ANONYMOUS App “Significantly” Increases Complication Reporting

Even in an era of enhanced transparency, some things go unreported. Take adverse events. They are, says new work from the Department of Orthopaedic Surgery at Cedars Sinai Medical Center in Los Angeles, California, underreported—despite the fact that morbidity and mortality conferences have been mandated by the Accreditation Council for Graduate Medical Education since 1983.

So the Cedars Sinai team decided to develop an app for residents to anonymously report complications.

A new American Orthopaedic Association Critical Issues in Education article—“There is an App for That: Mobile Technology Improves Complication Reporting and Resident Perception of Their Role in Patient Safety”—appears in the January-March 2021 edition of The Journal of Bone and Joint Surgery Open Access.

Co-author Carol Lin, M.D., M.A. director of the Geriatric Fracture Program at Cedars Sinai and Associate Residency Program Director, explained the genesis of the app to OTW, “Prior to the app our morbidity and mortality conferences focused on major complications such as reoperations or even deaths and required a paper form or email to the program director or chief residents.”

“We also saw there were a number of other complications such as pneumonias, urinary tract infections, minor wound complications that often did not get formally reported, even though they affected patient outcome. We ultimately wanted to encourage a culture of safety by reducing any barriers to reporting both major and minor complications by making the reporting process anonymous and easily accessible on mobile devices. The challenge was making sure that all of this was HIPAA [Health Insurance Portability and Accountability Act]-compliant.”

And they did. Using a list of potential complications based on the American Board of Orthopaedic Surgery complications list for part II, the researchers developed a web-based morbidity and mortality reporting mobile application. The researchers also hypothesized that the app would improve resident perception of their role in patient safety initiatives.

The team formally launched the app in August 2017. The team then assessed reported events from August 2016 through July 2019. Reports between August 2016 and July 2017 comprised the Pre-App cohort, while those reported between August 2017 and July 2019 were defined as the Post-App cohort.

Anonymous…Always Helpful

“In the Pre-App cohort,” wrote the authors, “there were 54 adverse events reported of a total of 3,443 surgeries performed (1.6%), with a mean of 4.0 events per month. In the Post-App cohort, a total of 176 adverse events were reported in year 1 of a total of 3,409 surgeries performed (5.2%), with a mean of 14.76 per month and 236 adverse events were reported in year 2 of a total of 3,825 surgeries performed (6.2%), with a mean of 19.66 per month.”

In practice, explained Dr. Lin, the app is a very convenient way to immediately note a complication. “If a resident is rounding or in clinic and notices a wound infection, s/he can simply open the app, enter the patient info and hit submit, all without needing permission from the attending. Since it’s anonymous the hope is that it would encourage reporting of complications for future quality improvement and remove any stigma.”

“Still, even with that frequent encouragement from the program director and chairman, it took several months before use of the app was integrated into the clinical workflow for the residents. There were also seemingly minor but important questions to address such as how to design the app interface to make reporting as simple and straightforward as possible, and how to categorize the complications.”

“What I hope most people take away from this project is the importance of being forthcoming with complications in patient care and resident education. What’s critical to remember is that complications will happen to everyone, but being able to discuss them openly and without judgment really helps everyone, including patients, in the long run.”

Cultural Changes at the Speed of Plate Tectonics

“Additionally, there’s a lot out there in the mobile computing world that we can embrace in medicine to make things more efficient and transparent. This project really taught us some of the complexities of database management, mobile user interface, and how to change the culture of a department, even when there is strong support from the leadership.”