Cultivating a Culture of Safety: Cleveland Clinic Akron General’s Patient Safety Curriculum for Residents

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an education podcast exploring the development and early impact of the patient safety curriculum for internal medicine residents at Cleveland Clinic Akron General. I'm your host, Dr. Tony Tizzano, Director of Student and Learner Health here at Cleveland Clinic in Cleveland, Ohio. Today, I'm very pleased to have Dr. Muhammad Husnain, internist and Director of the Clinician Educator Track and Patient Safety Education at Cleveland Clinic Akron General Hospital here to join us. Muhammad, welcome to today's podcast.

Dr. Muhammad Husnain:

Glad to be here, Tony, on behalf of our patient safety team.

Dr. Tony Tizzano:

Always good to have you. Also with us is Dr. Patrick Gallegos, Clinical Pharmacy Specialist for Internal Medicine and Pharmacy Residency Programs at Cleveland Clinic Akron General. Patrick, welcome.

Dr. Patrick Gallegos:

Tony, thank you for having me.

Dr. Tony Tizzano:

Finally, we have Tammy Lindsay, Quality Improvement Safety Coordinator at Cleveland Clinic Akron General. Tammy, thank you for joining today's podcast.

Tammy Lindsay:

It's a pleasure to be here, Tony.

Dr. Tony Tizzano:

So to get us started, if each of you would please tell us a little bit about yourselves, your educational backgrounds, what brought you to Cleveland, and your perspective roles here at Cleveland Clinic. We start with you, Muhammad.

Dr. Muhammad Husnain:

Thank you, Tony. I came to Cleveland for my internal medicine residency and never left. My wife and I decided to raise family here, and I joined Cleveland Clinic Akron General back in 2022 as associate program director. And one of my interests is learning the science and art of teaching, other than patient safety.

Dr. Tony Tizzano:

Perfect. Patrick.

Dr. Patrick Gallegos:

Tony, I'm a clinical pharmacy specialist of internal medicine at Cleveland Clinic Akron General. I'm also a professor of internal medicine and a clinical pharmacy professor at pharmacy practice at Northeast Ohio Medical University. I came to Akron to serve really as a clinician at Akron General and a faculty member at Neomed. It really combined my passions for direct patient care, teaching, and research. Today, my role is divided among caring for hospitalized patients, mentoring learners, conducting research, and helping educate healthcare professionals. I'm excited to be here and to share my experience with your audience.

Dr. Tony Tizzano:

And we're glad to have you. And Tammy, finally.

Tammy Lindsay:

Thank you. I am a registered nurse with a master's in nursing and an MBA, and I am a certified professional in patient safety. I spent the past 10 years at Akron General focused on patient safety and quality improvement, but my path into this work is deeply personal. After my dad experienced a medical error that ultimately contributed to his passing, I knew I wanted to be a part of changing the system, and I couldn't think of a better place to do that than at Cleveland Clinic. So I'm happy to be here.

Dr. Tony Tizzano:

Thank you so much. It's always interesting how most of us have something in our backgrounds or personal interest that drives us in a passion later in our careers. I'm glad to have that. So in today's segment, we'll explore how Cleveland Clinic's Akron General's internal medicine program integrates patient safety into its core curriculum of cultivating internists to provide safe, high quality, and patient-centered care by embedding safety principles across all training domains. So Muhammad, if you could please help us frame this topic for our listeners and the impetus for developing this program for your residents.

Dr. Muhammad Husnain:

Yeah, thank you, Tony. So this curriculum was developed back in 2024. So we wanted to move from lecturing and basic understanding among the residents about patient safety to something which is more hands-on. As we all know, and all the listeners, patient safety is a core component of Cleveland Clinic values. And for residents to learn this during their residency is extremely important so that when they graduate, they can provide safe and efficient care and learn the hands-on skill during training. So we changed the curriculum in a way that reflects what they need to know based on the ACGME systems-based practice milestones. So we aligned with, they should be able to identify the principles of patient safety, how to report patient safety using the institutional system, and use their experience for real life patient cases to investigate, to do root cause analysis, and then present that within the residency program and outside.

Dr. Tony Tizzano:

Yeah, and I think over time, patient safety has become a real science. And when you consider for our listeners, you know, when patients come to us in a hospital, they hope for three things. Number one, I hope you can fix me. Number two, please be kind to me. And third, please don't hurt me. I mean, that's top of mind for all of us, so this is critical work. Tammy, can you give us a sense of what the curriculum looks like, its mission and goals?

Tammy Lindsay:

Absolutely. The curriculum is really built around the idea that patient safety is not something that anyone discipline can do alone. It really takes the entire interdisciplinary team. We have nursing, patient safety, clinical risk, pharmacy, physicians, and our operational colleagues, all bringing their different perspectives together to understand what happened, and more importantly, how do we prevent it from happening again? The curriculum follows a three-part approach. So we have functional learning, simulation, and hands-on experience. So residents start with the foundational online patient safety education, and then we move into interactive workshops where they get to actually practice these things, like event reporting, as Dr. Husnain mentioned earlier, disclosure, severity assessment, and how to interview caregivers appropriately. From there, we really work through real patient safety cases and learn some of the tools that we use every day, such as the fishbone analysis and the five whys to really help us get beyond the question of what happened and start asking why did it happen?

And most importantly, what can we do differently to prevent it from happening again? They then put those skills into practice by participating in a supervised real life root cause analysis and developing actionable recommendations. And I think one of the most valuable parts of the program is that it culminates in a resident-led patient safety conference where they take all of those things that they learned and apply it to a real safety event. So they're not just learning about patient safety in a classroom setting, they're learning how to be an active part of the safety culture and how their role as physicians can really make healthcare safer for everyone.

Dr. Tony Tizzano:

Husnain, would you like to add to that?

Dr. Muhammad Husnain:

Thanks, Tammy, for going through what we do during the curriculum, but I would like to highlight the interprofessional team, extremely important to the success of any curriculum we do on patient safety, other than leadership support. And third important thing is using the resources provided by graduate medical education here at Cleveland Clinic. So interprofessional team, we have a set of various individuals, experts in various fields, including nursing, Julia Wallace is part of our team, risk management, Nancy Talbot. We have Jennifer Lacey from Internal Medicine Quality Department. We have attendings from within the residency program. Our program director is leading, you know, the patient safety curriculum along with us, Dr. And Dr. Wong, Dr. Dumford. So you see how these interprofessional individuals, other than pharmacy, we have Dr. Guygos with us, but Dr. Larry Frazee is also part of the curriculum. I would like to highlight within the clinical and system using available resource extremely important and graduate medical education led by Dr. Donato has provided tremendous support to make things practical and makes us do these things efficiently.

Dr. Tony Tizzano:

Yeah, I think that's a really key issue. I think reducing silos in healthcare. And Patrick, my question for you is in what ways do you interface as a pharmacist with residents and in this process, how is this interprofessional interaction a key strength for this program?

Dr. Patrick Gallegos:

Tony, my role is to mentor them in this process. I help them understand the medication use process, evaluate where breakdowns may have occurred, and think critically about how we can prevent similar events in the future. Pharmacy brings a unique perspective to these discussions because medications touch nearly every aspect of patient care. It's well known that medication errors contribute to approximately five to 8% of hospital admissions. We also know that many of the errors occur during the prescribing and the administration phases of care. And so what makes this curriculum especially effective is its interprofessional design that we talked about here with Dr. Husnain and Tammy. Residents are learning with and from experts in internal medicine, nursing, patient safety, pharmacy, and risk management. I think it's special because the greatest strength of our program is that it mirrors real world healthcare.

Dr. Tony Tizzano:

Yeah, I think it's a great point. You know, when I was in training, we didn't have pharmacists with us. In fact, we didn't have nurses with us on our rounds either. And I look at it now and there are persons from all these different teams coming together and I hope that it's helped to flatten the hierarchy that is so problematic in getting things done in medicine because there is no single individual who's more important than another on a team. I don't care how you look at it. There's always from the student on up, somebody who can contribute to the wellbeing of an individual. So Tammy, when you look at your expertise around patient safety and helping residents, how do you move from this notion that you did something wrong and someone's at blame to a more holistic approach that embraces systemness?

Tammy Lindsay:

That is a great question. That's really the heart of patient safety. One of the biggest things that we try to teach is that when something goes wrong, our first question should never be who made the mistake. It should be what happened and what factors contributed to it. And that shift really from individual blame to looking at the entire system is at the heart of patient safety. Our patient safety conference is a great opportunity to reinforce that. We create protected time for residents to openly talk through real patient safety events in a psychologically safe environment. And we use anonymity when appropriate so that people can focus on learning rather than worrying about blame or judgment. No matter how much we really teach these skills and focus on patient safety, you always have to reiterate it. I, like I said, I've been doing this 10 years and every single meeting I have, we're looking at the system and not the individuals.

And that's really at the heart of this. , We walk through the cases together, we look at what happened from different perspectives and encourage our residents to give their feedback and ask questions. And it helps them see that safety events are rarely about one person or one decision. Safety events are always, although those holes in the Swiss cheese lining up, it's a culmination of things that lead to these events happening. And I think that's where the real learning happens, moving from what did this person do wrong to what can we learn from this event and how can we make the system safer for the next patient and the next colleague that's in the same situation.

Dr. Tony Tizzano:

Great points. I think that, you know, underneath all of this is the statistical probability that when you do what we do, as complicated as it is with as many moving parts, air is inherent to that system. It's absolutely inherent to it at some level. And, you know, doing what airlines do, going through all these checklists, but there's pushback. And physicians are at blame for this too. And I would remember getting woken up in the middle of the night and saying, "Can you repeat what you just said, what the order was going to be, so to make sure I have it right." And it's like, you just wanna go to sleep. No, you need to repeat it. And you should look at that as a favor because we're having each other's backs going through it, but it's that attitude that I think you folks in this program with your residents are striking at the very heart of it early on.

So Patrick, why wait until PGY2 year for training residents in this curriculum?

Dr. Patrick Gallegos:

That's another great question, Tony. The PGY-2 year is really the point where residents have developed solid clinical foundations. They're also ready to start focusing on systems of care, and that's what we see in our program. It's really that time when they're transitioning into supervisors, teachers, and mentors while still serving as leaders of our healthcare teams. Our curriculum is really designed to build on their clinical experience and shape how they practice in the future. From my perspective as a pharmacist, this is also a stage where residents start to fully appreciate how different disciplines contribute to patient outcomes.

Dr. Tony Tizzano:

So I'm curious though, if the problem at the very beginning, your first day of medical school is we're not supposed to make mistakes. We're listening to the faculty talk to us and they seem like they know all this information that we don't know and we wanna be perfect because we're caring for other individuals. And I feel like in the beginning of medical training, you get a little, one of those finger pointing signs that goes 270 degrees and whenever there's a question like, "How did this happen?" You flip that and it can point anywhere but you because you never want it to be you. But it's okay to goof. We just have to fix the reason why we made the goof. And that's a tough thing to get to students who, when they begin their clerkships in the third year, they're worried about that. I don't wanna make a mistake.

And they're vulnerable because they feel it's part and parcel. Tammy, did you have something you wanted to add to that?

Tammy Lindsay:

Yeah. I just wanted to point out, we've seen that through this program in internal medicine and we've seen a significant increase. So with patient safety, one of the best things that we can do is report when an issue happens. And not just once it reaches the patient, but when there's an error, I ordered this on the wrong patient and then I recognized it and I fixed it, but that could have reached the patient. And if it was your colleague, so reporting these events that we can call near misses before they reach the patient, and then it's our job to take a look at those events and help strengthen that system. And our internal medicine team has increased their reporting through our safety event reporting system. We call SIRS 40% since this program, and they're telling on themselves. I hate to say that, but we applaud telling on yourself.

They are telling on themselves all the time, and that's really what we wanna see. That's when you know you have a culture of safety.

Dr. Tony Tizzano:

Yeah. And that's great character, Muhammad.

Dr. Muhammad Husnain:

Thank you, Tammy, for mentioning that. I think three things residents have learned over a couple of years. One is, I will reemphasize systems thinking. So one of the resident who's current chief resident came to me after he did his root cause analysis said, "I was surprised how many holes were in the system that led to this delay in transitioning patient from emergency department to the cardiac ICU." And then he used Susti's model popularized by James Reason into the presentation. So that was a peak moment, you know, for me to how they have learned on their own. Second thing they appreciate, which basically as faculty, as part of a residency team on patient safety, we should model also is creating psychological safety for the junior learners, for seniors and everybody in the team. I think that will continue to have a cultural shift, will move on with more and more psychological safety where people can share the mistakes without fear of retribution or any retaliation and continue to report more.

And third important thing which they have learned is using the real life cases from their own practice before you s - point fingers to anybody else. And I'm really happy that residents are coming back with their own things they have observed and want to include that as root cause analysis case. So these are a few things I would like to add.

Dr. Tony Tizzano:

So Muhammad, along the same line, since its inception, have you gotten a sense of the impact and success of this program?

Dr. Muhammad Husnain:

Thank you. It's a great question. First, I would start with appreciating the interprofessional teamwork and the functional curriculum team has made it possible, along with the leadership support. Second important thing, residents have done a tremendous job in implementing what they were supposed to do and with the supervision by the faculty and the experts in patient safety. We have seen a significant amount of increase, which Demi has already mentioned in safety reporting by the residents. And second important thing, they have presented their work on graduate medical education patient safety day in March 2025 and March 2026. Almost 18 abstracts were presented and that was really good to, to disseminate the scholarly work they have done on patient safety. Third important thing which we have seen is increase in their competency on the principles of patient safety, which in the language of ACGME for the residency training is systems-based practice one.

And we have seen significant growth in their competency and skill, , moving from level two to level three comparing before 2024 and after start of this curriculum. So these are few of the most important thing we have seen.

Dr. Tony Tizzano:

Yeah. And I'm curious, in, in previous conversations you've mentioned psychological safety and I'm just listening to the three of you talk and, you know, I feel psychologically safe working with you. Isn't that a, another critical step to feel that it's okay to come forward and say something without repercussions?

Dr. Muhammad Husnain:

We have seen that. I definitely agree, , Tony, what you have just said. We have seen among the residents, there is this foundation of culture shift. So residents among themselves are feeling safe to share that, "I did not know that. If I would have known this event could have been prevented or I would like to report this because this may help the program or, you know, the hospital to look into this into more deeper way." So I think these are a few of the things which are essential other than just culture.

Dr. Tony Tizzano:

Tammy, would you add to that?

Tammy Lindsay:

Yeah. I think throughout our hospital, I wanted to add to the psychological safety. Our president actually celebrates when people report errors that they made. She celebrates it in her health system leadership meeting, in our morning huddles. So it's really encouraging people to report when a mistake is made instead of trying to hide it or be ashamed of it. And we celebrate those because it helps us learn and become a safer organization.

Dr. Tony Tizzano:

Definitely helps us learn. So Patrick, I'm curious along these same lines, you know, pharmacy is now being added to the equation and I can only imagine the number of times since I retired and then came back and in practicing clinically again, so much has changed with medications, but I feel very comfortable calling our pharmacist. I mean, I think that's a part and parcel of what you bring to the table. Do you see more of that now than you used to?

Dr. Patrick Gallegos:

Absolutely. So, you know, I've been in practice for about 20 years, 22 if you count residency training. And throughout my training and everything, I've always been involved working with medical teams. I've been in academia for about 20 years as well. And that's something that you can see as a foundational training that happens in academia. You can see it really across the country if you look into health sciences centers. And as a pharmacist at work, you know, getting to work with the residents and with our attending physicians and, you know, the pharmacy residents that are there and the different nurse practitioners and the RNs and that group, our interprofessional design has really extended and improved quite a bit over my timeframe in practice, I would say. And I think that's what makes this program somewhat special, is the fact that we get to work as an interprofessional team and that we take the best of what everybody can offer.

Now, of course, everyone has to be competent in what they're doing, but I feel like we have a very competent group that does that work. And so absolutely, I agree with you 100%, Tony. I think we've seen a kind of a shift in that regard.

Dr. Tony Tizzano:

But it's having that pharmacist on the team, making rounds where you're available to have your brain picked. Same thing with having nursing. You know, I tell students all the time, especially in obstetrics, if you think you're gonna learn obstetrics and be on the OB unit and you're not spending time with the nursing staff who virtually run OB, you're making a big mistake. I mean, that's where you'll get the foundation of what you wanna do. So I love this. I think it's important for us as a profession. It's certainly important to our patients. So what lies on the horizon as this important curriculum evolves? What are next steps that you see that you'd like to see happen or want to do?

Dr. Muhammad Husnain:

I can take it first, Tony. So what we have learned through this curriculum, they use five-step approach to do the real life evaluations of the patient safety cases. So they use this approach like what happened, what should have ideally happened to the standard of care, what could be contributing factor using the fishbone, and then five-whys to see the underlying root cause or causes which led to systems failure, and then coming up with actionable recommendation. That's what we did in the last two academic years. However, we want them to use those actionable recommendations and converting that into real life quality improvement, patient safety improvement project and see how it can help the patients and the institute and the hospital if they start implementing those actionable recommendations. That could be a big shift where they can move from just suggesting a recommendation to actually implementing and change the system.

Dr. Tony Tizzano:

Well said.

Tammy Lindsay:

Patrick or Tammy? That's actually about what I was gonna say. We don't want our residents to just identify a problem and make recommendations. We wanna make sure that we follow those recommendations and see whether they actually lead to meaningful system level change and give our residents the opportunity to see the impact of their work and reinforce that their voice truly can contribute to making healthcare a safer place to work.

Dr. Tony Tizzano:

Patrick, you wanted to add?

Dr. Patrick Gallegos:

Yeah. One thing I'd like to add is I think looking at the future and on the horizon, something that would be advantageous for us as an institution is to create more patient safety mentors, because that'll help us further develop that culture of safety and not only make our residents more comfortable around safety, but even make the other healthcare professionals comfortable around safety.

Dr. Tony Tizzano:

Sure. And Patrick, along those lines, do you think there's a place for simulation in actually using a virtual kind of setting to disclose error and have to be the one who's actually doing it in a simulated environment? So do, do you see any value in that?

Dr. Patrick Gallegos:

Absolutely. And, and I think we started to see some of that in training. You know, we definitely have simulation for our medical residents. We sim- simulation at the academic medical centers, but I think trying to organize some sort of safety event like this is fantastic. Part of what we do in this session is we almost simulate these cases and talk about them in detail. Now, of course, we're not in a simulation center, but that's kind of what we're creating in that environment when we're going through those cases.

Dr. Tony Tizzano:

Outstanding. Finally, are there any questions that I didn't ask that you think are important for our listeners to know? We covered a lot.

Dr. Muhammad Husnain:

Yeah. I would say learning from my experience over like last two decades is patient safety is everybody's responsibility. So all we're part of the team as part of caregiver, everybody's contribution is important and every voice should matter. And we must not forget every single day we work with the patients.

Dr. Tony Tizzano:

Yeah. And I think to show gratitude for when someone does bring something up, you know, coming back into the clinical setting, I told the MA who goes in with patients and I'm always chaperoned in gynecologic exams. I said, "If you do not see me wash my hands when I enter that room, you stop me and just say, Dr. T, did you wash your hands? And I will thank them, "Yep, son of a gun, I forgot." And when the patient hears and sees that, they recognize that a team is taking care of them, not just an individual, but that more than one person has their best interest in mind. And I think th- that whole sense for students to be able to come forward from the very beginning, but we, to your points, each one of you have made, we have to set that tone of psychological safety ahead of time.

I want you to call me out. If you think I'm making a mistake, you can stop me right there. I don't care if the patient's there or not. I mean, that is why we're here and we can all make mistakes and I would, son of a gun, you're right, and go forward. That's a cultural shift for sure in medicine. And, and I think that students, the newer generation of learners is going to carry that torch because of the kind of work you're doing. So I applaud you all. Well, I want to thank you all so much, Muhammad, Tammy and Patrick. This was a fabulous and wonderfully insightful topic. To our listeners, if you would like to suggest an education topic to us or comment on an episode, please email us at education@ccf.org. Thank you very much for joining and we look forward to seeing you on our next podcast.

Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic education podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.