Faculty Development education Pearl ~~~~~~~~ Promoting an Attitude of Safety in Residents

1. Faculty Developmenteducation Pearl ~~~~~~~~Promoting an Attitude of Safety in Residents GRMEP Education Group: Gayla Jewell, PhD, RNC, NP Linda Youmans, MA, LPC 2012

2. What do New Residents think about Safety Events?

3. During 2011 orientation, new residents responded to, “Making errors in medicine is inevitable.” Responses: Strongly Agree 12.5% Agree 25% Neutral 25% Disagree 12.5% Strongly Disagree 25%

4. And, “Competent physicians do not make medical errors that lead to patient harm.” Responses: Strongly Agree 25% Agree 25% Neutral 25% Disagree 12.5% Strongly Disagree 12.5%

5. 2012 new residents responded to, “I am able to express safety concerns to attending and/or staff.” Responses: Yes 57.5% Somewhat 37.5% No 5%

6. What do these responses mean? How do you interpret that: • over 60% new residents are neutral about or disagree that “making errors is inevitable” and • 75% are neutral or agree that “competent physicians do not make medical errors that lead to patient harm”? Are their expectations realistic? Have they internalized a lack of tolerance for errors? Do they think that only incompetent physicians make errors? ….Or that errors are not to be talked about? Other interpretations?

7. How will knowing about these responses influence your teaching and interaction with residents?

8. Humanize making mistakes: Describe an error you made and what you learned Begins rounds with a “Safety Moment”

9. Ask the four questions to determine if experience is a safety event Was the procedure, treatment, or test appropriate and warranted based on nationally recognized standards of care? Was the complication a known risk, was it anticipated, and did the care team plan ahead to take steps to prevent it? Was the complication identified in a timely manner (i.e. at the time of occurrence)? Was the complication treated according to the standard of care and in a timely manner? Healthcare Performance Improvement, LLC www.hpiresults.com

10. Questions to determine if experience is a safety event If answers to ALL four questions areYES, the event is a known complication and not a Safety Event If the answer to ANY question is NO, the event is a Safety Event Healthcare Performance Improvement, LLC www.hpiresults.com

11. Hospital Partners Safety/Risk Management initiatives Spectrum Health https://insite.spectrum-health.org/Safety-Central/Pages/Home.aspx Click on “Safety Central” Helen DeVosChildrens Hospitalhttp://www.helendevoschildrens.org/qualityandsafety St Mary’s Health Centers http://www.mercyhealthsaintmarys.com/saint-marys-quality-safety

12. Helpful resources AHRQ Patient Safety Network http://psnet.ahrq.gov/primerHome.aspx GRMEP Education Specialist Gayla.Jewell@grmep.org GRMEP GME Advisor Linda.Youmans@grmep.org