New residents arrive with clinical training but often without day-one fluency in the practical skills that drive patient safety: documentation, order entry, handoffs and knowing when to escalate.
Quality leaders say the gap is real but rarely surfaces as a spike in safety events, because residents work under supervision. Instead, it shows up in the competencies that increasingly complex systems of care now demand. Health systems are moving to close it through onboarding, hardwired workflows and feedback loops rather than leaving it to individual judgment.
At Somerville, Mass.-based Mass General Brigham, the risk falls into two buckets, according to Chief Quality Officer Rachel Sisodia, MD. The first is a failure of risk intelligence: A new intern may not recognize how sick a patient is about to become.
“You can’t make a brand-new intern have the risk intelligence of a 20-year attending. You just can’t,” she said. “That’s why it’s a training program.”
The second, and more dangerous, risk is not knowing when or how to escalate safety concerns. Mass General Brigham’s answer is a system as opposed to a lesson. An early warning system embedded in the Epic EHR flags patients who appear to be deteriorating; when it fires, paging the attending is mandatory and the attending must come to the bedside.
“You wouldn’t get on a plane where one human who may have had a bad night does the safety check and flies the plane,” Dr. Sisodia said.
Training is weaker than hardwired systems, she said, so Mass General Brigham is building workflows that do not leave patients “vulnerable to heterogeneity in risk intelligence.”
Greenville, S.C.-based Prisma Health takes a similar view: Because residents are supervised, the gap seldom appears directly in safety data, said Chuck Carter, MD, designated institutional official for graduate medical education at the system and associate dean for graduate medical education at the University of South Carolina School of Medicine in Columbia.
The bigger shift, Dr. Carter said, is the rising weight of the Accreditation Council for Graduate Medical Education’s systems-based practice competency as trainees enter more complex care settings.
EHR fluency is an early focus. Medical students now train on a wider range of records, so order entry, handoff tools and medication reconciliation often require rapid catch-up, Dr. Carter said. Attending faculty increasingly have to separate a genuine clinical-judgment gap from simple unfamiliarity with the EHR.
Prisma Health, which has 720 residents and fellows across 53 programs on two South Carolina campuses, orients trainees to its clinical operating system from the start and this year added specific training on the resident’s role in safety reporting. This summer, 203 residents and 44 fellows started at Prisma.
Dr. Carter’s team also works to destigmatize reporting. “If you’re only ever reporting things that are a problem, you’re probably not reporting enough,” he said, encouraging residents to flag “hassles,” or situations that are not clearly unsafe but could be better.
Cleveland-based University Hospitals starts upstream in this regard, said Peter Pronovost, MD, PhD, chief quality and clinical transformation officer. Medical students typically get only an hour or two of patient-safety education, he said, so every new employee completes onboarding in what he calls the science of patient safety: practical principles such as simplifying and standardizing work, removing ambiguity and using call-and-response communication.
University Hospitals also runs a feedback loop: Error reports involving residents are reviewed with program directors to identify knowledge, procedural or teamwork gaps and revise onboarding accordingly.
“That’s been one of the bigger advances,” Dr. Pronovost said.
The health system is also piloting an AI tool to document clinical competencies, which are often stored on paper or in incompatible formats rather than a searchable database.
All three leaders pointed to the same request of medical schools: more exposure to systems-based practice and stronger communication skills. Those competencies are the hardest to assess at entry, Dr. Carter said, “but they’re not as hard to orient or to build training on, but they’re somewhat harder to assess.”
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