Changes in medical errors after implementation of a handoff program.

BACKGROUND: Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. METHODS: We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. RESULTS: In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. CONCLUSIONS: Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

Valuable Papers: A Year in (Re)View From the Association of Pediatric Program Directors.

Academic Pediatrics has been the official journal of the Association of Pediatric Program Directors (APPD) since 2009. The View from the APPD section of the journal is an important destination to highlight APPD members' scholarship regarding issues impacting residency and fellowship training. Since 2020, the annual commentary (Re)View from the APPD summarizes articles published in View over the past year, including their alignment with the overall APPD mission, values, and organizational priorities. This year's (Re)View summarizes the articles published over the past year, with commentary on how the scholarship aligns with APPD values.

Having a Voice: Resident Perceptions of Supervision, Decision-Making and Patient Care Ownership.

OBJECTIVE: Heightened resident supervision due to patient safety concerns is increasingly common in pediatrics and may leave residents with fewer opportunities for independent decision-making, a diminished sense of autonomy, and decreased engagement. This may ultimately threaten their development into competent clinicians. Understanding how pediatric residents experience supervision's influence on their involvement in decision-making, engagement in patient care, and learning is crucial to safeguard their transition to independent practice. In relation to supervision, our research investigated: 1) how residents navigated their involvement with clinical decision-making and 2) how opportunities to make clinical decisions influenced their engagement in patient care and learning. METHODS: From 2019-2020, we recruited 38 pediatric residents from three different programs for a qualitative interview-based study. Through a constructivist stance, we explored clinical decision-making experiences and performed thematic analysis using an iterative and inductive process. RESULTS: We identified three themes: 1) Residents perceived having autonomy when they had space to make independent decisions, regardless of supervisor's presence; 2) Patient care ownership resulted from having a voice in a variety of contributions to patient care; and 3) Supervisors' behaviors modulated patient care ownership and thereby residents' sense of feeling heard, their engagement in patient care, and their learning. CONCLUSIONS: Our results suggest that focusing on patient care ownership may better fit with current learning environments than aiming for independence and autonomy. They provide insight on how, in the pediatric learning climate of enhanced supervision, supervisors can preserve resident engagement in patient care and learning by augmenting patient care ownership and ensuring residents have a voice.

The Carbon Footprint and Cost of Virtual Residency Interviews.

Background: The shift from in-person to virtual residency interviews may impact greenhouse gas emissions (GHGE) and costs but the direction and amount of this change is not yet clear. Objective: To estimate GHGE and financial impacts of virtual interviews among applicants and programs. Methods: In 2020-2021 we sent a postinterview survey to 1429 applicants from 7 residency programs and 1 clinical psychology program at 1 institution. The survey collected origin of travel and transit type if in-person interviews had been held and excluded responses if the applicant would not have participated in an in-person interview, or if travel type or original city was missing. We used the International Civil Aviation Organization calculator to estimate flight-related GHGE in metric tons of carbon dioxide equivalent (MTCO2e) and Google Maps to estimate ground travel, with a standard CO2e per mile. Flight, hotel, and airport taxi costs were estimated using Expedia.com, Hotels.com, Uber, and Lyft. We aggregated these data and calculated median and interquartile ranges (IQRs) for applicant GHGE and cost savings, and assumed no cost or GHGE from virtual interviews. We used Wilcoxon signed rank sum tests to compare in-person 2019-2020 and virtual 2020-2021 GME program interview budgets. Results: The survey response rate was 565, or 40% of applicants; 543 remained after the exclusion criteria were applied. Reduction in applicant travel due to virtual interviews led to median estimated GHGE savings of 0.47 (IQR 0.30-0.61) MTCO2e and $490 (IQR $392-$544) per applicant, per interview. Programs savings ranged from $7,615 to $33,670 for the interview season. Conclusions: Virtual interviews in 8 GME programs were associated with lower estimated GHGE and costs, for applicants and programs, compared with in-person interviews.

Effectiveness of Virtual Residency Interviews: Interviewer Perspectives.

BACKGROUND AND OBJECTIVES: Virtual residency interviews were widely utilized during the COVID-19 pandemic. Little is known about the effectiveness, advantages, barriers, and acceptability of virtual interviews, casting uncertainty about how interviews should be conducted after the pandemic. We conducted a survey of interviewers to inform future decisions. METHODS: We developed and implemented an online postinterview survey of interviewers representing seven residency programs and two clinical psychology programs at one midsized academic medical center. We analyzed results using descriptive statistics. RESULTS: Of 312 interviewers, 136 completed the survey (44% response rate). A majority rated virtual interviews as very or extremely effective in creating a comfortable setting (79%), answering interviewee questions (86%), establishing a sense of connection (59%), evaluating interviewee strengths (64%), and communicating program culture (51%). About half felt virtual interviews were not effective at all or only slightly effective for evaluating interviewee strengths via informal interactions (51%). A similar portion agreed or strongly agreed that virtual tours (44%) and social environment (50%) information were adequate. The most frequent advantages were time efficiency (81%), reduced carbon footprint (61%) and cost savings (56%). Frequent disadvantages included technological issues (21%) and caregiving duties (18%). Most interviewers (91%) thought some form of virtual interviews should be incorporated postpandemic. CONCLUSIONS: Interviewers found virtual interviews to be effective in most aspects, and identified more advantages than barriers. The vast majority preferred incorporation of virtual interviews in the future. Virtual tours and social activities were areas for improvement.

Virtual Residency Interviews: Applicant Perceptions Regarding Virtual Interview Effectiveness, Advantages, and Barriers.

Background: Studies of the virtual interview format are needed to inform medical residency program leaders as they plan for future virtual interview seasons. Objective: In the current study, completed in 2021, we sought to assess applicant perspectives of virtual interview effectiveness, advantages, and barriers, including factors that might impact equity and inclusion. Methods: Interviewees applying to 7 residency programs and 2 clinical psychology programs at an academic medical center in the Pacific Northwest completed a post-interview survey. Results: A total of 565 of 1429 interviewees (40%) completed the survey. A vast majority (83%-96%) agreed virtual interviews were effective in each measured domain, except for learning institutional culture (352 of 565, 62%). Many also found information regarding social/living environments inadequate. Participants selected advantages to virtual interviews more frequently than disadvantages. Commonly selected advantages included cost savings, time efficiency, reduced burden of travel, and reduced carbon footprint. Disadvantages included time zone differences, access to an appropriate interview setting, and reliable access to internet. The majority of interviewees (84%, 456 of 542) desired to keep a component of virtual interviews in the future. There were no significant disparities in results based on gender, rural/suburban/urban location, race, or underrepresented minority status. Conclusions: Virtual interviews were perceived as effective, more advantageous than burdensome, and widely acceptable, with no disparities in these findings by included demographic characteristics.

The Impact of the COVID-19 Pandemic on Pediatric Graduate Medical Education: Lessons Learned and Pathways Forward.

In this article, the authors describe the impact of the COVID-19 pandemic on pediatric graduate medical education (GME), including the impact on clinical experiences for trainees, teaching methods used, trainee wellness, GME leader wellness and support, and the traditional interview process. A thorough literature review was done to identify impacts of the COVID-19 pandemic on pediatric GME. In addition, information was collected through Association of Pediatric Program Directors virtual cafes and conferences. Positive changes for GME from the COVID-19 pandemic included: the rapid transition to telehealth; asynchronous learning allowing for increased cross-program collaboration; innovative online teaching modalities; increased flexibility and decreased cost of online recruitment; and shared innovations across pediatric GME. Challenging aspects of the COVID-19 pandemic included: decreased learning about common childhood illnesses, such as bronchiolitis, acute otitis media, and influenza; decreased patient volumes and patient complexity in clinics and inpatient wards, leading to less practice developing efficiency, time management, and triaging skills; and an increased burden on trainees, including moral distress and decreased support from one another and other social supports. The COVID-19 pandemic has highlighted important opportunities in U.S. educational systems. As medical educators move forward, it will be important to learn from these while mitigating the negative impacts.

Resident Notes in an Electronic Health Record.

Adoption of electronic health records (EHRs) has forced a transition in medical documentation, yet little is known about clinician documentation in the EHR. This study compares electronic inpatient progress notes written by residents pre- and post introduction of standardized note templates and investigates resident perceptions of EHR documentation. A total of 454 resident progress notes pre- and 610 notes post-template introduction were identified. Note length was 263 characters shorter ( P = .004) and mean end time was 73 minutes later ( P < .0001) with new template implementation. In subanalysis of 100 notes, the assessment and plan section was 46 words shorter with the new template ( P < .01). Among survey respondents, 89% liked the new note templates, 78% stated the new templates facilitated note completion. The resident focus group revealed ambivalence toward the EHR's contribution to note writing. Note templates resulted in shorter notes. Residents appreciate electronic note templates but are unsure if the EHR supports note writing overall.

Families as Partners in Hospital Error and Adverse Event Surveillance.

Importance: Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective: To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Design, Setting, and Participants: We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. Main Outcomes and Measures: Error and AE rates. Results: Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates. Conclusions and Relevance: Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Optimizing Your Mentoring Relationship: A Toolkit for Mentors and Mentees.

INTRODUCTION: Mentorship is a vital component of academic and professional development. Mentees report positive impacts from mentorship programs, yet institutions and societies may struggle to meet their mentees' needs due to factors such as mentor fatigue and lack of mentor training. To address this in our own professional society, the Association of Pediatric Program Directors, we developed a mentor toolkit in order to utilize a variety of mentoring models, provide faculty development for midlevel mentors, and offer guidance to mentees. METHODS: Most of these tools were designed to be administered in an interactive format such as a workshop or seminar with think-pair-share opportunities. The toolkit begins by providing a definition of mentoring and reinforcing the benefits and the characteristics of effective mentoring relationships. Next, we discuss the important role that mentees have in creating and maintaining effective mentoring relationships (i.e., mentee-driven mentoring). We then introduce a mentoring mosaic activity designed to help mentees examine their professional network and think about how they might expand it to fulfill the spectrum of their mentoring needs. Next, we present guidelines for the implementation of four mentoring models that can be used within one's institution: traditional dyadic mentoring, peer group mentoring, meet the professor mentoring, and speed mentoring. We then provide tools that can be used to help facilitate effective mentoring development. RESULTS: This toolkit has successfully served as a self-guided resource at national meetings for many years, garnering positive feedback from mentors and mentees alike. DISCUSSION: The principles and methods are easily generalizable and may be used to guide mentorship programs within institutional and professional societies, as well as to assist mentors and mentees in optimizing their individual mentoring relationships.

Instructional design dogma: creating planned learning experiences in simulation.

Human lives depend on the performance of our trainees; thus, the educational methodology used to transform our learners into experts are of paramount importance. Effective use of simulation requires educators explore and apply educational theory as they discover who the learner is, how the learner learns, what the learning needs are, and which planned learning experiences are best suited to meet the learner's specialized needs. The purpose of this article is to portray simulation as an educational strategy in the context of a curriculum, to explore emerging theories from educational psychology, and to provide concrete examples of their application in simulation-based education.