title: A novel approach to increase residents' involvement in reporting adverse events.
abstract: OBJECTIVE
  In the wake of the Patient Safety and Quality Improvement Act of 2005, national attention has increasingly focused on adverse-event reporting as a means of identifying systems changes to improve patient safety. However, physicians and residents have demonstrated meager involvement in this effort.
  
  
  METHODS
  In 2008-2009, the authors measured participation in adverse-event reporting by 680 residents at Oregon Health & Science University before and after implementing a quality improvement initiative, which consisted of a financial incentive and multifaceted educational campaign. The primary measure of success was an increase in the average monthly adverse-event reports submitted by residents to greater than 5% of the institution's overall report submissions.
  
  
  RESULTS
  The average number of adverse events reported by residents increased from 1.6% to 9.0% of the institution's overall event reports, representing a 5.6-fold increase during the initiative (P < .001). The relative percentage of resident-submitted reports defined as "near-misses" increased from 6% to 27% during the initiative (P < .001).
  
  
  CONCLUSIONS
  The novel approach of integrating a retirement benefit and educational campaign to increase residents' involvement in adverse-event reporting was successful. In addition to increasing residents' contributions to adverse-event reporting to levels higher than any documented in the current literature, there was also a remarkable increase in the relative frequency of near-miss reporting by residents.
authors.affiliation: Department of Medicine, Portland Veteran Affairs Medical Center and Oregon Health & Science University, 3181 SW Sam Jackson Park Road OP-30, Portland, OR 97239-3098, USA. scottdav@ohsu.edu
authors.forename: David R
authors.initials: DR
authors.lastname: Scott
authors.forename: Melissa
authors.initials: M
authors.lastname: Weimer
authors.forename: Clea
authors.initials: C
authors.lastname: English
authors.forename: Lynn
authors.initials: L
authors.lastname: Shaker
authors.forename: William
authors.initials: W
authors.lastname: Ward
authors.forename: Dongseok
authors.initials: D
authors.lastname: Choi
authors.forename: Andrea
authors.initials: A
authors.lastname: Cedfeldt
authors.forename: Donald
authors.initials: D
authors.lastname: Girard
mesh_terms: D006801:Humans; D007396:Internship and Residency; D016014:Linear Models; D009922:Oregon; D010816:Physician Incentive Plans; D015397:Program Evaluation; D011446:Prospective Studies; D058996:Quality Improvement; D012308:Risk Management