The safety journal: Lessons learned with an error reporting tool to stimulate systems thinking

CONTEXT: National and international agencies have recognized the need to train all health care workers in the principles of patient safety. OBJECTIVE: To design a safety "journal" to encourage and aid in reporting of and learning from errors and to engage learners in system-based safety improvement. SETTING AND PARTICIPANTS: Large multisite family medicine residency program. Thirty third-year residents participated over a 2-year period. CURRICULUM DESIGN: As part of a patient safety curriculum, third-year residents take a didactic course on systems approach to patient safety. To reinforce the material, they are encouraged to keep a safety journal in which they record incidents (observed errors, anticipated errors, and close calls) and propose solutions, based on the principles taught in the didactic. OUTCOME MEASURE: Number and quality of safety journal entries with particular emphasis on the ability to devise feasible system-based solutions. RESULTS: In the first year, 42 entries were submitted, of which 55% included appropriate system-based solutions. In year 2, to encourage more structured thinking, a visual format for the journal was devised. Twenty-seven entries were submitted, and 81% included system-based solutions. CONCLUSIONS: The safety journal in the revised visual format, coupled with a didactic course, appeared to be effective as a teaching tool for stimulating residents to think from a systems perspective and to devise practical, system-based solutions to safety problems in their practices. However, the challenge remains to incorporate such tools, in a training environment, into institutional quality improvement efforts so as to bring to life for learners the importance of error reporting for improving patient safety.