Leveraging computerized sign-out to increase error reporting and addressing patient safety in graduate medical education

Abstract

Setting: Electronic reporting systems are important components of the patient-safety movement but have been problematic particularly in capturing information from physicians.

Objective: In an attempt to increase error reporting in our community hospital residency program, we devised a convenient safety log integrated into the computerized resident-patient sign-out.

Measurements and main results: Safety-log events are discussed in weekly safety reports with emphasis on developing a safety culture and preventing further events. We report our experience implementing the safety log. The program quadrupled our contribution to the hospital quality assurance system and has led to significant system innovations. Challenges have included sharing information and improving accountability without humiliating participants or alienating co-workers, as well as sustaining the project over time.

Conclusion: Residents are uniquely placed to provide insight into hospital systems. An error-reporting system based in a resident sign-out can leverage this role into an important tool for safety education and care improvement.

Figure 1

Non-optimal care and safety event form. Screenshot of a MS Access form linked to a resident sign-out database. Each record corresponds to a single admission. Multiple events for a single admission are combined on the same form. Frequency and impact radio buttons are converted into a 1–9 scale with higher numbers corresponding to increased severity. DC Discharge; VTE venous thromboembolism; ED emergency department.