SHM Converge Scientific Abstract ePoster Gallery-Fostering Active Learning of Patient Safety by Offering Physicians Continuing Medical Education Credit for Particpation in Root Cause Analyses

Fostering Active Learning of Patient Safety by Offering Physicians Continuing Medical Education Credit for Particpation in Root Cause Analyses

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This document describes a pilot program at Mount Sinai Beth Israel that turned weekly root cause analyses (RCAs) of real adverse events into an active learning opportunity for physicians by offering continuing medical education (CME) credit. RCAs were already conducted as one-hour virtual interdisciplinary meetings focused on identifying system causes rather than blaming individuals. Physicians were often invited for clinical input, and the team used this setting to teach patient safety principles in a practical, case-based way.<br /><br />The innovation was to award one AMA PRA Category 1 Credit for each RCA attended. The course was approved by the CME office and supported by a “train-the-trainer” model: course directors from quality and patient safety leadership oversaw 10 physicians trained in RCA principles. Learning objectives included applying patient safety concepts, using process maps and causal trees, and taking a systems approach to adverse event investigation. Educational themes included RCA methodology, high reliability, just culture, the Swiss cheese model, and the Five Whys.<br /><br />In the first four months, during 16 RCAs, 35 CME credits were awarded to 13 unique physicians across seven departments. Three RCAs did not offer CME because of technical or administrative issues. The program demonstrates that CME can be integrated into adverse event review processes at an urban tertiary care teaching hospital. The authors suggest this approach may help address the limited participation of faculty in safety event reviews and may improve engagement in patient safety learning. The next planned step is to explore Maintenance of Certification (MOC) credit.

Asset Subtitle

Daniel I. Steinberg

Meta Tag

Author List Bonnie Portnoy, Brijen Shah, Daniel I. Steinberg, Judith Block, Marian Bain, Paul Yu, Peter Brodhead

Category Innovations

Concept Root Cause Analysis

Concept Adverse Event

Concept Patient Safety

Concept Systems Approach

Concept Just Culture

Distinguished Non-Finalist

Presenter Organization Icahn School of Medicine at Mount Sinai

Presenting Author Daniel I. Steinberg

Track Patient Safety

Keywords

root cause analysis

CME credit

patient safety

adverse events

physician education

quality improvement

systems approach

high reliability

just culture

Swiss cheese model

Root Cause Analysis

Adverse Event

Patient Safety

Systems Approach

Just Culture