January 2017

Volume 2 Number 3

In this issue of the Journal we have selected abstracts relating to the important topic of patient safety and residents’ ability to report adverse events and their feelings about adequate supervision. We have included abstracts from Virginia (Appelbaum),  Toronto (Friedman), Denmark (Rasmussen),  Arizona (Min) and SanDiego  (Dollarhide).

These abstracts explore the role of various psychological factors in safety and safety reporting. Relationship with supervisors and sleep deprivation are among the important variables.


The effects of power, leadership and psychological safety on resident event



Appelbaum NP, Dow A, Mazmanian PE Jundt DK, Appelbaum EN.


Med Educ. 2016 Mar;50(3):343-50. doi: 10.1111/medu.12947.


CONTEXT: Although the reporting of adverse events is a necessary first step in

identifying and addressing lapses in patient safety, such events are

under-reported, especially by frontline providers such as resident physicians.


OBJECTIVES: This study describes and tests relationships between power distance

and leader inclusiveness on psychological safety and the willingness of residents

to report adverse events.


METHODS: A total of 106 resident physicians from the departments of neurosurgery,

orthopaedic surgery, emergency medicine, otolaryngology, neurology, obstetrics

and gynaecology, paediatrics and general surgery in a mid-Atlantic teaching

hospital were asked to complete a survey on psychological safety, perceived power

distance, leader inclusiveness and intention to report adverse events.


RESULTS: Perceived power distance (β = -0.26, standard error [SE] 0.06, 95%

confidence interval [CI] -0.37 to 0.15; p < 0.001) and leader inclusiveness (β =

0.51; SE 0.07, 95% CI 0.38-0.65; p < 0.001) both significantly predicted

psychological safety, which, in turn, significantly predicted intention to report

adverse events (β = 0.34; SE 0.08, 95% CI 0.18-0.49; p < 0.001). Psychological

safety significantly mediated the direct relationship between power distance and

intention to report adverse events (indirect effect: -0.09; SE 0.02, 95% CI -0.13

to 0.04; p < 0.001). Psychological safety also significantly mediated the direct

relationship between leader inclusiveness and intention to report adverse events

(indirect effect: 0.17; SE 0.02, 95% CI 0.08-0.27; p = 0.001).


CONCLUSIONS: Psychological safety was found to be a predictor of intention to

report adverse events. Perceived power distance and leader inclusiveness both

influenced the reporting of adverse events through the concept of psychological

safety. Because adverse event reporting is shaped by relationships and culture

external to the individual, it should be viewed as an organisational as much as a

personal function.

Supervisors and other leaders in health care should ensure

that policies, procedures and leadership practices build psychological safety and

minimise power distance between low- and high-status members in order to support

greater reporting of adverse events.



Perceptions of emergency medicine residents and fellows regarding competence, adverse events and reporting to supervisors: a national survey.


Friedman SM, Sowerby RJ, Guo R, Bandiera G.

CJEM. 2010 Nov;12(6):491-9.


OBJECTIVE: The authors sought to characterize the perceptions of emergency medicine (EM)

residents and fellows of their clinical and procedural competence, as well as

their attitudes, practices and perceived barriers to reporting these perceptions

to their supervisors.


METHODS: A Web-based survey was distributed to residents and fellows, via their

residency directors, in all Canadian EM residency programs outside of Quebec.


RESULTS: Of 220 residents and fellows contacted in 9 of 10 EM programs of the

Royal College of Physicians and Surgeons of Canada and 12 of 13 EM programs of

The College of Family Physicians of Canada, 82 (37.3%) completed all or part of

the survey.

Response rates varied slightly by question; 25 of 82 re-spondents

(30.5% [95% confidence interval (CI) 19.9%-41.1%]) agreed with the statement, “I

sometimes feel unsafe or un-qualified with undertaking unsupervised

responsibilities or procedures, but I do not report this to my senior physician”

and 32 of 81 (39.5% [95% CI 28.2%-50.8%]) had felt this within the past 6 months.

Moreover, 34 of 82 (41.5% [95% CI 30.2%-52.7%]) reported their lack of competence

to a supervisor half the time or less.


Trainees reported worry about loss of trust, autonomy or respect (38/80, 47.5% [95% CI 35.9%-59.1%]) or reputation (32/80, 40.0% [95% CI 28.6%-51.4%]). Nights on-call (30/79, 38% [95% CI

26.6%-49.3%]), admission decisions (13/79, 16.5% [7.6%-25.3%]) and central line

insertion (13/79, 16.5% [95% CI 7.6%-25.3%]) were reported to be frequently

undertaken despite not feeling competent. Suggestions to improve reporting

included encouragement to report without penalty (41/82, 50.0% [95% CI

38.6%-61.4%]) and a less judgmental environment (32/82, 39.0% [95% CI



CONCLUSION: Emergency medicine trainees report that they frequently do not feel

competent when undertaking responsibilities without supervision. Barriers to

reporting these feelings or reporting adverse events appear to relate to social

pressures and authority gradients. Modifications to the training culture are

encouraged to improve patient safety.



Work environment influences adverse events in an emergency department.


Rasmussen K Pedersen AH, Pape L, Mikkelsen KL, Madsen MD, Nielsen KJ.


Dan Med J. 2014 May;61(5):A4812.


INTRODUCTION: The psychosocial work environment has been recognised as a factor that contributes to the occurrence of errors and adverse events at hospitals.

There has been a strong focus on stress factors at intensive care units and

emergency departments. The purpose of this study was to investigate the

occurrence of adverse events and to examine the relationship between work-related

stressors, safety culture and adverse events at an emergency department.


METHODS: A total of 98 nurses and 26 doctors working in an emergency

department at a Danish regional hospital filled out a questionnaire on the

occurrence and pattern of adverse events, psychosocial work environment factors,

safety climate and learning culture.


RESULTS: The participants had experienced 742 adverse events during the previous

month. The most frequent event types were lack of documents, referrals not

performed, blood tests not available and lack of documentation. Problems related

to reporting and learning and insufficient follow-up and feedback after serious

events were the most frequent complaints. A poor patient safety climate and

increased cognitive demands were significantly correlated to adverse events.


CONCLUSION: This study supports previous findings of severe underreporting to the

mandatory national reporting system. The issue of reporting bias related to

self-reported data should be born in mind. Among work environment issues, the

patient safety climate and stress factors related to cognitive demands had the

highest impact on the occurrence of adverse events.


A real-time assessment of factors influencing medication events.


Dollarhide AW, Rutledge T, Weinger MB et al.


J Healthc Qual. 2014 Sep-Oct;36(5):5-12.


Reducing medical error is critical to improving the safety and quality of

healthcare. Physician stress, fatigue, and excessive workload are

performance-shaping factors (PSFs) that may influence medical events (actual

administration errors and near misses), but direct relationships between these

factors and patient safety have not been clearly defined.


This study assessed the real-time influence of emotional stress, workload, and sleep deprivation on self-reported medication events by physicians in academic hospitals. During an 18-month study period, 185 physician participants working at four

university-affiliated teaching hospitals reported medication events using a

confidential reporting application on handheld computers.

Emotional stress scores, perceived workload, patient case volume, clinical experience, total sleep, and demographic variables were also captured via the handheld computers.


Medication event reports (n = 11) were then correlated with these demographic and

PSFs. Medication events were associated with 36.1% higher perceived workload (p <

.05), 38.6% higher inpatient caseloads (p < .01), and 55.9% higher emotional

stress scores (p < .01). There was a trend for reported events to also be

associated with less sleep (p = .10). These results confirm the effect of factors

influencing medication events, and support attention to both provider and

hospital environmental characteristics for improving patient safety.


Sleep disturbances predict prospective declines in resident physicians’

psychological well-being.


Min AA,  Sbarra DA, Keim SM.

Med Educ Online. 2015; 20: 10.3402/meo.v20.28530.

BACKGROUND: Medical residency can be a time of increased psychological stress and sleep disturbance. We examine the prospective associations between self-reported  sleep quality and resident wellness across a single training year.


METHODS: Sixty-nine (N=69) resident physicians completed the Brief Resident

Wellness Profile (M=17.66, standard deviation [SD]=3.45, range: 0-17) and the

Pittsburgh Sleep Quality Index (M=6.22, SD=2.86, range: 12-25) at multiple

occasions in a single training year. We examined the 1-month lagged effect of

sleep disturbances on residents’ self-reported wellness.


RESULTS: Accounting for residents’ overall level of sleep disturbance across the

entire study period, both the concurrent (within-person) within-occasion effect

of sleep disturbance (B=-0.20, standard error [SE]=0.06, p=0.003, 95% confidence

interval [CI]: -0.33, -0.07) and the lagged within-person effect of resident

sleep disturbance (B=-0.15, SE=0.07, p=0.037, 95% CI: -0.29, -0.009) were

significant predictors of decreased resident wellness. Increases in sleep

disturbances are a leading indicator of resident wellness, predicting decreased

well-being 1 month later.


CONCLUSIONS: Sleep quality exerts a significant effect on self-reported resident

wellness. Periodic evaluation of sleep quality may alert program leadership and

the residents themselves to impending decreases in psychological well-being.


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