submitted. Since hospitalists are well-positioned to foster improvement in the culture of safety, we developed an interprofessional intervention in response.

Purpose: A group of hospitalists with experience in education, operations and patient safety piloted an “Interprofessional Patient Safety Huddle” to improve feedback on resident submitted event reports and improve our perceived culture of safety.

Description: This pilot took place on the hospitalist-run general internal medicine teaching service in a large academic medical center. An interdisciplinary group including faculty, nurses and quality/patient safety specialists developed an educational session for trainees during their didactic teaching slot. Teams were composed of a senior resident (PGY-2 or PGY-3), two PGY-1s and 1-2 medical students.The first session was planned for 15-minutes, but based on feedback the subsequent session was extended to 30-minutes. Content included:1. A five minute slide presentation reviewing local data on the AHRQ survey to provide a rationale for focusing on feedback;
2. Walking through a de-identified but real trainee event report submission;
3. A step-by-step rundown on the investigation and outcome of the report; and
4. Open discussion on barriers to reporting errors and closing the feedback loop.
Participants completed a survey instrument with a 5-point Likert scale that assessed overall satisfaction, value and content of the session and any suggested changes.
A total of 28 surveys over two sessions were completed that included 4 faculty, 4 residents, 8 Interns, 5 medical students, 6 nurses and 1 quality improvement advisor. Average overall satisfaction, perceived value and content were all rated greater than 4.5. There were no significant differences among the different disciplines. Comments were generally very positive with the most common suggestion for change being more education aimed at interns on how to submit error reports.

Conclusions: A simple intervention based on small-group discussion has the potential to enhance awareness and culture around patient safety. Based on the positive results of the survey, we plan to expand this quality and safety huddle to all of the hospitalist teaching teams, and if successful, generalize to other services and sites in our health system.

To cite this abstract:

Greenblatt, J; King, ES. SHINING LIGHT ON THE BLACK BOX OF ERROR REPORTING: DEVELOPMENT OF AN INTERPROFESSIONAL SAFETY HUDDLE. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 161. https://www.shmabstracts.com/abstract/shining-light-on-the-black-box-of-error-reporting-development-of-an-interprofessional-safety-huddle/. Accessed November 16, 2019.

« Back to Hospital Medicine 2018; April 8-11; Orlando, Fla.