Dr. Margarita Lam Antoniades of St. Michael's Hospital has worked on the development of a series of tools for teaching around patient safety incidents for family medicine residents, in collaboration with Dr. Thuy-Nga Pham and residents Roarke Copeland and Stephanie Goddard of Michael Garron Hospital, and with support from the University of Toronto.  

The department of Family Medicine at St. Michael's Hospital consists of six community clinics in Toronto, Ontario. It is an academic training site for family medicine residents at the University of Toronto. Currently, there are approximately 40 family practice residents training at St. Michael's.

Tell us about your initiative.

Many of our residents have received some teaching around quality improvement, but not with a dedicated focus on patient safety. We identified this as an opportunity and began looking at how we could highlight the role of patient safety in daily clinical practice. 

Patient safety is not easily taught in the classroom. To make it real for our residents in a clinical setting, we set out to develop a tool that would allow preceptors and residents to integrate learning from patient safety incidents into their daily routines and practice. The idea of resident incident reporting came from learners themselves: Stephanie and Roarke, residents from Michael Garron Hospital, developed a resident incident reporting tool for their local site as part of their residency quality improvement (QI) project. With the support of the central Department of Family and Community Medicine at the University of Toronto, we worked collaboratively to further develop this as a teaching tool. At St. Michael's Hospital, we decided to adapt the tool into an incident discussion tool – a non-threatening format – because we already had a hospital patient safety incident reporting system. It was designed to be short and practical enough to be used during routine clinic teaching to debrief and reflect on recent incidents. 

The tool consists of a fish bone/Ishikawa diagram, followed by a few questions to help guide reflection and thinking around systems changes. The fishbone diagram guides residents to frame incidents broadly, looking at contributing factors beyond their own actions. Clinicians can be very hard on themselves and tend to be narrow in their focus; this process takes them outside of that realm. In addition to using the tool, a judgement needs to be made about whether the incident raises systemic issues and should be reported on the formal patient safety reporting system. Submissions are reviewed quarterly by departmental leadership to determine whether systems changes are needed and to co-ordinate their implementation.

The number of patient safety incidents in primary care tends to be higher because of the larger volume of patients seen, with a lower number of critical incidents due to a higher level of acuity. The discussion tool can lead to reflection on a multitude of issues including prevention of medication errors, delayed diagnosis, missed diagnosis, miscommunication of test results and miscommunication between providers.

What issue has the patient safety discussion tool addressed and why?

The tool addresses the need for a framework to guide reflection on resident patient safety incidents that is simple enough to be integrated into day-to-day learning. With support from preceptors, residents can then be encouraged to think about how to change systems around them in order to reduce patient risk. It is versatile enough that it can be used to discuss all types of incidents from minor to major, including near misses.

Why is it innovative?

It is innovative because it presents a practical, engaging and non-threatening way to introduce family medicine residents to patient safety in the busy clinic setting, which is not currently part of the standard curriculum.

This initiative has the potential to create change at the personal, clinic, departmental and system level.

What was one major learning, or takeaway you can share with others?

Change is hard. It is important to recognize this.

The diverse population we treat, coupled with the reality of working across multiple sites did present a challenge. We needed to value the importance of partnerships. We also had challenges with infrastructure and a variety of processes, so we needed to be flexible.

Is it replicable, can others adopt what you've done?

These patient safety teaching tools are generic enough that they could be adapted to fit the local context in most family medicine settings. We would love to see them spread to other primary care teaching sites.

With the support of the Quality Improvement program of the department of Family and Community Medicine at the University of Toronto, we will be doing an evaluation of our work and we are hoping to publish our findings when available.

Where can people go to learn more?

Contact Margarita Lam-Antoniades at antoniadesm@smh.ca