Patient safety is increasingly being recognized as a vital component of medical practice, as reflected in global educational standards. The World Health Organization has published a patient safety curriculum for medical schools.1 Canadian family medicine residency program accreditation standards require “training in continuous improvement, with emphasis on improving systems of patient care, including patient safety.”2 Both the CanMEDS–Family Medicine and the US Accreditation Council for Graduate Medical Education competency frameworks include patient safety incident analysis as a competency.3,4
Unfortunately, patient safety has not been integrated into resident education adequately. In the United States, the 2022 Clinical Learning Environment Review interviewed residents and fellows in their third year of postgraduate training or above and found that only 52.3% reported having participated in an interprofessional patient safety event investigation.5 Many barriers exist to incorporating patient safety teaching in medical school curricula, including competing educational demands, lack of time and faculty comfort, and underdeveloped patient safety cultures and systems at the local level.6 Simple and practical tools for teaching patient safety are needed for use in the busy, fast-paced ambulatory care environment.
The tool
Incident analysis has been successfully integrated into many patient safety curricula1,7-9; however, it does not typically involve cases that learners have experienced directly. Here we share our experience with a simple novel Resident Patient Safety Incident Discussion Tool (Figure 1), implemented using cases experienced directly by family medicine residents. It was evaluated in an ambulatory family medicine setting at an academic teaching site affiliated with the University of Toronto in Ontario. A blank fillable version of the tool is provided in Appendix 1, available from CFPlus.*
Resident Patient Safety Incident Discussion Tool: Example of a completed tool.
The 1-page tool consists of a cause-and-effect diagram followed by reflection questions. It can be used in prescheduled teaching sessions or opportunistically as incidents occur in discussions with individual learners (eg, after a clinic). Users are prompted to consider a broad range of factors that may have contributed to an incident and to reflect on personal practices and systems changes that could have prevented it. They are also prompted to consider disclosure to the affected patient and reporting through formal institutional mechanisms.
The tool was first introduced to the St Michael’s Hospital Academic Family Health Team at a faculty development workshop in September 2019 along with basic training on patient safety and incident analysis. Thirty-minute incident discussions were subsequently scheduled every 6 months for small groups of 2 to 6 residents during protected teaching time before clinical half-days. Prior to each session, residents were each invited to bring forward a case in which they had been personally involved. A facilitator guide with tips was shared with faculty participants prior to the discussion (an edited version is presented in Box 1). Participant groups were each expected to complete the tool during the session and submit it anonymously to the postgraduate administrator. Completed tools were compiled and reviewed at the end of the academic year by the patient safety lead and by postgraduate and resident leaders to identify trends that may benefit from systems improvements. Departmental “Doing Better” rounds are also held biannually in which anonymized patient safety incidents involving faculty and staff are discussed in an interprofessional forum.
Tips for conducting resident patient safety incident discussions
Before the session
Create scheduled protected time for recurring resident patient safety incident discussions
Invite residents to bring forward a case prior to the session
If relevant, consider inviting interdisciplinary team members to participate—with consent of the resident involved
If possible, schedule the session with learners and faculty with pre-established supportive relationships; alternatively, consider facilitators not in a position to evaluate the residents
Choose a case
- Start with small, nonthreatening cases to build comfort (eg, a mislabelled specimen)
— A “near miss” or “good catch” can be an effective choice, as it is less emotionally challenging
— Avoid cases where there was a lack of knowledge or clinical judgment
— If residents are struggling to find cases, share examples from previous discussions or from your own practice
Choose a facilitator for the discussion
- This can be a faculty member or a resident with faculty support
During the session
Facilitation tips
- Choose a physical space that ensures privacy
- Assign a resident scribe to complete the tool
- Ensure you have a clearly defined problem before you start analyzing it
- Use the tool flexibly to support learning (the discussion is more important than filling out boxes)
- Avoid overemphasizing category selections in the cause-and-effect diagram; causes often fit multiple categories and some categories may not be applicable
Foster psychological safety
- At the onset, outline a framework for the discussion
— All that is discussed is to remain confidential
— The discussion is not tied to academic evaluation
— This is not for cases that involve a resident performance issue
— This discussion focuses on improving systems (both personal and broader) and not on attributing blame
- Role model by sharing your own experiences
- Acknowledge and normalize difficult emotions that may be associated with these incidents
- Support learners in reframing failure as an opportunity for learning and system improvement
After the session
Ensure residents have appropriate support if they have been triggered by the discussion (eg, faculty wellness adviser, local resident support helpline)
Consider collecting completed tool forms to allow central identification of opportunities for improvement in processes related to residents at your site
Evaluation
A mixed-methods tool evaluation was approved by the Unity Health Toronto Research Ethics Board and was conducted between 2020 and 2022. Participants completed an emailed postdiscussion questionnaire and participated in a 45-minute audiorecorded virtual focus group. Quantitative data were analyzed using basic descriptive statistics. Qualitative data were transcribed, de-identified, and analyzed inductively using descriptive thematic coding.10
Results
Eight faculty and 21 residents responded to the questionnaire (57% and 35% response rates, respectively), and 9 focus groups were held with residents (n=15) and faculty (n=6).
Most participants found the tool easy to use and helpful for teaching and learning patient safety (Table 1), stating “It’s very focused” (faculty) and “It’s an easy to use and effective tool!” (resident). Most faculty believed that 30 minutes was enough time to complete the analysis (Table 1). Many participants appreciated the structure that the tool provides for discussion, especially with complex incidents. “The nice thing about the tool is that it triggers you to remember all the pieces of the puzzle” (faculty). All survey participants agreed that the tool helped residents consider systems factors that may have contributed to incidents. Most residents said the tool gave them a systematic approach to use in future patient safety incidents in practice (Table 1).
Questionnaire results
Focus group comments highlighted that the tool’s systems focus helped depersonalize incidents, making debriefs less threatening. Participants commented on the emotional intensity of these incidents and the tool’s value in moving residents from a place of “guilt” toward learning and action. A faculty participant observed, “It really takes practice to be able to look at this topic with less emotion and then really be able to analyze and learn from things. The tool is great to help people learn to do that.” A resident said, “To think about it on a systems level, and talk it through with someone, suddenly it gets smaller, … the noise in our head gets quieter, and then we’re able to actually address the issue.”
This psychological shift was facilitated within an emotionally safe discussion space. Most participants said the discussion environment was safe, and none said they felt personally blamed (Table 1). Contributing positive factors included hosting discussions in a private space; having a familiar group of peers and facilitators; framing discussions as confidential, learning-focused, and non-evaluative; depersonalizing incidents with a systems focus; normalizing incident discussions; and having faculty role modelling. One resident explained, “When … the staff that are present kind of own up to their own errors or talk about things, mistakes that they’ve made in their careers, I think those things can increase the feeling of safety.”
Another agreed: “What would be really powerful is to have more role modelling of and normalizing of the ability to discuss your errors.”
Some residents felt that having familiar faculty members involved supported their safety; others preferred session facilitation by faculty members without evaluative roles. Both residents and faculty participants valued having regular protected time for these conversations: “[T]hat these patient safety incident discussions happen on at least a semiregular basis, I think has been really important for my learning” (resident).
Challenges identified were mostly related to tool formatting and technical issues and submitting the tool. Some shared uncertainty about how to categorize incident contributors. One faculty member perceived the tool as being “rigid.”
Outcomes of the debrief included a self-reported increase in the likelihood of patient safety incident reporting for both residents and faculty participants, and residents reported a higher likelihood of making changes in their personal practices (Table 1):
It definitely changed the way I provide vaccinations, and making sure that the issues that were addressed [do] not happen again … was very helpful.
[Completing the form with the team] was very helpful in helping me develop new processes moving forward.
Conclusion
A simple patient safety tool, applied to real-life cases within a deliberately crafted and psychologically supportive learning environment, has proven effective for instructing family medicine residents on patient safety. The succinct design renders the tool especially suitable for use in ambulatory family medicine settings. With its focus on process rather than content, it could also be used in many other health professions training contexts.
Acknowledgment
We acknowledge Drs Tia Pham, Stephanie Godard, and Roarke Copeland for contributing to the early planning of the project; Jessica Bytautas for conducting the initial interviews; the postgraduate leadership team at the St Michael’s Hospital Academic Family Health Team for supporting this project; and all the faculty and residents at the St Michael’s Hospital Academic Family Health Team who participated in this research project. Financial support for this work was received from the Office of Education Scholarship in the Department of Family and Community Medicine at the University of Toronto in the form of an Art of the Possible grant and from the Department of Family and Community Medicine at St Michael’s Hospital.
Notes
Teaching Moment is a quarterly series in Canadian Family Physician, coordinated by the Section of Teachers of the College of Family Physicians of Canada. The focus is on practical topics for all teachers in family medicine, with an emphasis on evidence and best practice. Please send any ideas, requests, or submissions to Dr Viola Antao, Teaching Moment Coordinator, at viola.antao{at}utoronto.ca.
Footnotes
↵* Appendix 1 is available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.
Competing interests
None declared
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro d’octobre 2024 à la page e171.
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