Patient Safety Event Reporting and Opportunities for Emergency Medicine Resident Education
| Autor: | Anne Jackson, Nastassia M. Savage, Angela B Creditt, Regina K. Senn, Robin R. Hemphill, Michael J. Vitto, Harinder S. Dhindsa, V. Ramana Feeser, Timothy Layng, Sally A. Santen |
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| Rok vydání: | 2019 |
| Předmět: |
Safety Management
Psychological intervention MEDLINE lcsh:Medicine 03 medical and health sciences Patient safety 0302 clinical medicine Medicine Humans 030212 general & internal medicine Original Research Risk Management Event (computing) business.industry lcsh:R lcsh:Medical emergencies. Critical care. Intensive care. First aid Virginia Internship and Residency 030208 emergency & critical care medicine lcsh:RC86-88.9 General Medicine medicine.disease EXPOSE Subject-matter expert Harm Emergency Medicine Medical emergency Patient Safety business Root cause analysis Emergency Service Hospital |
| Zdroj: | Western Journal of Emergency Medicine Western Journal of Emergency Medicine, Vol 21, Iss 4 (2020) |
| ISSN: | 1936-9018 |
| Popis: | Introduction: Healthcare systems often expose patients to significant, preventable harm causing an estimated 44,000 to 98,000 deaths or more annually. This has propelled patient safety to the forefront, with reporting systems allowing for the review of local events to determine their root causes. As residents engage in a substantial amount of patient care in academic emergency departments, it is critical to use these safety event reports for resident-focused interventions and educational initiatives. This study analyzes reports from the Virginia Commonwealth University Health System to understand how the reports are categorized and how it relates to opportunities for resident education. Methods: Identifying categories from the literature, three subject matter experts (attending physician, nursing director, registered nurse) categorized an initial 20 reports to resolve category gaps and then 100 reports to determine inter-rater reliability. Given sufficient agreement, the remaining 400 reports were coded individually for type of event and education among other categories. Results: After reviewing 513 events, we found that the most common event types were issues related to staff and resident training (25%) and communication (18%), with 31% requiring no education, 46% requiring directed educational feedback to an individual or group, 20% requiring education through monthly safety updates or meetings, 3% requiring urgent communication by email or in-person, and |
| Databáze: | OpenAIRE |
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