When a team of researchers from the main graduate medical education accrediting agency visited several hundred training sites to determine the state of patient safety training, they found that many residents and fellows lacked both an awareness of the range of conditions that define patient safety and an understanding of how clinical learning environments (CLE) use reportable events to improve systems of care. A report clarifies what needs to be done to ensure physicians-in-training are up to speed on the science and practice of patient safety.
The Accreditation Council for Graduate Medical Education’s (ACGME) Clinical Learning Environment Review (CLER) Program was created to provide U.S. teaching hospitals, medical centers, health systems and other clinical settings with feedback that addresses several key areas of training in CLEs, including patient safety, health care quality and professionalism.
The CLER “National Report of Findings 2016” presents aggregate, deidentified data from CLER visits to participating sites of about 300 ACGME-sponsoring institutions. One of its key findings, detailed in an issue brief on patient safety, was that many CLEs provided didactic training but few provided experiential learning.
As a result, residents, fellows and faculty alike often were not even aware of what constituted a patient safety event. In addition, while most residents and fellows were aware of their CLE’s patient safety event-reporting process, few had ever used it. And when they had filed a report, many received little or no feedback on it. Furthermore, few trainees participated in systems-based improvement efforts.
The report cites an instance of a CLER site visitor encountering a third-year resident while on walking rounds in a preoperative area. The visitor asked the resident whether, during his training, he had witnessed any adverse events or close calls. The resident said he had not, but when asked whether he had had any surgery cancellations due to abnormal laboratory tests, such as high INR levels, he seemed taken aback. “I had a patient case canceled this morning for that very reason,” the resident responded. “Fortunately, I caught it in time.”
He went on to say, “On the days that I have surgery, I always come in extra early to double check the lab values, and sometimes reorder tests if a test is missing or I suspect there is a problem.”
When pressed on what happened next, the resident appeared puzzled and responded, “The patient was sent home and told to reschedule. She wasn’t very happy about it.”
Yet the resident never submitted a patient safety event report. And when the CLER site visitor asked how often surgeries are canceled at the last minute due to high INR levels, the resident replied, “It happens all the time; worse yet, sometimes the high INR gets missed and then we can get bleeding problems.”
Didactic approaches, the report notes, may be helpful but are insufficient. “Experiential learning, through participation in activities such as interprofessional, interdisciplinary reviews of patient safety events, enables residents, fellows and faculty members to apply a systems approach to identifying and addressing potential causes of harm.” The report goes on to issue several recommendations, including:
Residents and fellows must be able to report into the CLE’s patient safety event-reporting systems. “By providing residents and fellows access to these systems, CLEs gain the input of front-line caregivers (and thereby decrease the risk to patients), residents and fellows have the opportunity to learn about the importance of how and what to report, and residents and fellows will be more likely to report in the future.”
Give trainees appropriate orientation and keep them apprised of site-specific processes. Since many programs’ residents and fellows rotate through a variety of CLEs, “it is also important for GME leaders to work with each of the CLEs where their residents and fellows rotate to understand the similarities and differences in approaches to patient safety and appropriately manage them, to maximize resident and fellow experience across CLEs, and to be aware of the strengths and weaknesses associated with any variability between the CLEs’ approaches to patient safety.”
Teach the value of reporting close calls. Lack of focus on reporting and learning from near misses prevents trainees from identifying possible precursors to harm events.
Give feedback on reported events. The experience of receiving feedback “encourages reporting and helps residents, fellows and faculty members understand how patient safety can be improved in individual departments and across the organization. When a resident, fellow or faculty member receives no response to a report, it deters future reporting.”
Don’t forget the faculty. “Leaders in CLEs and the GME community need to ensure that faculty members have the skills to educate and train residents and fellows to become competent in risk identification, harm reduction and creating a culture of safety. Without good role models, residents and fellows may receive messages from the faculty members (either implicit or explicit) that contradict the CLE’s efforts to create a culture of quality and safety.”
The ACGME recently partnered with the National Patient Safety Foundation (NPSF) to host a webinar (registration required) that examined data from the CLER report. Presented by Tejal Gandhi, MD, president and CEO of the NPSF, and Kevin B. Weiss, MD, ACGME’s senior vice president for institutional accreditation, the webinar includes eight recommendations from an NPSF expert panel.
“The approach to date has been in some respects a very piecemeal approach,” Dr. Gandhi said. “We liken it to Whac-A-Mole, where you’re dealing with a medication safety issue here, and a handoff issue there, and an infection issue over here. We’re tackling all of these disparate safety issues, but what we need to do is think about a total systems approach that’s really about foundational improvements that will hopefully raise all boats in terms of improving patient safety.”