The few studies of ambulatory SER do not adequately address the effect of intervention cessation, but researchers who implemented other ambulatory quality improvement efforts have reported that gains often deteriorate or revert to baseline without consistent, ongoing feedback [4]. Likewise, in hospital-based residency programs, a multifaceted approach that includes feedback can increase SER rates, but it is uncertain if the success of this approach can be maintained long-term without continuing feedback of some type [5–7].
There are likely many factors influencing SER in ambulatory clinics, many of which are also applicable in the hospital setting. These include ease of reporting, knowing what events to report, confidentiality of reporting, and the belief that reporting makes a difference in enhancing patient safety [8]. A strong culture of safety in ambulatory clinics may lead to enhanced voluntary SER [9], and a nonpunitive, team-based approach has been advocated to promote reporting and improve ambulatory safety [10]. Historically, our ambulatory medical group clinics have had a strong culture of safety and, with patient safety coaches present in all of our clinics, we have supported a nonpunitive, team-based approach to SER [11].
In our intervention, we made reporting safety events easy, reporters knew which events to report, events could be reported anonymously, and reporters were rewarded, at least with data feedback, for reporting. The only factor known to have changed was discontinuation of monthly feedback. Which factors are most important could not be determined by our work, but we strongly suspect that sustaining enhanced reporting rates requires ongoing audit and feedback to maintain a focus on event reporting.
Corresponding author: Herbert Clegg, MD, 108 Providence Road, Charlotte NC, 28207, hwclegg@novanthealth.org.
Financial disclosures: None.