Patient safety is a growing part of effective residency programs, so much so that the Accreditation Council for Graduate Medical Education (ACGME) has built quality and safety into its requirements. But a recent study in JAMA Dermatology suggests that improvements around patient safety cultures during residency may be necessary.
The study surveyed dermatology residents and found that many are “committing, failing to report and quietly witnessing patient safety errors.”
More than 80 percent of respondents reported cutting and pasting patient history information into an electronic health record without confirming its validity, a routine likely formed in medical school “when busy medical students mimic the practices of even busier residents as they scramble to compose multiple admission histories and physical examination reports,” the study states. “Consequently, a culture of efficiency is emphasized at the cost of safety and accuracy.”
More than one-half of the surveyed residents said they work with at least one attending physician who intimidates residents, reducing the likelihood of reporting safety issues they witness. Nearly 80 percent of residents said they have witnessed attending physicians purposefully disregarding required safety steps.
“It is difficult to expect graduating residents to practice a culture of safety if programs do not effectively role model these desired behaviors,” the study states. “Many residents who identify safety lapses are too intimidated to speak up when attending physicians are not practicing safe methods.”
The ACGME instituted its Clinical Learning Environment Review (CLER) program to assess the learning environment at sponsoring institutions, with an emphasis on those institutions’ responsibility for the quality and safety of their learning environments. According to CLER, institutions are expected to provide “opportunities for residents to report errors, unsafe conditions and near misses, and to participate in interprofessional teams to promote and enhance safe care.”
As safe care is becoming an increasing focus of residency programs, the study authors have made some suggestions for institutions to implement, including:
- Orientation and discussion of required safety steps for all attending physicians, residents and medical assistants
- Discussion of institutional safety steps taken after accidental exposure to blood or body fluids
- Faculty-directed morbidity and mortality conferences, in which faculty and residents explore where errors occurred
- Monitoring by the institution and program director for signs of an intimidating teaching environment with targeted faculty development when necessary
“The process of change begins with awareness, followed by open discussion about the local relevance of these safety issues, then plans for action to narrow practice gaps,” the study states. “Our data reinforce the need to modify systems to reduce injuries and improve communications between physicians.”
