Who Safety Curriculum · 2. Runciman B, Merry A, Walton M. Safety and ethics in healthcare: a guide...

WHO Patient SafetyCurriculum Guide

for Medical Schools

PART A: TEACHER’S GUIDE

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Why do medical students need patientsafety education?Health care outcomes have significantly improvedwith the scientific discoveries of modern medicine.However, studies from a multitude of countriesshow that with these benefits come significant risksto patient safety. We have learnt that hospitalizedpatients are at risk of suffering an adverse event,and patients on medication have the risk ofmedication errors and adverse reactions. A majorconsequence of this knowledge has been thedevelopment of patient safety as a specializeddiscipline. Clinicians, managers, health-careorganizations, governments (worldwide) andconsumers must become familiar with patient safetyconcepts and principles. Everyone is affected. Thetasks ahead of health care are immense and requireall those involved care to understand the extent ofharm to patients and why health care must move toadopt a safety culture. Patient safety education andtraining is only beginning to occur at all levels.Medical students, as future doctors and health-careleaders, must also be prepared to practise safehealth care. Though medical curricula arecontinually changing to accommodate the latestdiscoveries and new knowledge, patient safetyknowledge is different from other because it appliesto all areas of practice.

Medical students, as future clinicians, will need toknow how systems impact on the quality and safetyof health care, how poor communication can leadto adverse events and much more. Students needto learn how to manage these challenges. Patientsafety is not a traditional stand alone discipline;rather, it is one that integrates into all areas ofmedicine and health care. The World HealthOrganization’s (WHO) World Alliance for PatientSafety, and other projects such as this one, aims toimplement patient safety worldwide. Patient safetyis everyone’s business, all the way from patients topoliticians. As medical students are among thefuture leaders in health care, it is vital that they are

knowledgeable and skilful in their application ofpatient safety principles and concepts. The WHOPatient Safety Curriculum Guide for MedicalSchools sets the stage for medical students tobegin to practise patient safety in all their clinicalactivities.

Building students’ patient safety knowledge needsto occur throughout medical school. Patientsafety skills and behaviours should begin as soonas the students enter a hospital, clinic or healthservice. By getting students to focus on eachindividual patient, having them treat each patientas the unique human being they are and usingtheir knowledge and skills carefully studentsthemselves can be role models for others in thehealth-care system. Most medical students havehigh aspirations when they enter medicine, butthe reality of the system of health care sometimesdeflates their optimism. We want students to beable to maintain their optimism and believe thatthey can make a difference, both to the individuallives of patients and the health-care system.

What is the Curriculum Guide?The Curriculum Guide is a comprehensiveprogramme for implementation of patient safetyeducation in medical schools worldwide. Itcomprises two parts. Part A is a teacher’s guide,which has been designed to assist teachers toimplement the Curriculum Guide. We are awarethat patient safety is a new discipline and manyclinicians and faculty staff are unfamiliar with manyof the concepts and principles. This lays thefoundations for capacity-building in patient safetyeducation and Part B provides a comprehensive,ready-to-teach, topic-based patient safetyprogramme that can be implemented either as awhole or on a per topic basis.

1. Background

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Why was the Curriculum Guidedeveloped?Since the Harvard study [1] in 1991 first describedthe extent of harm to patients, other countrieshave found similar results, notwithstanding thedifferences in their cultures and health systems.The realization that health care actually harmspatients has increased scrutiny of patient care inthe context of an increasingly complex healthsystem. This complexity has been intensified byrapidly changing medical technology and servicedemands [2,3]. Doctors, nurses and allied health-care workers are expected to work whilemanaging this complexity, provide evidence-based health-care services and keep patientssafe. However, unless they are properly educatedand trained in patient safety concepts andprinciples they will struggle to do this.

Patient safety education for health professionals inthe higher education sector has not kept up withworkforce requirements [3-7]. Reporting ofspecific curricula on medical error or patient safetycourses in undergraduate medical education hasonly recently started to gain ground in thepublished literature [5,8]. The need for patientsafety education of medical clinicians wasconfirmed by a study of a multi-institutionalassessment of patient safety knowledge among693 medical trainees [9]. This study found thatknowledge levels of patient safety across a broadband of training, degrees and specialities weresubstantially limited, and that trainees were unableto self-assess their own knowledge deficiencies inpatient safety.

A number of factors have impeded patient safetyeducation. First, the lack of recognition by medicaleducators that teaching and learning patientsafety is an essential part of the undergraduatemedical curriculum, and that patient safety skillscan be taught [10,12]. Being a new area, manymedical educators are unfamiliar with the literature

are unsure how to integrate patient safety learninginto existing curriculum. [11-13] Second,educators need to be open to new areas ofknowledge [3]. One of the difficulties in introducingnew curricula is a reluctance to addressknowledge that originates from outside medicinesuch as systems thinking and qualityimprovement methods [12]. It has also beensuggested that the historical emphasis ontreatment of disease rather than prevention ofillness creates a culture that finds it difficult to givemerit to a “non-event”, that is, an adverse eventthat is preventable [3]. A third factor relates toentrenched attitudes regarding the traditionalteacher–student relationship—one that may behierarchical and competitive [10] and where an“expert” disseminates information to the student[3,4].

In 2007, the Association for Medical Education inEurope [10] called for patient safety education tobe integrated throughout the undergraduatecourse, including the first year, when awareness ofthe nature and the extent of threats to patientsafety can be raised and generic skills can bedeveloped. This Curriculum Guide seeks to fill thegap in patient safety education by providing acomprehensive curriculum designed to buildfoundation knowledge and skills for medicalstudents that will better prepare them for clinicalpractice in a range of environments.

1. Background

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References1. Brennan TA et al. Incidence of adverse events and

negligence in hospitalized patients: results of theHarvard Medical Practice Study I. New EnglandJournal of Medicine, 1991, 324:370–376.

2. Runciman B, Merry A, Walton M. Safety and ethics inhealthcare: a guide to getting it right, 1st ed. Aldershot,UK, Ashgate Publishing Ltd, 2007.

3. Stevens D. Finding safety in medical education. Quality& Safety in Health Care, 2002,11(2):109–110.

4. Johnstone MJ, Kanitsake O. Clinical risk managementand patient safety education for nurses: a critique.Nurse Education Today, 2007, 27(3):185–191.

5. Patey R et al. Patient safety: helping medical studentsunderstand error in healthcare. Quality & Safety inHealth Care, 2007, 16:256–259.

6. Singh R et al. A comprehensive collaborative patientsafety residency curriculum to address the ACGMEcore competencies. Medical Education, 2005,39:1195–1204.

7. Holmes JH, Balas EA, Boren SA. A guide fordeveloping patient safety curricula for undergraduatemedical education. Journal of the American MedicalInformatics Association, 2002, 9(Suppl. 1):s124–s127.

8. Halbach JL, Sullivan LL. Teaching medical studentsabout medical errors and patient safety: evaluation of arequired curriculum. Academic Medicine, 2005,80(6):600–606.

9. Kerfoot BP, Conlin PR, Travison TT, McMahon GT.Patient safety knowledge and its determinants inmedical trainees. Journal of General Internal Medicine.2007; 22(8): 1150-1154.

10. Sandars J et al. Educating undergraduate medicalstudents about patient safety: priority areas forcurriculum development. Medical Teacher, 2007,29(1):60–61.

11. Walton MM, Elliott SL. Improving safety and quality:how can education help? Medical Journal of Australia,2006, 184(Suppl. 10).

12. Walton MM. Teaching patient safety to clinicians andmedical students. The Clinical Teacher, 2007, 4:1–8.

13. Ladden MD et al. Educating interprofessional learnersfor quality, safety and systems improvement. Journal ofInterprofessional Care, 2006, 20(5):497–505.

1. Background

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The Curriculum Guide covers 11 topics, including16 of a total of 22 learning topics that wereincluded in the evidence-based Australian PatientSafety Education Framework (APSEF).* Anadditional topic not in APSEF was selected tosupport learning in infection control targeted bythe WHO programme to reduce infections throughbetter control. Figure 1 sets out the topicsselected for inclusion or exclusion.

What is the Australian Patient SafetyEducation Framework?[1]APSEF was developed using a four-stageapproach: literature review, development of learningareas and learning topics, classification into learningdomains, and conversion into a performance-basedformat. An extensive consultation and validationprocess was undertaken in Australia andinternationally. Published in 2005, the Framework isa simple, flexible and accessible templatedescribing the knowledge, skills and behavioursthat all health-care workers need to ensure safepatient care. The Framework is divided into level ofknowledge, skills and behaviours depending on a

person’s position and clinical responsibility in anorganization. The Framework is designed to assistorganizations and people develop educationalcurricula and training programmes. We havedeveloped the Curriculum Guide using theFramework in terms of content and rationale.

APSEF is freely available and can be accessedonline athttp://www.health.gov.au/internet/safety/publishing.nsf/Content/C06811AD746228E9CA2571C600835DBB/$File/framework0705.pdfThe accompanying bibliography can also beaccessed online athttp://www.health.gov.au/internet/safety/publishing.nsf/Content/C06811AD746228E9CA2571C600835DBB/$File/framewkbibli0705.pdf

Australian Patient Safety EducationFramework learning areas and topicsThere are 7 learning areas (categories) and 22learning topics in APSEF. Table 1 sets out theCurriculum Guide topics and the relationship withAPSEF.

* The topics left out were ones that we considered would already be covered in a medical school curriculum such as consent, evidenced-based practice and learning and teaching. Information technology was excluded because of the disparity in access to technology amonguniversity medical schools and health services.

7 Learning Categories

22 learning

3 learning Domains in each Learning topic

Knowledge - Skills - Behaviours

Underpinning/applied knowledge - Performance elements

Communictateeffectively

Usingevidence

Adverseevents

Workingsafely

Beingethical

Learning& teaching

Specificissues

Source: National Patient Safety Education Framework, Australia.

Figure 1. How is the NPSEF structured?

2. How were the Curriculum Guide topics selected?

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APSEF topic Included incurriculum

WHO topic

Communicating effectively

Involving patients and carers as partners in health care yes Topic 8

Communicating risk yes Topic 6

Communicating honestly with patients after an adverse event (open disclosure) yes Topic 8

Obtaining consent no Highly likely alreadycovered

Being culturally respectful and knowledgeable yes Topic 8

Identifying, preventing and managing adverse events and near misses

Recognizing, reporting and managing adverse events and near misses yes Topics 6,7

Managing risk yes Topic 6

Understanding health-care errors yes Topics 1,5

Managing complaints yes Topics 6,8

Using evidence and information

Employing best available evidence-based practice no

Using information technology to enhance safety no

Working safely

Being a team player and showing leadership yes Topic 4

Understanding human factors yes Topic 2

Understanding complex organizations yes Topic 3

Providing continuity of care Not directly covered

Managing fatigue and stress yes Topics 2,6

Being ethical

Maintaining fitness to work or practise yes Topic 6

Ethical behaviour and practice yes Topics1,6

Continuing learning

Being a workplace learner no

Being a workplace teacher no

Specific issues

Preventing wrong site, wrong procedure and wrong patient treatment yes Topic 10

Medicating safely yes Topic11

Infection control (not part of Australian framework) yes Topic 9

Table 1: APSEF plus WHO topics

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There were three main stages in the developmentof the Framework content and structure:1. Initial review of knowledge and development

of framework outline.2. Additional searching for content and

assignment of knowledge, skills, behavioursand attitudes.

3. Development of performance-based format.

Stage 1—Review of knowledge anddevelopment of framework outline

A search was conducted to identify the currentbody of knowledge relating to patient safety (asdescribed in the next section). The literature, books,reports, curricula and web sites collected were thenreviewed to identify the major activities associatedwith patient safety that had a positive effect onquality and safety. These activities were thengrouped into categories termed learning areas.Each learning area was analysed and further brokendown into major subject areas, termed learningtopics. See below for details of the literature reviewprocess and the Framework content structure.

The rationale for the inclusion of each learningarea and topic has been articulated in the body ofthe Framework and is summarized below.

Stage 2—Additional searching for content andassignment of knowledge, skills, behaviours andattitudes

Each learning topic formed the basis for a moreextensive search, including additional terms such aseducation, programmes, training, adverse events,errors, mistakes and organization/institution/healthfacility/health service. All the activities (knowledge,skills, behaviours and attitudes) for each topic werelisted until no more activities were forthcoming andthe sources exhausted. This list was then culled forduplication, practicality and redundancy. Theremaining activities were then categorized into

knowledge, skills or behaviours and attitudes.

The final step in this stage was to allocate eachactivity to the appropriate level corresponding tothe degree of responsibility of particular categoriesof health-care workers for patient safety:

Level 1 (Foundation) identifies the knowledge,skills, behaviours and attitudes that every health-care worker needs to have.

Level 2 is designed for health-care workers whoprovide direct clinical care to patients and workunder the supervision of, and for those withmanagerial, supervisory and/or advanced clinicalresponsibilities. Level 3 is for health-care workers who havemanagerial or supervisory responsibilities or aresenior clinicians with advanced clinicalresponsibilities. Level 4 (Organizational) identifies the knowledge,skills, behaviours and attitudes required for clinical and administrative leaders withorganizational responsibilities. Level 4 is not partof the progressive learning that underpins the firstthree levels.

The learning areas and topics were endorsed bythe Reference Group and Steering Committee.Extensive consultation with the wider healthsystem and community within Australia as well asinternationally completed the review andendorsement process for the learning areas andtopics and their content.

The outcome of this stage is shown in Table 2.This example is taken from the learning topic“involving patients and carers as partners in healthcare”.

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Stage 3—Development of performance-basedformat

The completed context matrix was translated into aperformance-based format, which takes fulladvantage of the modular nature of the Framework.The most extensive consultation occurred at thisstage of the Framework’s development. Individualhealth-care workers were interviewed about aspectsof every performance element in the Framework andthe entire Framework document was distributedacross the health-care sector for feedback.

The Curriculum Guide topics 1. What is patient safety? 2. What is human factors and why is it important

to patient safety? 3. Understanding systems and the impact of

complexity on patient care 4. Being an effective team player. 5. Understanding and learning from errors. 6. Understanding and managing clinical risk.7. Introduction to quality improvement methods.8. Engaging with patients and carers. 9. Minimizing infection through improved

infection control.10. Patient safety and invasive procedures.11. Improving medication safety.

Rationale for each Curriculum Guidetopic

Topic 1: What is patient safety? Health professionals are increasingly beingrequired to incorporate patient safety principlesand concepts into everyday practice. In 2002,WHO Member States agreed on a World HealthAssembly resolution on patient safety becausethey saw the need to reduce the harm andsuffering of patients and their families as well asthe compelling evidence of the economic benefitsof improving patient safety. Studies show thatadditional hospitalization, litigation costs,infections acquired in hospitals, lost income,disability and medical expenses have cost somecountries between US$ 6 billion and US$ 29billion a year [2,3].

A number of countries have published studieshighlighting the overwhelming evidence showingthat significant numbers of patients are harmeddue to their health care, either resulting inpermanent injury, increased length of stay (LOS) inhospitals or even death. We have learnt over thelast decade that adverse events occur notbecause bad people intentionally hurt patients butrather that the system of health care today is so


Level 1FoundationFor categories 1–4health-care workers

Level 2

For categories 2 and 3health-care workers

Level 3

For category 3 health-care workers

Level 4 OrganizationalFor category 4health-care leaders

Learning objectives Provide patients andcarers with theinformation they needwhen they need it

Use goodcommunication andknow its role ineffective health-carerelationships

Maximize opportunitiesfor staff to involvepatients and carers intheir care andtreatment

Develop strategies forstaff to include patientsand carers in planningand delivering health-care services

Knowledge

Skills

Behavioursand attitudes

Table 2. APSEF content matrix

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complex that the successful treatment andoutcome for each patient depends on a range offactors, not just the competence of an individualhealth care provider. When so many people anddifferent types of health-care providers (doctors,nurses, pharmacists and allied health) areinvolved, it is very difficult to ensure safe careunless the system of care is designed to facilitatetimely and complete information andunderstanding by all the health professionals. Thistopic presents the case for patient safety.

Topic 2: What is human factors and why is itimportant to patient safety? Human factors, engineering or ergonomics is thescience of the interrelationship between humans,their tools and the environment in which they liveand work [3]. Human factors engineering will helpstudents understand how people perform underdifferent circumstances so that systems andproducts can be built to enhance performance. Itcovers the human–machine and human-to-humaninteractions such as communication, teamworkand organizational culture.

Other industries such as aviation, manufacturingand the military have successfully appliedknowledge of human factors to improve systemsand services. Students need to understand howhuman factors can be used to reduce adverseevents and errors by identifying how and whysystems break down and how and why humanbeings miscommunicate. Using a human factorsapproach, the human–system interface can beimproved by providing better-designed systemsand processes. This involves simplifyingprocesses, standardizing procedures, providingbackup when humans fail, improvingcommunication, redesigning equipment andengendering a consciousness of behavioural,organizational and technological limitations thatlead to error.

Topic 3: Understanding systems and theimpact of complexity on patient care Students are introduced to the concept that ahealth-care system is not one but many systemsmade up of organizations, departments, units,services and practices. The huge number ofrelationships between patients, carers, health-careproviders, support staff, administrators,bureaucrats, economists and communitymembers as well as the relationships between thevarious health- and non-health-care services addto this complexity. This topic gives medicalstudents a basic understanding of complexorganizations using a systems approach. Thelessons from other industries are used to showstudents the benefits of a systems approach.

When students think in systems they will be betterable to understand why things break down andhave a context for thinking about solutions.Medical students need to understand how anindividual doctor or nurse working in a hospitalcan do their very best in treating and caring fortheir patients but alone that will not be enough toprovide a safe and quality service. This is becausepatients depend on many people doing the rightthing at the right time for them; in other words,they depend on a system of care.

Topic 4: Being an effective team player Medical students’ understanding of teamworkinvolves more than identification with the medicalteam. It requires students to know the benefits ofmultidisciplinary teams and how effectivemultidisciplinary teams improve care and reduceerrors. An effective team is one in which the teammembers communicate with one another as wellas combining their observations, expertise anddecision-making responsibilities to optimizepatient care [4].

The task of communication and flow ofinformation between health providers and patients


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can be complicated due to the spread of clinicalresponsibility among members of the health-careteam [5,6]. This can result in patients beingrequired to repeat the same information tomultiple health providers. More importantly,miscommunication has also been associated withdelays in diagnosis, treatment and discharge aswell as failures to follow up on test results [7-11].

Students need to know how effective health-careteams work, as well as techniques for includingpatients and their families as part of the health-care team. There is some evidence thatmultidisciplinary teams improve the quality ofservices and lower costs [12-14]. Good teamworkhas also been shown to reduce errors andimprove care for patients, particularly those withchronic illnesses [15-17]. This topic presents theunderlying knowledge required to become aneffective team member. However, knowledgealone will not make a student a good team player.They need to understand the culture of theirworkplace, and how it impacts upon teamfunctioning.

Topic 5: Understanding and learning fromerrors Understanding why health-care professionalsmake errors is necessary for appreciating howpoorly designed systems and other factorscontribute to errors in the health-care system.While errors are a fact of life, the consequences oferrors on patient welfare and staff can bedevastating. Medical students and other health-care professionals need to understand how andwhy systems break down and why mistakes aremade so they can act to prevent and learn fromthem. An understanding of health-care errors alsoprovides the basis for making improvements andimplementing effective reporting systems [18].Students will learn that a systems approach toerrors, which seeks to understand all theunderlying factors involved, is significantly better

than a person approach, which seeks to blamepeople for individual mistakes. Leape’s seminalarticle in 1994 showed a way to examine errors inhealth care, that focused on learning and fixingerrors instead of blaming those involved [19].Although his message has had a profound impacton many health-care practitioners, there are stillmany embedded in a blame culture. It is crucialthat students begin their vocation understandingthe difference between blame and systemsapproaches.

Topic 6: Understanding and managingclinical risk Clinical risk management is primarily concernedwith maintaining safe systems of care. It usuallyinvolves a number of organizational systems orprocesses that are designed to identify, manageand prevent adverse outcomes. Clinical riskmanagement focuses on improving the qualityand safety of health-care services by identifyingthe circumstances and opportunities that putpatients at risk of harm and acting to prevent orcontrol those risks. Risk management involvesevery level of the organization so it is essential thatmedical students understand the objectives andrelevance of the clinical risk managementstrategies in their workplace. Managingcomplaints and making improvements,understanding the main types of incidents in thehospital or clinic that are known to lead to adverseevents, knowing how to use information fromcomplaints, incident reports, litigation, coroners’reports and quality improvement reports to controlrisks [20] are all examples of clinical riskmanagement strategies.


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Topic 7: Introduction to quality improvementmethodsOver the last decade, health care has successfullyadopted a variety of quality improvement methodsused by other industries. These methods provideclinicians with the tools to: (i) identify a problem; (ii)measure the problem; (iii) develop a range ofinterventions designed to fix the problem; and (iv)test whether the interventions worked. Health-care leaders such as Tom Nolan, Brent James,Don Berwick and others have applied qualityimprovement principles to develop qualityimprovement methods for health clinicians andmanagers. The identification and examination ofeach step in the process of health-care delivery isthe bedrock for this methodology. When studentsexamine each step in the process of care theybegin to see how the pieces of care areconnected and measurable. Measurement iscritical for safety improvement. This topicintroduces the student to improvement methodsand the tools, activities and techniques that canbe incorporated into their practice.

Topic 8: Engaging with patients and carersStudents are introduced to the concept that thehealth-care team includes the patient and/or theircarer, and that patients and carers play a key rolein ensuring safe health care by: (i) helping with thediagnosis; (ii) deciding about appropriatetreatments; (iii) choosing an experienced and safeprovider; (iv) ensuring that treatments areappropriately administered; and (v) identifyingadverse events and taking appropriate action[21,22]. The health-care system underutilizes theexpertise patients can bring such as theirknowledge about their symptoms, pain,preferences and attitudes to risk. They are asecond pair of eyes if something unexpectedhappens. They can alert a health-care worker ifthe medication they are about to receive is notwhat they usually take, which acts as a warning tothe team that checks should be made. Research

has shown that there are fewer errors and bettertreatment outcomes when there is goodcommunication between patients and their carers,and when patients are fully informed andeducated about their medications [23-30]. Poorcommunication between doctors, patients andtheir carers has also emerged as a commonreason for patients taking legal action againsthealth-care providers [31,32].

Topic 9: Minimizing infection throughimproved infection controlWHO has a global campaign on infection control.We thought it important that this area be includedin the Curriculum Guide not only for consistencybut also because along with surgical care andmedications these areas constitute a significantpercentage of adverse events suffered bypatients. The problem of infection control inhealth-care settings is now well established, withhealth care-associated infections being a majorcause of death and disability worldwide. There arenumerous guidelines available to help doctors andnurses minimize the risks of cross-infection.Patients who have surgery or an invasiveprocedure are known to be particularly prone toinfections and account for about 40% of allhospital-acquired infections. The topic sets outthe main causes and types of infections to enablemedical students to identify those activities thatput patients at risk of infection and to preparestudents to take the appropriate action to preventtransmission.

Topic 10: Patient safety and invasiveproceduresWHO has a project on safe surgery. One of themain causes of errors involving wrong patients,sites and procedures is the failure of health-careproviders to communicate effectively (inadequateprocesses and checks) in preoperativeprocedures. Other examples of wrongsite/procedure/patient are: (i) the wrong patient in


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the operating room (OR); (ii) surgery performed onthe wrong side or site; (iii) wrong procedureperformed; (iv) failure to communicate changes inthe patient’s condition; (v) disagreements aboutstopping procedures; and (vi) failure to reporterrors.

Minimizing errors caused by misidentificationinvolves developing best-practice guidelines forensuring the correct patient receives the righttreatment [6]. Students can learn to understandthe value of all patients being treated inaccordance with the correctsite/procedure/patient policies and protocols.Such learning would include the benefit ofprotocols as well as knowledge of the underlyingprinciples supporting a uniform approach totreating and caring for patients.

One study of hand surgeons found that 21% ofsurgeons surveyed (n=1050) reported performingwrong site surgery at least once during theircareers [33].

Topic 11: Improving medication safety An adverse drug reaction has been defined byWHO [34] as any response to a medication that isnoxious, unintended and occurs at doses used forprophylaxis, diagnosis or therapy. Patients arevulnerable to mistakes being made in any one ofthe many steps involved in ordering, dispensingand administering medications.

Medication errors have been highlighted in studiesundertaken in many countries, including Australia,which [35] show that about 1% of all hospitaladmissions suffer an adverse event related to theadministration of medications. The causes ofmedication errors include a wide range of factorsincluding: (i) inadequate knowledge of patientsand their clinical conditions; (ii) inadequateknowledge of the medications; (iii) calculationerrors; (iv) illegible handwriting; (v) confusion

regarding the name of the medication; and (vi)poor history taking [37].

References1. Walton MM et al. Developing a national patient safety

education framework for Australia. Quality & Safety inHealth Care, 2006, 15(6):437–442.

2. Chief Medical Officer. An organisation with a memory.London, UK Department of Health, Report of an expertgroup on learning from adverse events in the NationalHealth Service, 1999.

3. Kohn LT, Corrigan JM, Donaldson MS, eds. To err ishuman: building a safer health system. Washington,DC, Committee on Quality of Health Care in America,Institute of Medicine, National Academy Press, 1999.

4. Greiner AC, Knebel E, eds. Health professionseducation: a bridge to quality. Washington, DC,National Academy Press, 2003.

5. Gerteis M et al. Through the patient’s eyes:understanding and promoting patient centred care.San Francisco, Jossey-Bass Publishers, 1993.

6. Chassin MR, Becher EC. The wrong patient. Annals ofInternal Medicine, 2002, 136(11):826–833.

7. Baldwin PJ, Dodd M, Wrate RM. Junior doctorsmaking mistakes. Lancet, 1998, 351:804–805.

8. Baldwin PJ, Dodd M, Wrate RM. Young doctors: work,health and welfare. A class cohort 1986–1996.London, Department of Health Research andDevelopment Initiative on Mental Health of the NationalHealth Service Workforce, 1998.

9. Anderson ID et al. Retrospective study of 1000 deathsfrom injury in England and Wales. British MedicalJournal, 1988, 296:1305–1308.

10. Sakr M et al. Care of minor injuries by emergencynurse practitioners or junior doctors: a randomisedcontrolled trial. Lancet, 1999, 354:1321–1326.

11. Guly HR. Diagnostic errors in an accident andemergency department. Emergency Medicine Journal,2001, 18:263–279.

12. Baldwin D. Some historical notes on interdisciplinaryand interpersonal education and practice in health carein the US. Journal of Interprofessional Care, 1996,10:173–187.

13. Burl JB et al. Geriatric nurse practitioners in long termcare: demonstration of effectiveness in managed care.Journal American Geriatrics Society, 1998, 46(4):506–510.

14. Wagner EH et al. Quality improvement in chronic illnesscare: a collaborative approach. Joint CommissionJournal on Quality Improvement, 2001, 27(2):63–80.

15. Wagner EH. The role of patient care teams in chronicdisease management. British Medical Journal, 2000,320(7234):569–572.


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16. Silver MP, Antonow JA. Reducing medication errors inhospitals: a peer review organisation collaboration.Joint Commission Journal on Quality Improvement,2000, 26(6):332–340.

17. Weeks WB et al. Using an improvement model toreduce adverse drug events in VA facilities. JointCommission Journal on Quality Improvement, 2001,27(5):243–254.

18. An organisation with a memory. London, UKDepartment of Health, 2000(http://www.npsa.nhs.uk/admin/publications/docs/org.pdf, accessed October 2004).

19. Walshe K. The development of clinical riskmanagement. In: Vincent C, ed. Clinical riskmanagement: enhancing patient safety, 2nd ed. London,British Medical Journal Books, 2001:45–61

20. Vincent C, Coulter A. Patient safety: what about thepatient? Quality & Safety in Health Care, 2002, 11:76–80.

21. National Patient Safety Agency. Seven steps to patientsafety: your guide to safer patient care. London,NPSA, 2003 (www.npsa.nhs.uk, accessed October2004).

22. Coiera EW, Tombs V. Communication behaviours in ahospital setting: an observational study. British MedicalJournal, 1998, 316(7132):673–676.

23. Clinical Systems Group, Centre for Health InformationManagement Research. Improving clinicalcommunications. Sheffield, University of Sheffield,1998.

24. Lingard L et al. I. Team communications in theoperating room: talk patterns, sites of tension andimplications for novices. Academic Medicine, 2002,77(3):232–237.

25. Gosbee J. Communication among healthprofessionals. British Medical Journal, 1998, 316–642.

26. Parker J, Coeiro E. Improving clinical communication:a view from psychology. Journal of the AmericanMedical Informatics Association, 2000, 7:453–461.

27. Smith AJ, Preston D. Communications betweenprofessional groups in a National Health Service Trusthospital. Journal of Management in Medicine, 1669,10(2):31–39.

28. Britten N et al. Misunderstandings in prescribingdecisions in general practice: qualitative study. BritishMedical Journal, 2000, 320:484–488.

29. Greenfield S, Kaplan SH, Ware JE Jr. Expandingpatient involvement in care. Effects on patientoutcomes. Annals of Internal Medicine, 1985,102(April):520–528.

30. Lefevre FV, Wayers TM, Budetti PP. A survey ofphysician training programs in risk management and

communication skills for malpractice prevention.Journal of Law, Medicine and Ethics, 2000, 28(3):258.

31. Levinson W et al. Physician–patient communication:the relationship with malpractice claims among primarycare physicians and surgeons. Journal of the AmericanMedical Journal, 1997, 277(7):553–559.

32. Joint Commission on Accreditation of HealthcareOrganizations. Guidelines for implementing theuniversal protocol for preventing wrong site, wrongprocedure and wrong person surgery. Chicago,JCAHO, 2003.

33. Meinberg EG, Stern PJ. Incidence of wrong-sitesurgery among hand surgeons. Journal of Bone JointSurgery, 2003;85(A(9)):193–197.

34. World Health Organization. International drugmonitoring—the role of the hospital WHO Report. DrugIntelligence and Clinical Pharmacy, 1970, 4:101–110.

35. Runciamn WB et al. Adverse drug events andmedication errors in Australia. International Journal forQuality in Health Care, 2003, 15(Suppl. 1):i49–i59.

36. Smith J. Building a safer NHS for patients: improvingmedication safety. London, UK Department of Health,2004.


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The aims of the Curriculum Guide are to:• prepare medical students for safe practice in

the workplace;• inform medical schools of the key topics in

patient safety;• enhance patient safety as a theme

throughout the medical curriculum;• provide a comprehensive curriculum to assist

teaching and integrating patient safetylearning;

• further develop capacity for patient safetyeducators in medical schools;

• promote a safe and supportive environmentfor teaching students about patient safety;

• introduce or strengthen patient safetyeducation in medical schools worldwide;

• raise the international profile of patient safetyteaching and learning;

• foster international collaboration on patientsafety education research in the highereducation sector.

Underpinning principles

Capacity-building is integral tocurriculum changeThe main reason that WHO embarked on thisproject was to assist medical schools to developpatient safety education in their medical schools.The requirement of medical schools to developand integrate patient safety learning into themedical curricula is a challenge for many medicalschools because of the limited education andtraining of faculty staff in patient safety conceptsand principles. One cannot expect medicalschools to develop new curricula or reviewexisting curricula if they are unfamiliar with therequirements of the discipline of patient safety.

Medical educators come from many backgrounds(clinicians, clinician educators, non-clinicianeducators, managers, health professionals) andtheir collective experience is necessary to deliver a

rigorous medical programme. Many are experts intheir particular disciplines and usually keep up todate using the accepted professional pathwaysfor their area. Patient safety knowledge requiresadditional learning that falls outside thesetraditional routes. To be an effective patient safetyteacher, health professionals need to be providedwith the knowledge, tools and skills necessary forimplementing patient safety education in theirinstitutions. This is why a Teacher’s Guide (Part A)has been developed to accompany theCurriculum Guide. It provides practical advice andinformation for each stage of curriculumdevelopment and renewal, from assessingcapacity to staff development to programmedesign and implementation.

A flexible curriculum to meet individualneedsWe recognize that the curriculum of most medicalprogrammes is already filled beyond capacity. Thisis why we have designed each topic as standalone, thus allowing for wide variations in patientsafety education implementation. The topics arealso designed so they can be integrated intoexisting curricula, particularly in the doctor–patientstream. The topics in the Curriculum Guide haveeach been designed with enough content for a60–90 minute educational session and feature avariety of ideas and methods for teaching andassessing so that educators can tailor materialaccording to their own unique needs, context andavailable resources. There is no requirement toabsolutely follow the outline provided. Teachersneed to pay attention to the local environment,culture and student learning experiences and thenselect the most appropriate teaching method forthe content selected.

Easily understood language for atargeted yet global audienceThe Teacher’s Guide (Part A) of the CurriculumGuide is written for medical educators (those with

3. Aims of the Curriculum Guide

17

the capacity to introduce or enhance patientsafety education at various levels), while theCurriculum Guide (Part B: Topics) is written forteachers and students. The Curriculum Guide waswritten with a global audience in mind and inlanguage easily understood by those with Englishas both a first and second language.

A curriculum guide for all countries,cultures and contextsEvery attempt has been made to ensure that thecontent in this curriculum takes into account thewide variety of contexts in which medicaleducators and students teach and learn. AnExpert Group, representing all WHO regions, hasassessed the curriculum to ensure culturalappropriateness. Although some of the teachingactivities and suggestions for students may not beculturally appropriate in every country, we aremindful that in all countries we need to changemany of the aspects of clinical care. Muchprofessional behaviour once thought appropriateis today no longer acceptable when taking patientsafety considerations into account. For example,junior doctors or nurses will rarely speak up whenthey see a senior clinician about to make an error;this is universal and applies to all cultures tovarying degrees. However, patient safetyprinciples require that everyone is responsible forpatient safety and should speak up even whenthey are lower in the medical and health-carehierarchy. Teachers will need to make a judgementabout the health-care environment and whether itis ready and prepared for the introduction ofpatient safety.

Teaching and assessment strategies are designedto take into account both diversity in availableresources and environmental differences,considerations that may be in terms of adeveloped versus developing country or aclassroom versus a simulation centre.

A curriculum guide that is based onlearning in a safe and supportiveenvironmentWe are mindful that students respond best whenthe learning environment is one that is safe,supportive, challenging and engaging. Patientsafety learning occurs in many places—beside thebed, in simulated environments and in theclassroom. It is essential that students aresupported in their learning and not made to feelhumiliated or inadequate. The activities in theCurriculum Guide are designed to beimplemented in a supportive learning environmentwhere students feel comfortable asking questions,volunteer what they do not understand and sharetheir understanding in an honest and open way.

3. Aims of the Curriculum Guide

18

Teacher’s Guide (Part A) The Teacher’s Guide (Part A) relates to buildingcapacity for patient safety education, programmeplanning and design. Suggestions are providedregarding how patient safety education might beapproached and implemented using the materialpresented in Part B. In Part A, we try to guide thereader through some important steps designed tosupport and achieve the implementation phase ofcurriculum development.

Curriculum Guide topics (Part B)The topics represent the actual patient safetyeducation curriculum.

4. Structure of the Curriculum Guide

19

How to use this Curriculum GuideThis Curriculum Guide provides you withresources for teaching medical students aboutpatient safety. It identifies the topics to be taught,how it might be taught and how you can assessthe different topics in the curriculum. Caseexamples have been selected are available at theend of each topic. These cases can be used todemonstrate a particular aspect of the topic underdiscussion. We recognize that the best learningoccurs when the case study used reflects localexperiences, therefore, we encourage teachers tomodify the cases so that they reflect theexperiences of the health-care providers andlocally available resources.

How to review your curriculum forpatient safety learning

• Identify the learning outcomesTo start the process of curriculum development orrenewal it is important to first identify the learningoutcomes for patient safety. Part B contains thetopics that have been chosen for this CurriculumGuide; whereas learning outcomes are furtherdiscussed in Part A.

• Know what is already in the medicalcurriculum

We use the word curriculum to refer to the broadspectrum of teaching and learning practices,including the strategies for developing skills andbehaviours as well as using appropriateassessment methods to test whether the learningoutcomes have been achieved. Medical studentsare guided in their learning by a medical curriculumthat sets out the requisite knowledge, skills andbehaviours required to demonstrate competencyat the completion of their medical degree.

Before new material is introduced into acurriculum it is important to know what curriculumalready exists as well as students’ clinical

experiences in the hospitals and/or the differentclinical environments. It may be that students arealready experiencing some patient safetyeducation in the hospitals and clinics that is notwritten down. The curriculum may already coversome aspects of this patient safety curriculumsuch as the importance of protocols inhandwashing to avoid infection transmission.Getting a picture of existing material in themedical curriculum is necessary to identify thoseopportunities for enhancing patient safetyteaching.

The patient safety curriculum we have designed isdescribed in Part B of this document. We haveidentified the topics, resources, teachingstrategies and assessment methods that willmake patient safety teaching easier to introduceand integrate into the curriculum.

• Build on what is already in the curriculumA good approach to patient safety education is toenhance existing parts of the medical curriculumrather than see patient safety as a new subject toteach. There are elements of patient safety thatare new and will be additional to the existingcurriculum, but there are many aspects of patientsafety that can be added onto or achieved withfurther development of a subject or topic thatalready exists.

We have found that mapping topics or areas inthe existing curriculum will help identifyopportunities to include patient safety conceptsand principles. Areas such as clinical skillsdevelopment, professional and personaldevelopment, patient–doctor and community–doctor themes, health law, medical ethics, clinicalethics and communication are all suitable forincluding patient safety concepts and principles.The University of Sydney developed a template toreview their medical curriculum and offer it as anexample that can be followed (see Table 3).

5. Implementing the Curriculum Guide

20

Mapping medical curriculum will also help identifythe opportunities for including patient safetyconcepts in an integrated fashion.

How to assess the capacity of facultyto integrate patient safety teaching intothe existing curriculumOne of the biggest challenges facing all medicalschools is the growing shortage of clinicianteachers generally. There are few who know howto integrate patient safety principles and conceptsinto their clinical teaching. Many good cliniciansintuitively adopt patient safety methods into theirpractice but may not know how to articulate whatthey do. Perhaps this is because they view anydiscussions about “systems” as the province ofadministrators and managers. Others may notthink patient safety teaching important or relevantto their practice. Engaging clinicians in the areawill be the first challenge for you. Building capacityof the faculty can take time, but there are anumber of steps that can be taken to engageclinicians in patient safety teaching.

SurveyOne way to find out who is interested in teachingpatient safety is to conduct a survey of theclinicians who teach medical students. In someinstitutions there may be hundreds of teachers andin others not so many. Identify the clinicians whoare in the best position to incorporate patient safety

teaching and make sure they are included in thesurvey. The mapping exercise described above willhelp identify those people who currently teach andin a position to integrate patient safety concepts.The survey could include questions in relation tointerest or knowledge of patient safety and practicein patient safety methods. This process could alsoidentify those people who may be interested informing a group or committee to oversee thedevelopment of the patient safety curriculum.

Focus groupRun a focus group of clinicians to find out whatthe current state of knowledge is about patientsafety. This will also provide information about theclinicians’ attitudes towards including patientsafety learning in the curriculum.

Face-to-face meetingsIndividual meetings with clinicians will help toconvey a clear message about patient safetyeducation. This provides an opportunity to explainthe basis and urgency for patient safety educationas well as establish a relationship for later work.

Convene a round tableInvite a select group of clinicians who you thinkmay be interested and those who are possiblechampions of a round table discussion aboutpatient safety education for medical students.(The benefit of a round table format is that there is


Session/area ofthe curriculum

Year Where is thepatient safetycontent?

Potentialpatient safetylearning

How is patientsafety beingtaught?

How is patientsafety beingassessed?

Comments

Ethics 1 Respect forpatientautonomy

Honesty afteran adverseevent

Lecture Ethics essay,MCQ, OSCE

Many patient safetyprinciples have anethical basis thatcan be used tomake explicit thepatient safetylesson

Table 3. Map of patient safety content in the existing medical programme (example)

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no one expert obviously in charge and the groupseeks to discuss and resolve the issues togetherin a collegial fashion.)

Conduct a seminar on patient safetySeminars are typical venues for building newknowledge. Seminars can be good for exposingclinicians new to the area to experts or respectedclinicians who know about patient safety.Seminars can either be a half day or a full day.Topics that could be included in such a seminarinclude: (i) what is patient safety; (ii) the evidenceof why patient safety is important; (iii) how todevelop a curriculum for patient safety; (iv) how toteach patient safety; and (v) how to assess patientsafety. It is important to remember to maintaincontext of the programme, which is to buildcapacity for faculty staff and clinicians to teachpatient safety to medical students.

How to identify like-minded colleaguesor associatesIf you undertake the activities set out above inrelation to building capacity this will help identifylike-minded people interested in teaching patientsafety. Another way is to convene a meeting andsend an open invitation to faculty staff andclinician teachers. Make sure to schedule themeeting at a time convenient for as many peopleas possible in order to attract maximumattendance (for example, clinicians who seepatients during the day may want to come butcannot because of work demands). Another wayis to put an article in the faculty newsletter oruniversity news. This will let people know aboutpatient safety, and even if they are not interestedin getting involved, the article will raise awarenessof the need to include patient safety education inthe curriculum.

Patient safety teaching requires the engagementof interested and knowledgeable staff who eitherself-select, or have been appointed or nominated

as a result of previous contacts or meetings aboutpatient safety. It is also a good idea to check theavailability of experts from other faculties anddisciplines such as nursing, engineering (humanfactors knowledge), psychology (behaviouralpsychology, process and improvement theories)and pharmacy (medication safety).

Techniques to find out where patientsafety could fit into the medicalcurriculumBrainstorming is a technique that requires andencourages everyone to suggest ideas for solvinga problem. The problem being how to bestintroduce patient safety learning into thecurriculum. Each medical school will be different;they will have different resources, capacity andinterest in patient safety. Patient safety may notyet be a community or government concern sothe urgency to include patient safety educationmay not be a priority.

Convening introductory workshops on theCurriculum Guide for medical students will providean opportunity for members of the faculty tobecome familiar with the core topics in patientsafety. It will also allow them to express anyreservations they have about the programme andclarify any concerns or questions.

Patient safety is best considered in the context ofmultidisciplinary learning. Staff should beencouraged to reflect on the feasibility ofcombining some of the patient safety sessionswith other health professionals. While thisCurriculum Guide has been designed for medicalstudents, it can easily be adapted to other health-care students. Other professions and disciplineshave much to contribute, particularly in teachingsome of these topics. Engineers may be able toteach about systems, safety cultures and humanfactors engineering. Psychologists andbehavioural scientists, nursing and pharmacy


22

faculty can teach about how their disciplines havemade safety improvements. Striving for diversitygives the maximum chance to enable students tolearn from other disciplines, particularly in thecontext of a team approach to patient safety.

Reaching agreementAs in all discussions about curriculum there will bedifferent views about what should be included andwhat should be left out. The important thing is tostart and build on that. This means thatcompromise may be better in the long run—getting something started rather than debatingand discussing the issues for lengthy periods oftime. Another technique is to introduce new topicsinto the curriculum using a pilot, which couldidentify any problems and be used as a guide forfuture topics. It also allows faculty staff memberswho are unsure of the value of patient safetylearning to get used to the idea.

The next section gives more details aboutdeveloping and integrating the Curriculum Guideinto existing curriculum.


23

General comments Patient safety is a relatively new discipline andintroducing any new material into an existingmedical curriculum is always challenging. Whatshould be taught? Who should teach it? Whereand how will it fit in with the rest of thecurriculum? What does it replace?

If your medical school is in the process of renewingan existing curriculum or if you belong to a newmedical school, this is an ideal time to make a casefor allocating space for patient safety education.However, most medical school curricula are wellestablished and already full. It is unusual to find ablock of free time waiting for a new area of study.

This section provides ideas on how to integratepatient safety teaching and learning into an existing

medical curriculum. The benefits and challenges ofdifferent approaches will be covered to help youdetermine the likely best fit for your school and tohelp you anticipate and plan what is required.

The nature of patient safety education:• it is new;• it spans a number of fields not traditionally

taught in medical schools such as humanfactors, systems thinking, effective teamworkbehaviours and managing error;

• it links with many existing and traditionalmedical school subjects (applied sciencesand clinical sciences) (see Box 1 forexamples);

• it contains new knowledge and performanceelements (see Box 2 for examples);

• it is highly contextual.

An example of how a patient safety topic such as correct patient identification has specific applications in numerousdisciplines in medicine:

Discipline Patient safety application

Obstetrics How are newborn babies identified as belonging to their mother so that babies are notaccidentally mixed up and leave hospital with the wrong parent(s)?

Surgery If a patient needs a blood transfusion, what checking processes are in place to ensure theyreceive the correct blood type?

Ethics How are patients encouraged to speak up if they do not understand why the doctor is doingsomething to them that they were not expecting?

Box 1. Linking patient safety education with traditional medical school subjects

Patient safety competencies for a particular topic can be divided into knowledge and performance requirements. Ideally,learning will occur in both categories, e.g. correct patient Identification

Domain Patient safety example

Broad knowledge Understanding that patient identification mix-ups can and do occur, especially when care isdelivered by a team. Learning what situations increase the likelihood of a patient mix-up such ashaving two patients with the same condition, patients who cannot communicate and staff beinginterrupted mid-task.

Applied knowledge Understanding the importance of correct patient identification when taking blood for cross-matching. Understanding how errors can occur during this task and learning about the strategiesused to prevent error in this situation.

Performance Demonstrating how to correctly identify a patient by asking the patient their name as an open-ended question such as “What is your name?” rather than as a closed question such as “Are youJohn Smith?”

Box 2. Linking patient safety education with new knowledge and performance elements

6. How to integrate patient safety into your medicalschool curriculum

24

The field of patient safety is also very broad. Giventhis breadth and the need for contextualizingpatient safety principles, there are likely to bemany opportunities in your curriculum toincorporate effective patient safety education intoexisting sessions. However, some areas of patientsafety are relatively new to medicine and may notbe so easy to graft onto an existing session andhence are likely to need their own time slot in thecurriculum.

How to establish best fit using genericcurriculum structuresOnce you have reviewed your existing curriculum,determined what patient safety areas are alreadytaught and decided what patient safety topics youwant to teach, it is time to think about how toincorporate the new content into your curriculum.

When thinking about your medical school’scurriculum consider the following questions:• How is your overall curriculum structured?• When and where in the curriculum are

particular subjects and topics taught thatmight lend themselves to inclusion of patientsafety content?

• How are individual topics structured in termsof learning objectives, delivery methods andassessment methods?

• How is your curriculum delivered?

Once you have answered these questions it willbecome more apparent where and how patientsafety can be included in your curriculum.

How is your overall curriculum structured?• Is it a traditional curriculum? Students first

learn about the basic and behaviouralsciences and once these are complete,concentrate on the clinical disciplines.Education tends to be discipline-specificrather than integrated.

In this setting, clinical application andperformance elements of patient safety may bebest introduced in the later years of the course.However, broad knowledge of patient safetyprinciples can still be effectively introduced in theearly years.

• Is it an integrated curriculum? Basic,behavioural and clinical sciences and clinicalskills are covered in parallel throughout thecourse and learning is integrated.

In this setting, there are advantages to verticalintegration of knowledge, application andperformance elements of patient safety educationthroughout the course.

Knowledge and performance requirementsof patient safety:• Are ideally learnt in the context of the clinical

setting; relevance is more apparent oncestudents understand how health care isdelivered and are more familiar with theworkplace environment.

• Will be more likely to change practice ifstudents have the opportunity to use whatthey have learnt shortly after it is covered inthe curriculum.

When teaching a patient safety topic, there areadvantages if the knowledge and performancerequirements are covered together. A clearunderstanding of the scope of a problem inpatientsafety will provide motivation and insight whenlearning about performance requirements.

Students are also less likely to feel demoralizedabout the risks facing patients from the health-care system they will soon be a part of; if theyexplore solutions (applications) and learn practicalstrategies (performance elements) to make themsafer doctors at the same time, they will be morepositive. For logistical reasons it may not be

6. How to integrate patient safety into your medical school curriculum

25

possible to cover the knowledge and performancerequirements of a patient safety topic at the sametime. For example, there is a lecture on medicationerror in the second year but the students do notpractise safe drug administration techniques until aclinical skills workshop in the fourth year. If this isthe case, it will be helpful to inform students in thesecond year that they will learn safe drugadministration in the fourth year, and then in thefourth year, refer back to the lecture they had inthe second year on medication error. This waymotivation for safe practice will not be lost andstudents will feel more confident about theirpotential to graduate as a safe practitioner.

If your curriculum is traditional, then knowledgeand performance requirements of patient safetyare best taught in later years when students havemore knowledge of the clinical disciplines,exposure to patients and clinical skills training. Thecontext for the knowledge and performancerequirements should match the students’ ability toput into practice their new knowledge.Introductory patient safety knowledge can still beincluded in the early years in subjects such as

public health, epidemiology, ethics or otherbehavioural science-based subjects. Suitabletopics for early introduction include: (i) what ispatient safety; (ii) introduction to human factorsengineering; and (iii) systems and complexity inhealth care.

If your curriculum is integrated and students aretaught clinical skills from the first year, then patientsafety topics are best introduced early andvertically integrated throughout the entire course.This makes patient safety a constant theme andprovides opportunities to reinforce and build uponearlier learning. Ideally, students should beexposed to patient safety education prior to andupon entering the clinical environment.

When and where in the curriculum areparticular subjects and topics taught thatmight lend themselves to inclusion of patientsafety teaching?Box 3 sets out opportunities for examiningintegration of patient safety topics.


Patient safety topic Subjects that could house patient safety topics.

Minimizing infection throughimproved infection control

MicrobiologyProcedural skills trainingInfectious diseasesClinical placements

Improving medication safety PharmacologyTherapeutics

Being an effective team player Advanced life-support trainingOrientation programmesCommunication skills training (interprofessional)

What is patient safety? EthicsIntroduction to the clinical environmentClinical and procedural skills training

Box 3. Integration of patient safety topics

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Any clinical discipline can potentially house apatient safety topic if a sample case is part of thesession and is relevant to that discipline. Forexample, a case involving a medication error in achild could be used as the starting point forteaching about understanding and learning fromerrors while studying paediatrics. Similarly, duringthe surgical rotation a clinician could teach thetopic “patient safety and invasive procedures”.Medicine or obstetrics could house the topic of“understanding and learning from errors” if thecase was relevant to that particular discipline. Thelearning, however, is generic and relevant for alldisciplines and all students.

How are individual curriculum topicsstructured in the following areas?• learning objectives• delivery methods• assessment methods.

Implementation of new patient safety content intoyour curriculum will be more efficient if theassociated learning objectives, delivery andassessment methods are consistent with thestructure of objectives, delivery and assessmentmethods of existing subjects.

How is your curriculum delivered?• lectures• clinical placements• online activities• on the ward activities• small group tutorial teaching• problem-based learning (PBL)• simulation/skills laboratories• traditional tutorials.

It will probably be easier to incorporate patientsafety topics into pre-existing educational deliverymethods familiar to students and staff.

Examples of models for implementationExample 1: Patient safety as a stand alone subjectin a traditional curriculum occurring in the finalyears. See chart 1.• educational methods could consist of a

combination of lectures, small groupdiscussions, project work, practicalworkshops or simulation-based exercises;

• adding a layer of patient safety to priorknowledge before entering the workforce.


Years 1and 2:

basic, applied

and behavioural

sciences

Years 3 and 4:

clinical

disciplines and

clinical skills

Patient safety topics

Chart 1: Implementation of patient safety as a stand alone subject in a traditional curriculum

27

Example 2: Patient safety as a stand alone subjectin an integrated curriculum. See chart 2.

Patient safety could be a stand alone subject withlinks to other subjects, e.g. lectures at the start ofterm that relate to topics that will come up intutorials or on placement over the course of the year.


Year 1 Topics 1 and 2: What is patient safety?;

introduction to human factors engineering

Year 2 Topics 3 and 5: understanding systems and

the impact of complexity on patient care;

understanding and learning from errors

Year 3 Topics 4, 7, 9 and 10: being an effective

team player; methods for quality

improvement; minimizing infection through

improved infection control; reducing risks

associated with invasive procedures

Year 4 Topics 6, 8 and 11: how to mange clinical

risk; engaging with patients and carers;

improving medication safety

PBL

Clinical skills workshops and clinical placements

Chart 2: Implementation of patient safety as a stand alone subject in an integrated curriculum

28

Example 3: Integrating patient safety into pre-existing subjects—example A. See chart 3.

A number of subjects could set aside somesessions where the main objective of the tutorialor lecture is to cover a patient safety topic.

In the fourth year there could be a lecture onmedication safety as part of therapeutics, aworkshop on safe drug administration in theclinical skills programme and a PBL case thatdemonstrates the multifactorial nature of errorusing a case of medication error.


Year 1 PBL Patientsafetycase

Clinicalskills

Patientsafetyactivity

Lecture PatientSafetytopic


Clinicalskills




Clinicalskills




Clinicalskills



Chart 3: Implementation of patient safety as a stand alone subject in an pre-existing subjects (A)

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Example 4: Integrating patient safety into pre-existing subjects—example B . See Chart 4.

Work together with subject leaders to incorporateelements of patient safety into selectededucational sessions. Although the main focus of

the session is not a patient safety topic, elementsof patient safety education are weaved into thesession. For this to occur, session objectivesshould include an element of patient safety. SeeBox 4 for examples.


Year 1 PBL Patient safetycase

Patient safetycase

Clinical skills Patient safetyactivity

Patient safetyactivity





Lecture Patient safetytopic


Patient safetycase









Patient safetycase









Patient safetycase








Chart 4: Implementation of patient safety as a stand alone subject in an pre-existing subjects (B)

30


The more patient safety topics are integrated intothe established curriculum, the easier it will be toincorporate the performance requirements in ameaningful way, and provide context for patientsafety concepts.

However, there should be a word of caution: themore that patient safety is integrated into theexisting curriculum, the more it is dispersed,dependent on a greater number of teachers and itbecomes harder to coordinate effective delivery.You will need to find the balance betweenintegration of the new material and ability tocoordinate its delivery. It is a good idea to keep adetailed record of what patient safety is integratedinto the existing curriculum, how it is being taughtand how it is being assessed. From aneducational perspective, integration of patientsafety is ideal; however, this aim needs to bebalanced by the practicalities of implementation.When asked by a university or accrediting bodywhere and how patient safety is taught to medicalstudents the faculty needs to have informationthat is sufficiently detailed to allow an observer toattend such a session and see patient safetyeducation being delivered. It may be that a

combination of the above approaches is moreappropriate for your setting.

Once you have an overall plan of what, where andhow you want to incorporate patient safety intoyour curriculum, it will be easier to add to thecurriculum in a piecemeal fashion, topic by topicover time, rather than trying to add every aspectof your plan at once. This way you can learn asyou go, and start achieving small goals early.

Integration of patient safety into aproblem-based learning programmeMany medical schools use PBL as a majorcomponent for delivering curriculum. One of themany benefits of PBL is the integration of basic,behavioural and clinical science material in thecontext of solving a clinical problem. If the clinicalproblem also includes aspects of the realities ofthe health-care delivery system then there will beopportunities to explore issues relating to patientsafety. PBL is well suited to patient safetyteaching and learning. This section provides ideasto help you effectively include patient safetymaterial into your PBL programme.

Pre-existing session Patient safety education component

Clinical skills tutorial at the bedside Patients are always provided with an explanation andconsent to being part of the educational process at the startof the session. Tutors role model respecting patients wishes.Patients are always included as part of the team.Tutors invite patient to join case discussion as they haveinformation important to their care.

Procedural skills session on IV cannulation Sterile technique and sharps disposal are included.Involve patient in risk discussion about infection.Practise consent.

Lecture on blood transfusion Patient risk and ways to minimize risk are included as part ofthe lecture.Verification protocols to ensure correct patient.

PBL on pulmonary embolism where the index case iscommenced on an oral anticoagulant

Students are encouraged to discuss the importance ofpatient education when prescribing potentially dangerousmedication.

Box 4. Examples of how patient safety topics can be weaved in with pre-existing sessions

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There are many variations of the PBL process.The relevance of some of the ideas we present willdepend on which PBL model your school hasadopted. In this section, PBL is assumed to havethe following characteristics:• small group learning with a facilitator (tutor or

teacher) present;• a clinical case is used as the starting point for

learning;• as students attempt to understand the case

through group discussion, issues andproblems arise that will form the basis offurther study;

• students undertake self-directed study(resources may be provided to help guidestudents with their study);

• students come together as a group to sharetheir learning and collectively improve theirunderstanding of the issues that arose fromthe clinical case;

• PBL sessions have specified learningobjectives and PBL learning is assessable.

The nature of the PBL process is aligned withstrategies that promote patient safety in theworkplace such as:• collaborative learning;• reviewing cases, identifying problems and

issues as a group;• sharing the workload and

exploring/researching problems as anindividual;

• learning from and teaching peers;• group problem solving;• respecting roles and responsibilities;• showing respect to colleagues.

Many of the skills developed in the PBL processwill assist students to be effective future membersof health-care teams involved in continuousquality improvement in the workplace.

How learning issues emerge from theproblem-based learning caseFor a PBL session to achieve its aims the clinicalcase needs to be written in a way that promotescuriosity and discussion.

Example of a PBL case:Jeremy So is a 15-year-old boy who arrives at thelocal medical clinic with noisy breathing and itch.His father says he was fine 30 minutes ago andthat he just became unwell quite suddenly. Onexamination, Jeremy looks distressed andnervous. He has a puffy face, his lips are hugeand he can hardly open his eyes as they are soswollen. He has red blotches on his skin and he isscratching his body. Every time he breathes in hemakes a noise.

From this case a number of questions may arisein the minds of the students:• What is the most likely diagnosis? What else

could it be?• What could have caused the problem?• How does the diagnosis explain all the clinical

features?• What is the underlying pathophysiology of the

condition—can the features be explained byunderstanding the pathophysiology?

• What is likely to happen to Jeremy if he doesnot get treatment?

• What is the treatment?

Example of the same case written to elicitdiscussion of medical error as well as answersto the above questions:

Jeremy is a 15-year-old boy who arrives at thelocal medical clinic with noisy breathing and itch.His father says he was fine 30 minutes ago andthat he just became unwell quite suddenly. Onexamination, Jeremy looks distressed andnervous. He has a puffy face, his lips are hugeand he can hardly open his eyes as they are so


32

swollen. He has red blotches on his skin and he isscratching his body. Every time he breathes in hemakes a noise.

Jeremy’s father says his son was like this oncebefore after having some medicine called penicillinand he was told never to have penicillin againbecause it could kill him. Jeremy saw a doctor thismorning because of a runny nose, sore throat andfever. The doctor prescribed amoxicillin, whichJeremy started earlier today. Jeremy’s fatherwonders if his son might also be allergic to thisnew medicine amoxicillin.

With the case written in this way some additionalquestions for discussion may arise:• How might Jeremy have been given

amoxicillin when he has a known seriousallergy to penicillin?

• Why Jeremy was prescribed an antibioticwhen the most likely cause of his symptomsis a viral upper respiratory tract infection?

• This problem was preventable; has someonemade a mistake?

• How can this type of situation be prevented?What is the doctor’s role? What is thepatient/carer’s role in prevention of thissituation?

• How much should the doctor explain toJeremy and his father about how the mistakewas made?

In addition to a well-written case, clearly statedlearning objectives help keep students’ discussionon the intended path. It may be that only theteacher has access to the learning objectives andcan guide students in the right direction if needbe. So, in this sample case, as well as objectivesthat relate to the pathophysiology, clinicalmanifestations and treatment of severe allergicreactions, one or two of the objectives could befocused on patient safety issues.

For example:• list a doctor’s responsibilities when

prescribing medication.• list strategies to minimize patients being given

medications that may harm them.

Some schools may provide students with pre-determined questions as part of the PBL process.For example:• What are doctors’ responsibilities when

prescribing a new medication?• How is a thorough allergy history performed?• Define the following terms: medical error,

adverse event, near miss.

Suggestions for adjusting problem-basedlearning sessions to include elements ofpatient safety• Include information in the case that relates to

a patient safety issue. To achieve this, includeaspects of the realities of the health-caredelivery system, which will provideopportunities to explore issues relating topatient safety.

• Make the case relevant to your local health-care environment.

• The case may include a near miss or adverseevent such as the above example.

• The case may include a threat to patientsafety thus helping students to recognizewhere the hazards in the system are.

A case may include a nurse (or medical student)noticing some important information that thedoctor has overlooked. The case can describe thenurse being assertive (speaking up), the doctorbeing receptive to the nurse and the patient’s carebeing improved as a result.

The patient safety issue may be a major or minorcomponent of the case.• If your school has learning objectives for each

PBL case, include patient safety knowledge


33

in the objectives.• If your school has pre-determined questions

for PBL cases, include questions aboutpatient safety.

• If your school provides resources and/orreference material for students doing PBLcases, include patient safety literature.

• If your school provides tutor notes as part ofthe PBL process, include patient safetyliterature.

• Use PBL cases that cover broad patientsafety concepts early in the programme (suchas the multifactorial nature of error or humanfactors) and cases that include specificapplications of patient safety concepts later inthe programme. This will help studentsreinforce major concepts over time and applytheir knowledge to different situations.

Integration of patient safety into aprocedural skills training programmeInvasive procedures have the potential to harmpatients. This is especially so when proceduresare being done by learners who are still lacking inexperience. Procedures can cause harm throughcomplications, pain and emotional distress, notbeing effective and not being necessary in the firstplace. The knowledge, skill and behaviour of thedoctor performing the procedure can help tominimize some of the potential risks for patients.Integrating patient safety education withprocedural skills training at an undergraduate levelwill help medical students to be mindful of theirresponsibilities to patients when embarking oninvasive procedures. This section provides somesuggestions on how to integrate patient safetyeducation with procedural skills training in yourschool.As a starting point, consider the followingquestions:1. When, where and how are procedural skills

taught in your school?2. What are the skills taught?

3. When do students start to perform theseprocedures on patients? Ideally, the patientsafety messages should precede or coincidewith this.

Patient safety topics to consider including ina procedural skills training programme

Broad patient safety topics that are relevant forall procedures:• The learning curve. Understand that an

inexperienced clinician is more likely to causeharm and/or fail a procedure compared to anexperienced clinician. What strategies can beused to help minimize harm while still allowingfor learning to take place; for example, therole of careful preparation, planning,background knowledge, observation ofothers performing the procedure, simulation,supervision, feedback and follow-up ofpatients (topics 2, 5 and 6).

• What is the required background knowledgea doctor needs to acquire about a procedurebefore undertaking that procedure (topics 6and 10)?

• Sterile precautions (topic 11).• Communicating risk (topics 6 and 9).• Correct patient Identification, correct side,

correct patient (topic 10).• Follow-up of test results (topics 2, 6, 9 and 10).

Patient safety knowledge and skills applied tothe performance of specific procedures: • Common problems/hazards/traps, trouble

shooting (topics 2 and 5).• Common and serious complications and how

to minimize them (topic 1 and 5).• Advice for patients regarding follow-up (topics

6 and 9).• Equipment familiarity (topic 2). • Specific applications of broad patient safety

topics (all topics).


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For example: Correct patient identification whentaking a blood sample. How to label sample tubesto minimize chance of misidentification: label atthe bedside, check patients name with an open-ended question, make sure the patient’s namematches the label on the sample tube and thelabel on the request form, i.e. perform a “three-way check”.

A variety of educational methods can be used tointroduce the broad patient safety topics as theyapply to performing invasive procedures—forexample, lectures, readings, group discussion,tutorials, online activities and even PBL.

The best time to learn the knowledge andperformance requirements of a patient safety topicis when learning the steps of the procedure. Thismay occur in a practical tutorial at the bedside,using simulation in a skills laboratory or as a tutorialwithout a “hands-on” component. Students couldbe asked to read a particular article or guidelinesprior to attending the teaching session.

Tutorials on particular procedures provide anexcellent opportunity to reinforce genericprinciples, to detail patient safety applications fora particular procedure and for students to practiseperformance elements of patient safety.

If your school utilizes immersive scenario-basedsimulation training, for example, to learn basic andadvanced life support, there is an opportunity toincorporate team training into that programme.The advantages of this type of training forincorporating patient safety issues are the realisticsituations that mirror many real-life challenges thatcan emerge from the scenario. For example,knowing what to do in an emergency situation isdifferent from actually doing it, especially whenworking as part of a team. The real elementsintroduced are time pressure, stress, teamwork,communication, equipment familiarity, decision-

making in action and knowing the environment.Similar to other forms of experiential learning, thereare opportunities to practise the performancerequirements demonstrating safe practice.

Note: Immersive scenario-based teaching usingsimulation can be a highly effective way forstudents to learn, but can also be quiteconfronting for students and not always acomfortable way to learn. Attention to creating asafe and supportive learning environment is veryimportant if this educational method is used. Seethe section on underpinning educational principlesfor more details on creating a safe and supportivelearning environment.

Clinical skills training programmeClinical skills training includes learning how to takea history, how to perform a physical examination,clinical reasoning, test ordering and interpretation,procedural skills and communication skills such asproviding information, counselling and obtaininginformed consent.

A range of methods are used to teach clinicalskills such as bedside tutorials, practising withsimulated patients, practising with peers,observing videos of expert performance,participation in the clinical environment andpresenting cases.

Consider when and how your school delivers itsclinical skills programme.

A number of patient safety topics will beappropriate for inclusion in a clinical skillsprogramme. And since the programme may offeropportunities to practise performance elements ofpatient safety, it is important that good habits bedeveloped early. Note that bedside tutorials offerrich opportunities for tutors to role model safepractice—for example, patient-centredcommunication and hand hygiene.


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Clinical skills training may provide opportunities forstudents to learn about and practise the followingpatient safety performance elements:• communicating risk;• asking permission;• accepting refusal;• being honest with patients;• empowering patients—helping patients be

active participants in their own care;• keeping patients and relatives informed;• hand hygiene; • patient-centred focus during history taking

and physical examination;• clinical reasoning—diagnostic error,

consideration of risk benefit ratio of procedures,investigations and management plans.

How to collaborate with ward-basedteachers and teachers of clinical skillsFor patient safety principles to be integratedbroadly throughout the curriculum, thecooperation of many individual teachers will needto occur, particularly if patient safety education isto be delivered in small group settings such asPBL and clinical skills tutorials.

We mentioned in the beginning of this section thatmany teachers will not be familiar with patientsafety concepts and specific knowledge andperformance requirements will be new. Forexample, students may see clinicians in theworkplace asking patients their name in a hurriedand disrespectful manner, taking shortcuts that maycompromise patient safety or display a “blame andshame” attitude when things go wrong. Tutors willneed to reflect on their own practice if they are to beeffective patient safety teachers and role models.

The following strategies may assist to engageclinical teachers in patient safety teaching:• conduct a patient safety workshop or lecture

series for teachers;• invite guest speakers to promote patient safety;

• engage/excite teachers about the inclusion ofpatient safety in the curriculum;

• parallel patient safety education in thepostgraduate setting;

• clearly state patient safety learning objectives intutor notes;

• provide tutors notes on patient safety topics;• assess patient safety content in exams.

Using case studies

Build local case studiesCase studies can either demonstrate how not to dosomething (learning from a person’s negativeexperience) or how to do something right (learningfrom a person’s positive experience). For example, ifa case study is being developed for the topic “beingan effective team player”, then the local case studywould have elements of teams that are familiar tothe local institutions, local clinics or hospitals.

The following steps will assist in building local casesrelevant to the topic being taught.• Review the sections of each topic in this

Curriculum Guide outlining: - the relevance of the topic to the workplace; - the learning objectives for the topic.

• Write down the activities that are captured inthe objectives.

• Obtain case studies from: - the Curriculum Guide; or- ask doctors and nurses in the hospital or

clinic to provide cases that can be identified. • Develop a story that contains the elements set

out in the objectives.

The context of the case study should be familiar tothe students and clinicians. For example, if there areno intensive care units (ICUs) locally available, thenthe case studies should avoid mentioning ICUs orplacing the case study in an ICU.


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How to modify the case studies in theCurriculum GuideMost of the case studies are written to illustrate abehaviour or process. Many of the cases we haveselected and those supplied by the WHO ExpertGroup relate to more than one topic such asunderstanding errors, communication, teamworkand engaging with patients. We have listed all of thecases under each topic that we think could be usedto demonstrate an appropriate learning objective.Different types of cases have been used, rangingfrom health services that rely heavily on technologyto ones with limited access to technologicalservices. This means that many of the case studieswill apply to most medical schools; if not, the casestudies can be modified by changing theenvironment in which the case takes place. Thecase can also have another type of health providerinvolved when the one identified in the case studydoes not exist. For example, patients can bechanged from male to female or female to male (ifclinically appropriate), can have family memberspresent or absent, or come from a rural area or acity. After a case study has been modified to takeinto account local elements, give the case study toa colleague to see if it makes sense and is relevantto the topic, local environment and context.


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For patient safety education to result in safepractice and improved patient outcomes it needsto be meaningful to students. As with anyteaching, one of the major challenges is to ensuretransfer of the learning to the workplace. Whatcan educators do to encourage students to applytheir learning in a practical way on the job?

The following strategies can help.

Context is highly relevant in teachingpatient safety

Contextualize patient safety principles Patient safety principles need to be made relevantto the daily activities of health-care workers. Aimto show students when and how patient safetyknowledge can be applied in practice. This meansusing examples that students can relate to.

Use examples that are realistic for yoursettingThink about the sort of work most of yourstudents will be doing after they graduate andhave this in mind when choosing clinical contextsin which to incorporate patient safety education.Including a case about malnutrition, morbidobesity or malaria is not particularly useful if theseconditions are extremely uncommon in yourclinical practice setting. Use situations andsettings that are common and relevant for themajority of your graduates.

Identify practical applicationsHelp students identify the situations in which theycan apply their patient safety knowledge andskills. This way they are more likely to recognizeopportunities for safe practice in the workplace asthey arise. For example, correct patientidentification is important in:• sending off blood samples;• administering medication;• putting labels on imaging request forms;

• writing in patients files;• writing on patients medication charts;• performing procedures;• working with patients who have difficulty with

communication.

Use examples that are of interest or soon willbe relevant to studentsDraw on situations that the students may findthemselves in when they are junior doctors and/oras medical students on clinical placement. Forexample, if the topic is about being a patientadvocate, it is far better to use an example of astudent being assertive with a surgeon rather thanthe senior hospital doctor needing to be assertivewith hospital management. This way, therelevance of the material will be more apparent tostudents, resulting in better motivation for learning(see Box 5 for an example).

Box 5. Practical application example

Give students the opportunity to practiseapplying their patient safety knowledge andskillsBy giving students the opportunity to practise“safe practice”, it will hopefully become habitual,and students will be more inclined to approachclinical situations with a patient safety mindset.

Practising “safe practice” can occur as soon asstudents commence their medical training—forexample, in:• tutorials or private study, e.g. brainstorming

solutions for hazardous situations;• a simulation setting, e.g. skills laboratory,

While observing a surgical operation amedical student notices that the surgeon isclosing the wound and there is still a packinside the patient. The student is not sure ifthe surgeon is aware of the pack and iswondering whether to say something.

7. Educational principles essential for patient safetyteaching and learning

38

simulation laboratory, role play;• the clinical environment, e.g. hand hygiene

when seeing patients, correct patientidentification when drawing blood from apatient;

• patient interactions—when advising, studentscan practise encouraging patients to beinformed, ask questions and be proactive inensuring care progresses as planned.

Create an effective learning environmentAspects of the learning environment can also havea bearing on the effectiveness of teaching andlearning. An ideal learning environment is one thatis safe, supportive, challenging and engaging.

Safe and supportive learning environmentsA safe and supportive learning environment is onein which:• students feel comfortable to ask “stupid”

questions;• volunteer what they do not understand; • share what they do understand in an honest

and open way.

Students who feel safe and supported tend to bemore open to learning, enjoy being challengedand are more prepared to actively participate inlearning activities.

If students feel unsafe and not supported they willtend to be reluctant to disclose knowledge deficitsand less likely to engage actively for fear of feelingembarrassed or being humiliated in front of theirteachers and peers. The student’s primary aimbecomes self-preservation rather than learning.Attention to creating a safe and supportivelearning environment not only makes learningmore enjoyable, but also, importantly, makeslearning more effective. The teacher has asignificant role in making the learning environmenta comfortable place for students.

Suggestions for helping to create a safe andsupportive learning environment:• Introduce yourself to students and ask the

students to introduce themselves. Show aninterest in them as individuals as well asshowing an interest in their learning.

• At the start of your teaching session, explainhow the session will run. This will let thestudents know what to expect, and also whatis expected of them.

• Orient learners to the environment you areteaching in. This is especially important if youare in the clinical environment or a simulationenvironment. Students need to know what isexpected of them if they are in a new setting.Simulation environments can be confusing assome aspects are real, some aspects are not,and the learner is asked to pretend that someaspects are real. Make sure the learnersknow the level of immersion required for therole play, and how realistically you expectthem to treat the situation. It may beembarrassing for a student to talk to anintravenous (IV) cannulation insertion practicearm as if it were a real patient when theteacher’s intention was just to use the IVinsertion practice arm for practising themanual aspects of the task.

• Invite students to ask questions and speakup if there is anything they do notunderstand. This sends the message that notknowing is okay.

• Never criticize or humiliate a student for lackof knowledge or poor performance. Rather,this should be viewed as a learningopportunity.

• If active participation is required, ask forvolunteers rather than singling people outyourself.

• Consider demonstrating how to do somethingyourself before asking students to have a turn.For example, when teaching about how tocreate a sterile field before doing a lumbar

7. Educational principles essential for patient safety teaching and learning

39

puncture, it is much more efficient todemonstrate how to do it correctly at theoutset, rather than have a student do it in frontof their peers before having been taught howand making mistakes that need to becorrected.

• When asking questions of a group of studentsit is best to ask the question first, then givestudents time to think about the question andthen look for someone to provide a response.Avoid choosing a student before asking thequestion. Some students will find this unnervingand may have trouble thinking clearly if a wholeclass is waiting for their response.

• If, as the teacher, you are asked a question youdo not know the answer to, do not try to hidethis fact or apologize for not knowing. Torespond in such a way would send a messageto the students that not knowing isunacceptable. A useful quote to remember is,“the three most important words in medicaleducation are ‘I don’t know’” [1].

• When providing feedback on performances inthe clinical (or simulation) setting, make it atwo-way conversation. Ask students for theiropinion before giving your own and includeaspects of performance that were done welland areas that need more work. Help studentsdevelop a plan for addressing the areas thatneed more attention.

Challenging and engaging learningenvironmentsStudents who are challenged by the teacher arelikely to progress their learning more rapidly. Achallenging learning environment is one wherestudents are encouraged to think about and dothings in new ways. Assumptions are challengedand new skills are developed. Students valuethese kinds of learning activities. It is important toemphasize the difference between a challenginglearning environment and an intimidating learningenvironment. In fact, a safe and supportive

learning environment is a prerequisite forchallenging students. When students feel safe andsupported they are open to being challenged,when they are challenged they will be moreinclined to engage in the process.

Another important facet to effective teaching is theuse of engaging learning activities, which requirestudents to exercise their brain, mouth or hands,not just their ears. Try to avoid activities wherestudents are simply passive recipients ofinformation. The more active the activity, the morelikely it is to impact on the students learning.

Experiential learning activities such as interviewinga patient, practising a procedural skill in aworkshop and role play are usually very engagingsimply by virtue of the fact that they requirestudents to do things. Small group work such asPBL also tends to be engaging because of thecollaborative nature of the activity, the tendency ofthe case to generate questions in the minds of thelearners and the need to solve problems.

It can be challenging to deliver lectures that areengaging. The following strategies may help: • try to be interactive;• pose questions to the students;• have students discuss an issue or share their

experience in pairs;• tell a story to illustrate a point;• use case examples or problems that students

can easily relate to as the starting point forthe lecture;

• relate theoretical concepts to concreteexamples;

• have students critique a video, case,statement, solution or problem.

Activities such as observing a hospital activity,reading an article or observing an invasiveprocedure can be made more engaging ifstudents have a task to complete as part of the


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process. Ideally, the task would help developcritical reflection skills. For example, if studentsare required to attend morbidity and mortalitymeetings, they could have some pre-setquestions to address based on their observations.

Teaching stylesIndividual educators tend to adopt a preferredstyle of teaching if the option exists [2]. Thepreferred style is likely to be determined by acombination of the teacher’s beliefs about whatworks best, their aptitudes and what they feelmost comfortable with.

Styles can range from teacher-led where theteacher adopts the expert role and presentsinformation to the learners via a lecture ordemonstrates how to do something via rolemodelling, to student centred where the teachermay simply facilitate students to learn forthemselves and from peers—for example, PBL orsmall group project work. Teachers who adopt thestudent centred approach may see their role as amotivator and guide for students as they workthrough a learning activity. The teacher’s skills maybe in formulating engaging learning activities,facilitating group discussion, asking thoughtprovoking questions and/or providing effectivefeedback.

Each teaching style has advantages anddisadvantages, which will vary with the content tobe taught, the number of students, the students’preferred learning styles (if known), the teacher’sabilities and the time and resources available forthe teaching session. Advantages of student-centred styles include the encouragement ofcollaboration, communication and proactive groupproblem solving skills among students: all usefulexperiences for being an effective team memberin the workplace. It is helpful to be aware not onlyof your preferred teaching style, but also to beaware of other ways of teaching that may be

equally or more effective in particularcircumstances. The ability to be flexible isencouraged. It may be that you will need to adjustyour usual methods to fit in with the overallcurriculum delivery design at your school.

Harden identifies six important roles of theteacher: [3]• information provider;• role model;• facilitator;• assessor;• planner; • resource producer.

As an information provider in the field of patientsafety, it is important to be well informed about it.This requires knowledge of basic patient safetyprinciples, why it is important in the clinical settingand what staff can do to promote patient safety inthe workplace. Spending time reflecting on one’sown practice and approaches to hazards in theworkplace will help identify relevant teachingpoints for your students. There are many ways aclinical teacher can role model safe practice.When you are in the clinical setting with patients,students will notice how you:• interact with patients and families;• respect the wishes of patients and families;• inform patients and families of risks;• consider risk–benefit ratios in determining

management plans;• respond to and invite questions from patients

and families; • wash your hands between patients; • adopt a team approach;• welcome advice from colleagues;• adhere to workplace protocols;• acknowledge uncertainty;• acknowledge and learn from your own and

others’ errors [4];• problem solve systems issues; • look after yourself and your colleagues.


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You can be a very effective patient safety teachersimply by being a safe practitioner yourself in thepresence of students who are eager to learn.

Considering the patient in patient safetylearning Patient safety education can be incorporated intomany different educational settings from theclinical environment to the lecture theatre and PBLtutorial room simply by being mindful of where thelearning opportunities are. The following halfquestions may give you ideas about how to createa patient safety learning moment:• What are the hazards for the patient here…• What do we need to be mindful of in this

situation…• How can we minimize the risks…• What would make this situation more risky for

the patient…• What should we do if X should occur…• What will be our plan B…• What would we say to the patient if X

occurred…• What are our responsibilities…• Who else can help with this

situation…nursing staff? Patient?• What happened? How can we prevent this in

the future….• What can we learn from this situation…• Let’s look at the risk–benefit ratio of your

suggested plan…

Some of the best teaching students willexperience comes from patients themselves. Theirrole in medical education has a long history,usually in relation to describing their experience ofa disease or illness. However, they can also teachstudents about communication, riskcommunication, ethics, responses to adverseevents and more.

A cautionary noteRemember that students may becomedemoralized if there is undue emphasis on risk,errors and patient harm. An effective patient safetyteacher will be able to balance this by addressingthe positive aspects of the area such as solutionsto problems, progress in patient safety andequipping students with concrete strategies toimprove their practice. It is also important toremind students of the success of the majority ofpatient care episodes. Patient safety is aboutmaking care even better.

Resource materialTeaching on the run series(http://www.meddent.uwa.edu.au/go/about-the-faculty/education-centre/teaching-on-the-run/teaching-resources).

National Center for Patient Safety of the USDepartment of Veterans Affairs(www.patientsafety.gov)

ABC of learning and teaching in medicine Editedby Peter Cantillon, Linda Hutchinson and DianaWood, British Medical Journal Publishing Group,2003.(http://hsc.unm.edu/som/ted/mes/British%20Medical%20Journal%20series%20on%20Medical%20Education.htm)

ABC of Patient Safety, Edited by John Sandarsand Gary Cook, Malden, MA, Blackwell PublishingLtd, 2007.

Runciman B, Merry A, Walton M. Safety andethics in health care: a guide to getting it right, 1sted. Aldershot, UK, Ashgate Publishing Ltd, 2007.


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References1. Editor’ choice. “I don’t know”: the three most

important words in education. British Medical Journal,1999, 318(7193).

2. Vaughn L, Baker R. Teaching in the medical setting:balancing teaching styles, learning styles and teachingmethods. Medical Teacher, 2001, 23(6):610–612.

3. Harden RM, Crosby J. Association for MedicalEducation in Europe Guide No 20: the good teacher ismore than a lecturer - the twelve roles of the teacher.Medical Teacher, 2000, 22(4):334–347.

4. Pilpel D, Schor R, Benbasset J. Barriers to acceptanceof medical error: the case for a teaching programme.Medical education, 1998, 32(1):3–7.


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The purposes of assessment Assessment is an integral part of any curriculum.The content and format of assessment proceduresstrongly influence the study behaviour and learningoutcomes of the students. It is essential thatassessments used in the patient safety curriculumsupport the exit learning outcome objectives aswell as providing appropriate motivation anddirection for the students. Assessments should bemeaningful and give confidence to teachers,course planners and external stakeholders such asaccreditation bodies, standards boards and thefuture employers of our students. WHOrecommends that guidelines such as theinternational best practice in developingassessment guidelines are considered whenassessing elements in medical curricula.

Formative assessmentsFormative assessments are a vital and inherent partof the learning process for students. A wide rangeof such activities is possible within all componentsof a medical programme. Self-assessment is theability of students to assess their own learningneeds and choose educational activities that meetthese needs. (The preponderance of evidencesuggests that students have a limited ability toaccurately self-assess and may need to focusmore on external assessment.)

Summative assessmentAll components of assessment that the studentshave to pass, or have to complete beforeprogression from one part of the course toanother may occur, are regarded as summative. Ingeneral terms, they fall into two types ofassessment: end-of-course examinations and in-course assessments.

End-of-course summative assessmentsSuch assessments can typically be at the end ofan eight-week block, end of term, end of year orend of programme. The bulk of this chapter

covers the requirements of end-of-courseassessments.

In-course summative assessmentsThere is a range of course assessments that caneasily be introduced in the patient safetycurriculum. Many schools could incorporate theseelements into existing portfolios or the “record ofachievement”.

Some features of “best assessment”practices in patient safety The following assessment principles will apply toachieving the aims of patient safety curriculum.The assessments should:• drive learning in the intended direction of

meeting the exit learning outcomes of a newlygraduated doctor capable of safe patient care;

• have a strong formative element, with regularopportunities for remediation and counsellingthroughout the course;

• be integrated with, for example, clinicalcompetence and not be discipline based;

• be included in examinations of clinicalcompetence and professional behaviours in allstages of the course;

• be included in examinations of basic sciences,e.g. integrated in population health sciencesat all stages of the course;

• be progressive and ensure proportions ofmaterial from previous stages will be includedin all subsequent exams;

• be developed with the expectation that theywill meet quality assurance standards;

• claim fairness by engaging students and staffin the process of development;

• be motivating and provide direction for whatstudents need to learn to practise safely;

• be feasible and acceptable to both faculty andstudents;

• conform to the “house style” to add to theprofessional appearance of the procedures.

8. How to assess patient safety

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Defining what is to be tested

BlueprintingStudents internationally are concerned about theamount of material in the curriculum that they haveto learn, and are made anxious by not knowingwhat might be assessed. Blueprinting is a way ofdefining the range of competencies (or knowledge)to be tested. These will be drawn directly from thelearning outcomes of the curriculum. It is importantto ensure that the planned assessment adequatelysamples the range of competencies by the end ofthe medical degree.

Some competencies need to be systematicallyassessed to ensure that students build on theirknowledge and integrate into their clinicalpractice. To create a blueprint, the dimensions ofthe grid are created to cover the expectedcompetencies. One should ensure there is evenweighting of the components being assessedand, therefore, adequate sampling of the material.For example, Table 4 shows different componentsof patient safety that might be assessed in end-of-year assessments throughout the five years of anundergraduate medical degree.

Select appropriate test methodsIt is important to emphasize that assessment inpatient safety is aligned with the agreed learningoutcomes. It is unlikely that any particularassessment format is suitable to assess everythingrequired. It is best to be aware of the range ofassessment methods and make a decision basedon an understanding of their strengths andlimitations. Let the purpose of the assessment, forexample, “to assess knowledge of health-care law inthe unconscious patient” drive the choice of format,in this case a modified essay question (MEQ) or amultiple choice question (MCQ).

Quality improvement methods may be bestassessed via a student project. There are a numberof basic concepts in assessment to help decidewhich type of assessment format is most

appropriate. One of the most well known of these isMiller’s triangle, which suggests that a student’sperformance is made up of four levels (see Figure 2):• knows• knows how• shows how• does.

For example, “showing how” is related to specificcompetencies that are appropriate for the level ofexpertise of the student. These can be examinedby, for example, an objective structured clinicalexamination (OSCE) station.


Assessable learningoutcomes

Year that curriculum modules are first assessed in a typical programme

Year 1 Year 2 Year 3 Year 4

Health law X

Health-care systems X

Communication X

Safe patient care X

Quality improvement X

Table 4. A blueprint showing end-of-course assessments for components of the patient safetycurriculum

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Figure 2. Miller’s triangle

Source: Miller GE. The assessment of clinicalskills/competence/performance. Academic Medicine,(Supplement), 1990, 65:S63-S67.

Again, looking at Figure 2, one can see thatknowledge (knows) can be tested by MCQs, forexample.

Typical assessment formats within a medicalschool might include:

Written:• multiple choice items (1 from 4/5);• extended matching questions (EMQ);• structured short answer questions;• modified essay question (MEQ);• extended written work (e.g. project reports,

posters);• portfolio/log books.

Clinical/practical:• multiple station exams;• direct observation of performance (e.g.

observed long cases, mini clinical evaluationexercise [Mini-CEX]);

• 360 degree or multisource feedback (MSF);• structured reports (e.g. attachment

assessments);• oral presentations (e.g. projects, case-based

discussion);• structured oral exams.

There are some strengths and weaknesses withall of these formats and which need to beconsidered when choosing the right assessmentfor a particular learning outcome within a patientsafety curriculum.

Written

Multiple choice question/extended matchingquestionMCQ and EMQ are very attractive formats in thatthey can test a wide sample of the curriculum,can be machine marked and give reliable scoresof a student’s ability. However, their maindrawback in testing aspects of clinicalcompetence, such as patient safety, is that theytend to test knowledge only. This is appropriatewith, for example, health-care law and aspects ofpatient safety in public health. It is not appropriatein testing, for example, ethical reasoning. Anexample of an MCQ is given in Appendix 2. TheEMQ has been designed to address the issue ofguessing in multiple choice exams.

Modified essay questions/key feature The traditional essay is used in some places.There is great advantage in allowing students toevidence their critical thinking, reasoning andproblem solving skills. However, marking essaysfor large classes are resource intensive andsubject to much variability in judges marks.However, MEQs or key feature formats aredesigned to be answered in 5–10 minutes, andencourage short note responses to appropriatescenarios. Providing a model answer and markingscheme helps examiners maintain somestandardization. Several MEQs on a range ofdifferent subjects can be asked in the time it takesto write one essay sampling just one area of thecurriculum. An example is given in Appendix 2.

Various (w ritten or computer-based) selected and constructed response questions (i tem writing technology)

Dir ect observation in simulated contexts (e.g. OSCE)

Dir ect observation in real-li fe contexts (emerging technology)

Knows

Shows how

Knows how

Does }}}


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Portfolio/logbookA spectrum of assessment methods to evidencewith respect to key learning outcomes, rangingfrom a log of clinical activities, through a record ofachievements throughout a segment of theprogramme, to documentation supporting anannual appraisal, complete with learning plans. Aparticularly useful component of the portfolio is thecritical incident. Here students are asked to reflectin a structured way on clinical situations they haveobserved where patient safety was an issue.

Clinical/practicalThere is a wealth of research evidence to suggestthat having more than one observer improves theaccuracy of competency assessments. It is veryimportant that considerations of patient safety areincorporated within the marking rubrics, examinertraining and feedback sessions of each of theassessments that is used in the medical schoolcontext. If the topic is assessed separately, it willdrive students to learn patient safety assomething extra to be added on, rather than asan integral part of safe patient care.

Objective structured clinical examination (OSCE)OSCE comprises of a circuit of short simulatedclinical cases assessed either by a standardizedpatient or the clinical teacher. Patient safety canbe incorporated as at least one item within thechecklist for each simulated scenario.Alternatively, a single case can be entirelydedicated to a patient safety case—e.g.communicating an adverse event to a simulatedpatient recovering from routine abdominal surgery.Cases in which the student is required to look attreatment charts, X-rays or investigations aresometimes called static stations as they do notrequire the student to be observed. This allows,for example, prescribing errors to be simulatedand the students actions recorded. An example isgiven in Appendix 2.

Multisource feedback (MSF)MSF are collated views from a range of health-care workers or peers about the student in theclinical learning environment. Ideally, checklistitems about safe patient care and goodcommunication would be included in the ratingform.

Mini clinical evaluation exercise (mini-CEX)A mini-CEX is where the supervisor observes astudent performing a history, examination orcommunication exercise on a real patient andrates the student on several domains. Aggregatedscores of several encounters are used todetermine the competency of the student. Onceagain, it is important to ensure that elements ofpatient safety are included on the rating form. It isparticularly important in a mini-CEX to have goodpreparation of clinical raters and ensuring thattrainers of supervisors include references topatient safety in the training sessions.

End of clinical placement assessments/globalrating scalesThis assessment aims to give a credible view of astudent’s progress and is usually completed bythe supervisor, based on personal knowledge orafter consultation with colleagues. Patient safetycriteria need to be included.

Case-based discussion (CBD)The CBD is a structured discussion of clinicalcases by the supervisor focusing on clinicalreasoning and decision-making. It takes realcases in which the student has been involved.This is a relatively underexplored technique forexamining the understanding of patient safetyissues as related to real cases.


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Matching assessment to expected learningoutcomesIt is always important to match assessments tointended learning outcomes. Most medicalcurricula will have learning outcomes, some moredetailed than others. In Table 5, the complete listof learning outcomes for patient safety can beeasily matched with appropriate assessments.

A sample of patient safety outcomes have beenmodified from the Australian Junior DoctorCurriculum Framework. The Framework has beenaligned with many sources, including theAustralian Patient Safety Education Framework,and shows that patient safety concepts arecompletely integrated.


Competencies Assessmentformat

Safe patient care: systems

Understand the complex interaction between the health-care environment, doctor and patient Essay

Aware of mechanisms that minimize error, e.g. checklists, clinical pathways

Safe patient care: risk and prevention MCEQ/MEQ

Know the main sources of error and risk in the clinical workplace Essay/MEQ

Understand how personal limitations contribute to risk Viva/Portfolio

Promote risk awareness in the workplace by identifying and reporting potential risks to patients and staff Portfolio

Safe patient care: adverse events and near misses

Understand the harm caused by errors and system failures Essay/MEQ

Aware of principles of reporting adverse events in accordance with local incident reporting systems MEQ

Understand principles of the management of adverse events and near misses MEQ

Safe patient care: public health

Understand the key health issues of your community MCQ

Aware of procedures for informing authorities of “notifiable diseases” MCQ

Understand principles disease outbreak management MEQ

Safe patient care: infection control

Understand prudent antibiotic/antiviral selection MCQ

Practise correct handwashing and aseptic techniques OSCE

Always use methods to minimize transmission of infection between patients OSCE

Safe patient care: radiation safety

Know the risks associated with exposure to radiological investigations and procedures MCQ/MEQ

Know how to order radiological investigations and procedures appropriately MEQ

Safe patient care: medication safety

Know the medications most commonly involved in prescribing and administration errors MCQ

Know how to prescribe and administer medications safely OSCE

Know the procedures for reporting medication errors and near misses in accordance with localrequirements

Portfolio

Table 5. Sample of typical end of medical programme learning outcomes for patient safety showingtypical assessment formats

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Communication Assessmentformat

Patient interaction: context

Understand the impact of the environment on communication, e.g. privacy, location MEQ

Use good communication and know its role in effective health-care relationships OSCE

Develop strategies to deal with the difficult or vulnerable patient OSCE

Patient interaction: respect

Treat patients courteously and respectfully showing awareness and sensitivity to different backgrounds OSCE/mini-CEX

Maintain privacy and confidentiality

Provide clear and honest information to patients and respect their treatment choices OSCE/mini-CEX

Patient interaction: providing information

Understand the principles of good communication OSCE/mini-CEX/MSF

Communicate with patients and carers in ways they understand OSCE

Involve patients in discussions about their care Portfolio

Patient interaction: meetings with families or carers

Understand the impact of family dynamics on effective communication Portfolio

Ensure relevant family/carers are included appropriately in meetings and decision-making Portfolio

Respect the role of families in patient health care MEQ/portfolio

Patient interaction: breaking bad news

Understand loss and bereavement MEQ

Participate in breaking bad news to patients and carers OSCE

Show empathy and compassion OSCE

Patient interaction: open disclosure

Understand the principles of open disclosure MEQ

Ensure patients are supported and cared for after an adverse event OSCE

Show understanding to patients following adverse events OSCE

Patient interaction: complaints

Understand the factors likely to lead to complaints MEQ/portfolio

Respond appropriately to complaints using the local procedures OSCE

Adopt behaviours to prevent complaints OSCE

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Resource materialNewble M et al. Guidelines for assessing clinicalcompetence, Teaching and Learning in Medicine,1994, 6:213–220.

Roberts C et al. Assuring the quality of highstakes undergraduate assessments of clinicalcompetence. Medical Teacher, 2006, 28:535–543

Safety and Quality Council, Australian PatientSafety Education Framework, The AustralianCouncil for Safety and Quality in Healthcare,Commonwealth of Australia, 2005.

Van Der Vleuten, C.P. The assessment ofprofessional competence: developments,research and practical implications. Advances inHealth Science Education, 1996, 1:41–67.

Case-based discussionSouthgate L et al. The General Medical Council’sperformance procedures: peer review ofperformance in the workplace. Medical Education,2001, 35 (Suppl. 1):9–19.

Miller GE. The assessment of clinicalskills/competence/performance. AcademicMedicine, (Supplement), 1990, 65:S63–S67.

Mini clinical evaluation exerciseNorcini J. The Mini Clinical Evaluation exercise(Mini-CEX). The Clinical Teacher. 2005, 2(1):25–30.

Norcini J. The Mini-CEX: a method for assessingclinical skills. Annals of Internal Medicine,2003,138(6):476–481.

Multisource feedbackArcher J, Norcini J, Davies H. Use of SPRAT forpeer review of paediatricians in training. BritishMedical Journal, 2005, 330(1251–1253).

Violato C, Lockyer J, Fidler H. Multisourcefeedback: a method of assessing surgicalpractice. British Medical Journal, 2003,326(7388):546–548.

Multiple choice questionsCase SM, Swanson DB. Constructing written testquestions for the basic and clinical sciences.Philadelphia, National Board of MedicalExaminers, 2001.

Objective structured clinical examinationNewble DI. Techniques for measuring clinicalcompetence: objective structured clinicalexaminations. Medical Education, 2004, 35199–203.

PortfoliosWilkinson T et al. The use of portfolios forassessment of the competence and performanceof doctors in practice. Medical Education, 2002,36(10):918–924.


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IntroductionIn this section we have summarised some generalprinciples of evaluation. Following the publicationof this document, WHO plans to make availablestandard evaluation tools for this curriculum.

As individuals, we engage in evaluation every day:what to eat, what clothes to wear, how good thatmovie was. Evaluation is an important componentof any curriculum, and should be included in yourstrategy for implementing patient safety curriculaat your institution or in your hospital/classroom. Itcan be as simple as having students complete aquestionnaire after exposure to a patient safetysession to see what they thought, or as complexas a faculty-wide review of the entire curriculum,which may involve surveys and focus groups withstudents and staff, observation of teachingsessions and other evaluation methods.

Evaluation involves three main steps:• developing an evaluation plan; • collecting and analysing information;• disseminating the findings to appropriate

stakeholders for action.

How evaluation differs fromassessment Information on assessment and evaluation can beconfusing due to the fact that some countries usethe two terms interchangeably. The easiest way toremember the difference between assessmentand evaluation is that assessment is aboutmeasuring student performance, while evaluationis about examining how and what we teach. Inassessment, data are collected from a singlesource (the student), whereas in evaluation, datamay be collected from a number of sources(students, patients, teachers and/or otherstakeholders).

Assessment = student performance.Evaluation = quality of courses/programmes,quality of teaching.

Step 1: Developing an evaluation plan

What is being evaluated?A fundamental first step in developing anevaluation plan is identifying the evaluation object:is it a single patient safety session? Is it the entirecurriculum? Are we evaluating the faculty’scapacity for implementation? Are we evaluatingteacher performance/effectiveness? Objects forevaluation can be classified either as policy,programme, product or individual [1]—and all canbe applied in the educational setting.

Who are the stakeholders?There are often many stakeholders involved in theevaluation of patient safety education. However, itis important to identify a primary audience as thiswill impact the question(s) you want yourevaluation to answer. The primary audience maybe the university, the faculty, hospitaladministration, teachers, students or patients/thepublic. For example, you may be the primarystakeholder if you are a teacher wanting to knowhow your students are responding to theintroduction of patient safety education in yourcourse.

What is the purpose of the evaluation?After identifying the primaryaudience/stakeholder(s), the next thing to decideis what you are trying to achieve from theevaluation. What question(s) are you trying toanswer? These may differ depending on your rolein patient safety education. Table 6 givesexamples of the kinds of questions that might beasked depending on the primary stakeholder.

9. How to evaluate patient safety curricula

51

What form(s) of evaluation is/are mostappropriate?Evaluation types or forms can be categorized asfollows: proactive, clarificative, interactive,monitoring and impact [2]. The forms differ in

terms of primary purpose of the evaluation, thestage of programme/curriculum implementationyou are at, the kinds of questions you are askingand the key approaches required. Table 7provides a summary of each form of evaluation.


Stakeholder Possible questions for evaluation

Hospital administrators/clinical staff Does teaching patient safety to interns result in a decreasednumber of adverse events?

University faculty How can this patient safety curriculum best be implementedin our institution?

Individual teachers Am I delivering the curriculum effectively? Are studentsenjoying it? Are they learning?

Table 6: Examples of stakeholder questions

Table 7: Forms of evaluation (adapted from Owen [1])

Purpose Proactive Clarificative Interactive Monitoring Impact

Orientation Synthesis Clarification Improvement Justification; fine tuning

Justification; accountability

Major focus Context forcurriculum

All elements Delivery Delivery; outcomes Delivery; outcomes

State ofprogramme/curriculum

None (not yetimplemented)

Developmentphase

Developmentphase

Settled;implemented

Settled;implemented

Timing relative toimplementation

Before During During During After

Key approachesNeeds assessmentReview of theliterature

EvaluabilityassessmentLogic developmentAccreditation

ResponsivenessAction researchDevelopmentalEmpowermentQuality review

ComponentanalysisDevolvedperformanceassessmentSystems analysis

Objectives-basedNeeds-basedGoal-freeProcess-outcomeRealisticPerformance audit

Gatheringevidence

Review ofdocuments,databasesSite visitsFocus groups,nominal grouptechnique, Delphitechnique forneeds assessment

Combination ofdocumentanalysis, interviewand observation

Findings includeprogramme planand implicationsfor organization. Can lead toimproved morale

On-siteobservationQuestionnairesInterviewsFocus groups

Degree of datastructure dependson approach. Mayinvolve providers(teachers) andprogrammeparticipants(students)

A systemsapproach requiresavailability ofmanagementinformationsystems, the useof indicators andthe meaningful useof performanceinformation

Pre-ordinateresearch designsTreatment andcontrol groupswhere possibleObservationTests and otherquantitative data

Determining all theoutcomes requiresuse of moreexploratorymethods andqualitativeevidence

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Purpose Proactive Clarificative Interactive Monitoring Impact

Types ofquestions

- Is there a needfor theprogramme?

- What do weknow about theproblem that theprogramme willaddress?

- What isrecognized asbest practice?

- What are theintendedoutcomes andhow is theprogrammedesigned toachieve them?

- What is theunderlyingrationale for theprogramme?

- What elementsneed to bemodified tomaximizeintendedoutcomes?

- Is theprogrammeplausible?

- Which aspectsof theprogramme areamenable tosubsequentmonitoring orimpactevaluation?

- What is theprogrammetrying toachieve?

- How is it going?- Is the delivery

working?- Is delivery

consistent withthe programmeplan?

- How coulddelivery bechanged tomake it moreeffective?

- How could thisorganization bechanged tomake it moreeffective?

- Is theprogrammereaching thetargetpopulation?

- Isimplementationmeeting statedobjectives andbenchmarks?

- How isimplementationgoing betweensites?

- How isimplementationnow comparedto a month/6months/1 yearago?

- Are our costsrising or falling?

- How can wefinetune theprogramme tomake it moreefficient? Moreeffective?

- Are there anyprogramme sitesthat needattention toensure moreeffectivedelivery?

- Has theprogrammebeenimplemented asplanned?

- Have the statedgoals beenachieved?

- Have the needsof students,teachersandothersserved by theprogrammebeen achieved?

- What are theunintendedoutcomes?

- How dodifferences inimplementationaffectprogrammeoutcomes?

- Is theprogrammemore effectivefor someparticipants thanfor others?

- Has theprogrammebeen cost-effective?

Table 7 (Continued): Forms of evaluation (adapted from Owen [1])

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Step 2: Collecting and analysing information

CollectionThere are a number of data sources and collectionmethods to consider in an evaluation of patientsafety curricula or any other evaluation object.How many and which ones you use depends onyour evaluation’s purpose, form, scope and scale.Potential data sources include:• students (prospective, current, past,

withdrawn);• self (engaging in self-reflection);• colleagues (teaching partners, tutors,

teachers external to the course);• discipline/instructional design experts;• professional development staff;• graduates and employers (e.g. hospitals);• documents and records (e.g. teaching

materials, assessment records).

Data may be collected from the above listedsources in a variety of ways, including self-reflection, questionnaires, focus groups, individualinterviews, observation and documents/records.

Self-reflectionSelf-reflection is an important activity for a medicalor clinical educator and has an important role inevaluation. An effective method for reflectioninvolves:• writing down your experience of teaching (in

this case, patient safety education) orfeedback received from others;

• describing how you felt and whether youwere surprised by those feelings;

• re-evaluating your experience in the contextof assumptions made: [3]

- Were they good assumptions? Why, orwhy not?

Engaging in self-reflection will allow for thedevelopment of new perspectives and a greatercommitment to action in terms of improving or

enhancing curriculum and/or teaching.

QuestionnairesQuestionnaires are easily the most commonmethod of data collection, providing informationon people’s knowledge, beliefs, attitudes andbehaviour [4]. If you are interested in research,and publishing the evaluation results, it may beimportant to use a previously validated andpublished questionnaire. This will save you bothtime and resources, and will allow you to compareyour results with those from other studies usingthe same instrument. It is always useful as a firststep to search the literature for any such tools thatmay already be in existence.

More often than not, however, teachers/faculties/universities choose to develop questionnaires fortheir own individual use. Questionnaires may becomprised of open- and/or closed-endedquestions and can take a variety of formats suchas tick-box categories, rating scales or free text.Good questionnaire design is integral to thecollection of quality data, and much has beenwritten about the importance of layout and how toconstruct appropriate items [3-5]. You may wishto consult one of the references or resourcesprovided prior to developing your questionnaire forevaluation of patient safety teaching or curricula.

Focus groupsFocus groups are useful as an exploratory methodand means of eliciting student or tutorperspectives [6]. They often provide more in-depth information than questionnaires and allowfor more flexible, interactive exploration ofattitudes towards and experiences of curriculumchange. They can be used in conjunction withquestionnaires or other data collection methodsas a means of checking or triangulating data, andcan vary in terms of structure and delivery fromthe conversational and flexible to the strictlyregimented and formal. Depending on resources


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available and level of analysis sought, you maywish to audio or video record focus groups inaddition to or in place of taking notes.

Individual interviewsIndividual interviews provide the opportunity formore in-depth exploration of one’s attitudestowards potential curriculum change andexperiences with the curriculum once it has beenimplemented. As with focus groups, they can beunstructured, semi-structured or structured informat. Although individual interviews provideinformation on a narrower range of experiencethan focus groups, they also allow the interviewerto explore more deeply the views and experiencesof a particular individual. One-on-one interviewsmay be a useful method for obtaining evaluationdata from colleagues or faculty leaders/administrators.

ObservationFor some forms of evaluation it may be useful toconduct observations of patient safetyeducational sessions to obtain an in-depthunderstanding of how material is being deliveredand/or received. Observations should involve theuse of a schedule to provide a framework forobservations. The schedule can be relativelyunstructured (e.g. a simple notes sheet) or highlystructured (e.g. the observer rates the object ofevaluation on a variety of pre-determineddimensions and makes comments on each).

Documents/recordsAs part of your evaluation, you may also wish toexamine documental or statistical informationsuch as teaching materials used or studentperformance data gathered. Other informationsuch as hospital data on adverse events may alsobe useful, depending on your evaluationquestion(s).

AnalysisYour data collection may involve just one of theabove or other methods, or it may involve several.In either case, there are three interconnectedelements to consider in terms of data analysis [1]:• data display—organizing and assembling

information collected in a meaningful way;• data reduction—simplifying and transforming

the raw information into a more workable orusable form;

• conclusion drawing—constructing meaningfrom the data with respect to your evaluationquestion(s).

Step 3: Disseminating findings and takingaction

All too often the conclusions and recommendationsof evaluations are not acted upon—the first step inavoiding this is ensuring that this valuableinformation is fed back in a meaningful way to allrelevant stakeholders. If the evaluation is on thequality of patient safety teaching, then results (e.g.from student questionnaires, peer-observedteaching sessions) must be relayed to anddiscussed not only with administration, but alsowith the teachers. Brinko [7] provided an excellentreview of best practice on the process of givingfeedback be it for students or colleagues. It isimportant that any feedback is received in a waythat encourages growth or improvement. If theevaluation focuses on effectiveness of the patientsafety curriculum, any conclusions andrecommendations for improvement must becommunicated to all who had a hand inimplementing the curriculum (e.g. at the institution,faculty, teacher and student levels). The format fordissemination must be meaningful and relevant.Effective communication of evaluation outcomes,findings and recommendations is a key catalyst forimprovements in patient safety teaching andcurriculum design.


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ResourcesYou may find the following resources useful forvarious stages of your evaluation planning andimplementation:

Centre for the Advancement of Learning andTeaching, University of Tasmania. Projectevaluation toolkit, 2005(http://www.utas.edu.au/pet/index.html, accessed15 May 2008).

DiCicco-Bloom B, Crabtree BF. The qualitativeresearch interview. Medical Education, 2006,40:314–321.

Learning Technology Dissemination Initiative,Hariot Watt University. The evaluation cookbook,1999 (http://www.icbl.hw.ac.uk/ltdi/cookbook/,accessed 15 May 2008).

Nelson C. Evaluation of a patient safety trainingprogram. Santa Monica, RAND Health, 2005(http://www.rand.org/pubs/technical_reports/2005/RAND_TR276.pdf, accessed 15 May 2008.

Neuman WL. Social research methods: qualitativeand quantitative approaches, 6th ed. Boston,Pearson Educational Inc, Allyn and Bacon, 2006.

Payne DA. Designing educational project andprogram evaluations: a practical overview basedon research and experience. Boston, KluwerAcademic Publishers, 1994.

University of Wisconsin-Extension. ProgramDevelopment and Evaluation, 2008(http://www.uwex.edu/ces/pdande/evaluation/,15 May 2008.)Wilkes M, Bligh J. Evaluating educationalinterventions. British Medical Journal, 1999,318:1269–1272.

References1. Owen J. Program evaluation: forms and approaches,

3rd ed. Sydney, Allen & Unwin, 2006.2. Boud D, Keogh R, Walker D. Reflection, turning

experience into learning. London, Kogan Page. 1985.3. Boynton PM, Greenhalgh T. Selecting, designing and

developing your questionnaire. British Medical Journal,2004,328:1312–1315

4. Leung WC. How to design a questionnaire. StudentBritish Medical Journal, 2001, 9:187–189.

5. Taylor-Powell E. Questionnaire design: askingquestions with a purpose. University of Wisconsin-Extension, 1998(http://learningstore.uwex.edu/pdf/G3658-2.pdf, 15May 2008).

6. Barbour RS. Making sense of focus groups. MedicalEducation, 2005, 39:742–750.

7. Brinko K. The practice of giving feedback to improveteaching: what is effective? Journal of HigherEducation, 1993, 64(5):574–593.


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Each topic has a set of tools that have beenselected from the World Wide Web and designedto assist health practitioners improve the caredelivered to patients. We have only included toolsthat are freely available on the Internet. All of thesites were accessible as of May 2008.

Included in the list are examples of guidelines,checklists, web sites, databases, reports and factsheets and an outcome focused qualityimprovement initiative designed to assist health-care teams, professionals and administratorsimplement a patient safety activity or lead anorganization towards a safety culture.

Very few of the tools have been through a rigorousvalidation process. Most measures in quality tendto be about processes of care and quality thatapply to small groups of patients in highlycontextualized environments [1] such as an ICU ora ward in a rehabilitation unit.

Most patient safety initiatives require healthprofessionals to measure the steps they take inthe delivery care process. This is because one willnot be able to tell if the planned changes madeany difference to patient care or the outcome.Focusing on measurement has been a necessaryand important step in teaching patient safety; ifyou do not measure, how do you know that animprovement has been made? Even thoughstudents will not be expected to measure theirclinical outcomes by the time they graduate, theyshould be familiar with the plan-do-study-act(PDSA) cycle that forms the basis ofmeasurement. Many of the tools on the Internetare based on the PDSA cycle.

Reference1. Pronovost PJ, Miller MR, Wacher RM. Tracking

progress in patient safety: an elusive target Journal ofAmerican Medical Association, 2006, 6:696–699.

10. Web-based tools and resources

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IntroductionMedical students and junior doctors areaccustomed to learning new information bystudying and then working hard to apply their newknowledge and skills in patient care. In the case ofpatient safety, just “trying harder” will not work [1].Hence, a great deal of thought needs to be givento the timing and format of educational delivery.

The purpose of this chapter is to outline thevarious strategies that can be used to assistpatient safety understanding. These are the sameas the variety of teaching strategies that are usedfor teaching other aspects of medicine. Thechallenge for the educator is to see if patientsafety elements can be incorporated into existingteaching and learning activities. If so, it avoidspatient safety topics being seen as an “add on”—and hence extra work—rather than simply beingpart of a holistic approach to clinical education.

A fundamental principle, in keeping with theprinciples of effective teaching, is thatopportunities for “active learning” should bemaximized, during which the learners engage withthe learning process in a meaningful fashion, ratherthan being passive recipients of information.

Active learning can be summarized with thefollowing statement: [2]

Don’t tell students when you can show them, anddon’t show them when they can do it themselves.

Lowman has outlined some teaching strategiesfor increasing the effectiveness of active learning,including: [3]• use information that is of interest to learners

and involves real-life events;• present dramatic or provocative material;• reward learners;• tie themes together with as many topics as

possible;

• activate prior knowledge using pretests andconcept maps and gathering backgroundinformation;

• challenge learners by presenting topics thatare more difficult from time to time;

• demonstrate the behaviours you are seekingto promote.

Lectures [4]In a lecture, the teacher presents a topic to a largegroup of students. This traditionally occurs in aface-to-face setting; however, recently someuniversities give students the option of viewing thelecture online via pod-casting.

Lectures should have both:• aims—indicating the general theme of the

lecture, e.g. the aim of this lecture is tointroduce you to the topic of patient safety;

• objectives—relating directly to the learningand that should be achievable by the end ofthe lecture, e.g. by the end of this lecture youwill be able to list three major studies thathighlight the extent of harm caused by health-care delivery.

Lectures should last about 45 minutes, asconcentration falls after this time. It is, therefore,important that they do not contain too muchmaterial—aim for four or five key points at the most.

Lectures are often structured as follows, withthree principal elements (set, body, close):• the set, or introduction, is the initial period of

the lecture when the lecturer explains why thetopic is important and outlines the objectivesof the session;

• the body is the main content part of thelecture;

• the conclusion should revisit the objectivesand the key points of the presentation.

11. Activities to assist patient safety understanding

58

Benefits:• able to convey information to large numbers

of students at one time;• useful for providing an overview of broad

topics, to impart factual information andintroduce theoretical concepts;

• provide up-to-date information and ideas thatare not easily accessible in texts or papers;

• can explain or elaborate on difficult conceptsand ideas and how these should beaddressed.

Challenges:• keeping large numbers of students actively

engaged;• junior staff generally prefer more experiential

techniques;• presentation skills;• usually there is some dependence on

technology;• content (medical harm) can be discouraging.

Examples:• introduction to patient safety;• introduction to human factors.

Learning on the run during clinicalplacementsTeaching that occurs in the context of wardrounds or in bedside teaching sessions.

Benefits:• ward-based teaching provides one of the

best opportunities to teach and observehistory and examination skills as well ascommunication and interpersonal skills—theteacher can also role model safe, ethical,professional practice;

• patient safety issues are everywhere in theclinical environment;

• contextualized;• real—hence highly relevant;• interesting and often challenging.

Challenges:• lack of time due to work pressures;• lack of knowledge of how to incorporate

patient safety topics into bedside teaching;• opportunistic—not possible to prepare and

difficult to deliver a uniform curriculum.

Examples:• hand hygiene issues on the ward;• patient identification processes.

Resource:Teaching on the run series(http://www.meddent.uwa.edu.au/go/about-the-faculty/education-centre/teaching-on-the-run/teaching-resources).

Small group activities—learning with othersLearning done in the setting of a small group,usually with a tutor. The main feature is studentparticipation and interactivity, used in relation to aparticular problem, with more onus on thestudents to be responsible for own learning, e.g.PBL, project work.

Benefits:• sharing own stories;• learning from peers;• multiple perspectives;• learning teamwork and communication skills.

Challenges:• group dynamics;• resource implications in terms of tutor time;• expertise of the tutor.

Examples:• human factors considerations of commonly

used clinical equipment;• teamwork in the clinical environment.


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Resources:University of Colorado, Denver, Health SciencesProgrammehttp://www.uchsc.edu/CIS/SmGpChkList.html.Scottish Council for Postgraduate Dental andMedical Educationhttp://www.nes.scot.nhs.uk/Courses/ti/SmallGroups.pdf.

Case discussionA group of students—often with a tutor—discussa clinical case.

Benefits:• can use an actual or made-up case to

illustrate patient safety principles;• contextualized—makes concepts real and

relevant;• learn to solve problems as they arise in the

workplace;• enables linking of abstract concepts to the

real situation.

Challenges:• choosing/developing realistic cases that

encourages students to become activelyengaged in the discussion;

• using the case effectively to challengethinking and generate thoughtful learning;

• encouraging students to generate theproblem solving themselves.

Resources:• incident analyses from parent hospital;• agency for health-care research and quality

weekly morbidity and mortality cases;• http://webmm.ahrq.gov/

GamesEncompasses a spectrum from computer gamesto situational role play.

Benefits:• fun, enjoyable;• challenging;• can illustrate teamwork, communication.

Challenges:• relating the game to the workplace;• clearly defining the purpose of the game

upfront.

Resource: • Examples of teamwork generating games

http://wilderdom.com/games/InitiativeGames.html

Independent studyStudy undertaken by the student on their own,e.g. assignment work, essays.

Benefits:• student can proceed at own pace;• student can focus on own knowledge gaps;• opportunity for reflection;• cheap, easy to schedule;• flexible for learner.

Challenges:• motivation;• lack of exposure to multiple inputs;• may be less engaging;• marking the work and providing the feedback

is time consuming for the teacher.

Buddying a patient in hospital (patienttracking) A student follows the course of an individualpatient throughout their hospital stay. Includesaccompanying the patient for all investigationsand procedures.

Benefits:• includes the opportunity to learn about the

health-care system;


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• see things from the patient’s perspectives;• see how different health-care areas interact

together.

Challenges:• time tabling;• shaping the experience into a learning

exercise;• limited opportunity for students to:

- share their learning;- get feedback from peers;- get assessed.

Role play (docu-drama)One of the oldest known educational methods.Allows students to act out roles of health-careprofessionals in particular situations. These fallinto two types: • students improvise the dialogue and actions

to fit a pre-determined scenario;• students “act out” the roles and dialogue of a

case study situation.

Benefits:• cheap;• requires little training;• always available;• interactive—enables learners to try on “what

if” scenarios;• experiential—introduces and sensitized

learners to the roles that patients, theirfamilies and health-care practitioners andadministrators play in patient safetysituations;

• allows the learner to adopt a more senior role,or the role of a patient;

• can demonstrate different perspectives;• ideal for exploring factors in association with

interprofessional teamwork andcommunication in the prevention of patientsafety errors.

Challenges:• writing the scripts;• developing sufficiently meaningful situations

that allow for choices, decisions, conflicts; • time consuming;• not all students are involved (some only get to

watch);• students can get off the topic and the role

play fizzles out.

Resource:Kirkegaard M, Fish, J. Doc-U-Drama: using dramato teach about patient safety. Family Medicine,2004, 36(9):628–630.

Simulation In the context of health care, simulation is definedas “an educational technique that allowsinteractive, and at times immersive activity byrecreating all or part of a clinical experiencewithout exposing patients to the associated risks”[5]. It is likely that in the future increased access tovarious forms of simulation training will emergebecause of the increasing ethical imperative toavoid patient harm [6].

A number of different simulation modalities areavailable, including: • screen-based computer simulators;• low-tech models or mannequins used to

practise simple physical manoeuvers;• standardized patients (patient actors);• sophisticated computerized (“realistic”) full-

body patient mannequin simulators;• virtual reality devices.

Benefits: [7]• no risk to patients;• many scenarios can be presented, including

uncommon but critical situations in which arapid response is needed;

• participants can see the results of theirdecisions and actions; errors can be allowed to


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occur and reach their conclusion (in real life amore capable clinician would have to intervene);

• identical scenarios can be presented todifferent clinicians or teams;

• the underlying causes of the situation areknown;

• with mannequin-based simulators clinicianscan use actual medical equipment, exposinglimitations in the human–machine interface;

• with full recreations of actual clinicalenvironments complete interpersonalinteractions with other clinical staff can beexplored and training on teamwork,leadership and communication provided;

• intensive and intrusive recording of thesimulation session is feasible, includingaudiotaping and videotaping; there are noissues of patient confidentiality—therecordings can be preserved for research,performance assessment or accreditation.

Challenges:• some modalities are very expensive;• specialized expertise required for teaching

and for upkeep of some of the trainingdevices.

Resource:Society for Simulation in Healthcare(www.ssih.org).

Improvement projects Quality improvement is a continuous cycle ofplanning, implementing strategies, evaluating theeffectiveness of these strategies and reflection tosee what further improvements can be made.Quality improvement projects are typicallydescribed in terms of the PDSA cycle [8] as follows:• plan—the change, based on perceived ability

to improve a current process;• do—implement the change;• study—analyse the results of the change;

• act—what needs to happen next to continuethe improvement process?

Benefits:PDSA approaches encourage clinicians to developand be actively engaged in strategies that theyhope will lead to improvement. It also promotesevaluation of these changes once the strategieshave been implemented. Therefore, this can be avery useful approach to have students involved ata ward or clinical unit level, ideally as part of amultidisciplinary team approach to patient safety.Most quality improvement projects by their verynature have a patient safety element to them.• motivating• empowering • learn about change management• learn to be proactive• learn to problem solve.

Challenges:• sustaining momentum and motivation• time commitment.

Example: • hand hygiene issues in a clinical environment.

ResourcesTeaching Quality Improvement Presentation,Institute for Healthcare Improvementhttp://www.ihi.org/NR/rdonlyres/60C85294-F1F9-49D9-8D89-F3DFBD2376A5/1150/TeachingQualityImprovementPresentation.pdf

Bingham JW. Using a health-care matrix to assesspatient care in terms of aims for improvement andcore competencies. Joint Commission Journal onQuality and Patient Safety, 2005,31(2:February):98–105.

AHRQ mortality and morbidity web site(http://www.webmm.ahrq.gov/).


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References1. Kirkegaard M, Fish J. Doc-U-Drama: using drama to

teach about patient safety. Family Medicine, 2004,36(9):628–630.

2. Davis BG. Tools for teaching. San Francisco Jossey-Bass Publishers, 1993.

3. Lowman J. Mastering the techniques of teaching. SanFrancisco, Jossey-Bass, 1995.

4. Dent JA, Harden, RM. A practical guide for medicalteachers. Edinburgh, Elsevier, 2005.

5. Maran NJ, Glavin RJ. Low- to high-fidelity simulation -a continuum of medical education? Medical Education,2003, 37(Suppl. 1):22–28.

6. Ziv A WP, Small SD, Glick S. Simulation-based medicaleducation: an ethical imperative. Academic Medicine,2003, 78(8):783–788.

7. Gaba, DM. Anaesthesiology as a model for patientsafety in healthcare. British Medical Journal, 2000,320(785–788).

8. Cleghorn GD, Headrick L. The PDSA cycle at the coreof learning in health professions education. JointCommission Journal on Quality Improvement, 1996,22(3):206–212.

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Patient safety impacts on all countriesIn 2002, WHO Member States agreed on a WorldHealth Assembly resolution on patient safetybecause they saw the compelling evidence of theneed to reduce the harm and suffering of patientsand their families, and the economic benefits ofimproving patient safety. The extent of patient harmfrom their health care has been exposed by thepublication of international studies from a numberof countries including Australia, Canada, Denmark,New Zealand, the United Kingdom and the UnitedStates of America. The concerns of patient safetyare international, and it is widely recognized thatadverse events are considerably underreported.While the bulk of patient safety research might bedone in Australia, the United Kingdom and theUnited States, patient safety advocates wish to seepatient safety adopted in all countries around theworld, not just those that have had the resourcesto study and publish their patient safety initiatives.This internationalization of patient safety requiresnovel approaches to the education of futuredoctors and health-care practitioners.

GlobalizationThe global movements of doctors in training haveproduced many opportunities for enhancingpostgraduate medical education and training. Themobility of students and teachers, and theinternational interconnectedness of experts incurriculum design, instructional methods andassessment, married with local campus andclinical environments, have led to a concordancein what constitutes good medical education.There have been initiatives to attack the problemsof variable standards across the world in theoutputs of medical schools. The InternationalInstitute of Medical Educators has identified theGlobal Minimum Education Requirements with theexpress purpose of defining the minimumcompetencies that all physicians must have,regardless of where they receive their generalmedical education or training [1].

The World Federation of Medical Education hasalso published standards for international bestpractice in medical school accreditation.

There is evidence that developing countries thathave invested heavily in future generations ofhealth-care workers have seen their assetsstripped by the predations of the health-caresystems of richer developing nations during timesof workforce shortages [2].

The globalization of health-care delivery hasforced medical education to recognize thechallenges of preparing medical students who arenot only able to work in their country of training,but also work in other health-care systems.Harden [3] described a three-dimensional modelof medical education based on the:• student (local or international); • teacher (local or international);• curriculum (local, imported or international).

In the traditional approach to teaching andlearning patient safety, local students and localteachers use a local curriculum. In theinternational medical graduate or overseasstudent model, students from one country pursuein another country a curriculum taught anddeveloped by teachers in the latter. In the branch-campus model, students, usually local, have animported curriculum taught jointly by internationaland local teachers.

A second important consideration in theinternationalization of medical education is theaffordability of e-learning technologies that allow aglobal interconnectivity where the provider of ateaching resource, the teacher of that resource andthe student do not all have to be on campus, in ahospital or out in a community at the same time.

The old style of curriculum emphasizes themobility of students, teachers and curriculum

12. How to foster and engage in a transnationalapproach to patient safety education

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across the boundaries of two countries, by mutualagreement, with a high expectation that thecountry of practice would provide much of thetraining when the student graduates.

The new way is a transnational approach in whichinternationalization of patient safety education isintegrated and embedded within a curriculum andinvolves collaboration between a number ofschools in different countries. In this approach, theprinciples of patient safety are taught in the globalcontext rather than the context of a single country.

This model offers a range of considerablechallenges and opportunities for internationalcollaboration in patient safety education. ThisCurriculum Guide serves as an excellent base inthis regard. It is important that the standards ofinternational medical education bodies, forexample, the World Federation of MedicalEducation, are reviewed to ensure that theprinciples of patient safety are included. Similarly,a dialogue is held with national accrediting bodiesof medical schools around the world to ensurethat patient safety principles are included in theiraccreditation checklists.

At a more local level, it is important for countries tocustomize and adapt materials. A good example ofa transnational approach to medical education is theexperience with international virtual medical schools[4]. Here a number of international universities havecollaborated to form a virtual medical school,dedicated to enhanced learning and teaching. Thismodel could be adaptable to patient safety.

Common components of a transnational virtualpatient safety curriculum could be:• a virtual library that would provide access to

up-to-date resources, tools and learningactivities and access to international patientsafety literature (for example, the topicsincluded in this curriculum);

• a research section that would both facilitateand encourage international collaboration;

• a curriculum map that identifies common areasof global interest in patient safety—it is vital thatstaff and students are able to customizeprogrammes to meet their local and individualneeds;

• a collaboration section that includes onlinediscussions among students from differentcountries who participate as part of acollaborative learning environment in aninternational community of learners; a place forteachers to share experiences;

• an “ask-the-expert” facility with online accessto patient safety experts from differentcountries;

• a bank of virtual patient safety cases withemphasis on a ethical hazards, disclosure andapology;

• an approach to patient safety that includescultural awareness and respects competences;

• an assessment bank of patient safety items forsharing—for example, the Hong KongInternational Consortium for Sharing StudentAssessment Banks is a group of internationalmedical schools that maintains a formative andsummative bank of assessment items acrossall aspects of medical courses.

Content experts in patient safety and educationaldevelopers are in limited supply and often work inisolation. This impedes the sharing of information,innovation and development and often results inunnecessary duplication of resources and learningactivities. A transnational approach to patientsafety education will ensure that there is trueinternational capacity-building in patient safetyeducation and training. It is one way thatdeveloped nations can assist developing nationsby sharing their substantial curriculumdevelopment resources.

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References1. Schwarz MR, Wojtczak A. Global minimum essential

requirements: a road towards competency-orientedmedical education. Medical Teacher, 2002, 24:125–129.

2. Karle H. Global standards and accreditation in medicaleducation: a view from the WFME. AcademicMedicine, 2006, 81(12).

3. Harden RM. International medical education and futuredirections: a global perspective. Academic Medicine,2006, 81(12):S22–S29.

4. Harden RM, Hart IR. An international virtual medicalschool (IVIMEDS): the future for medical education?Medical Teacher, 2002, 24:261–267.

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