A Multifaceted Intervention to Increase Surgery Resident Engagement in Reporting Adverse Events

Abstract

Background: Although most residents have been involved in an adverse or near-miss event, they are not likely to report these incidents. To improve the culture of patient safety and to increase adverse event reporting among General Surgery residents, a multifaceted intervention focused on education, feedback, and event resolution was developed and implemented.

Methods: Adverse events involving surgery patients at Boston Medical Center were monitored for 2 months before and for 10 months after implementation of the intervention in May 2014.

Results: There was a significant increase in the number of adverse events reported by residents, from 0 to 30 per 2-month period (χ(2) = 8.56, p = 0.003). The classification types of reports filed by residents differed significantly from those of incidents submitted by other reporters (p < 0.0001).

Conclusion: An intervention focused on addressing barriers to reporting adverse events can significantly increase the volume of incidents reported by surgery residents. Involving residents in patient safety efforts may enhance an institution's ability to identify adverse events and to improve the overall culture of care.

Keywords: Patient Care; Practice-Based Learning and Improvement; Systems-Based Practice; adverse event reporting; clinical learning environment review; patient safety; resident education.