J.B. Ziemba is assistant professor and assistant program director, Division of Urology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ORCID: http://orcid.org/0000-0002-0962-2055 .
J.S. Berns is associate dean for graduate medical education and professor, Division of Renal-Electrolyte and Hypertension, Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Acad Med. 2021 Jul 1;96(7):997-1001. doi: 10.1097/ACM.0000000000004064.
The Accreditation Council for Graduate Medical Education calls for resident participation in real or simulated interprofessional analysis of a patient safety event. There are far more residents who must participate in these investigations than available institutional root cause analyses (RCAs) to accommodate them. To correct this imbalance, the authors developed an institutionally sponsored, interprofessional RCA simulation program and implemented it across all graduate medical education (GME) residency programs at the Hospital of the University of Pennsylvania.
The authors developed RCA simulations based upon authentic adverse events experienced at their institution. To provide relevance to all GME programs, RCA simulation cases varied widely and included examples of errors involving high-risk medications, communication, invasive procedures, and specimen labeling. Each simulation included residents and other health care professionals such as nurses or pharmacists whose disciplines were involved in the actual event. Participants adopted the role of RCA investigation team, and in small groups systematically progressed through the RCA process.
A total of 289 individuals from 18 residency programs participated in an RCA simulation in 2019-2020. This included 84 interns (29%), 123 residents (43%), 20 attending physicians (7%), and 62 (21%) other health care professionals. There was an increase in ability of GME trainees to correctly identify factors required for an RCA investigation (62% pre vs 80% post, P = .02) and an increase in intent to "always report" for each adverse event category (3% pre vs 37% post, P < .001) following the simulation.
The authors plan to expand the RCA simulation program to other GME clinical sites while striving to involve all GME learners in this educational experience at least once during training. Additionally, by collaborating with health system patient safety leaders, they will annually review all new RCAs to identify cases suitable for simulation adaptation.
毕业后医学教育认证委员会要求住院医师参与真实或模拟的跨专业患者安全事件分析。必须有更多的住院医师参与这些调查，而现有的机构根本原因分析 (RCA) 无法容纳所有参与的住院医师。为了纠正这种不平衡，作者开发了一个机构赞助的跨专业 RCA 模拟项目，并在宾夕法尼亚大学医院的所有住院医师规范化培训 (GME) 住院医师项目中实施。
作者根据机构内发生的真实不良事件开发了 RCA 模拟。为了使所有 GME 项目都具有相关性，RCA 模拟案例差异很大，包括涉及高风险药物、沟通、侵入性程序和标本标记的错误示例。每个模拟都包括住院医师和其他医疗保健专业人员，如护士或药剂师，他们的专业涉及实际事件。参与者扮演 RCA 调查团队的角色，并在小组成员中系统地逐步完成 RCA 流程。
在 2019-2020 年期间，来自 18 个住院医师项目的 289 人参加了 RCA 模拟。其中包括 84 名实习生（29%）、123 名住院医师（43%）、20 名主治医生（7%）和 62 名（21%）其他医疗保健专业人员。GME 培训生正确识别 RCA 调查所需因素的能力有所提高（模拟前为 62%，模拟后为 80%，P=.02），对每种不良事件类别的“始终报告”意向也有所提高（模拟前为 3%，模拟后为 37%，P<0.001）。
作者计划将 RCA 模拟项目扩展到其他 GME 临床站点，同时努力使所有 GME 学习者在培训期间至少有一次参与这种教育体验。此外，通过与医疗系统患者安全领导者合作，他们将每年审查所有新的 RCA，以确定适合模拟改编的案例。
