title: Increasing Trainee Reporting of Adverse Events With Monthly Trainee-Directed Review of Adverse Events.
abstract: Underreporting of adverse events by physicians is a barrier to improving patient safety. In an effort to increase resident and medical student (hereafter "trainee") reporting of adverse events, trainees developed and led a monthly conference during which they reviewed adverse event reports (AERs), identified system vulnerabilities, and designed solutions to those vulnerabilities.
  
  
  
  Monthly conferences over the 22-month study period were led by pediatric trainees and attended by fellow trainees, departmental leadership, and members of the hospital's quality improvement team. Trainees selected which AERs to review, with a focus on common near misses. Discussions were directed toward the development of potential solutions to issues identified in the reports. Trainee submissions of AERs were tracked monthly.
  
  
  
  The mean number of AERs submitted by trainees increased from 6.7 per month during the baseline period to 14.1 during the study period (P < .001). The average percent of reports submitted by trainees increased from a baseline of 27.6% to 46.1% during the study period (P = .0059). There was no significant increase in reporting by any other group (attending, nursing, or pharmacy). Multiple meaningful solutions to identified system vulnerabilities were developed with trainee input.
  
  
  
  Trainee-led monthly adverse event review conferences sustainably increased trainee reporting of adverse events. These conferences had the additional benefit of having trainees use their unique perspective as frontline providers to identify important system vulnerabilities and develop innovative solutions.
authors.affiliation: Boston Children's Hospital, Boston, Mass. Electronic address: alla.smith@childrens.harvard.edu.
authors.forename: Alla
authors.initials: A
authors.lastname: Smith
authors.affiliation: Boston Children's Hospital, Boston, Mass.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Hatoun
authors.affiliation: Quality and Patient Safety Department, Boston Medical Center, Boston, Mass.
authors.forename: James
authors.initials: J
authors.lastname: Moses
mesh_terms: D030881:Disclosure; D006801:Humans; D007396:Internship and Residency; D019300:Medical Errors; D061214:Patient Safety; D010372:Pediatrics / Q000193:education*; D058996:Quality Improvement
keywords: adverse event reporting; patient safety; resident education