P2D251: Safety USHERSS: A Quality Improvement Initiative on Utilizing the Safety Huddle to Empower Residents as Safety Stewards (USHERSS)

Purpose/Objectives: ACGME requires that all residents know their responsibilities and know how to report patient safety events at their clinical site, including near misses. The Clinical Learning Environment Review National Report in 2018 found that residents were aware of their clinical learning environment’s process for reporting patient safety events, however events were often not entered into the event reporting system as residents often felt most comfortable reporting events through the chain-of-command and resolving issues locally. The report also found that residents lacked clarity and awareness of the range of reportable patient safety events. This initiative addresses these opportunities by using a standardized process to conduct safety huddles, improving use of event reporting systems, engaging stakeholders, and creating a space for residents to discuss patient safety concerns regularly and transparently share corrective actions.

Design/Methods: University of South Florida (USF) residents within categorical pediatrics and medicine-pediatrics programs were educated on how to submit patient safety events through RL Solutions at Tampa General Hospital. Additionally, residents were provided with education on types of safety events including near misses to increase awareness of which events should be reported. Monthly standardized resident-led safety huddles were held with pediatric and medicine-pediatric residents during required didactics starting in October 2022. Each safety huddle provided an open forum for residents to speak about witnessed safety issues and included updates from previous safety huddles. Pre-evaluation data was collected from RL Solutions prior to October 2022.

Results: In the 12 months prior to start of the USHERSS initiative, a total of 1 patient safety report was filed by a pediatric or medicine-pediatric resident. Since implementing consistent resident-led patient safety huddles, a total of 46 patient safety reports have been filed by 9 residents including 3 near miss events over the course of 6 months.

Conclusion/Discussion: The implementation of regular resident-led safety huddles resulted in a significant increase in the number of resident-reported safety events. This continues to enforce the importance of resident education on improving the use of event reporting to advance patient safety and enhance healthcare quality. Further studies could consider the impact of post-graduate year in residency on frequency of reported events.