title: An Improvement Approach to Integrate Teaching Teams in the Reporting of Safety Events.
abstract: OBJECTIVE
  Patient safety events are underreported by physicians. Baseline data demonstrated that physicians submitted 3% of event reports at Our Lady of the Lake Children's Hospital. Our aim was to increase the proportion of safety reports filed by residents and faculty to 6% of all reports within a 9-month period.
  
  
  METHODS
  We used the Model for Improvement and serial Plan, Do, Study, Act cycles to test interventions we hypothesized would improve physician recognition and reporting of patient safety events. We tracked the percentage of Our Lady of the Lake Children's Hospital event reports entered by residents or faculty over time as the primary outcome measure. Changes to teaching team processes included "patient safety rounds" prompted by text messages, an inpatient "superintendent" rotation with core patient safety responsibilities, and a "just-in-time" faculty development program called "QI on the Fly."
  
  
  RESULTS
  Physician-reported events increased to a monthly average of 24% of all events reported, an improvement that has been sustained over 17 months. Resident reporting accounted for most of the increase in physician reports. Increased physician reporting was temporally associated with implementation of the "superintendent" rotation. The total number of events reported increased as a result of increased physician reporting.
  
  
  CONCLUSIONS
  Incorporating patient safety responsibilities into a teaching team's workflow can increase physician safety event reporting. We plan additional Plan, Do, Study, Act cycles to spread this approach to other clinical settings and investigate the impact increased reporting might have on patient care.
authors.affiliation: Division of Pediatrics, Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana; alston.dunbar@ololrmc.com.
authors.forename: Alston E
authors.initials: AE
authors.lastname: Dunbar
authors.affiliation: Division of Health and Safety, and.
authors.forename: Marcie
authors.initials: M
authors.lastname: Cupit
authors.affiliation: Division of Academic Affairs, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Vath
authors.affiliation: Division of Pediatrics, Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana.
authors.forename: Kyle
authors.initials: K
authors.lastname: Pontiff
authors.affiliation: Division of Pediatrics, Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana.
authors.forename: Natalie
authors.initials: N
authors.lastname: Evans
authors.affiliation: Division of Pediatrics, Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana.
authors.forename: Melissa
authors.initials: M
authors.lastname: Roy
authors.affiliation: Division of Pediatrics, Our Lady of the Lake Children's Hospital, Baton Rouge, Louisiana.
authors.forename: Michael
authors.initials: M
authors.lastname: Bolton
mesh_terms: D005180:Faculty, Medical; D006776:Hospitals, Pediatric; D006801:Humans; D007396:Internship and Residency; D008145:Louisiana; D019300:Medical Errors; D061214:Patient Safety; D010372:Pediatrics / Q000193:education; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration*; D012308:Risk Management / Q000458:organization & administration; D056164:Teaching Rounds