IMPROVING PATIENT SAFETY EVENT REPORTING AND LEARNING IN ORTHOPAEDIC SURGERY: A QUALITY IMPROVEMENT (QI) INITIATIVE IN POSTGRADUATE EDUCATION
Notice bibliographique
Résumé
Reflecting on patient safety events is a crucial aspect of clinical care and an educational opportunity for surgical trainees. Diligently documenting adverse events (AE) and discussing key learning points encourages constructive reflection to prevent event recurrence. This QI initiative aims to implement a multimodal program to increase participation in and standardize AE reporting and engage trainees in safety-related learning. After 18 months of piloting this initiative, we evaluated its effectiveness in optimizing our M&M Rounds and improving case tracking. Our QI initiative involved using the Ottawa M&M Model (OM3)1 to guide M&M Rounds, creating a centralized AE tracking tool, and launching new initiatives to remind trainees to document AEs. In March 2022, we transitioned to the OM3 Model1 for holding M&M Rounds and created a GoogleDoc spreadsheet to track AE cases. We designed a PowerPoint template based on the OM3 framework for case presentations at Rounds. After Rounds, attendees completed an evaluation survey with questions formatted according to the OM3 score card.2 Each question is scored out of three points [total: 24]. We calculated the average quarterly OM3 scores and individual question scores from Quarter Three of 2021 to Quarter Three of 2023. In October 2023, we implemented initiatives to improve the consistency of AE tracking. We designed newsletters to share project progress. Monthly editions were distributed to faculty and trainee site leads and provided updates on each site's performance and recently tracked AEs. Quarterly editions were distributed to staff, residents, and fellows and highlighted key AEs and their learning points along with a detailed guide for organizing M&M Rounds. Reminder posters with a QR code linking to the AE GoogleDoc were placed in orthopaedics on-call and/or hand-over rooms. Also, we emailed reminders for completing the post-rounds surveys. There was a 3.11-point increase in OM3 scores after transitioning to the new format [14.59 pre-transition versus 17.70 post-transition]. Individual scores improved for six questions [activity frequency, method of discussions, case finding, case selection, case analysis, impact, and outcomes]. There was a significant 1.05-point improvement in the method of discussions [1.50 vs. 2.55; p Transitioning to OM3 significantly improved the structure of our M&M Rounds, case selection, and learning outcomes. Our initiatives that focused on elevating awareness for patient safety and spotlighting lessons learned increased the number of AEs reported. Future studies should examine strategies to improve (MDT) attendance at M&M Rounds.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,008 | 0,018 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,000 |
| Bibliométrie | 0,001 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».