Three elements provide important context for residents and faculty to engage PS/QI, which includes reporting incidents:
1. Patient Safety and Quality Improvement are essential components of health care and the Marshfield Clinic Health System’s Mission, Vision, Core Values and Promise.
2. Just Culture is essential to our Mission, Vision, Core Values and Promise. This involves addressing errors and near misses. MCHS president, Dr. Susan Turney explains this here. This essential role is reflected in MCHS policy which states “ All physicians, providers, residents, and employees involved or who witness an incident are obligated to report using the Incident Reporting System.”
3. Faculty and residents must actively participate in use of the incident reporting system. The ACGME Common Program Requirements engages the Just Culture model, noting that “faculty, residents and fellows must actively participate in patient safety systems and contribute to a culture of safety.” CPR VI.A.1.a).(1).(a) (pages 38-39). ACGME considers incident reporting a competency that must be taught and demonstrated.
VI.A.1.a).(1) - (3) A culture of safety requires continuous identification of vulnerabilities and a willingness to transparently deal with them…the program, its faculty, residents and fellows must actively participate in patient safety systems and contribute to a culture of safety… residents, fellows, faculty members and other clinical staff members must: know their responsibilities in reporting patient safety events at the clinical site; know how to report patient safety events, including near misses, at the clinical site…
DOE and Clinical Risk Management developed a tool to help residents develop competency in incident reporting. The tool provides simulated events to enter into a practice version of the Incident Reporting System. There are 6 steps in the use of the practice tool.
1. Watch this video which introduces the Incident Reporting System and describes the workflow for a report.
2. Watch these videos which guide you through making a report. (We picked 2 examples from the 9 categories).
-example for a medication/chemotherapy incident
-example for unprofessional behavior
3. Use one of the simulation incidents for your practice report. Scenarios are on the Q Drive at
Q>Residents>RL. Your program staff will provide you with the password to the document.
4. Open the Incident Reporting System practice site and it will prompt you to log in using your MCHS credentials (username and password).
5. Enter and submit the report.
6. Email to Aimie Eckelberg your name, program and the Form Type and Scenario number of the simulation incident you submitted.