Monica Mattes poster.pptxImproving Pediatric Resident Safety Event Reporting Using Quality Improvement Methods
Improving Pediatric Resident Safety Event Reporting Using Quality Improvement Methods
Monica D. Mattes, MD, Hadley S. Sauers-Ford, MPH, CCRP, Denise Selleck, MSN, RN, Christina Slee, MPH, Joanne E. Natale, MD, PhD, Jennifer L. Rosenthal, MD, MAS
Monica D. Mattes, MD, Hadley S. Sauers-Ford, MPH, CCRP, Denise Selleck, MSN, RN, Christina Slee, MPH, Joanne E. Natale, MD, PhD, Jennifer L. Rosenthal, MD, MAS
Oral Presentation
Oral Presentation
Monica Mattes.m4aBackground: Safety event reporting systems facilitate identification of system-level targets to improve patient safety. Resident physicians report few safety events despite their role as front-line providers and the frequent occurrence of events.
Background: Safety event reporting systems facilitate identification of system-level targets to improve patient safety. Resident physicians report few safety events despite their role as front-line providers and the frequent occurrence of events.
Objective: To increase the number of pediatric resident safety event submissions from <1 to 4 submissions per 14-day period within 12 months.
Objective: To increase the number of pediatric resident safety event submissions from <1 to 4 submissions per 14-day period within 12 months.
Methods: We conducted an iterative quality improvement process with 39 pediatric residents at a children’s hospital. Interventions focused on four key drivers: user-friendly event submission process, resident buy-in, non-punitive safety culture, and data transparency. The primary outcome measure of number of pediatric resident event submissions was analyzed using statistical process control. Balancing measures included time from submission to feedback, duplicate submissions, and non-event submissions. As a control, the primary outcome measure was monitored for non-pediatric residents during the same period.
Methods: We conducted an iterative quality improvement process with 39 pediatric residents at a children’s hospital. Interventions focused on four key drivers: user-friendly event submission process, resident buy-in, non-punitive safety culture, and data transparency. The primary outcome measure of number of pediatric resident event submissions was analyzed using statistical process control. Balancing measures included time from submission to feedback, duplicate submissions, and non-event submissions. As a control, the primary outcome measure was monitored for non-pediatric residents during the same period.
Results: Mean number of pediatric resident event submissions increased from 0.9 to 5.7 submissions per 14 days. Impactful interventions included a designated space in the resident workroom to list safety events to submit, monthly emails with project data, and an inter-resident competition. There were no duplicate submissions or non-event submissions in the post-intervention period. Time from submission to feedback was shorter for pediatric residents in comparison to non-pediatric residents. The control group showed no sustained change in event submissions.
Results: Mean number of pediatric resident event submissions increased from 0.9 to 5.7 submissions per 14 days. Impactful interventions included a designated space in the resident workroom to list safety events to submit, monthly emails with project data, and an inter-resident competition. There were no duplicate submissions or non-event submissions in the post-intervention period. Time from submission to feedback was shorter for pediatric residents in comparison to non-pediatric residents. The control group showed no sustained change in event submissions.
Conclusions: Our improvement process was associated with significant increase in pediatric resident safety event submissions without an increase in the number of submissions categorized as duplicates or non-events. This project provided increased awareness of patient safety events.
Conclusions: Our improvement process was associated with significant increase in pediatric resident safety event submissions without an increase in the number of submissions categorized as duplicates or non-events. This project provided increased awareness of patient safety events.
Resident Statement of Involvement: Conceptualized and designed the study, led the multidisciplinary improvement team, led the implementation of interventions, drafted the manuscript.
Resident Statement of Involvement: Conceptualized and designed the study, led the multidisciplinary improvement team, led the implementation of interventions, drafted the manuscript.