249599 Interprofessional performance monitoring: Improving patient safety by detecting co-workers' medical errors

Tuesday, November 1, 2011

Michal Tamuz, PhD , School of Public Health, Department of Health Policy and Management, SUNY Downstate Medical Center, Brooklyn, NY
The 2000 Institute of Medicine report recommended that healthcare organizations establish learning environments in which providers receive feedback on medical errors. Detecting mistakes is especially important in high-risk settings, such as intensive care units (ICUs), where the adverse drug event rate is twice that outside ICUs. Teaching hospitals share ubiquitous expectations that nurses, staff pharmacists, and clinical pharmacists (“other professionals”) will monitor the decisions of medical trainees (“residents”), who are expected to make mistakes as they rotate through different hospital units. These physicians-in-training are simultaneously responsible for monitoring other professionals' clinical decisions. Yet relatively little is known about how residents experience error detection discussions with other professionals. In a qualitative study of residents, we examined interactions between residents and other professionals as they detected and discussed each other's medication-related mistakes. We first asked how residents responded when other professionals caught residents' potential mistakes and secondly, how residents described noticing other professionals' mistakes. We also explored how such episodes of interprofessional performance monitoring influenced residents' individual learning, patient safety, and learning environments. We examined extensive interviews with a purposeful random sample of 17 non-surgical residents working in three tertiary care hospital ICUs. The 30-page interview transcripts were supplemented by field notes, document review, and observations of routine activities. Our data analysis stemmed from a resident supervision study developed from a research project on how hospitals learn from medication errors. Beginning without pre-existing codes, the research team analyzed the interview transcripts by applying the constant comparative method. We identified residents' descriptions of joint decision making episodes involving residents and other professionals in which they detected and discussed each other's mistakes. We compared among individual resident's episodes, classified episodes by perceived error detection accuracy (e.g., true/false positives), and identified exemplars for each category. The exploratory results highlight residents' perspectives on how residents and other professionals learn from detecting each other's mistakes. The mistake-detection exemplars varied in their implications for residents' individual learning, patient safety, and developing learning environments. Themes related to interpersonal communication and building trust emerged from the analyses, especially for inaccurate error detection. Further research could examine how nurses, staff pharmacists and clinical pharmacists experienced interprofessional performance monitoring. Practically, the results could assist team-training experts in adapting “mutual performance monitoring” and related teamwork methods for specialized healthcare contexts. Theoretically, the results could contribute to building a conceptual framework for understanding how individual learning patterns cumulate to form unit-level learning environments.

Learning Areas:
Administration, management, leadership
Communication and informatics
Provision of health care to the public
Social and behavioral sciences

Learning Objectives:
Describe how nurses, staff pharmacists, and clinical pharmacists detect and discuss possible mistakes by medical trainees. Describe how medical trainees detect and discuss possible mistakes by nurses, staff pharmacists and clincial pharmacists Discuss the implications of these episodes of interprofessional performance monitoring for resident's individual learning, patient safety, and developing learning environments. Describe how understanding interprofessional performance monitoring can inform efforts to develop context-specific team-training methods in healthcare organizations.

Keywords: Health Care Quality, Safety

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have actively participated in collecting and analyzing the data.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.