Improving patient safety by promoting a learning environment for medical trainees

The influential 2000 Institute of Medicine (IOM) report called for healthcare organizations to establish learning environments in which caregivers could receive feedback on their mistakes. Creating learning environments is especially important for medical trainees (“residents”) who are expected to make mistakes as they rotate through various hospital units. Mistakes threaten patient safety, in particular, in high-risk settings such as intensive care units (ICU), where the rate of adverse drug events is twice that of non-ICU settings. Residents seek to learn from attending physicians and other higher-ranking physicians. However, fearful of being judged incompetent, they can hesitate and refrain from asking questions of higher-ranking physicians, especially after hours. Teaching hospitals also share ubiquitous expectations for nurses, staff pharmacists, and clinical pharmacists (“other professionals”) to monitor the safety of medication orders. Yet relatively little is known about how residents experience and respond to the interactions with other professionals and whether other professionals provide a learning environment for residents. In a qualitative study, we examined how ICU-based residents learned and received feedback about their errors from other professionals. We examined in-depth interviews with 17 residents working in ICUs of three tertiary care hospitals, as part of a larger research project on how hospitals learn from medication errors. We interviewed a purposeful random sample of residents to reduce bias and enhance the credibility of the small sample. Each audio-recorded interview lasted about 75 minutes and resulted in a 30-page transcript, on average. Field notes, document review, and observations of routine activities supplemented the interviews. A coding team began the data analysis without pre-existing codes and analyzed the interview transcripts by applying the constant comparative method. The qualitative data analysis yielded two sets of themes. The residents reported that other professionals used specific methods for assessing, intervening in, and communicating about the residents' clinical decisions. Nurses and pharmacists, for example, applied distinctive methods of assessing residents' treatment choices, whereas they exhibited common communication strategies. A second set of themes described the organizational conditions that fostered a learning environment. These ranged from prosaic measures for providing the residents access to other professionals-- to the nuanced role of the attending physician in setting norms for residents to consider feedback from non-physicians. By highlighting the processes through which residents learn from other professionals and, conversely, how other professionals create a non-judgmental learning environment for residents, we propose practical suggestions for hospital administrators and caregivers to improve patient safety.