To form an effective Graduate Medical Â鶹´«Ã½Ó³»­ (GME) Team that monitors safety and quality.

The Clinical Learning Environment Review (CLER) Program mandates quality and safety teams in all residency programs. We present the first resident GME-led quality and safety team with a scope of responsibility to review all Patient Safety Reports, monitor quality improvement projects, and supervise and standardize mortality and morbidity conferences.

36,000 Outpatient and 288 inpatient encounters were reviewed for quality and safety of care in a population of three million beneficiaries to the national capital region. GME reviewed reported  patient safety events, formulated a system-wide response; provided guidance to the residents, attending physicians, and ancillary staff on new system changes. We developed the first standardized mortality and morbidity conference.  Efficacy of changes made by the safety team was later assessed via departmental survey.

Patient Safety Reports (PSR) increased from one to seventeen a year. Three instances, for required GME-led enterprise-wide changes. Two critical medicines, Intravenous phenytoin and immunoglobulin were standardized through ordering templates. GME safely guided the enterprise through the first FDA recall of lumbar puncture needles affecting over fourteen patients. The neurology first Fish Bone Diagram-driven mortality and morbidity conference was conducted for the Department of defense. Our survey of 56 staff members showed 50% awareness of our safety team efforts.

Critical changes were made to the largest institution in the military through effective communication from GME-led quality and safety team. A culture of safety was encouraged with impactful involvement of physicians who are early in their careers, resulting in improvement in the safe delivery of patient care in critical areas of neurology.  Active participation in patient safety should begin in residency and can have a positive impact on the health care institution as a whole.