SHM Converge Scientific Abstract ePoster Gallery-Closing the Loop: Utilizing Peer Education and Sharing Safety Solutions to Increase Resident Error Reporting

Pdf Summary

This quality improvement project aimed to increase error reporting by internal medicine residents, recognizing that reporting is essential to hospital safety but often underused by trainees. Prior research showed residents face barriers such as not knowing how to submit reports and not seeing how reporting leads to improvement.<br /><br />Using Plan-Do-Study-Act cycles, chief residents led two main interventions: regular education on how to use the hospital’s electronic error reporting system, and a “Close-The-Loop” feedback program that shared investigation outcomes back with residents who reported concerns. Educational efforts included emails, reminders, and onboarding teaching. The reporting system itself was also migrated in December 2020, but this change alone did not appear to increase reporting.<br /><br />Resident-reported safety events were tracked through the hospital system. Before the interventions, Medicine residents submitted 35 reports total, or 3.2 per month. After the interventions, reporting increased to 87 total reports, or 7.9 per month, a statistically significant rise (p=0.03).<br /><br />The most commonly reported concerns involved patient triage (21.8%), communication problems (20.7%), and treatment delays (19.5%). The authors concluded that residents often voice concerns to peers or chief residents without realizing these issues should be formally reported. Education plus feedback on what happened after reporting helped close that gap and improved resident engagement in safety reporting.<br /><br />Limitations included reliance on self-identified reports, since anonymous reports could not be attributed to residents, and possible effects from COVID-related disruptions to inpatient training. Overall, the project suggests that combining peer education with feedback on safety investigations can meaningfully increase resident reporting and strengthen safety culture.

Asset Subtitle

Vinh-Tung P. Nguyen

Meta Tag

Author List Ali Mustafa, Emily Leven, Vinh-Tung P. Nguyen

Category Innovations

Concept Resident Error Reporting

Concept Patient Safety Program

Concept Safety Event Report

Concept Close-the-Loop Feedback Program

Concept Clinical Learning Environment

Distinguished Finalist

Presenter Organization Division of Hospital Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai

Presenting Author Vinh-Tung P. Nguyen

Track Quality Improvement

Keywords

quality improvement

resident error reporting

patient safety

internal medicine residents

electronic reporting system

close-the-loop feedback

PDSA cycles

safety culture

communication problems

treatment delays

Resident Error Reporting

Patient Safety Program

Safety Event Report

Close-the-Loop Feedback Program

Clinical Learning Environment