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

Ranjit Singh; Bruce Naughton; Ashok Singh; Diana R Anderson; Gurdev Singh

Study

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

September 12, 2007

Singh R, Naughton B, Singh A, et al. J Patient Saf. 2007;3(3):135-141.

View more articles from the same authors.

Family medicine residents were encouraged to keep a journal of errors and near misses they observed while caring for patients, as a complement to a didactic course on patient safety.

Available at

Related Resources From the Same Author(s)

A patient safety objective structured clinical examination.

June 3, 2009

A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.

December 14, 2005

Prioritizing threats to patient safety in rural primary care.

May 23, 2007

Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.

July 20, 2005

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

March 5, 2014

Patient safety, systems design and ergonomics.

June 21, 2006

Improving Medication Safety in High Risk Medicare Beneficiaries Toolkit.

August 1, 2012

How a series of errors led to recurrent hypoglycemia.

July 12, 2006

How one health system overcame resistance to a surgical checklist.

May 29, 2019

Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans.

March 6, 2005

Developing a principle-based approach to safe medication practices.

November 11, 2015

Five strategies for clinicians to advance diagnostic excellence.

March 2, 2022

Joshua’s Story.

December 3, 2014

Human costs of training doctors.

August 11, 2010

Piecing together medication administration.

May 27, 2009

CPOE: it don't come easy.

January 14, 2009

Can we use incident reports to detect hospital adverse events?

March 12, 2008

Challenges ahead in technology training: a report on the training initiative of the Committee on Technology.

October 11, 2006

Measurement of diagnostic errors is a key first step to their reduction.

December 9, 2015

Implementing and validating a comprehensive unit-based safety program.

May 11, 2005

Frustrated with your EHR? Don't blame your vendor—safety is a shared responsibility.

December 20, 2017

Preventing high-alert medication errors in hospital patients.

May 27, 2015

Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observational study.

March 3, 2021

How Professionals Make Decisions.

May 4, 2005

Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies.

January 23, 2008

Structured override reasons for drug–drug interaction alerts in electronic health records.

May 15, 2019

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

November 24, 2010

Adverse Events in Hospitals: Methods for Identifying Events.

March 17, 2010

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.

January 9, 2019

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

January 18, 2012

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.

March 19, 2014

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.

February 11, 2015

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

February 18, 2009

Adverse Events in Hospitals: State Reporting Systems.

January 14, 2009

Adverse Events in Hospitals: Overview of Key Issues.

January 14, 2009

Preventing medication mistakes.

May 16, 2012

Alleged kidnapper agrees to extradition.

March 28, 2007

SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience.

May 13, 2015

Application of electronic trigger tools to identify targets for improving diagnostic safety.

October 17, 2018

Genome detectives solve a hospital's deadly outbreak.

September 5, 2012

Avoiding medical error.

February 14, 2007

Safe handover in psychiatry: is it time to set standards?

August 2, 2006

Target pill bottles now convenient and cute.

May 18, 2005

Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites.

August 3, 2022

A better approach to medical malpractice claims? The University of Michigan experience.

August 5, 2009

Developing an adverse event reporting system using administrative data.

March 19, 2008

Hospitals leery of reporting serious errors.

March 16, 2011

Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety.

August 16, 2023

Patient-safety and quality initiatives in the intensive-care unit.

April 5, 2006

The Canadian interprofessional patient safety competencies: their role in health-care professionals' education.

March 7, 2012

The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, System Failures and Lack of Mindfulness.

February 10, 2016

Placing Diagnosis Errors on the Policy Agenda.

May 21, 2014

Mental mayhem: the peril of multitasking in medicine.

July 17, 2019

Most adverse events at hospitals still go unreported.

August 22, 2012

Tragic medication errors result in accidental abortions and premature birth—safety advocates say drug mistakes are still too frequent, despite advances.

September 2, 2009

Error rate greatest in hospital radiology.

January 31, 2006

Surgical site infection prevention: a review.

February 1, 2023

Risks are high at low-volume hospitals.

June 17, 2015

Blaming others for threatening events.

March 6, 2005

For some troops, powerful drug cocktails have deadly results.

February 23, 2011

Why doctors should own up to their medical mistakes.

February 13, 2013

Use of dimensional analysis to reduce medication errors.

March 15, 2006

Capturing more emergency department errors via an anonymous web-based reporting system.

September 21, 2005

Do HSMRs really measure patient safety?

August 13, 2008

Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system.

February 15, 2006

Fighting a common enemy: a catalyst to close intractable safety gaps.

August 5, 2020

Diagnostic Error in Medicine.

September 25, 2013

Safety in the NICU: preventing medication errors with computerized provider order entry.

January 9, 2008

To ask or not to ask?: the results of a formative assessment of a video empowering patients to ask their health care providers to perform hand hygiene.

February 10, 2010

Diagnosis: Interpreting the Shadows.

July 26, 2017

Awareness of patient safety grows with increased outpatient surgeries.

October 8, 2014

Lean Six Sigma reduces medication errors.

May 18, 2005

Stopping deaths from incorrect drug doses.

April 2, 2008

'Superbug' scourge spreads as U.S. fails to track rising human toll.

September 21, 2016

How safe do patients feel?

December 14, 2005

Nursing bedside clinical handover—an integrated review of issues and tools.

November 12, 2014

The path to diagnostic excellence includes feedback to calibrate how clinicians think.

February 20, 2019

Ounce of prevention: to reduce errors, hospitals prescribe innovative designs.

May 17, 2006

Using clinical decision support to improve medication reconciliation.

December 13, 2006

Understanding the peer, manager, and system influence on patient safety.

February 10, 2021

Conversations with...Lucian Leape, MD.

July 17, 2013

Error reporting in organizations.

October 18, 2006

Dashboards for visual display of patient safety data: a systematic review.

October 27, 2021

Policies to promote shared responsibility for safer electronic health records.

September 29, 2021

Health IT-Enabled Quality Measurement: Perspectives, Pathways, and Practical Guidance.

October 2, 2013

Sources of Power: How People Make Decisions.

March 6, 2005

Prevention of potential errors in resuscitation medications orders by means of a computerised physician order entry in paediatric critical care.

February 28, 2007

Chemotherapy dose limits set by users of a computer order entry system.

March 8, 2006

Considering human factors and developing systems-thinking behaviours to ensure patient safety.

February 21, 2018

Safe healthcare.

March 6, 2005

Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue.

June 7, 2006

WebM&M Cases

Poorly Advanced Directives

February 1, 2012

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides.

February 16, 2022

Operational measurement of diagnostic safety: state of the science.

October 7, 2020

Innovation in Perioperative Patient Safety.

February 27, 2013

Quality and Safety Education.

August 12, 2009

The lost sponge: patient safety in the operating room.

October 17, 2012

Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.

June 16, 2021

Related Resources

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice.

March 12, 2014

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

March 5, 2014

Primary care physician communication at hospital discharge reduces medication discrepancies.

December 18, 2013

First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP).

December 11, 2013

Enhance patient safety by identifying and minimizing risk exposures affecting nurse practitioner practice.

November 20, 2013

Patient Safety Toolkits.

October 30, 2013

Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial.

September 11, 2013

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

August 21, 2013

Impact of individual and team features of patient safety climate: a survey in family practices.

August 14, 2013

Adherence to drug–drug interaction alerts in high-risk patients: a trial of context-enhanced alerting.

August 7, 2013

Resilient actions in the diagnostic process and system performance.

July 17, 2013

Safety climate and its association with office type and team involvement in primary care.

May 29, 2013

Advanced practice nursing students' identification of patient safety issues in ambulatory care.

April 10, 2013

Types and origins of diagnostic errors in primary care settings.

March 6, 2013

Certain uncertainties: modes of patient safety in healthcare.

December 19, 2012

The relationship of self-report of quality to practice size and health information technology.

October 10, 2012

Electronic medical record availability and primary care depression treatment.

September 26, 2012

Patient safety perceptions of primary care providers after implementation of an electronic medical record system.

September 12, 2012

Threats to patient safety in the primary care office: concerns of physicians and nurses.

August 8, 2012

Information distortion in physicians' diagnostic judgments.

July 18, 2012

Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led intervention to reduce medication errors in primary care.

June 27, 2012

Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims.

June 13, 2012

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians.

June 6, 2012

Investigating the Prevalence and Causes of Prescribing Errors in General Practice: The PRACtICe Study.

May 16, 2012

Medical errors reported by French general practitioners in training: results of a survey and individual interviews.

April 4, 2012

Emotional impact of patient safety incidents on family physicians and their office staff.

March 21, 2012

Diagnostic errors in primary care: lessons learned.

February 22, 2012

Miscoding, misclassification and misdiagnosis of diabetes in primary care.

February 22, 2012

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Family Medicine

Primary Care

General Internal Medicine

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

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site