PM2061: Incident Reporting by Pediatric Trainees: An Analysis of Events

Purpose/Objectives: Incident reporting system is integral to improving patient safety and quality of care. Trainee engagement is vital. As frontline providers they can bring into focus both latent conditions and active failures. The extent of participation of pediatric trainees (resident and fellow) and concerns raised by them is not well documented. The aim of this study is to describe and analyze incidents logged in the institutional incident reporting system by the pediatric trainees.

Design/Methods: We prospectively analyzed incidents reported by our trainees from November 2020 - February 2022. We are a quaternary care academic children’s hospital that employs a confidential, voluntary and web-based incident reporting system. In general, the events are forwarded to the leader of the location where the event occurred. The leader reviews, investigates and identifies improvement/coaching opportunities for the event in question. For this endeavor, the trainees were given education on when and how to complete an incident report. Additionally, a multidisciplinary incident reporting team was created to review and analyze trainee specific incident reports. We measured the change in frequency of incident reporting and analyzed events to determine potential contributing factors and overall impact. Information was shared during monthly graduate medical education meetings to provide feedback and foster an incident reporting culture.

Results: A total of 113 reports were made during the study period, mostly (93; 82%) by the residents. More than half (62; 55%) pertained to in-patient setting. We noted a significant increase in number of incident reports during the study period (Figure 1). Majority (66; 58%) were related to perceived issues in clinical care (treatment delay: 27; delayed testing: 17; inappropriate disposition: 9; suboptimal monitoring/treatment: 8; device related: 5), followed by transition/sign-out issues (19; 17%), professional conduct (9; 8%), and medication/imaging errors (7; 6%). System-related issues were noted to be the most common (43; 38%) contributing factors followed by human failures (27; 25%), communication breakdown (24; 21%) and unprofessional employee behavior (9; 8%) (Table1). In 10 (9%) events the underlying cause were deemed to be primarily illness-related or a known device complication. Provider and/or system related factors negatively impacted patients in more then half (61; 54%) of the reported events (delay in care: 43; unwarranted or repeat testing/treatment: 9; additional monitoring: 4; and escalation of care: 5). None of the events was associated with severe harm or death.

Conclusion/Discussion: Trainee incident reports, comprehensively reviewed with feedback given to trainees, can favorably impact trainee engagement. This approach may also improve overall effectiveness of incident reporting systems by providing valuable information for targeted improvements.