DOES RESIDENCY TRAINING COMPROMISE PATIENT SAFETY?

1990 ◽  
Vol 70 (Supplement) ◽  
pp. S36 ◽  
Author(s):  
R. Brown ◽  
H. R. Vijayakumar
Keyword(s):  
Patient Safety ◽  
Residency Training ◽  
Compromise Patient Safety

Quality and Patient Safety in a Pathology Residency Training Program

2020 ◽  
Vol 154 (Supplement_1) ◽  
pp. S95-S96
Author(s):  
R Demkowicz ◽  
S Sapatnekar ◽  
D Chute
Keyword(s):  
Patient Safety ◽  
Residency Training ◽  
Chief Resident ◽  
Residency Training Program ◽  
Basic Structure ◽  
Learning Activities ◽  
Before And After ◽  
Quality And Patient Safety ◽  
The Impact ◽  
Quiz Scores

Abstract Introduction/Objective Since the start of the new millennium, optimization of Quality and Patient Safety (QPS) has taken a renewed focus in the healthcare industry. Consequently, the Accreditation Council for Graduate Medical Education has mandated that QPS be a part of residency training. We have previously presented our curriculum designed to meet the specific needs of Pathology training programs, and covering four content areas: Handoffs, Error Management, Laboratory Administration, and Process Improvement. We are now presenting implementation. Methods To implement this curriculum, we 1) created online modules for self-directed learning on basic topics (using courses developed by IHI and CAP, and assigned articles), and paired these with faculty-facilitated interactive learning activities on more complex topics, including proficiency testing, root cause analysis and test utilization, 2) assigned every resident to a QPS project that was aligned with departmental priorities, led by a faculty advisor, and ran over 8- 10 months, and 3) appointed a QPS Chief Resident to coordinate and support the residents’ QPS activities. We measured the impact of the curriculum by comparing RISE laboratory accreditation percentiles and QPS curriculum quiz scores before and after curriculum implementation. Results After its implementation, RISE percentiles increased by at least 25 for every PGY, and QPS quiz scores increased by at least 10% for 3 of 4 PGY. Every QPS project was presented at Grand Rounds, and 4 were presented externally, including 2 at national conferences. Conclusion Our curriculum was successful in improving residents’ knowledge and competence in QPS. Challenges included designing appropriate learning activities, tracking completion of activities, coordinating faculty schedules and maintaining resident buy-in to the curriculum. We believe that the basic structure of our curriculum offers a solid foundation to which revisions can be made as QPS priorities evolve, and which can be readily adapted to other programs and locations.

scholarly journals A Brief Analysis of Telemetry-Related Events

2019 ◽  
pp. 42-50
Author(s):  
Elizabeth Kukielka ◽  
Kelly Gipson ◽  
Rebecca Jones
Keyword(s):  
Patient Safety ◽  
Cardiac Rhythm ◽  
Reporting System ◽  
Healthcare Providers ◽  
Steady Increase ◽  
Monitoring Equipment ◽  
Safety Reporting ◽  
Common Event ◽  
Life Threatening ◽  
Compromise Patient Safety

Successful telemetry monitoring relies on timely clinician response to potentially life-threatening cardiac rhythm abnormalities. Breakdowns in the processes and procedures associated with telemetry monitoring, as well as improperly functioning telemetry monitoring equipment, may lead to events that compromise patient safety. An analysis of reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from January 2014 through December 2018 identified 558 events specifically involving interruptions or failures associated with telemetry monitoring equipment or with the healthcare providers responsible for setting up and maintaining proper functioning of that equipment. The analysis highlighted a steady increase in the quantity of event reports associated with telemetry monitoring submitted to PA-PSRS. User errors accounted for nearly half (47.1%, 263 of 558) of events in the analysis. The most common event subtypes included: errors involving batteries in telemetry monitoring equipment (14.0%); errors in which patients were not connected to telemetry monitoring equipment as ordered (12.9%); errors involving broken, damaged, or malfunctioning telemetry monitoring equipment (10.9%); and errors in which patients were connected to the wrong telemetry monitoring equipment (9.0%).

scholarly journals LO093: A national needs assessment survey for the development of a quality improvement and patient safety curriculum for Canadian emergency medicine residents

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S62-S62 ◽  
Author(s):  
L.B. Chartier ◽  
S. Vaillancourt ◽  
M. McGowan ◽  
K. Dainty ◽  
A.H. Cheng
Keyword(s):  
Emergency Medicine ◽  
Medical Education ◽  
Patient Safety ◽  
Quality Improvement ◽  
Needs Assessment ◽  
Residency Training ◽  
Royal College ◽  
Assessment Tool ◽  
Postgraduate Medical Education ◽  
Clinical Scenarios

Introduction: The Canadian Medical Education Directives for Specialists (CanMEDS) framework defines the competencies that postgraduate medical education programs must cover for resident physicians. The 2015 iteration of the CanMEDS framework emphasizes Quality Improvement and Patient Safety (QIPS), given their role in the provision of high value and cost-effective care. However, the opinion of Emergency Medicine (EM) program directors (PDs) regarding the need for QIPS curricula is unknown, as is the current level of knowledge of EM residents in QIPS principles. We therefore sought to determine the need for a QIPS curriculum for EM residents in a Canadian Royal College EM program. Methods: We developed a national multi-modal needs assessment. This included a survey of all Royal College EM residency PDs across Canada, as well as an evaluative assessment of baseline QIPS knowledge of 30 EM residents at the University of Toronto (UT). The resident evaluation was done using the validated Revised QI Knowledge Application Tool (QIKAT-R), which evaluates an individual’s ability to decipher a systematic quality problem from short clinical scenarios and to propose change initiatives for improvement. Results: Eight of the 13 (62%) PDs responded to the survey, unanimously agreeing that QIPS should be a formal part of residency training. However, challenges identified included the lack of qualified and available faculty to develop and teach QIPS material. 30 of 30 (100%) residents spanning three cohorts completed the QIKAT-R. Median overall score was 11 out of 27 points (IQR 9-14), demonstrating the lack of poor baseline QIPS knowledge amongst residents. Conclusion: QIPS is felt to be a necessary part of residency training, but the lack of available and qualified faculty makes developing and implementing such curriculum challenging. Residents at UT consistently performed poorly on a validated QIPS assessment tool, confirming the need for a formal QIPS curriculum. We are now developing a longitudinal, evidence-based QIPS curriculum that trains both residents and faculty to contribute to QI projects at the institution level.

scholarly journals Improving patient safety through education: how visual recognition skills may reduce medication errors on surgical wards

2011 ◽  
Vol 2 (1) ◽  
pp. 1
Author(s):  
Christopher R. Davis ◽  
Edward C. Toll ◽  
Paul M. Bevis ◽  
Helena P. Burden
Keyword(s):  
Patient Safety ◽  
Medication Errors ◽  
Undergraduate Education ◽  
Visual Recognition ◽  
Healthcare Professionals ◽  
Postgraduate Training ◽  
Response Rate ◽  
Recognition Rate ◽  
Compromise Patient Safety ◽  
The Uk

Medication errors compromise patient safety and cost £500m per annum in the UK. Patients who forget the name of their medication may describe the appearance to the doctor. Nurses use recognition skills to assist in safe administration of medications. This study quantifies healthcare professionals’ accuracy in visually identifying medications. Members of the multidisciplinary team were asked to identify five commonly prescribed medications. Mean recognition rate (MRR) was defined as the percentage of correct responses. Dunn’s multiple comparison tests quantified inter-professional variation. Fifty-six participants completed the study (93% response rate). MRRs were: pharmacists 61%; nurses 35%; doctors 19%; physiotherapists 11%. Pharmacists’ MRR were significantly higher than both doctors and physiotherapists (P<0.001). Nurses’ MRR was statistically comparable to pharmacists (P>0.05). The majority of healthcare professionals cannot accurately identify commonly prescribed medications on direct visualization. By increasing access to medication identification resources and improving undergraduate education and postgraduate training for all healthcare professionals, errors may be reduced and patient safety improved.

A quality improvement project focused on assessment of risk level of outpatient psychiatry patients

2017 ◽  
Vol 41 (S1) ◽  
pp. s898-s898
Author(s):  
T. Tuvia ◽  
M. Kats ◽  
C. Aloezos ◽  
M. To ◽  
A. Ozdoba ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Residency Training ◽  
Psychiatry Residency ◽  
Care Quality ◽  
Quality Improvement Project ◽  
Risk Level ◽  
List Type ◽  
Psychiatry Residency Training ◽  
Improvement Project

Since the implementation of the Clinical Learning Environment Review by the Accreditation Council for Graduate Medical Education, there has been an emphasis on training residents in health care quality as well as patient safety. As such, psychiatry residency training programs have had to incorporate quality improvement (QI) projects into their training. We developed a QI curriculum, which not only included resident and faculty participation, but also encouraged other staff in our department to focus on patient safety as well as improving their performance and the quality of care provided to the patients.In this poster, we present the development of our curriculum and will include a successful QI project to highlight this. This project focused on creating an algorithm to help assign patient risk level, which is based on evidence based risk factors. This project was created due to a survey conducted in our clinic which demonstrated that clinicians, and in residency training in particular, identifying and managing high risk patients can be anxiety provoking for trainees. We will present the specifics of this QI project, and additionally outline the steps that were taken to develop and integrate the QI project into clinical practice.Objectives(1) Learn how to successfully incorporate a QI project and curriculum into a psychiatry residency training program.(2) Understand both resident and faculty perspectives on what resources facilitated participation in QI.(3) Present the development of a quality improvement project focused on risk assessment of outpatient psychiatric patients.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Implementation of the TeamSTEPPS Curriculum With Baccalaureate Nursing and Social Work Students Utilizing Student Trainers: A Qualitative and Quantitative Study

2020 ◽  
Vol 26 (3) ◽  
pp. e63-e69
Author(s):  
Susan L. Huehn ◽  
Mary Beth Kuehn ◽  
Genesis M. Fukunaga Luna Victoria
Keyword(s):  
Patient Safety ◽  
Social Work ◽  
Nursing Students ◽  
Training Program ◽  
Communication Skills ◽  
Social Work Students ◽  
Skills Training ◽  
Clinical Experiences ◽  
Qualitative And Quantitative ◽  
Compromise Patient Safety

Nursing and social work education programs are seeking innovative ways to prepare students to function as collaborative members of interprofessional teams upon graduation. Communication is a key linked to a decrease in medical errors, which compromise patient safety. In response to nursing students' concerns about clinical experiences in which they had witnessed poor communication with the potential to jeopardize patient care, faculty members identified a communication skills training program designed to improve team performance. Senior nursing and social work students at the beginning of their last semester of school were trained in selected modules of the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training program and subsequently trained their student colleagues. The goal was to emphasize communication skills and strategies in a sustainable student trainer model. Qualitative and quantitative data about participant experiences revealed significant improvement in teamwork attitudes and communication skills following the training.

scholarly journals Reform Workplace Practices of Chain Pharmacies to Reduce Medication Errors

2020 ◽  
Vol 17 (02) ◽  
Author(s):  
Crystal D. Grant ◽  
Daniel J. Desautels ◽  
Jennifer Puthota
Keyword(s):  
Patient Safety ◽  
Data Collection ◽  
Health Effects ◽  
Medication Errors ◽  
Working Conditions ◽  
Pharmacy Practice ◽  
Quality Metrics ◽  
Adverse Health Effects ◽  
Compromise Patient Safety ◽  
Minimal Data

Pharmacists employed by chain pharmacies have raised concerns over corporate-mandated practices that compromise patient safety. Harsh working conditions and the pressure to meet mandated quality metrics have increased the likelihood of medication errors. Complications associated with medication errors exceed $40 billion and cause adverse health effects for hundreds of thousands of Americans annually. Despite their ubiquity, chain pharmacies face varying regulations as state pharmacy boards dictate individual statewide policies. There is minimal data collection on pharmacy practices and state pharmacy boards do not require pharmacies to report errors. We recommend Congress pass a bill mirroring the Illinois Pharmacy Practice Act to improve pharmacists’ working conditions and mandate data collection on medication errors nationwide.

scholarly journals Classification of Failures in the Perception of Conversational Agents (CAs) and Their Implications on Patient Safety

2021 ◽  
Author(s):  
Haris Aftab ◽  
Syed Hammad Hussain Shah ◽  
Ibrahim Habli
Keyword(s):  
Patient Safety ◽  
Insulin Dose ◽  
Conversational Agents ◽  
User Interactions ◽  
Safety Issues ◽  
Healthcare Settings ◽  
Medication Dose ◽  
Compromise Patient Safety ◽  
Administrative Tasks

The use of Conversational agents (CAs) in healthcare is an emerging field. These CAs seem to be effective in accomplishing administrative tasks, e.g. providing locations of care facilities and scheduling appointments. Modern CAs use machine learning (ML) to recognize, understand and generate a response. Given the criticality of many healthcare settings, ML and other component errors may result in CA failures and may cause adverse effects on patients. Therefore, in-depth assurance is required before the deployment of ML in critical clinical applications, e.g. management of medication dose or medical diagnosis. CA safety issues could arise due to diverse causes, e.g. related to user interactions, environmental factors and ML errors. In this paper, we classify failures of perception (recognition and understanding) of CAs and their sources. We also present a case study of a CA used for calculating insulin dose for gestational diabetes mellitus (GDM) patients. We then correlate identified perception failures of CAs to potential scenarios that might compromise patient safety.

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