A Novel Approach to Establish and Enhance Event Reporting Systems Among Resident Physicians

Abstract

Background

Event reporting systems are an integral part of patient safety programs that continue to remain a challenge primarily due to systems‐based barriers. Smartphone use in patient care continues to be an ever‐growing facet of medicine and patient care. Combining the problem of event reporting challenges with the modern resource of mobile phones may be used to promote a culture of safety and increase event reporting in the emergency department (ED) and the hospital among residents.

Methods

We introduced a new method of event reporting for emergency medicine (EM) residents in the ED using a mobile messaging application widely used throughout the hospital to facilitate physician communication to report events. Implementation of the intervention occurred in three phases. During the preintervention phase, we retrospectively reviewed EM resident rates of event reporting and administered a survey regarding their attitudes toward the traditional system of event reporting. We then introduced the mobile messaging application–based event reporting system and tracked the number of events recorded during the first 8 months of implementation. Following the intervention, we administered a postintervention survey to the EM residents inquiring about the same metrics that were used in the preintervention survey.

Results

Forty EM residents reported a total of 147 events during the 8 months of the intervention phase compared to 12 reports during the prior year as whole, resulting in a 12‐fold increase. The postintervention scores ranged from 55 to 73 with a mean (±SD) of 65 (±9). EM resident satisfaction rates and comfort level with the new reporting system increased by 232 and 104%, respectively, and the likelihood of reporting an event increased by 127% (p < 0.02). The time required by EM residents to submit a report also decreased significantly.

Conclusion

The implementation of a mobile application to target systems barriers associated with event reporting significantly increased event reporting by EM residents, improved EM resident attitudes about event reporting, and reduced the time required to submit an event, ultimately promoting a culture of safety.

Event reporting is an essential part of patient safety, quality improvement, and cost‐effective care in the emergency department (ED). A previous study reported that only 5% to 10% of events are reported. ¹ This may be due to inconsistencies in clinician preference and existing reporting systems. In 2019, a total of 97.1% of faculty, residents, and medical students used a smartphone as part of their clinical practice. ² In addition, the use of Health Insurance Portability and Accountability Act (HIPAA)‐compliant modes of communications have rapidly expanded over the past several decades to include smartphone applications such as group text messaging applications. ³ , ⁴ Another recent study reported that residents prefer to use text messaging as a primary means of communication within the hospital system due its ease of use and efficiency. ⁵ However, existing event reporting systems are often composed of paper forms, phone‐based systems, or Web‐based reporting; these methods predictably increase the use of resources or require a computer terminal. ⁶ , ⁷ Prior attempts to improve event reporting have primarily focused on educational and cultural factors aimed at increasing the perceptual importance of event reporting as well as using technology to increase the ease of reporting events. ¹ , ⁸ , ⁹ , ¹⁰

Communication in the ED is unique and presents challenges not classically encountered in other hospital settings. Multiple staff members are typically situated in a central location where the primary means of communication is person to person. ¹¹ Emergency medicine (EM) residents also simultaneously care for multiple patients at one time, deal with frequent interruptions, and perform a variety of tasks involved in direct and indirect patient care ¹² ; it is possible that event reporting in the ED is underutilized due to both time constraints and shifting priorities compounded by an inefficient reporting system. EM residents spend a significant amount of time prioritizing tasks based on the urgency of the patient’s presentation and communication with other ED and hospital staff, which makes event reporting a low priority due to its time‐consuming nature and inefficient means of reporting. ¹³ , ¹⁴ , ¹⁵

Resident physicians are in a unique position to help improve patient safety and quality of care due to the large number of hours devoted to working in the hospital compared to other staff members. The 2017 American College of Graduate Medical Education (ACGME) report on Common Residency Program Requirements reports that identifying and addressing near misses and unsafe conditions are “essential for the success of any patient safety program.” ¹⁶ Therefore, residents can and should be involved in event reporting both for accreditation and patient safety. However, physicians make up only 1% to 2% of all event reporting due to factors such as time constraints, cultural factors, and a lack of awareness regarding the importance of event reporting. ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹

The literature suggests that the optimal event reporting system is readily available 24 hours a day, has the ability to store and sort data, is able to attach pictures and videos, and is easily accessible to clinicians. ⁹ Mobile‐based text messaging applications provide a way of expanding event reporting by reducing systems barriers for residents in the ED. Rubin et al. ¹⁰ showed that the implementation of a mobile‐based event reporting system significantly increased reporting by all clinicians in an anesthesiology and critical care department.

If residents are key players in event reporting but are dissatisfied with the efficiency of event reporting systems, we hypothesized that a streamlined interface that builds on an already‐existing communication system would increase resident attitudes toward, and frequency of, event reporting in the ED. This urban academic center ED currently uses a secure mobile text messaging application for HIPAA‐compliant communications between clinicians throughout the hospital. The text messaging application has been used to decrease the time taken to admit a patient to the hospital from the ED as well as to decrease ED to catheterization‐lab time during emergent care of ST‐elevation myocardial infarction. ²² In an effort to increase event reporting, our ED introduced this existing HIPAA‐compliant text messaging application as a means to more easily report events. We aimed to assess the attitudes and ease of use between the prior and new reporting systems as well as to compare the rates of event reporting by residents in the ED during the implementation of the new reporting system.

METHODS

This study was conducted at an urban academic emergency department and consisted of 40 EM residents postgraduate years (PGY) 1 to 4. Participation in this study was voluntary for EM residents. We conducted the study in three phases: during the preintervention phase, we evaluated the attitudes towards the existing reporting system, resident satisfaction, time utilized to submit a report, and the likelihood of reporting an event in the prior year. The questionnaire used for the study can be found in Data Supplement S1 (available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10554/full). This questionnaire with a scoring system between 0 and 100 was given to EM residents on their attitudes toward the Medical Information Data Analysis System (MIDAS) event reporting system. EM residents were given instructions on navigating the new reporting mechanism and reporting an event. The questionnaires were marked by two separate members of the research team and handed over to a third member who entered the data in an Excel spreadsheet. To report an event, the EM residents sent a message to the MIDAS Event Reporting role with “who, what, where, when” characteristics of the event. For example, “John Doe MRN 12345 was given the wrong dose of insulin in the emergency department.”

In the intervention phase, we implemented the new text messaging–based system and tracked the number of reports for 8 months. The postintervention phase consisted of reevaluating the attitudes toward the reporting system, resident satisfaction, time utilized to submit a report, and the likelihood of reporting an event with the new event reporting system. This study was deemed exempt by the institutional review board at George Washington University because it was considered a quality improvement project. During the intervention phase, we created a profile using the hospital’s text messaging–based application titled “MIDAS event reporting” that was directly routed to the hospital’s risk management department. When a message was received, the risk management department was responsible for responding to the reported event. In addition to responding to the reported event, a risk management specialist entered the information into the hospital’s MIDAS interface.

During the postintervention phase, we reviewed the number of events reported during the 8‐month implementation period and surveyed EM residents’ satisfaction with the new reporting system as well as measured the comfort level with the reporting system and the likelihood of submitting a report. An interdisciplinary team composed of ED staff proficient in quality and safety developed the anonymous surveys for both the pre‐ and the postintervention phases; the survey was not piloted or validated. We used a scoring system between 0 and 100 for each question. The preintervention phase started in July 2018, the intervention phase started mid‐August, and we resurveyed the EM residents in March. The primary outcome included the number of events reported and the secondary outcomes were the satisfaction with the new reporting system, time taken to report, and likelihood of future reporting.

RESULTS

The preintervention survey characterized on Figure 1 showed that most EM residents knew that MIDAS incident reporting was used for quality improvement, reporting events, potential harm, near misses, and errors; however, the vast majority did not understand how to report an event. Most EM residents also reported a low likelihood for submitting an event (mean score = 30/100). The overall satisfaction with the computer‐based reporting system was also low (mean score = 22/100). In addition, 21% of EM residents reported taking 5 to 15 minutes to submit an event report through the MIDAS reporting system, another 21% of EM residents took 15 to 30 minutes to submit a report, and 10% of residents took 30 to 60 minutes to report an event; the remaining 48% of participants reported that they never reported a MIDAS event (Figure 2).

Figure 1.

Resident’s rating of comfort level, likelihood of reporting, and overall satisfaction with event reporting (scale 1–100).

Figure 2.

Residents’ time spent submitting a MIDAS event report (preintervention) versus mobile phone–based event report (postintervention). MIDAS = Medical Information Data Analysis System.

During the 8‐month intervention phase, 31 residents (78%) submitted a total of 147 reports through the secure text messaging–based system; this constituted a 12‐fold increase in event reporting when compared to the entire prior year in which only 12 reports were submitted. The postintervention survey (Figure 1) showed that EM residents were more comfortable submitting a MIDAS report through the secure text messaging application with an average score of 55/100 and that they were more likely to submit a MIDAS through text in a given year (score 68/100). Residents also spent less time reporting each event with 46% of the residents taking 1 to 5 minutes, 15% taking 5 to 15 minutes, and 0% taking any longer than 15 minutes; 38% did not submit a MIDAS report (Figure 2).

The overall satisfaction with event reporting increased by 232% and EM residents reported a 104% increase (score increase of 28 points) in the comfort level with reporting an event. The likelihood of event reporting increased by 127% (score increase in 38 points) during the intervention period (Figure 1; p < 0.02). We also recorded the number of events reported per month which showed a sharp increase in reporting during the months of December and January (Figure 3).

Figure 3.

Number of reports filed by month during the intervention period.

DISCUSSION

Our study showed that even with such an easily implementable intervention, event reporting increased 12‐fold and resident satisfaction with reporting systems increased 232%. The time used to report events was also drastically reduced, and the comfort level with event reporting doubled. This was accomplished by building onto an existing communication system, resulting in a system that was intuitive and simple for reporters to utilize.

We aimed to reduce barriers to reporting using smartphone devices rather than logging in and submitting a report using a computer terminal. As the use of smartphone devices continues to increase in all aspects related to patient care, its use will continue to considerably influence and shape modern medical practice. ⁸ , ⁹ , ¹⁰ , ²² , ²³ , ²⁴ , ²⁵ Application‐based communication has been shown in the past to provide more accurate patient management and prompt care. ¹ It has also been shown in the past that increased event reporting is associated with improved patient outcomes. ²⁶ , ²⁷ This project supports existing evidence and aims to improve event reporting by reducing commonly reported systems‐based barriers to event reporting by residents and clinicians including time constraints and shifting priorities which are commonplace in the ED. ²⁸ , ²⁹

Event reporting is an important part of hospital quality improvement and patient safety; resident physicians rapidly respond to circumstances and make medical decisions appropriately. ³ EM residents experience frequent interruptions and are influenced by the urgency of both the patients and the urgency of the message being communicated. ¹⁴ , ¹⁵

We did not change the analytical database used by the hospital and we did not change or address the manner in which events are investigated. Instead, the intervention created an avenue for EM residents to report events easily and efficiently without significant interruptions to patient care. The intervention in this study primarily focused on reducing systems‐based barriers by simplifying the reporting method that clinicians use as part of quality improvement within the hospital setting. Prior to the intervention, the hospital used a Web‐based reporting system accessible by all clinical staff including medical students as a means of event reporting. The system requires a computer terminal and necessitates that clinicians fill out an online form to report an event. The event is then added into the MIDAS analytic database that is directly routed to the hospital’s risk management department for further action. The introduction of our simpler method of event reporting may lead to an increase in the detection of events, near misses, and errors and lead to improved patient safety and better outcomes by identifying events that might not have been otherwise recognized.

More studies are required to assess the long‐term safety outcomes of this intervention and its impact on patient safety and resident satisfaction, as well as the implications of this intervention across more hospital systems. Despite this, our intervention shows great potential for improvement of event reporting and, therefore, patient safety and quality of care.

LIMITATIONS

This study has several limitations. The introduction of a new system can lead to an increase in event reporting. Yet we believe that the length of the study was sufficient to allow for degeneration of this effect. We do not believe that the rates of events changed during the intervention method. The intervention was also compared to the prior 12 months of events, and the rate of events was stable over time. However, the inability to regulate event incidence cannot be ruled out as a limitation. There was also a large increase in the number of reports during the intervention phase in the months of December and January. It was not possible to determine the reason for this abrupt change since the preintervention period did not have enough reports to provide an adequate comparison. The setting of this study was as a quality improvement project and our survey was not validated. Other potential weaknesses include the small sample size, recall bias regarding exact time of reporting the event, and response bias by EM residents filling out surveys regarding a new method of event reporting. Of note, the percentage of EM residents who never submitted a report remained high both in the pre‐ and postintervention surveys, and we were not sure about the reasons behind this. Additionally, all hospitals may not have the existing infrastructure to implement our intervention with the same ease.

CONCLUSION

The introduction of a mobile phone–based text messaging HIPAA‐compliant application increased the rate and number of event reporting and decreased the time and equipment required for reporting. In addition, the introduction of this reporting mechanisms addresses the guidelines of the ACGME by expediting and simplifying the event reporting process.

Supporting information

Data Supplement S1. Survey.

AEM Education and Training. 2021;5:1–7