Stephanie Lam, DO,
University of Chicago Hospital Comer Children's Hospital
Chicago, Illinois
Disclosure information not submitted.
Brett Palama, MD
Clinical Associate
University of Chicago Hospital Comer Children's Hospital
Chicago, Illinois, United States
Disclosure information not submitted.
Title: Promoting Safety Event Reporting in a Pediatric Intensive Care Unit
Introduction: Voluntary patient safety event reporting was introduced after the Institute of Medicine reported up to 100,000 patient deaths per year may be preventable. While error reporting was meant to empower frontline personnel in patient safety, consistent reporting lacks. Barriers include lack of follow-up after submission, time constraints and unclear ownership of who should report the event. We aim to evaluate the impact of an educational module on attitudes surrounding event reporting in a pediatric intensive care unit (PICU).
Methods: This was a prospective study conducted at Comer Children’s Hospital. All resident, fellow and attending physicians in the PICU were invited to participate. On day one of their PICU rotation, residents took a pre-intervention survey, which used 8 items to query 7 core domains that either facilitate (experience reporting, responsibility to self, community, and profession) or impede (attitudinal barriers, uncertainty, and fears of reporting) reporting. Each item was scored from 1-4 (strongly disagree to strongly agree) culminating in a total score (range 8-32). Higher scores indicated more positive attitudes. Experience reporting was evaluated categorically (yes/no). A module was given on reportable events, submission, reporting importance and barriers. After two weeks, a second module on report processing and follow-up was given. At the end of the rotation, residents completed a post-intervention survey. Fellows and attendings took a pre-intervention survey separately at the start of the study, received both modules at once and took a post-intervention survey at the end of the study. A paired t-test compared pre and post data.
Results: 27 respondents completed both pre and post-intervention surveys (13/33 resident, 7/8 attending, 7/8 fellow). Pre-intervention scores ranged from 20-29 (mean 25.1) and post-intervention scores ranged from 20-32 (mean 26.6, p=.02). Domains with the most improvement were responsibility to community (pre 2.6 vs post 3.1, p< .01) and self (pre 3.7 vs post 3.9, p=0.1). The modules did not have an impact on respondents who had not used the reporting system prior.
Conclusion: Our educational modules are associated with a positive impact on the event reporting attitudes of PICU providers, with significant improvement in responsibility to community.