Original Research

An Analysis of the Involvement and Attitudes of Resident Physicians in Reporting Errors in Patient Care

Journal of Clinical Outcomes Management. 2021 March;28(2):62-69 | 10.12788/jcom.0040

References

1. Zallman L, Ma J, Xiao L, Lasser KE. Quality of US primary care delivered by resident and staff physicians. J Gen Intern Med. 2010;25(11):1193-1197.

2. Bagain JP. The future of graduate medical education: a systems-based approach to ensure patient safety. Acad Med. 2015;90(9):1199-1202.

3. Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical disclosure program. Ann Intern Med. 2010;153(4):213-221.

4. Kaldjian LC, Jones EW, Wu BJ, et al. Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Arch Intern Med. 2008;168(1):40-46.

5. Rowin EJ, Lucier D, Pauker SG, et al. Does error and adverse event reporting by physicians and nurses differ? Jt Comm J Qual Patient Saf. 2008;34(9):537-545.

6. Turner DA, Bae J, Cheely G, et al. Improving resident and fellow engagement in patient safety through a graduate medical education incentive program. J Grad Med Educ. 2018;10(6):671-675.

7. Macht R, Balen A, McAneny D, Hess D. A multifaceted intervention to increase surgery resident engagement in reporting adverse events. J Surg Educ. 2015;72(6):e117-e122.

8. Scott DR, Weimer M, English C, et al. A novel approach to increase residents’ involvement in reporting adverse events. Acad Med. 2011;86(6):742-746.

9. Stewart DA, Junn J, Adams MA, et al. House staff participation in patient safety reporting: identification of predominant barriers and implementation of a pilot program. South Med J. 2016;109(7):395-400.

10. Vidyarthi AR, Green AL, Rosenbluth G, Baron RB. Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program. Acad Med. 2014;89(3):460-468.

11. Fok MC, Wong RY. Impact of a competency based curriculum on quality improvement among internal medicine residents. BMC Med Educ. 2014;14:252.

12. Wijesekera TP, Sanders L, Windish DM. Education and reporting of diagnostic errors among physicians in internal medicine training programs. JAMA Intern Med. 2018;178(11):1548-1549.

13. Levinson DR. Hospital incident reporting systems do not capture most patient harm. Washington, D.C.: U.S. Department of Health and Human Services Office of the Inspector General. January 2012. Report No. OEI-06-09-00091.

14. Evans JR, Mathur A. The value of online surveys. Internet Research. 2005;15(2):192-219.

15. Marcano Belisario JS, Jamsek J, Huckvale K, et al. Comparison of self‐administered survey questionnaire responses collected using mobile apps versus other methods. Cochrane Database of Syst Rev. 2015;7:MR000042.

16. Manfreda KL, Batagelj Z, Vehovar V. Design of web survey questionnaires: three basic experiments. J Comput Mediat Commun. 2002;7(3):JCMC731.

17. Wright ND, Groisman‐Perelstein AE, Wylie‐Rosett J, et al. A lifestyle assessment and intervention tool for pediatric weight management: the HABITS questionnaire. J Hum Nutr Diet. 2011;24(1):96-100.

This study measured residents’ attitudes and knowledge regarding the filing of a PASS report. It also aimed to increase both the frequency of and knowledge about filing a PASS report with interventions. The results from each survey indicated a statistically significant increase in knowledge of when to file a PASS report. In the first survey, 53.7% of residents responded they they were involved in an instance where they should have filed a PASS report but did not. In the second survey, 58.5% of residents reported being involved in an instance where they should have filed a PASS report but did not. This difference was statistically significant (P = 0.036), sugesting that the intervention was successful at increasing residents’ knowledge regarding PASS reports and the appropriate times to file a PASS report.

The survey results also showed a trend toward increasing aggregate knowledge level of how to file PASS reports on the first survey and second surveys (from 31.5% vs 55.2%. This demonstrates an increase in knowledge of how to file a PASS report among residents at our hospital after the intervention. It should be noted that the intervention that was performed in this study was simple, easy to perform, and can be completed at any hospital system that uses a similar system for reporting patient errors.

Another important trend indicating the effectiveness of the intervention was a 15% increase in knowledge of what the PASS report acronym stands for, along with a 13.1% aggregate increase in the number of residents who filed a PASS report. This indicated that residents may have wanted to file a PASS report previously but simply did not know how to until the intervention. In addition, there was also a decrease in the aggregate percentages of residents who had never filed a PASS report and an increase in how many PASS reports were filed.

While PASS reports are a great way for hospitals to gain data and insight into problems at their sites, there was also a negative view of PASS reports. For example, a large percentage of residents indicated that filing a PASS report would not make any difference and that PASS reports are often used as a form of retaliation, either against themselves as the submitter or the person(s) mentioned in the PASS report. More specifically, more than 50% of residents felt that PASS reports were sometimes or often used as a form of retaliation against others. While many residents correctly identified in the survey that PASS reports are not equivalent to a “write-up,” it is concerning that they still feel there is a strong potential for retaliation when filing a PASS report. This finding is unfortunate but matches the results of a multicenter study that found that 44.6% of residents felt uncomfortable reporting patient errors, possibly secondary to fear of retaliation, along with issues with the reporting system.¹²

It is interesting to note that a minority of residents indicated that they feel that PASS reports are filed as often as they should be (25.9% on first survey and 24.1% on second survey). This is concerning, as the data gathered through PASS reports is used to improve patient care. However, the percentage reported in our study, although low, is higher than that reported in a similar study involving patients with Medicare insurance, which showed that only 14% of patient safety events were reported.¹³ These results demonstrate that further interventions are necessary in order to ensure that a PASS report is filed each time a patient safety event occurs.