Using a resident-led patient safety quality council to educate future QI leaders.

Resident-led councils represent an important initiative to involve trainees in patient safety, but little is known about how to create and sustain one of these councils. We evaluated the impact of a resident-led patient safety council in an internal medicine residency program. We assessed change in resident perception of safety issues over 3 years, scholarship activities, and behavioral choices to participate or lead patient safety activities after residency.The Stony Brook Internal Medicine Residency Program formed the Patient Safety and Quality Council (PSQC) in 2014, consisting of fifteen peer-nominated residents serving a three-year term. Surveys were distributed annually from 2014 to 2017 to measure resident council members' perception of patient safety. The number of safety-related abstract/publications were tracked during and one year after graduation. Additionally, graduates from the council were surveyed to assess the influence of the council on post residency involvement and leadership in safety activities.A total of 18 residents have participated in the council from 2014 to 2017. Overall, resident perception of safety culture improved. A total of 17/18 (94%) PSQC resident members demonstrated scholarship activities in safety during residency: 8/18 (44%) were engaged in an independent Quality Improvement (QI) project, 5/18 (27%) achieved a quality improvement leadership role post residency. A total of 15 of 18 (83%) recent graduates suggest that involvement with the safety council during residency fostered future involvement in patient safety.Implementation of a resident-led safety council can help to improve the safety culture, generate scholarly activities, and encourage continued participation in patient safety after graduation.

The transformation of hospital medicine to tackle the COVID-19 pandemic crisis.

The coronavirus disease 2019 (COVID-19) pandemic is placing extraordinary strains not only on hospital-wide systems but most especially on hospital medicine across the nation. The specific challenges faced by our hospitalist services are unfathomable. Hospitalist leaders are tasked to rapidly restructure clinical operations to accommodate the large surge in COVID-19 patients. In this perspective, we focus on the management strategies conducted by the Division of Hospital Medicine to tackle the major crisis that specifically impacted the general medicine services.

A resident-led initiative to improve patient safety event reporting in an internal medicine residency program.

BACKGROUND: Despite the Clinical Learning Environment Review's recommendations of their use, patient safety event reporting systems are underutilized by residents. OBJECTIVE: We aimed to identify perceived barriers to event reporting amongst internal medicine residents and implement a targeted quality improvement initiative to address the identified barriers and increase overall resident event report rates. METHODS: A total of 94 Internal Medicine (IM) residents participated in the educational intervention in 2018. We measured residents' perception of barriers to event reporting and employed the results of the questionnaire to create a skill-based educational workshop. We conducted the plan-do-study-act model to test a structured educational intervention and its effectiveness on pre-post IM residents' event report rates and compared it to report rates of Non-Internal Medicine (Non-IM) residents. Additionally, we assessed pre-post intervention knowledge, skills, and attitudes in event reporting. RESULTS: 94/94 (100%) of IM residents had a significantly higher median percent of patient safety event reporting when compared to pre-intervention (23.6% compared to 5.88%, p-value = 0.0030) and when compared to Non-IM residents (23.6% compared to 5.31%, p-value = 0.0002). Residents performed better on the post-test compared to the pre-test (90% compared to 30%, p-value = 0.0001) for knowledge. 100% of the critical action items were completed and 90% of participants reported their perception of the event reporting process improved. CONCLUSIONS: By elucidating common reasons why residents are not reporting patient safety events, a specific intervention can be created to target the identified impediments and improve resident event reporting. ABBREVIATIONS: IM: Internal Medicine IM; Non-IM: Non-Internal Medicine; IOM: Institute of Medicine I; ACGME CLER: Accreditation Council for Graduate Medical Education Clinical Learning Environment Review; GME: Graduate Medical Education; IRB: Institutional Review Board; PDSA: Plan, Do, Study, Act.

Using the jigsaw technique to teach patient safety.

Background: Medical education is rapidly changing where there has been decreased emphasis on passive didactics and increased focus on novel modes of teaching and learning to address the unique needs of millennial learners. As educators, it is challenging to keep up and find active teaching strategies outside of routine small group exercises to engage learners. Although the traditional small group activities, such as cased-based learning, allows for interactive and effective teaching, this modality may require the use of multiple faculty facilitators, which can be a difficult resource to find. The jigsaw learning method is cooperative learning that utilizes peer teaching and promotes collaborative learning, and additionally, only one facilitator is required of this type of learning technique.Objectives: We aimed to assess the effectiveness of the jigsaw method by comparing it to the traditional small group learning method to teach principles of diagnostic reasoning. Design: Residents were assigned to either the traditional small group teaching method or the jigsaw method. We compared pre-test, post-test, one-year follow-up test results between participants, and resident perception of the exercises.Results: A 2 × 3 repeated measures ANOVA indicated statistically significant improvement in tests scores from before to after participation with the jigsaw method compared to the traditional small group method. Post-survey demonstrated higher resident satisfaction with the jigsaw method.Conclusion: Our study demonstrates that a jigsaw cooperative learning approach can be used as an effective method to promote collaborative learning and engagement.

Outcomes of a Resident-Led Early Hospital Discharge Intervention.

BACKGROUND: Early morning patient discharge from the hospital is increasingly being recognized as a key dimension of quality of care. At our institution, there is a significantly lower early discharge rate on the teaching hospitalist teams in comparison with the non-teaching teams. OBJECTIVE: To implement a resident-driven intervention in the teaching medical services to increase overall discharge order rate before 11 am (DOB-11) and assess the effect of this intervention on hospital length of stay (LOS), 30-day readmission rates (RR), and resident perception. DESIGN: Interrupted time series as well as controlled before-after designs. PARTICIPANTS: All inpatients discharged from general medicine units. INTERVENTIONS: We implemented an educational didactic in conjunction with resident-attending daily walk rounds followed by resident-led multidisciplinary discharge huddles to identify next-day discharges. MAIN MEASURES: The primary outcome was DOB-11 rates 18 months pre- and 12 months post-intervention. SECONDARY OUTCOMES: LOS and RR. Additionally, we assessed residents' perception of the early discharge protocol. KEY RESULTS: The DOB-11 rate increased from 12 to 29% (p < 0.001), LOS increased by 1.47 days (P < 0.001), and RR increased by 0.32% (P = 0.84), respectively, on the teaching teams. Compared with the non-teaching (control) teams, the teaching teams registered a greater increase in DOB-11 rate (by 17%, p < 0.001; ratio of adjusted ORs 2.16; 95% CI, 1.65, 2.85; p value < 0.001), small increase in LOS (by 0.74 day, p = 0.39; ratio of adjusted post-/pre-intervention ratio [teaching] and post-/pre- intervention ratio [non-teaching] = 1.05, 95% CI, 0.97, 1.14, p = 0.23), and relative increase in RR (by 3.98%, p = 0.07, and ratio of ORs = 1.35, 95% CI, 1.03, 1.8), p = 0.03). Approximately 55% (16/29) of the residents agreed that the early discharge initiative helped in understanding the importance of prioritizing patients for early discharge. Additionally, 55% (20/36) of the residents "agreed" that the early discharge initiative compromised their learning during teaching rounds. CONCLUSION: Our study demonstrates that DOB-11 is an achievable goal, not only for non-teaching teams but also for resident-run teaching teams.

Using near-miss events to improve MRI safety in a large academic centre.

Near-miss events represent an opportunity to identify and correct errors that jeopardise patient safety. The MRI environment poses potential safety threats and is frequently associated with near misses or adverse events related to improper safety screening for presence of cardiac pacemakers and other potential contraindications. At our institution, MRI safety screening lacked a formalised structure and standardisation; the process relied on a single-step safety screening process. As a result, we observed a significant number of near misses associated with improper MRI screening that resulted in 'close calls' in patients with incompatible metals implants. The purpose of this project was to use a quality improvement approach to analyse the near-miss pattern and create a multistep intervention to decrease the number of near misses associated with MRI screening and to ultimately decrease the potential for patient harm. Using the Plan-Do-Study-Act model, we decreased the number of MRI near misses from 22 to zero near misses in 1 year after implementation. The project demonstrates successful transformation of near misses to a never event: a reportable event that should never happen. The project also demonstrates the importance in targeting and prioritising a pattern of near misses, which are unplanned events that do not result in injury but had great potential to do so.

A Day Seven Reflection Circle to Enhance Resilience in Residents after a Difficult Patient Loss.

This article was migrated. The article was marked as recommended. Caring for the dying patient can have significant impact on physicians in training, and if unaddressed, can lead to burnout and potentially compromised patient care. The literature suggests didactics and real time supportive interventions such as "post code debriefs" may be most effective in addressing the impact of death on physicians. In this paper, we highlight and discuss a reflection that is conducted several days after the event, when resident physicians are more self-aware of their mental hygiene and the residual impact of challenging event on their personal and professional well-being.

Effectiveness of an interprofessional patient safety team-based learning simulation experience on healthcare professional trainees.

BACKGROUND: Although the American Council of Graduate Medical Education (ACGME) mandates formal education in patient safety, there is a lack of standardized educational practice on how to conduct patient safety training. Traditionally, patient safety is taught utilizing instructional strategies that promote passive learning such as self-directed online learning modules or didactic lectures that result in suboptimal learning and satisfaction. METHODS: During the summer of 2015, 76 trainees consisting of internal medicine interns and senior-level nursing students participated in an interactive patient safety workshop that used a flipped classroom approach integrating team based learning (TBL) and interprofessional simulated application exercises. RESULTS: Workshop trainees demonstrated an increase in knowledge specifically related to patient safety core concepts on the Team Readiness Assurance Test (TRAT) compared to the Individual Readiness Assurance Test (IRAT) (p = 0.001). Completion rates on the simulation application exercises checklists were high except for a few critical action items such as hand-washing, identifying barriers to care, and making efforts to clarify code status with patient. The Readiness for Interprofessional Learning Scale (RIPLS) subscale scores for Teamwork and Collaboration and Professional Identity were higher on the post-workshop survey compared to the pre-workshop survey, however only the difference in the Positive Professional Identity subscale was statistically significant (p = 0.03). A majority (90%) of the trainees either agreed that the safety concepts they learned would likely improve the quality of care they provide to future patients. CONCLUSIONS: This novel approach to safety training expanded teaching outside of the classroom and integrated simulation and engagement in error reduction strategies. Next steps include direct observation of trainees in the clinical setting for team-based competency when it comes to patient safety and recognition of system errors.

A Patient with Nafcillin-Associated Drug-Induced Liver Failure.

Nafcillin-induced acute liver injury is a rare and potentially fatal complication that has been known since the 1960s but inadequately studied. At this time, the only proven treatment is early discontinuation of the drug. Because of the high prevalence of nafcillin class antibiotic use in the United States, it is important for clinicians to have a high clinical suspicion for this diagnosis. We present a case of liver failure attributable to nafcillin use in a 68-year-old male with a history methicillin-sensitive Staphylococcus and L3/L4 osteomyelitis. After starting long-term antibiotic therapy, he presented with painless jaundice which necessitated discontinuation of the drug. At the time of presentation, the patient's lab work exhibited a bilirubin/direct bilirubin of 9.4/8.2 mg/dL, alkaline phosphatase of 311 IU/L, and aspartate transaminase/alanine transaminase of 109/127 IU/L. The patient was switched to i.v. vancomycin given the concern for drug-induced liver injury. Imaging did not show obstruction of the hepatobiliary or pancreaticobiliary trees. Serology was unremarkable for viral etiology, autoimmune processes, Wilson disease, and hemochromatosis. A liver biopsy showed findings consistent with drug-induced liver injury. The patient's liver function tests peaked at day 7 of admission and trended towards normal levels with cessation of nafcillin therapy. The patient was discharged with a diagnosis of nafcillin-induced acute liver injury. Our case highlights the importance of early recognition of the diagnosis and careful monitoring of liver function when nafcillin is employed in the clinical setting.

A Quality Improvement Approach to Standardization and Sustainability of the Hand-off Process.

There is mounting evidence that communication and hand-off failures are a root cause of two-thirds of sentinel events in hospitals. Several studies have shown that non-standardized hand-offs have yielded poor patient outcomes and adverse events. At Stony Brook University Hospital, there were numerous reported adverse events related to poor hand-off during the transfer of patient responsibility from one resident caregiver to the next. A resident-conducted root cause analysis identified lack of a standardized hand-off process and formal training on safe and efficient hand-off among caregivers as key contributing factors. This quality improvement project used the PDSA methodology to test the use of a standardized method, the IPASS mnemonic, and compare it to our conventional hand-off method in our internal medicine residency program. The main goals of this study were to test the feasibility and effectiveness of a standardized I- PASS hand-off and to create a robust sustainability model that includes 1) integration of I-PASS handoff in the Electronic Medical Record (EMR), 2) direct observation of the hand-off process by faculty and senior residents, and 3) surveillance and reporting of hand-off compliance scores. Compared to hand-off with a conventional method, the use of the I-PASS method resulted in significantly fewer reported adverse events (χ2=4.8, df=1, p=0.04). I-PASS was successfully integrated into our EMR system and residents were mandated to use this as the sole method of hand-off. An EMR audit conducted six months after implementation revealed poor compliance, which ultimately led to the creation of a sustainability model that improved overall compliance from 60% to 100%.

Improving transitions of care: a resident-driven approach to address delays in patient care during the direct admission process.

BACKGROUND: The direct admission process is a complex system that can be aggravated by inherent gaps in communication leading to inefficient continuity of care and patient safety issues. Bypassing the emergency room, triage is often associated with long periods of unmonitored observation and significant delays in patient assessment. We identified significant communication gaps, delays in placement of admission orders and patient assessment during the direct admission process at our institution. To address this issue, we created and implemented a standardised direct admission flow diagram that consists of a step-by- step direct admission process, which includes a communication device and a triage power plan in the Electronic Medical Record. METHODS: We used the Plan-Do-Study-Act (PDSA) model for Quality improvement to address communication gaps in the direct admission process Baseline measurement confirmed two critical gaps in communication: 1) communication to the Medical Admitting Resident (MAR), the central source of communication of all medicine admissions, and 2) delays in placement of orders and assessment of the patient. RESULTS: Two months after implementation of a standardised process that addressed the two major gaps in communication, we found that communication to the MAR increased from 16% (7/42) to 100% (15/15). Additionally, the average time for order placement and assessment of patient decreased from 153 minutes to 53 minutes (n=15). CONCLUSION: In order to improve the safety of direct admissions, the entire process must be carefully analysed and potential delays in patient assessment should be minimised. A standardised flow diagram that identified and targeted specific communication gaps can minimise delays in patient care.

Teaching Patient Safety Using an Interprofessional Team-Based Learning Simulation Model in Residency Training.

INTRODUCTION: Teaching and learning patient safety require demonstration of competencies such as teamwork, communication skills, and recognition of systems error. This patient safety TBL simulation-training program was developed to fulfill core patient safety objectives outlined by the ACGME and ACGME Clinical Learning Environment Review Program. The goal of the program is to enhance patient safety and quality care concepts and facilitate hands-on teamwork skills and core attitudes towards patient safety. This program served as a mandatory part of the residency core curriculum. METHODS: It was delivered as a 3-hour workshop session during medicine resident orientation. The workshop included an introductory presentation, one TBL activity, and three 1-hour interprofessional simulated application cases using either high-fidelity mannequins or standardized patients. Following each application case activity, trainees participated in a postcase scenario debriefing moderated by faculty facilitators. RESULTS: A total of 76 trainees participated, and 20 interprofessional teams were created. An independent-samples t test revealed that the Group Readiness Assurance Test scores were significantly higher than the Individual Readiness Assurance Test scores. Although the Readiness for Interprofessional Learning Survey's Teamwork and Professional Identity subscale scores were higher postworkshop compared to preworkshop, the differences were not statistically significant. Over 90% of the participants agreed that the safety concepts they learned would likely improve the quality of care they provide to future patients. DISCUSSION: A simulation model centered on an interprofessional team can be used as an important training technique to teach health care professionals realistic, hands-on principles of patient safety.

Learning From Errors: Curriculum Guide for the Morbidity and Mortality Conference With a Focus on Patient Safety Concepts.

INTRODUCTION: Morbidity and mortality conferences are Accreditation Council for Graduate Medical Education-required educational series that are part of all residency training programs. This conference offers trainees an opportunity to discuss patient cases where errors or complications may have occurred. Conventionally, most of the allotted time is spent on case presentation and therapeutic debates, which is a lost opportunity to teach fundamental principles of patient safety, error analysis, and strategies for system-wide improvement. The goal of this resource is to refocus the content of morbidity and mortality and transform it into a platform for teaching patient safety principles and emphasizing error reduction strategies. METHODS: It was delivered as a 1-hour workshop session once a month during usual conference times. The workshop includes a mortality case review followed by a small-group activity in which trainees are assigned specific safety tasks, including systematic analysis of an error, conducting root cause analysis, and resident peer review. RESULTS: Postsurveys demonstrated that 90% of the trainees either agreed or strongly agreed that the safety concepts they learned would likely improve the quality of care they provide to future patients. DISCUSSION: We learned that morbidity and mortality could be used to effectively teach principles of patient safety and could create system-wide improvements.