grmep education group: gayla jewell, phd, rnc, np linda youmans, ma, lpc 2012

FACULTY DEVELOPMENTEDUCATION PEARL

~~~~~~~~

PROMOTING AN ATTITUDE OF SAFETY

IN RESIDENTS

GRMEP Education Group:

Gayla Jewell, PhD, RNC, NP

Linda Youmans, MA, LPC

2012

What do New

Residents

think about

Safety Events?

During 2011 orientation, new residents responded to, “Making errors in medicine is inevitable.”

Responses:

Strongly Agree 12.5%

Agree 25%

Neutral 25%

Disagree 12.5%

Strongly Disagree 25%

And, “Competent physicians do not make medical errors that lead to patient harm.”

Responses:

Strongly Agree 25%

Agree 25%

Neutral 25%

Disagree 12.5%

Strongly Disagree 12.5%

2012 new residents responded to, “I am able to express safety concerns to attending and/or staff.”

Responses:

Yes 57.5%

Somewhat 37.5%

No 5%

What do these responses mean?How do you interpret that:

• over 60% new residents are neutral about or disagree that “making errors is inevitable” and

• 75% are neutral or agree that “competent physicians do not make medical errors that lead to patient harm”?

Are their expectations realistic?

Have they internalized a lack of tolerance for errors?

Do they think that only incompetent physicians make errors?

….Or that errors are not to be talked about?

Other interpretations?

How will knowing about these

responses influence your teaching and interaction with residents?

Humanize making mistakes: Describe an error you made and what you learned

Begins rounds with a “Safety Moment”

Ask the four questions to determine if experience is a safety eventWas the procedure, treatment, or test

appropriate and warranted based on nationally recognized standards of care?

Was the complication a known risk, was it anticipated, and did the care team plan ahead to take steps to prevent it?

Was the complication identified in a timely manner (i.e. at the time of occurrence)?

Was the complication treated according to the standard of care and in a timely manner?

Healthcare Performance Improvement, LLC www.hpiresults.com

Questions to determine if experience is a safety event

If answers to ALL four questions are YES, the event is a known complication and not a Safety Event

If the answer to ANY question is NO, the event is a Safety Event

Healthcare Performance Improvement, LLC www.hpiresults.com

Hospital Partners Safety/Risk Management initiatives

Spectrum Health https://insite.spectrum-health.org/Safety-Central/Pages/Home.aspx

Click on “Safety Central”

Helen DeVos Childrens Hospital http://www.helendevoschildrens.org/qualityandsafety

St Mary’s Health Centershttp://www.mercyhealthsaintmarys.com/saint-marys-quality-safety

Helpful resources

AHRQ Patient Safety Network http://psnet.ahrq.gov/primerHome.aspx

GRMEP Education Specialist Gayla.Jewell@grmep.org

GRMEP GME Advisor Linda.Youmans@grmep.org