Dunbar Alston E, Cupit Marcie, Vath Richard J, Pontiff Kyle, Evans Natalie, Roy Melissa, Bolton Michael
Division of Pediatrics, Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana;
Division of Health and Safety, and.
Pediatrics. 2017 Feb;139(2). doi: 10.1542/peds.2015-3807.
Patient safety events are underreported by physicians. Baseline data demonstrated that physicians submitted 3% of event reports at Our Lady of the Lake Children's Hospital. Our aim was to increase the proportion of safety reports filed by residents and faculty to 6% of all reports within a 9-month period.
We used the Model for Improvement and serial Plan, Do, Study, Act cycles to test interventions we hypothesized would improve physician recognition and reporting of patient safety events. We tracked the percentage of Our Lady of the Lake Children's Hospital event reports entered by residents or faculty over time as the primary outcome measure. Changes to teaching team processes included "patient safety rounds" prompted by text messages, an inpatient "superintendent" rotation with core patient safety responsibilities, and a "just-in-time" faculty development program called "QI on the Fly."
Physician-reported events increased to a monthly average of 24% of all events reported, an improvement that has been sustained over 17 months. Resident reporting accounted for most of the increase in physician reports. Increased physician reporting was temporally associated with implementation of the "superintendent" rotation. The total number of events reported increased as a result of increased physician reporting.
Incorporating patient safety responsibilities into a teaching team's workflow can increase physician safety event reporting. We plan additional Plan, Do, Study, Act cycles to spread this approach to other clinical settings and investigate the impact increased reporting might have on patient care.
医生对患者安全事件的报告不足。基线数据显示，在湖滨圣母儿童医院，医生提交的事件报告仅占3%。我们的目标是在9个月内将住院医师和教职员工提交的安全报告比例提高到所有报告的6%。
我们采用改进模型和连续的计划、执行、研究、行动循环来测试我们假设能改善医生对患者安全事件的认知和报告的干预措施。我们将随着时间推移由住院医师或教职员工录入的湖滨圣母儿童医院事件报告的百分比作为主要结果指标进行跟踪。教学团队流程的改变包括通过短信推动的“患者安全查房”、具有核心患者安全职责的住院“主管”轮转，以及一个名为“即时质量改进”的“即时”教职员工发展项目。
医生报告的事件增加到每月平均占所有报告事件的24%，这一改善已持续了17个月。住院医师报告的增加占医生报告增加的大部分。医生报告的增加在时间上与“主管”轮转的实施相关。由于医生报告的增加，报告的事件总数也增加了。
将患者安全职责纳入教学团队的工作流程可以增加医生对安全事件的报告。我们计划进行更多的计划、执行、研究、行动循环，以将这种方法推广到其他临床环境，并研究报告增加可能对患者护理产生的影响。
