SHM Converge Scientific Abstract ePoster Gallery-Make It Count Twice: Combining Hospital Medicine Division Event Analysis With a Resident Patient Safety Curriculum

Pdf Summary

This poster describes a hospital medicine–resident patient safety collaboration at Thomas Jefferson University Hospital. The program integrated an internal medicine intern safety event curriculum into the hospital medicine division’s existing Patient Safety Committee to improve event review, faculty education, action planning, and follow-up.<br /><br />The process had four steps: Session 1 involved reviewing a case, building a timeline, and deciding whom to interview. During intersession work, participants interviewed staff, created flow diagrams, and brainstormed causes. In Session 2, they developed causal threads, wrote causal statements, and created action plans. Findings were then presented at a safety event report-out with stakeholders, who helped prioritize and implement changes. Loop closure occurred within three months to check progress with intern teams.<br /><br />Six near-miss or low-harm safety events were reviewed by interprofessional teams within 45 days of each event. Examples included an incorrect tube feed formula causing hyperglycemia, inappropriate PRN medication administration, delayed assessment after interhospital transfer, a fall from a chair while restrained, incorrect admission to the wrong hospital, and delayed MRI leading to delayed stroke diagnosis. Each review produced a causal statement and an action plan, and all reviews led to policy or procedure changes.<br /><br />Outcomes were favorable. Among 19 PGY1 learners surveyed, all responded. Learners reported increased reporting of safety events, better interprofessional communication, and greater awareness of institutional protocols. Thirty-five behavioral changes were identified overall. Most learners found the experience valuable, and many felt motivated to make personal safety changes. Participants also noted improved safety skills, reduced blame culture, and better alignment around safety goals.<br /><br />The authors conclude that combining resident patient safety education with an established hospital medicine safety process produced meaningful systems improvements. Key success factors were having a designated faculty leader to drive implementation and strong interprofessional collaboration.

Asset Subtitle

Sonia Bharel

Meta Tag

Author List Alexis Wickersham, Michelle Perkons, Rebecca C. Jaffe, Sonia Bharel, Timothy Kuchera

Category Innovations

Concept Patient Safety Curriculum

Concept Safety Event Review

Concept Causal Analysis

Concept Action plan

Concept System Improvement

Distinguished Non-Finalist

Presenter Organization Sidney Kimmel Medical College at Thomas Jefferson University

Presenting Author Sonia Bharel

Track Patient Safety

Keywords

patient safety

hospital medicine

resident education

internal medicine

safety event review

causal statements

action planning

interprofessional collaboration

near-miss events

policy change

Patient Safety Curriculum

Safety Event Review

Causal Analysis

Action plan

System Improvement