Abstract
Quality improvement and patient safety education is an Accreditation Council for Graduate Medical Education (ACGME) common program requirement for hematology/oncology fellowships. Interprofessional clinical patient safety activities, such as root cause analyses (RCA), can be challenging to incorporate into busy schedules. We report on a multicentered experience utilizing a simulated RCA educational module in an attempt to provide fellows with the tools needed to participate in a live RCA and to increase awareness of the need to analyze patient safety events. The 2-h module included a didactic session explaining the basics of an RCA including common terminology, effective chart review, and personal interviews. The fellows assessed a patient safety event of a missed coagulopathy and created an event flow map and fishbone analysis. They then formed root cause/contributing factor statements and proposed a solution. Twenty-three fellows from two institutions completed the experience. There was a significant difference in fellow reported comfort with participating in a live RCA (p = 0.03), and in utilizing the tools of an RCA following the mock RCA experience (p = 0.005). About 70% of respondents felt that as a result of the mock RCA, they were more likely to report a near miss or adverse event and were more likely to be thorough in their documentation. Mock RCAs are a feasible method of incorporating ACGME-required patient safety activities into hematology/oncology fellow education and are effective in increasing their comfort and understanding of important quality improvement skills.
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“ACGME Common Program Requirements (Fellowship) https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2019.pdf (Accessed 4/12/20)
Bar-On M, Berkeley RP (2016) Early engagement of residents into the root cause analysis process. J Grad Med Educ 8(3):459–460. https://doi.org/10.4300/JGME-D-15-00669.1
Quraishi SA, Kimatian SJ, Murray WB, Sinz EH (2011) High-fidelity simulation as an experiential model for teaching root cause analysis. J Grad Med Educ 3(4):529–534. https://doi.org/10.4300/JGME-D-11-00229.1
Swamy L, Worsham C, Bialas MJ et al (2018) The 60-minute root cause analysis: a workshop to engage interdisciplinary clinicians in quality improvement. MedEdPORTAL 14:10685. https://doi.org/10.15766/mep_2374-8265.10685
Murphy M, Duff J, Whitney J, Canales B, Markham MJ, Close J (2017) Implementation of a mock root cause analysis to provide simulated patient safety training. BMJ Open Qual 6:e000096. https://doi.org/10.1136/bmjoq-2017-000096
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Wallace, D., Cochran, D., Duff, J. et al. A Multicentered Academic Medical Center Experience of a Simulated Root Cause Analysis (RCA) for Hematology/Oncology Fellows. J Canc Educ 37, 911–914 (2022). https://doi.org/10.1007/s13187-020-01899-8
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DOI: https://doi.org/10.1007/s13187-020-01899-8