Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center.

BACKGROUND: Conferences, processes, and/or meetings in which adverse events and near misses are reviewed within clinical programs at a single academic medical center were identified. METHODS: Leaders of conferences, processes, or meetings-"process leaders"-in which adverse events and near misses were reviewed were surveyed. RESULTS: On the basis of responses from all 45 process leaders, processes were classified into (1) Morbidity and Mortality Conferences (MMCs), (2) Quality Assurance (QA) Meetings, and (3) Educational Conferences. Some 22% of the clinical programs used more than one of these three processes to identify and review adverse events and near misses, while 10% had no consistent participation in any of them. Explicit criteria for identifying and selecting cases to be reviewed were used by 58% of MMCs and 69% of QA Meetings. The explicit criteria used by MMCs and QA Meetings varied widely. Many MMCs (54%, 13/24), QA Meetings (54%, 7/13), and Educational Conferences (70%, 7/10) did not review all the adverse events or near misses that were identified, and several MMCs (46%, 6/13), QA Meetings (29%, 2/7), and Educational Conferences (57%, 4/7) had no other process within their clinical program by which to review these remaining cases. CONCLUSIONS: There was wide variation regarding how clinical programs identify and review adverse events and near misses within the MMCs, QA Meetings, and Educational Conferences, and some programs had no such processes. A well-designed, coordinated process across all clinical areas that incorporates accepted approaches for event analysis may improve the quality and safety of patient care.

Instituting a culture of professionalism: the establishment of a center for professionalism and peer support.

BACKGROUND: There is growing recognition that an environment in which professionalism is not embraced, or where expectations of acceptable behaviors are not clear and enforced, can result in medical errors, adverse events, and unsafe work conditions. METHODS: The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Women's Hospital (BWH), Boston, to educate the hospital community regarding professionalism and manage unprofessional behavior. CPPS includes the professionalism initiative, a disclosure and apology process, peer and defendant support programs, and wellness programs. Leadership support, establishing behavioral expectations and assessments, emphasizing communication engagement and skills training, and creating a process for intake of professionalism concerns were all critical in developing and implementing an effective professionalism program. The process for assessing and responding to concerns includes management of professionalism concerns, an assessment process, and remediation and monitoring. RESULTS: Since 2005, thousands of physicians, scientists, nurse practitioners, and physician assistants have been trained in educational programs to support the identification, prevention, and management of unprofessional behavior. For January 1, 2010, through June 30, 2013, concerns were raised regarding 201 physicians/scientists and 8 health care teams. CONCLUSIONS: The results suggest that mandatory education sessions on professional development are successful in engaging physicians and scientists in discussing and participating in an enhanced professionalism culture, and that the processes for responding to professionalism concerns have been able to address, and most often alter, repetitive unprofessional behavior in a substantive and beneficial manner.

Peer Support to Promote Surgeon Well-being: The APSA Program Experience.

BACKGROUND: Peer support programs have evolved to train physicians to provide outreach and emotional first aid to their colleagues when they experience the inevitable challenge of a serious adverse event, whether or not it is related to a medical error. Most pediatric surgeons have experienced the trauma of a medical error, yet, in a survey of APSA membership, almost half said that no one reached out to them, and few were satisfied with their institution's response to the error. Thus, the APSA Wellness Committee developed an APSA-based peer support program to meet this need. METHODS: Peer supporters were nominated by fellow APSA members, and the group was vetted to ensure diversity in demographics, practice setting, and seniority. Formal virtual training was conducted before the program went live in 2020. Trained supporters were surveyed 6 months after the program launched to evaluate their experiences with providing peer support. RESULTS: 15 referrals were made in the first year, 60 % of which were self-initiated. Most referrals were for distress related to adverse events or toxic work environments (33 % each). While only about 25 % of trained supporters had provided formal support through the APSA program, more than 80 % reported using the skills to support colleagues and trainees within their own institutions. CONCLUSION: Our experience in the first year of the APSA peer support program demonstrates the feasibility of building and maintaining a national program to provide emotional first aid by a professional society to expand the safety net for surgeons who are suffering.

Patient Safety/Quality Improvement Primer, Part IV: Psychological Safety-Drivers to Outcomes and Well-being.

Psychological safety is the concept that an individual feels comfortable asking questions, voicing ideas or concerns, and taking risks without undue fear of humiliation or criticism. In health care, psychological safety is associated with improved patient safety outcomes, increased clinician engagement, and greater creativity. A culture of psychological safety is imperative for physician well-being and satisfaction, which in turn directly affect delivery of care. For health care professionals, psychological safety creates an environment conducive to trust and openness, enabling the team to focus on high-quality care. In contrast, unprofessional behavior reduces psychological safety and threatens the culture of the organization. This patient safety/quality improvement primer considers the barriers and facilitators to psychological safety in health care; outlines principles for creating a psychologically safe environment; and presents strategies for managing conflict, microaggressions, and lapses in professionalism. Individuals and organizations share the responsibility of promoting psychological safety through proactive policies, conflict management, interventions for microaggressions, and cultivation of emotional intelligence.

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace.

BACKGROUND: Unprofessional behaviour undermines organizational trust and negatively affects patient safety, the clinical learning environment, and clinician well-being. Improving professionalism in healthcare organizations requires insight into the frequency, types, sources, and targets of unprofessional behaviour in order to refine organizational programs and strategies to prevent and address unprofessional behaviours. OBJECTIVE: To investigate the types and frequency of perceived unprofessional behaviours among health care professionals and to identify the sources and targets of these behaviours. METHODS: Data was collected from 2017-2019 based on a convenience sample survey administered to all participants at the start of a mandatory professionalism course for health care professionals including attending physicians, residents and advanced practice providers (APPs) working at one academic hospital in the United States. RESULTS: Out of the 388 participants in this study, 63% experienced unprofessional behaviour at least once a month, including failing to respond to calls/pages/requests (44.3%), exclusion from decision-making (43.0%) and blaming behaviour (39.9%). Other monthly experienced subtypes ranged from 31.7% for dismissive behaviour to 4.6% for sexual harassment. Residents were more than twice as likely (OR 2.25, p<0.001)) the targets of unprofessional behaviour compared to attending physicians. Female respondents experienced more discriminating behaviours (OR 2.52, p<0.01). Nurses were identified as the most common source of unprofessional behaviours (28.1%), followed by residents from other departments (21%). CONCLUSIONS: Unprofessional behaviour was experienced frequently by all groups, mostly inflicted on these groups by those outside of the own discipline or department. Residents were most frequently identified to be the target and nurses the source of the behaviours. This study highlights that unprofessional behaviour is varied, both regarding types of behaviours as well as targets and sources of such behaviours. This data is instrumental in developing training and remediation initiatives attuned to specific professional roles and specific types of professionalism lapses.

Creation and evaluation of a novel, interdisciplinary debriefing program using a design-based research approach.

BACKGROUND: The emergency department (ED) witnesses the close functioning of an interdisciplinary team in an unpredictable environment. High-stress situations can impact well-being and clinical practice both individually and as a team. Debriefing provides an opportunity for learning, validation, and conversation among individuals who may not typically discuss clinical experiences together. The current study examined how a debriefing program could be designed and implemented in the ED so as to help teams and individuals learn from unique, stressful incidents. METHODS: Based on the theory of workplace-based learning and a design-based research approach, the evolved nature of a debriefing program implemented in the real-life context of the ED was examined. Focus groups were used to collect data. We report the design of the debriefing intervention as well as the program outcomes in terms of provider's self-perceived roles in the program and program impact on provider's self-reported clinical practice as well as the redesign of the program based on said feedback. RESULTS: The themes of barriers to debriefing, provision of perspectives, psychological trauma, and nurturing of staff emerged from focus group sessions. Respondents identified barriers and concerns regarding debriefing, and based on this information, changes were made to the program, including offering of refresher sessions for debriefing, inclusion of additional staff members in the training, and remessaging the purpose of the program. CONCLUSIONS: Data from the study reinforced the need to increase the frequency and availability of debriefing didactics along with clarifying staff roles in the program. Future work will examine continued impact on provider practice and influence on departmental culture.

Toward Constructive Change After Making a Medical Error: Recovery From Situations of Error Theory as a Psychosocial Model for Clinician Recovery.

BACKGROUND: Making a medical error is a uniquely challenging psychosocial experience for clinicians. Feelings of personal responsibility, coupled with distress regarding potential or actual patient harm resulting from a mistake, create a dual burden. Over the past 20 years, experiential accounts of making an error have provided evidence of the associated distress and impacts. However, theory-based psychosocial support interventions to improve both individual outcomes for the involved clinicians and system-level outcomes, such as patient safety and workforce retention, are lacking. There is a need for evidence-based ways to both structure and evaluate interventions to decrease the distress of making a medical error and its impacts. Such interventions play a role within wider programs of health professional support. We sought to address this by developing a testable, psychosocial model of clinician recovery after error based on recent evidence. METHODS: Systematic review methodology was used to identify studies published between January 2010 and June 2021 reporting experiences of direct involvement in medical errors and/or subsequent recovery. A narrative synthesis was produced from the resulting articles and used as the basis for a team-based qualitative approach to model building. RESULTS: We identified 25 studies eligible for inclusion, reporting evidence primarily from experiences of doctors and nurses. The identified evidence indicates that coping approach, conversations (whether they occur and whether they are perceived to be helpful or unhelpful), and learning or development activities (helpful, unhelpful or absent) may influence the relationship between making an error and both individual clinician outcomes of emotional impact and resultant practice change. Our findings led to the development of the Recovery from Situations of Error Theory model, which provides a preliminary theoretical basis for intervention development and testing. CONCLUSIONS: The Recovery from Situations of Error Theory model is the first testable psychosocial model of clinician recovery after making a medical error. Applying this model provides a basis to both structure and evaluate interventions to decrease the distress of making a medical error and its impacts and to support the replication of interventions that work across services and health systems toward constructive change. Such interventions may be embedded into the growing body of peer support and employee support programs internationally that address a diverse range of stressful workplace experiences.

Disclosure Coaching: An Ask-Tell-Ask Model to Support Clinicians in Disclosure Conversations.

ABSTRACT: Error disclosure is a high-stakes, emotionally charged interaction for patients and families as well as clinicians. A failed disclosure can result in emotional distress, reduced patient and family trust, litigation, and lost opportunities to learn from and prevent subsequent errors. However, many clinicians have little expertise in handling these challenging interactions and can inadvertently make a bad situation worse. Even those clinicians who have had formal disclosure training may have trouble remembering what they were taught when faced with the need to actually discuss an error with patients. Providing just-in-time coaching to clinicians is recommended by national standards. However, there is scant training material to guide error disclosure coaches. Therefore, we developed an "Ask-Tell-Ask" model and materials to guide the disclosure coaching process. The Ask-Tell-Ask model is well-suited to provide clinicians with targeted interactive teaching immediately before a disclosure without overwhelming them with lecture-style facts that they are unlikely to retain. Such teaching would ideally be provided by trained disclosure coaches, available for just-in-time support of clinicians throughout the disclosure process. The Ask-Tell-Ask model can also help risk managers, department heads, clinical managers, attending physicians, service chiefs, and others who assist clinicians with error disclosure. Here, we describe a comprehensive approach to coaching developed over years of coaching experience that incorporates the model, its rationale, step-by-step coaching strategies and guidance (including sample scripts), and organizational considerations regarding implementation of a coaching program to support patient-centered transparent communication after harmful events.

The Impact of Adverse Events on Clinicians: What's in a Name?

Unanticipated patient adverse events can also have a serious negative impact on clinicians. The term second victim was coined to highlight the experience of health professionals with these events and the need to effectively support them. However, there is some controversy over use of the term second victim. This article explores terminology used to describe the professionals involved in adverse events and services to support them. There is a concern that use of the term victim may connote passivity or stigmatize involved clinicians. Some patient advocates are also offended by the term, believing that it deemphasizes the experience of patients and families. Despite this, the term is now coming into widespread use by clinicians and health care managers as well as policy makers. As the importance of emotional support for clinicians continues to gain visibility, the terminology surrounding it will undoubtedly change and evolve. At this time, it may be most appropriate to label this important phenomenon in a way that local leaders are comfortable with-in a way that promotes its recognition and adoption of solutions. For example, for policy makers and health care managers, the term second victim may have value because it is memorable and connotes urgency. For support programs that appeal directly to health care workers, different language may attract more users. Debate concerning the benefits and drawbacks to this terminology will enhance and further drive its evolution, while helping retain our industry's focus on the importance of developing and evaluating programs to support clinicians in need.

The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety. A study of resident experiences and perceptions before and after hours reductions.

BACKGROUND: Limiting resident work hours may improve patient safety, but unintended adverse effects are also possible. We sought to assess the impact of Accreditation Council for Graduate Medical Education resident work hour limits implemented on July 1, 2003, on resident experiences and perceptions regarding patient safety. METHODS: All trainees in 76 accredited programs at 2 teaching hospitals were surveyed in 2003 (preimplementation) and 2004 (postimplementation) regarding their work hours and patient load; perceived relation of work hours, patient load, and fatigue to patient safety; and experiences with adverse events and medical errors. Based on reported weekly duty hours, 13 programs experiencing substantial hours reductions were classified into a "reduced-hours" group. Change scores in outcome measures before and after policy implementation in the reduced-hours programs were compared with those in "other programs" to control for temporal trends, using 2-way analysis of variance with interaction. RESULTS: A total of 1770 responses were obtained (response rate, 60.0%). Analysis was restricted to 1498 responses from respondents in clinical years of training. Residents in the reduced-hours group reported significant reductions in mean weekly duty hours (from 76.6 to 68.0 hours, P < .001), and the percentage working more than 80 hours per week decreased from 44.0% to 16.6% (P < .001). No significant increases in patient load while on call (patients admitted, covered, or cross covered) were observed. Between 2003 and 2004, there was a decrease in the proportion of residents in the reduced-hours programs indicating that working too many hours (63.2% vs 44.0%; P < .001) or cross covering too many patients (65.9% vs 46.9%; P = .001) contributed to mistakes in patient care. There were no significant reductions in these 2 measures in the other group, and the differences in differences were significant (P = .03 and P = .02, respectively). The number of residents in reduced-hours programs who reported committing at least 1 medical error within the past week remained high in both study years (32.9% in 2003 and 26.3% in 2004, P = .27). CONCLUSIONS: It is possible to reduce residents' hours without increasing patient load. Doing so may reduce the extent to which fatigue affects patient safety as perceived by these frontline providers.

Resident identification of feedback and teaching on rounds.

Feedback and teaching occur regularly on teaching hospital wards. Although feedback has important implications for resident learning, residents often report that they receive little feedback. The significant overlap of teaching and feedback in clinical education may contribute to resident difficulty with feedback identification. We sent a survey with seven scenarios to internal medicine residents across the country. Two of the scenarios contained teaching, two contained feedback, and three contained combined teaching and feedback. From October 2017 to April 2018, 17% of residents (392/2346) from 17 residency programs completed the survey. Participating residents correctly identified both feedback scenarios 89% of the time, both teaching scenarios 64% of the time, and all three combined teaching and feedback scenarios 38% of the time. Interns were less likely than upper-level residents to correctly identify combined teaching and feedback scenarios (P = 0.005). Residents may have difficulty identifying feedback in the context of teaching. This confusion may contribute to residents' perceptions that they receive little feedback.

We Have Enough Information to Act.

Evidence clearly indicates that physicians are suffering. This is harming our profession, our colleagues, other health care team members, and sometimes our patients. There are efforts nationally and internationally to explore ways of promoting wellness and decreasing the high levels of burnout among physicians. While promoting wellness is a complex challenge, and the solutions will need to be multifactorial, the literature suggests that the most effective interventions are organizational. Instead of putting the burden solely on us as individuals to be able to cope with challenging environments, we should be working toward improving the culture and processes in the workplace. Some technical solutions will be needed, but the challenges will also require adaptive solutions that address issues of trust and support. Our Center for Professionalism and Peer Support offers organizational initiatives designed to foster a culture of trust and respect through professionalism, conflict management, peer support, and disclosure coaching programs.

Videofluoroscopic findings in dysphagic patients with cricopharyngeal dysfunction: before and after open cricopharyngeal myotomy.

OBJECTIVES: Functional outcomes after open cricopharyngeal myotomy (CPM) for Zenker's diverticulum (ZD) and cricopharyngeal dysfunction without diverticulum (CPD) have not been uniformly measured by videofluorographic swallow study (VFSS). Here we characterize preoperative VFSS findings in these groups and evaluate the effect of CPM on swallowing via postoperative VFSS. METHODS: We performed a retrospective review of paired preoperative and postoperative VFSS results from 50 patients (36 with ZD and 14 with CPD) over 6 years. Semiquantitative scales were used to assess 1) degree of stasis in the pharyngeal recesses; 2) degree of narrowing at the pharyngoesophageal sphincter (PES); 3) aspiration; and 4) diverticular size. Findings were compared between the groups and across subjects. RESULTS: Pharyngeal stasis was more severe in subjects with CPD than in subjects with ZD, both before and after CPM (p = .02 and p = .0002, respectively). The CPM improved PES narrowing in both groups (p = .03; p = .06) and reduced diverticular size in the ZD group (p < .001), but it did not significantly reduce the stasis severity or the proportion of patients with aspiration. CONCLUSIONS: According to VFSS, CPM opens up the PES and decreases diverticular size. More severe stasis in CPD suggests that diffuse pharyngeal weakness may play a role in this disease, and may partially explain the variable post-CPM outcomes that have been observed in CPD.

Well-Being in Graduate Medical Education: A Call for Action.

Job burnout is highly prevalent in graduate medical trainees. Numerous demands and stressors drive the development of burnout in this population, leading to significant and potentially tragic consequences, not only for trainees but also for the patients and communities they serve. The literature on interventions to reduce resident burnout is limited but suggests that both individual- and system-level approaches are effective. Work hours limitations and mindfulness training are each likely to have modest benefit. Despite concerns that physician trainee wellness programs might be costly, attention to physician wellness may lead to important benefits such as greater patient satisfaction, long-term physician satisfaction, and increased physician productivity. A collaborative of medical educators, academic leaders, and researchers recently formed with the goal of improving trainee well-being and mitigating burnout. Its first task is outlining this framework of initial recommendations in a call to action. These recommendations are made at the national, hospital, program, and nonwork levels and are meant to inform stakeholders who have taken up the charge to address trainee well-being. Regulatory bodies and health care systems need to be accountable for the well-being of trainees under their supervision and drive an enforceable mandate to programs under their charge. Programs and individuals should develop and engage in a "menu" of wellness options to reach a variety of learners and standardize the effort to ameliorate burnout. The impact of these multilevel changes will promote a culture where trainees can learn in settings that will sustain them over the course of their careers.

The educational impact of ACGME limits on resident and fellow duty hours: a pre-post survey study.

PURPOSE: To assess the educational impact of Accreditation Council for Graduate Medical Education resident work-hour limits implemented in July 2003. METHOD: All trainees in all 76 accredited programs at two large teaching hospitals were surveyed between May and June 2003 (before work-hour reductions) and then between May and June 2004 (after work-hour reductions) about hours, education, and fatigue. Based on changes in weekly duty hours, 13 programs experiencing substantial reduction in hours were classified into a reduced-hours group. Differences in assessments of educational endpoints before and after policy implementation by trainees in the reduced-hours group were compared with those in other programs to control for potential temporal trends, using two-way ANOVA with interaction. RESULTS: The number of respondents was 1,770 (60% response rate). The reduced-hours group reported a significant decrease in time spent directly caring for patients (from 48.5 to 42.3 mean h/wk, P = 0.03), but the volume of important clinical experiences, including procedures, was preserved, as was the sense of clinical preparedness. On 22 questions related to educational quality and adequacy, only three differences in differences were significant, with the reduced-hours group reporting a relative increase in opportunities for research, decrease in quality of faculty teaching, and decrease in educational satisfaction. The percentage of trainees reporting frequent negative effects of fatigue dropped more in the reduced-hours programs than in the other programs (P < 0.05). CONCLUSION: This study shows that it may be possible to reduce residents' hours--and the perceived adverse impact of fatigue--while generally preserving the self-assessed quality, quantity, and outcomes of graduate medical education.