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OBJECTIVES To develop physicians who can practice safely, we need better understanding of how the clinical learning environment affects trainee well-being. Two psychosocial constructs may help us understand the context: psychological safety (belief one can speak up without concerns) and perceived organizational support (degree to which members feel that their organization cares for them and values their contributions). The objective of this study is to test a moderated mediation model to determine how humiliation (X) impacts trainees' well-being (Y) while taking into account psychological safety (mediator) and organizational support (moderator). METHODS Between May and June 2018, a single health system recruited resident physicians across 19 programs to complete an anonymous electronic survey to assess facets of the clinical learning environment, well-being, and experiences of humiliation. In a moderated mediation analysis, mediation helps explain how a predictor variable (X) impacts an outcome variable (Y) through a mediating variable, whereas moderation helps explain under what conditions such a relationship exists. RESULTS Of 428 residents, 303 responded (71%) to the survey across 19 training programs. The effects of humiliation on well-being were mitigated by psychological safety, which varied depending on the levels of perceived organizational support. Environments rated 1 SD below the mean on perceived organization support by residents had a stronger negative impact of public humiliation on psychological safety. CONCLUSIONS The findings suggest that humiliation is associated with well-being through the effects of psychological safety and influenced by organizational support. Further work might explore the relationship by investing resources (e.g., faculty development, mentorship) to increase psychological safety and reduce humiliation during training, especially within environments prone to be perceived as unsupportive of trainees.

Study objective Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs. Methods Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ=0.84 to 0.92), and identified relationships between PSN characteristics and punitive reporting were described. Results A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%). Conclusion Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.

Mistreatment in the learning environment is associated with negative outcomes for trainees. While the Association of American Medical Colleges (AAMC) annual Graduation Questionnaire (GQ) has collected medical student reports of mistreatment for a decade, there is not a similar nationally benchmarked survey for residents. The objective of this study is to explore the prevalence of resident experiences with mistreatment.Residents at three academic institutions were surveyed using questions similar to the GQ in 2018. Quantitative data were analyzed based on frequency and Mann-Whitney U tests to detect gender differences.Nine hundred ninety-six of 2682 residents (37.1%) responded to the survey. Thirty-nine percent of residents reported experiencing at least one incident of mistreatment. The highest reported incidents were public humiliation (23.7%) and subject to offensive sexist remarks/comments (16.0%). Female residents indicated experiencing significantly more incidents of public embarrassment, public humiliation, offensive sexist remarks, lower evaluations based on gender, denied opportunities for training or rewards, and unwanted sexual advances. Faculty were the most frequent instigators of mistreatment (66.4%). Of trainees who reported experiencing mistreatment, less than one-quarter reported the behavior.Mistreatment in the academic learning environment is a concern in residency programs. There is increased frequency among female residents.

The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.

Emergency physicians (EP) make clinical decisions multiple times daily. In some instances, medical errors occur due to flaws in the complex process of clinical reasoning and decision-making. Cognitive error can be difficult to identify and is equally difficult to prevent. To reduce the risk of patient harm resulting from errors in critical thinking, it has been proposed that we train physicians to understand and maintain awareness of their thought process, to identify error-prone clinical situations, to recognize predictable vulnerabilities in thinking, and to employ strategies to avert cognitive errors. The first step to this approach is to gain an understanding of how physicians make decisions and what conditions may predispose to faulty decision-making. We review the dual-process theory, which offers a framework to understand both intuitive and analytical reasoning, and to identify the necessary conditions to support optimal cognitive processing. We also discuss systematic deviations from normative reasoning known as cognitive biases, which were first described in cognitive psychology and have been identified as a contributing factor to errors in medicine. Training physicians in common biases and strategies to mitigate their effect is known as debiasing. A variety of debiasing techniques have been proposed for use by clinicians. We sought to review the current evidence supporting the effectiveness of these strategies in the clinical setting. This discussion of improving clinical reasoning is relevant to medical educators as well as practicing EPs engaged in continuing medical education.

Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs.Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ=0.84 to 0.92), and identified relationships between PSN characteristics and punitive reporting were described.A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%).Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.

BackgroundAssessments of the clinical learning environment could allow early interventions to improve graduate medical education. To date, measurement tools for this have not been identified.ObjectiveWe established the concurrent validity of 2 instruments that assess cultural facets of the clinical learning environment by correlating them with external program evaluation data.MethodsIn 2017 we surveyed residents across 19 training programs on their perceptions of organizational support by using the Short Survey of Perceived Organizational Support (SPOS), and psychological safety by using the Psychological Safety Scale (PSS). Data were aggregated to the program level and correlated with results from the Accreditation Council for Graduate Medical Education (ACGME) Resident Survey.ResultsOf 511 residents, 322 (63%) completed the survey, and 496 of 516 residents (96%) completed the ACGME Resident Survey. Perceived organizational support correlated positively with overall program evaluation score (r = 0.75, P ConclusionsThe SPOS and PSS correlated with key ACGME Resident Survey domains. Programs showing greater support of residents were likely to show more positive ratings on program evaluation metrics. Teaching institutions may benefit from actively monitoring and improving aspects of their learning environment through internal assessments.

This quality improvement project describes 22 OR patient falls reported in the Veterans Health Administration between January 2010 and February 2016. Most (n = 15; 68%) involved patient falls from the OR bed. Other patient falls (n = 6; 27%) occurred when the patient was transferred to or from the OR bed, and one fall (5%) occurred at another time. Root causes of the falls included tilting of the OR bed, issues with safety restraints, malfunctioning OR bed or gurney locks, inadequate patient sedation, and poor communication among team members. One fall (5%) resulted in a major injury, four falls (18%) resulted in minor injuries, six falls resulted in no injury, and 11 falls (50%) had no reported outcome. Falls in the OR, although rare, can be injurious. We drafted recommendations based on the root causes that include specific guidance on communication, teamwork, best practices, restraints and equipment, and training.

Kicking the Can Down the Road Every spring, U.S. medical schools graduate some students who should not be allowed to become doctors. Despite multiple incentives for promoting, and barriers to dismi...

Background Multiple studies have shown that bathing with chlorhexidine gluconate (CHG) wipes reduces hospital-acquired infections (HAIs). We employed a mathematical model to assess the impact of CHG patient bathing on central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and hospital-onset Clostridium difficile (C diff) infections and the associated costs. Methods Using a Markov chain, we examined the effect of CHG bathing compliance on HAI outcomes and the associated costs. Using estimates from 2 different studies on CHG bathing effectiveness for CLABSI, CAUTI, and C diff, the number of HAIs per year were estimated along with associated costs. The simulations were conducted, assuming CHG bathing at varying compliance rates. Results At 32% reduction in HAI incidence, increasing CHG bathing compliance from 60% to 90% results in 20 averted infections and $815,301.75 saved cost. Conclusions As CHG bathing compliance increases, yearly HAIs decrease, and the overall cost associated with the HAIs also decreases.

A primary strategy of central line-associated bloodstream infection (CLABSI) prevention is standardized, aseptic insertion of central lines. We compared hospital-wide CLABSI rate pre- and post-implementation of a dedicated procedure team as well as central line checklist completion and patient-specific variables between the procedure team and other providers. No significant differences were found. Further CLABSI prevention should focus on central line maintenance.

We assessed the impact of an embedded electronic medical record decision-support matrix (Cerner software system) for the reduction of hospital-onset Clostridioides difficile. A critical review of 3,124 patients highlighted excessive testing frequency in an academic medical center and demonstrated the impact of decision support following a testing fidelity algorithm.

Objective While the study of suicide on mental health units has a long history, the study of patient safety more generally is relatively new. Our objective was to determine the type and relative frequency of adverse events occurring on Veterans Health Administration (VHA) mental health units; the primary root causes for these events; and make recommendations for abating or mitigating these events. Methods We searched our national database for any reported adverse event that occurred on an inpatient mental health unit between January 1, 2015 and December 31, 2016. We found 87 Root Cause Analysis (RCA) reports and 9780 safety reports. The safety reports were coded for type of event and the RCAs were further coded for underlying causes and severity. Results Of the 87 RCA reports, there were 31suicide attempts, 16 elopements, 10 assaults, 8 events involving hazardous items on the unit, 7 falls, 6 unexpected deaths, 3 overdoses and 6 cases coded as “other”. For the 9780 safety reports falls were the most common event, followed by medication events, verbal assaults, physical assaults, medical problems and hazardous items on the unit. Conclusions As with medical units, patients on mental health units are at risk for many types of adverse events. The same focus on patient safety is just as important for our mental health patients as for our medical patients. Mental health unit staff should undertake a structured assessment of all risk on their units. This broad approach may be more successful than focusing on a particular event type.

Author(s): Martin, Daniel R.; Ankel, Felix; Hemphill, Robin R.; Heron, Sheryl; Khandelwal, Sorabh; Merritt, Christopher; Westergaard, Mary; Santen, Sally A.

Communication failure is a significant source of adverse events in health care and a leading root cause of sentinel events reported to the Joint Commission. The Veterans Health Administration National Center for Patient Safety established Clinical Team Training (CTT) as a comprehensive program to enhance patient safety and to improve communication and teamwork among health care professionals. CTT is based on techniques used in aviation's Crew Resource Management (CRM) training. The aviation industry has reached a significant safety record in large part related to the culture change generated by CRM and sustained by its recurrent implementation. This article focuses on the improvement of communication, teamwork, and patient safety by utilizing a standardized, CRM-based, interprofessional, immersive training in diverse clinical areas. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate before and after CTT. The scores for all of the 27 questions on the questionnaire showed an increase from baseline to 12 months, and 11 of those increases were statistically significant. A recurrent training is recommended to maintain the positive outcomes. CTT enhances patient safety and reduces risk of patient harm by improving teamwork and facilitating clear, concise, specific and timely communication among health care professionals.

Background ICUs' provision of complex care for critically ill patients results in an environment with a high potential for adverse events. A study was conducted to characterize adverse events in Veterans Health Administration (VHA) ICUs that underwent root cause analysis (RCA) and to identify the root causes and their recommended actions. Methods This retrospective observational study of RCA reports concerned events that occurred in VHA ICUs or as a result of ICU processes from January 1, 2013, through December 31, 2014. The type of event, root causes, and recommended actions were measured. Results Some 70 eligible RCAs were identified in 47 of the 120 facilities with an ICU in the VHA system. Delays in care (30.0%) and medication errors (28.6%) were the most common types of events. There were 152 root causes and 277 recommended actions. Root causes often involved rules, policies, and procedure processes (28.3%), equipment/supply issues (15.8%), and knowledge deficits/education (15.1%). Common actions recommended were policy, procedure, and process actions (34.4%) and training/education actions (31.4%). Of the actions implemented, 84.4% had a reported effectiveness of "much better" or "better." Conclusion ICU adverse events often had several root causes, with protocols and process-of-care issues as root causes regardless of event type. Actions often included standardization of processes and training/education. Several recommendations can be made that may improve patient safety in the ICU, such as standardization of care process, implementation of team training programs, and simulation-based training.

Background The 2012 Academic Emergency Medicine Consensus Conference, “Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success” noted that emergency medicine (EM) educators often rely on theory and tradition when molding their approaches to teaching and learning, and called on the EM education community to advance the teaching of our specialty through the performance and application of research in teaching and assessment methods, cognitive function, and the effects of education interventions. Objective The purpose of this article was to review the research-based evidence for the effectiveness of self-assessment and to provide suggestions for its use in clinical teaching and practice in EM. Discussion This article reviews hypothesis-testing research related to self-assessment behaviors and learning. Evidence indicates that self-assessment is inherently flawed when used in isolation. We review a multi-dimensional approach to informed self-assessment that can serve as the basis for life-long learning and development. Conclusions Advancing EM education will require that high-quality education research results be translated into actual curricular, pedagogical, assessment, and professional development changes. The informed self-assessment framework is a method that is applicable to teaching and practice in EM.

There is a high risk for death by suicide after discharge from an inpatient mental health unit. To better understand system and organizational factors associated with postdischarge suicide, we reviewed root cause analysis reports of suicide within 7 days of discharge from across all Veterans Health Administration inpatient mental health units between 2002 and 2015. There were 141 reports of suicide within 7 days of discharge, and a large proportion (43.3%, n = 61) followed an unplanned discharge. Root causes fell into three major themes including challenges for clinicians and patients after the established process of care, awareness and communication of suicide risk, and flaws in the established process of care. Flaws in the design and execution of processes of care as well as deficits in communication may contribute to postdischarge suicide. Inpatient teams should be aware of the potentially heightened risk for suicide among patients with unplanned discharges.

Safety reports related to products and devices used in health care have demonstrated that not all items can be considered equal in terms of usability, compatibility, and functionality, which can result in patient safety concerns. Hospital systems use a wide variety of products when providing care to patients. This variability may contribute to purchasers failing to fully understand and define the needs for these products. In addition, it is necessary to define what a high-quality product is, including what minimal technical requirements it must meet. The Veteran’s Health Administration (VHA) is the largest health care system in the United States; as such, it possesses the ability to learn from a large group of health care providers as well as a great deal of purchasing power. Purchasing for Safety is a procedure for investigating medical devices or products with an end goal of improving the purchasing decision. Purchasing for Safety can help hospitals and health care systems to systematically evaluate medical products and devices for issues that may lead to patient safety concerns. By conducting careful testing and documenting methods and findings, the test team can assist stakeholders in making purchasing decisions that may ultimately result in better patient care. The greater formality introduced in Purchasing for Safety will help hospitals justify purchasing decisions, and the thoroughness of the investigation will promote patient safety.

Objective This study describes reported adverse events related to gastrointestinal (GI) scope and tube placement procedures (between January 2010 and June 2012), in the Veterans Health Administration. Adverse events, including those related to GI procedures resulting in preventable harm, continue to occur. Methods This is a descriptive review of root cause analysis reports of GI scope and tube placement procedures from the National Center for Patient Safety database. Adverse event type, procedure, location, severity, and frequency were extracted. Spearman ρ was used to determine associations between types of adverse events and harm levels. Results We reviewed 27 cases of reported adverse events related to GI invasive procedures. Of the adverse events for which we could determine location (n = 25), 10 (40%) were in the operating room and 15 (60%) occurred in a nonoperating room. Endoscopies were associated with the least amount of harm. The most frequently reported adverse event types were human factors (22.22%, n = 6) and retained items (18.52%, n = 5). Retained item events were associated with the most harm. The most common root causes were lack of standardization in the process of care and suboptimal communication. Conclusions Retained items after invasive procedures and human factors errors were the most common and harmful type of adverse event in this study. Efforts to reduce adverse events during GI invasive procedures include improving situational awareness of the risk of retained items, standardization of care, communication between providers, and inspection of instruments for intactness before and after procedures.

Mistreatment of trainees is common in the clinical learning environment. Resident mistreatment is less frequently tracked than medical student mistreatment, but data suggest mistreatment remains prevalent at the resident level. To address resident mistreatment, the authors developed an Educational Advance to engage emergency medicine residents and faculty in understanding and improving their learning environment. The authors designed a small-group session with the following goals: 1) Develop a shared understanding of mistreatment and its magnitude; 2) Recognize the prevalence of resident mistreatment data and identify the most common types of mistreatment; 3) Relate study findings to personal or institutional experiences; and 4) Generate strategies for combating mistreatment and strengthening the clinical learning environment at their home institutions. Design was a combination of presentation, small group discussion, and facilitated discussion. Results were presented to participants from a previously administered survey of resident mistreatment. Public humiliation and sexist remarks were the most commonly reported forms. Faculty were the most frequent perpetrators, followed by residents and nurses. A majority of respondents who experienced mistreatment did not report the incident. Session participants were then asked to brainstorm strategies to combat mistreatment. Participants rated the session as effective in raising awareness about resident mistreatment and helping departments develop methods to improve the learning environment. Action items proposed by the group included coaching residents about how to respond to mistreatment, displaying signage in support of a positive learning environment, zero tolerance for mistreatment, clear instructions for reporting, and intentionality training to improve behavior.

Introduction: Healthcare systems often expose patients to significant, preventable harm causing an estimated 44,000 to 98,000 deaths or more annually. This has propelled patient safety to the forefront, with reporting systems allowing for the review of local events to determine their root causes. As residents engage in a substantial amount of patient care in academic emergency departments, it is critical to use these safety event reports for resident-focused interventions and educational initiatives. This study analyzes reports from the Virginia Commonwealth University Health System to understand how the reports are categorized and how it relates to opportunities for resident education. Methods: Identifying categories from the literature, three subject matter experts (attending physician, nursing director, registered nurse) categorized an initial 20 reports to resolve category gaps and then 100 reports to determine inter-rater reliability. Given sufficient agreement, the remaining 400 reports were coded individually for type of event and education among other categories. Results: After reviewing 513 events, we found that the most common event types were issues related to staff and resident training (25%) and communication (18%), with 31% requiring no education, 46% requiring directed educational feedback to an individual or group, 20% requiring education through monthly safety updates or meetings, 3% requiring urgent communication by email or in-person, and

General guidance for personal protective equipment (PPE) is provided by the Occupational Safety and Health Administration and the United States Centers for Disease Control and Prevention. Previous research of PPE demonstrates the ability of gloves to harbor infectious pathogens. We surveyed health care workers to investigate current PPE practices during linen removal from patient rooms and during patient transport. The results suggest a possible risk for cross-contamination of the environment from overuse of gloves.

Mistreatment has been correlated with burnout and poor well-being in medical students, but data regarding residents and faculty are limited. The objective was to investigate the prevalence of mistreatment towards surgical housestaff and faculty and characterize such experiences.In 2018, the Department of Surgery surveyed housestaff and faculty on incidents of mistreatment.Clinical faculty (63%) and residents (72%) completed the mistreatment survey. Excluding public embarrassment, 48% of residents and 29% of clinical faculty experienced mistreatment. Residents experienced public embarrassment and public humiliation more frequently than faculty, however faculty were subjected to racially or ethnically offensive remarks/names more frequently than residents (p .05). Faculty within and external to their department were most cited as instigators of mistreatment. Residents experienced mistreatment most often by faculty, co-residents, and nurses. Reporting of the behaviors was low.Incidents of mistreatment are frequently occurring for surgical residents and faculty.

In a 12-month study, a nurse driven protocol was implemented at a tertiary academic medical center. The purpose of the nurse driven protocol was to identify community-onset Clostridioides difficile infections, expeditiously isolate patients with presumed C difficile diarrheal illness, and prevent transmission while simultaneously decreasing the incidence of hospital-onset C difficile. The overall adherence to fidelity of the protocol was poor and failed to have a significant impact on infection rates.

We implemented an electronic medical record (EMR) decision support tool for ordering urine cultures per evidence-based guidelines. Following the EMR change, we found a significant increase in proportion of cultures ordered for catheterized intensive care unit (ICU) patients meeting guidelines. We surveyed providers and found poor understanding of urine culture guidelines for catheterized ICU patients. EMR-based interventions and educational opportunities have potential to improve urine culture guideline adherence and reduce unnecessary testing and antibiotic use.

Background The 2012 Academic Emergency Medicine Consensus Conference, “Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success” noted that emergency medicine (EM) educators often rely on theory and tradition in molding their approaches to teaching and learning, and called on the EM education community to advance the teaching of our specialty through the performance and application of research in teaching and assessment methods, cognitive function, and the effects of education interventions. Objective The purpose of this article is to review the research-based evidence for the effectiveness of the one-minute preceptor (OMP) teaching method, and to provide suggestions for its use in clinical teaching and learning in EM. Discussion This article reviews hypothesis-testing education research related to the use of the OMP as a pedagogical method applicable to clinical teaching. Evidence indicates that the OMP prompts the teaching of higher level concepts, facilitates the assessment of students' knowledge, and prompts the provision of feedback. Students indicate satisfaction with this method of clinical case–based discussion teaching. Conclusion Advancing EM education will require that high quality education research results be translated into actual curricular, pedagogical, assessment, and professional development changes. The OMP is a pedagogical method that is applicable to teaching in the emergency department.

The objective was to analyze reported flash burns experienced by patients on home oxygen therapy (HOT) in the Veterans Health Administration (VHA) using a qualitative, retrospective review of VHA root cause analysis reports between January 2009 and November 2015. Of 123 cases of reported adverse events related to flash burns, 100 cases (81%) resulted in injury, and 23 (19%) resulted in death. Although 89% of veterans claimed to have quit smoking (n = 109), 92% (n = 113) of burns occurred as a result of smoking. The most common root cause was risk identification issues. Recommended actions were standardized risk assessment policies, patient education, and the adoption of fire stop valves. Patients with a history of smoking who are on HOT should be considered for fire stop valves and offered consistent counseling and follow-up using a combination of harm reduction and shared decision-making techniques. Standardization of risk identification and documentation is recommended.

Background Residencies are grappling with ways to identify methods to internally monitor and improve their learning environments. Building on prior work, the objective of this study was to determine emergency medicine (EM) internal evaluations of perceived organizational support and psychological safety and compare to the results from the Accreditation Council for Graduate Medical Education (ACGME) Resident Survey for the purpose of program improvement and to explore factors affecting residents' perception of their learning environment. Methods In 2017, the Virginia Commonwealth University School of Medicine Office of Graduate Medical Education and Office of Quality and Safety conducted an in-person, anonymous safety survey of the residents across 19 residency programs on the Short Survey of Perceived Organizational Support (SPOS) and Psychological Safety Scale (PSS). These were compared to the ACGME Resident Survey for 19 programs. Resident interviews and open response evaluation data informed content analysis on program experiences. Results Institutional response rates were 63% for the internal learning environment survey and 96% for ACGME Resident Safety Survey. EM residents responded positively on the SPOS and PSS compared to other programs (ranked second highest scores on both scales). One-hundred percent of respondents agreed or strongly agreed on SPOS items: "Help is available from my department when I have a problem." "My department really cares about my well-being." "My department values my contribution to its well-being." Furthermore, EM had the highest overall training experience score (mean = 4.83) on the ACGME survey compared to the 18 other training programs. Qualitative responses suggest program strengths included supportive program leadership, positive working relationships with faculty, and emphasis on trainee wellness. Conclusions Compared to other programs, EM has created a positive environment of safety and support as perceived by their residents. Internal surveys of the learning environment can help programs understand their culture for purposes of improvement and align with the ACGME survey.

Problem Multiple-choice question (MCQ) examinations represent a primary mode of assessment used by medical schools. It can be challenging for faculty to produce content-aligned, comprehensive, and psychometrically sound MCQs. Despite best efforts, sometimes there are unexpected issues with examinations. Assessment best practices lack a systematic way to address gaps when actual and expected outcomes do not align. Approach The authors propose using root cause analysis (RCA) to systematically review unexpected educational outcomes. Using a real-life example of a class's unexpectedly low reproduction examination scores (University of Michigan Medical School, 2015), the authors describe their RCA process, which included a system flow diagram, a fishbone diagram, and an application of the 5 Whys to understand the contributors and reasons for the lower-than-expected performance. Using this RCA approach, the authors identified multiple contributing factors that potentially led to the low examination scores. These included lack of examination quality improvement (QI) for poorly constructed items, content-question and pedagogy-assessment misalignment, and other issues related to environment and people. Outcomes As a result of the RCA, the authors worked with stakeholders to address these issues and develop strategies to prevent similar systematic issues from reoccurring. For example, a more robust examination QI process was developed. Next steps Using an RCA approach in health care is grounded in practice and can be easily adapted for assessment. Because this is a novel use of RCA, there are opportunities to expand beyond the authors' initial approach for using RCA in assessment.

Recent research investigating diagnosis has generally relied upon one of two approaches to categorize and assess the antecedents of diagnostic error: (a) describing diagnostic error as a result of flaws in human cognition or (b) explaining diagnostic error as a result of working with complex health information systems. Each approach has uncovered important features that promote diagnostic error. However, each approach has inherent limitations, and integrating results from one approach to the other has proved difficult. In the current study, a cognitive engineering technique known as work domain analysis was implemented to provide a framework for uncovering the relationship between diagnosis, complex health systems, and theories of cognition and reasoning. The resulting model of diagnosis provides a comprehensive, novel perspective of the diagnostic process that offers a new foundation to formulate empirical inquiries about diagnosis and provides new avenues for the design and development of health information technologies, assessment strategies, and diagnosis-centered simulation paradigms.

OBJECTIVE: Suicide was the 10th leading cause of death for Americans in 2010. The suicide rate is highest among men who are aged 75 and older. The prevalence of suicidal behavior in nursing homes and long-term care (LTC) facilities was estimated to be 1%. This study describes the systemic vulnerabilities found after suicidal behavior in LTC facilities as well as steps to decrease or mitigate the risk. METHOD: This is a retrospective review of root-cause analysis (RCA) reports of suicide attempts and completions between 1 January 2000 and 31 December 2013 in the Veterans Health Administration LTC and nursing home care units. The RCA reports of suicide attempts and completions were coded for patient demographics, method of attempt or completion, root causes, and actions developed to address the root cause. RESULTS: Thirty-five RCA reports were identified. The average age was 65 years, 11 had a previous suicide attempt, and the primary mental health diagnoses were depression, posttraumatic stress disorder, and schizophrenia. The primary methods of self-harm were cutting with a sharp object, overdose, and strangulation. CONCLUSIONS: It is recommended that all staff members are aware of the signs and risk factors for depression and suicide in this population and should systematically assess and treat mental disorders. In addition, LTC facilities should have a standard protocol for evaluating the environment for suicide hazards and use interdisciplinary teams to promote good communication about risk factors identified among patients. Finally, staff should go beyond staff education and policy to make clinical changes at the bedside. Published 2015. This article is a U.S. Government work and is in the public domain in the USA. Language: en

Background The Universal Protocol has been associated with the prevention of wrong surgery procedures; however, such events still occur. This article explores wrong surgery events, defined as those incorrect procedures (wrong site, wrong side, wrong procedure, wrong patient, wrong level, wrong implant) that would have occurred despite the Universal Protocol including the performance of a time-out by the surgical team. Understanding why some of these events are not caught by the steps of the Universal Protocol, culminating in the time-out, can help the field to add upstream and downstream safeguards to help prevent these never events. Methods The Veterans Health Administration database of root cause analyses was queried for all cases involving an incorrect surgical procedure between 2004 and 2013 to determine the relative frequency and characteristics of wrong surgery events because of errors upstream and downstream to the Universal Protocol. This subgroup of wrong surgery events was selected from among all the wrong surgery events by 2 clinicians with expertise in patient safety (Kappa = .91). Results Forty-eight cases of wrong surgery events because of upstream/downstream errors were analyzed, representing 16% of the 308 root cause analyses for wrong surgery events reported during this period. Upstream errors included mislabeling of specimens, while downstream errors were associated with ineffective intraoperative process. Surgical procedures that were particularly vulnerable included wrong level spine operations, wrong patient prostatectomies, wrong implant cataract procedures, and wrong site skin lesion excisions. Conclusions Wrong surgery events can and do occur despite adherence to Universal Protocol including a time-out. The prevention of incorrect procedures requires complementary safety behaviors and technologies to address errors that occur upstream and downstream to the Universal Protocol and the time-out.

Continuous subcutaneous insulin infusion (CSII) devices are commonly used in the treatment of patients with diabetes mellitus. These devices release basal doses of insulin and can be used to deliver boluses of insulin when needed. Use errors involving CSII devices may have serious consequences: an overdose of insulin can result in hypoglycemia and even death, while too little insulin may result in diabetic ketoacidosis and coma. A targeted search of the database of adverse events in the Veterans Health Administration yielded information about patient safety incidents involving CSII devices, including the location and type of error. A model of CSII therapy that includes relevant characteristics of the user, use environment, and task was developed and used to explore potential error modes. By examining adverse events associated with CSII device use and by considering other potential error modes, it may be possible to redesign devices, treatment plans, hospital policy and procedures to minimize the risk of patient harm.

Medication mishaps are a common cause of morbidity and mortality both within and outside of hospitals. While the use of a variety of technologies and techniques have promised to improve these statistics, instead of eliminating errors, new ones have appeared as quickly as old ones have been improved. To truly improve safety across the entire enterprise, we must ensure that we create a culture that is willing to accept that errors occur in normal course of operation to the best of people. Focus must not be on punishment and shame, but rather building a fault tolerant system that maintains safety of both staff and patients.

Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions.RCA reports from VHA hospitals from May 30, 2012, to May 1, 2015, were reviewed for root causes, severity of patient outcomes, and actions. These elements were coded by consensus and analyzed using descriptive statistics.During the study period, 3228 RCAs were submitted, of which 292 involved an anesthesia provider. Thirty-six of these were specific to anesthesia care. We reviewed these 36 RCA reports of adverse events specific to anesthesia care. Types of event included medication errors (28%, 10), regional blocks (14%, 5), airway management (14%, 5), skin integrity or position (11%, 4), other (11%, 4), consent issues (8%, 3), equipment (8%, 3), and intravenous access and anesthesia awareness (3%, 1 each). Of the 36 anesthesia events reported, 5 (14%) were identified as being catastrophic, 10 (28%) major, 12 (34%) moderate, and 9 (26%) minor. The majority of root causes identified a need for improved standardization of processes.This analysis points to the need for systemwide implementation of human factors engineering-based approaches to work toward further eliminating anesthesia-related adverse events. Such actions include standardization of processes, forcing functions, separating storage of look-alike sound-alike medications, limiting stock of high-risk medication strengths, bar coding medications, use of cognitive aids such as checklists, and high-fidelity simulation.

Background Root cause analyses (RCA) are often completed in health care settings to determine causes of adverse events (AEs). RCAs result in action plans designed to mitigate future patient harm. National reviews of RCA reports have assessed the safety of numerous health care settings and suggested opportunities for improvement. However, few studies have assessed the safety of receiving care from physical therapists, occupational therapists, or speech and language pathology pathologists. Objective The objective of this study was to determine the types of AEs, root causes, and action plans for risk mitigation that exist within the disciplines of rehabilitation medicine. Design This study is a retrospective, cross-sectional review. Methods A national search of the Veterans Health Administration RCA database was conducted to identify reports describing AEs associated with physical therapy, occupational therapy, or speech and language pathology services between 2009 and May 2016. Twenty-five reports met the inclusion requirements. The reports were classified by the event type, root cause, action plans, and strength of action plans. Results Delays in care (32.0%) and falls (28.0%) were the most common type of AE. Three AEs resulted in death. RCA teams identified deficits regarding policy and procedures as the most common root cause. Eighty-eight percent of RCA reports included strong or intermediate action plans to mitigate risk. Strong action plans included standardizing emergency terminology and implementing a dedicated line to call for an emergency response. Limitations These data are self-reported and only AEs that are scored as a safety assessment code 3 in the system receive a full RCA, so there are likely AEs that were not captured in this study. In addition, the RCA reports are deidentified and so do not include all patient characteristics. As the Veterans Health Administration system services mostly men, the data might not generalize to non–Veterans Health Administration systems with a different patient mix. Conclusions Care provided by rehabilitation professionals is generally safe, but AEs do occur. Based on this RCA review, the safety of rehabilitation services can be improved by implementing strong practices to mitigate risk to patients. Checklists should be considered to aid timely decision making when initiating an emergency response.

Studies of inpatient suicide attempts and completions on medical-surgical and intensive care units are rare, and there are no large studies in the United States. We reviewed 50 cases, including 45 suicide attempts and 5 completed suicides, that occurred on medical surgical or intensive care units in the Veterans Health Administration between December 1, 1999 and December 31, 2012. The method, location, and the root causes of the events were categorized. The most common methods included cutting with a sharp object, followed by overdose and hanging. Root causes included problems with communication of risk, need for staff education in suicide assessment, and the need for better treatment for depressed and suicidal patients on medical units. Based on these results, we made our recommendations for managing suicidal patients on medical-surgical and intensive care units, including improved education for staff, standardized communication about suicide risk, and clear management protocols for suicidal patients. Journal of Hospital Medicine 2014;9:182–185. Published 2014 Society of Hospital Medicine

Introduction One thousand five hundred suicides take place on inpatient psychiatry units in the United States each year, over 70% by hanging. Understanding the methods and the environmental components of inpatient suicide may help to reduce its incidence. Methods All Root Cause Analysis reports of suicide or suicide attempts in inpatient mental health units in Veterans Affairs (VA) hospitals between December 1999 and December 2011 were reviewed. We coded the method of suicide, anchor point and lanyard for cases of hanging, and implement for cutting, and brought together all other reports of inpatient hazards from VA staff for review. Results There were 243 reports of suicide attempts and completions: 43.6% (106) were hanging, 22.6% (55) were cutting, 15.6% (38) were strangulation, and 7.8% (19) were overdoses. Doors accounted for 52.2% of the anchor points used for the 22 deaths by hanging; sheets or bedding accounted for 58.5% of the lanyards. In addition, 23.1% of patients used razor blades for cutting. Conclusions The most common method of suicide attempts and completions on inpatient mental health units is hanging. It is recommended that common lanyards and anchor points be removed from the environment of care. We provide more information about such hazards and introduce a decision tree to help healthcare providers to determine which hazards to remove.