Professional Documents
Culture Documents
Patient Safety Curriculum
Patient Safety Curriculum
Designed by 22 Design
Printed in France
Medical Curriculum Foreword
Medicine has changed greatly over the last century. Our knowledge of the physiology, biochemistry
and genetics of human life has improved, as has our understanding of the diseases that affect health.
As the technical ability to treat disease has grown, the complexity of medical practice has increased
significantly. The same drugs and surgeries that can save lives have the potential to cause harm. Modern
health care is delivered in teams, not by individuals. Modern clinicians rely on the support of intricate
health-care systems to enable them to carry out their task. Errors can occur at each stage in any of these
processes. There is a constant threat of accidental harm, which cannot easily be removed.
High risk organisations, such as the airline industry, meticulously apply layers of protection to their routine
work to reduce risk to acceptable levels. Systems are built so that human error – which is to some extent
inevitable – does not cause catastrophe. Flying has now become very safe.
In recent years, a science of patient safety has developed. Harm to patients is not inevitable and can be
avoided. To achieve this, clinicians and institutions must learn from past errors, and learn how to prevent
future errors. We need to adapt our ways of working to make safe health care a robust and achievable goal.
Traditionally, curricula for doctors and medical students have focused on pure clinical skills: diagnosis of
illness, treatment of disease, after-care and follow-up. However, team working, quality improvement and
risk management have been overlooked. These skills are fundamental to patient safety.
It is therefore fitting that the WHO Patient Safety has developed this curriculum which will enable and
encourage medical schools to include patient safety in their courses. Reducing harm caused by health
care is a global priority. Incorporating the knowledge of how to do this into the medical student curriculum
is an urgent necessity.
This Curriculum Guide is only a start. A plan is underway to adapt it for use by other health-care professionals
including nurses and pharmacists. It is only one strand of what we need to build safer health-care systems.
However, there is no doubt that engaging clinicians from the earliest stages of their training is crucial.
This Guide is a timely, valuable project, and I look forward to seeing its early and widespread use.
Acronyms 2
Appendices
1
Acronyms
2
PART A: TEACHER’S GUIDE
Why do medical students need patient future leaders in health care, it is vital that they are
safety education? knowledgeable and skilful in their application of
Health care outcomes have significantly improved patient safety principles and concepts. The WHO
with the scientific discoveries of modern medicine. Patient Safety Curriculum Guide for Medical
However, studies from a multitude of countries Schools sets the stage for medical students to
show that with these benefits come significant risks begin to practise patient safety in all their clinical
to patient safety. We have learnt that hospitalized activities.
patients are at risk of suffering an adverse event,
and patients on medication have the risk of Building students’ patient safety knowledge needs
medication errors and adverse reactions. A major to occur throughout medical school. Patient
consequence of this knowledge has been the safety skills and behaviours should begin as soon
development of patient safety as a specialized as the students enter a hospital, clinic or health
discipline. Clinicians, managers, health-care service. By getting students to focus on each
organizations, governments (worldwide) and individual patient, having them treat each patient
consumers must become familiar with patient as the unique human being they are and using
safety concepts and principles. Everyone is their knowledge and skills carefully students
affected. The tasks ahead of health care are themselves can be role models for others in the
immense and require all those involved care to health-care system. Most medical students have
understand the extent of harm to patients and why high aspirations when they enter medicine, but
health care must move to adopt a safety culture. the reality of the system of health care sometimes
Patient safety education and training is only deflates their optimism. We want students to be
beginning to occur at all levels. Medical students, as able to maintain their optimism and believe that
future doctors and health-care leaders, must also they can make a difference, both to the individual
be prepared to practise safe health care. Though lives of patients and the health-care system.
medical curricula are continually changing to
accommodate the latest discoveries and new What is the Curriculum Guide?
knowledge, patient safety knowledge is different The Curriculum Guide is a comprehensive
from other because it applies to all areas of programme for implementation of patient safety
practice. education in medical schools worldwide. It
comprises two parts. Part A is a teacher’s guide,
Medical students, as future clinicians, will need to which has been designed to assist teachers to
know how systems impact on the quality and safety implement the Curriculum Guide. We are aware
of health care, how poor communication can lead that patient safety is a new discipline and many
to adverse events and much more. Students need clinicians and faculty staff are unfamiliar with many
to learn how to manage these challenges. Patient of the concepts and principles. This lays the
safety is not a traditional stand alone discipline; foundations for capacity-building in patient safety
rather, it is one that integrates into all areas of education and Part B provides a comprehensive,
medicine and health care. The World Health ready-to-teach, topic-based patient safety
Organization’s (WHO) World Alliance for Patient programme that can be implemented either as a
Safety, and other projects such as this one, aims to whole or on a per topic basis.
implement patient safety worldwide. Patient safety
is everyone’s business, all the way from patients to
politicians. As medical students are among the
4
1. Background
Why was the Curriculum Guide are unsure how to integrate patient safety learning
developed? into existing curriculum. [11-13] Second,
Since the Harvard study [1] in 1991 first described educators need to be open to new areas of
the extent of harm to patients, other countries knowledge [3]. One of the difficulties in introducing
have found similar results, notwithstanding the new curricula is a reluctance to address
differences in their cultures and health systems. knowledge that originates from outside medicine
The realization that health care actually harms such as systems thinking and quality
patients has increased scrutiny of patient care in improvement methods [12]. It has also been
the context of an increasingly complex health suggested that the historical emphasis on
system. This complexity has been intensified by treatment of disease rather than prevention of
rapidly changing medical technology and service illness creates a culture that finds it difficult to give
demands [2,3]. Doctors, nurses and allied health- merit to a “non-event”, that is, an adverse event
care workers are expected to work while that is preventable [3]. A third factor relates to
managing this complexity, provide evidence- entrenched attitudes regarding the traditional
based health-care services and keep patients teacher–student relationship—one that may be
safe. However, unless they are properly educated hierarchical and competitive [10] and where an
and trained in patient safety concepts and “expert” disseminates information to the student
principles they will struggle to do this. [3,4].
Patient safety education for health professionals in In 2007, the Association for Medical Education in
the higher education sector has not kept up with Europe [10] called for patient safety education to
workforce requirements [3-7]. Reporting of be integrated throughout the undergraduate
specific curricula on medical error or patient safety course, including the first year, when awareness
courses in undergraduate medical education has of the nature and the extent of threats to patient
only recently started to gain ground in the safety can be raised and generic skills can be
published literature [5,8]. The need for patient developed. This Curriculum Guide seeks to fill the
safety education of medical clinicians was gap in patient safety education by providing a
confirmed by a study of a multi-institutional comprehensive curriculum designed to build
assessment of patient safety knowledge among foundation knowledge and skills for medical
693 medical trainees [9]. This study found that students that will better prepare them for clinical
knowledge levels of patient safety across a broad practice in a range of environments.
band of training, degrees and specialities were
substantially limited, and that trainees were unable
to self-assess their own knowledge deficiencies in
patient safety.
5
1. Background
References
1. Brennan TA et al. Incidence of adverse events and
negligence in hospitalized patients: results of the
Harvard Medical Practice Study I. New England
Journal of Medicine, 1991, 324:370–376.
2. Runciman B, Merry A, Walton M. Safety and ethics in
healthcare: 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 management
and patient safety education for nurses: a critique.
Nurse Education Today, 2007, 27(3):185–191.
5. Patey R et al. Patient safety: helping medical students
understand error in healthcare. Quality & Safety in
Health Care, 2007, 16:256–259.
6. Singh R et al. A comprehensive collaborative patient
safety residency curriculum to address the ACGME
core competencies. Medical Education, 2005,
39:1195–1204.
7. Holmes JH, Balas EA, Boren SA. A guide for
developing patient safety curricula for undergraduate
medical education. Journal of the American Medical
Informatics Association, 2002, 9(Suppl. 1):s124–s127.
8. Halbach JL, Sullivan LL. Teaching medical students
about medical errors and patient safety: evaluation of a
required curriculum. Academic Medicine, 2005,
80(6):600–606.
9. Kerfoot BP, Conlin PR, Travison TT, McMahon GT.
Patient safety knowledge and its determinants in
medical trainees. Journal of General Internal Medicine.
2007; 22(8): 1150-1154.
10. Sandars J et al. Educating undergraduate medical
students about patient safety: priority areas for
curriculum 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 and
medical students. The Clinical Teacher, 2007, 4:1–8.
13. Ladden MD et al. Educating interprofessional learners
for quality, safety and systems improvement. Journal of
Interprofessional Care, 2006, 20(5):497–505.
6
2. How were the Curriculum Guide topics selected?
The Curriculum Guide covers 11 topics, including person’s position and clinical responsibility in an
16 of a total of 22 learning topics that were organization. The Framework is designed to assist
included in the evidence-based Australian Patient organizations and people develop educational
Safety Education Framework (APSEF).* An curricula and training programmes. We have
additional topic not in APSEF was selected to developed the Curriculum Guide using the
support learning in infection control targeted by Framework in terms of content and rationale.
the WHO programme to reduce infections through
better control. Figure 1 sets out the topics APSEF is freely available and can be accessed
selected for inclusion or exclusion. online at
http://www.health.gov.au/internet/safety/publishin
What is the Australian Patient Safety g.nsf/Content/C06811AD746228E9CA2571C600
Education Framework?[1] 835DBB/$File/framework0705.pdf
APSEF was developed using a four-stage The accompanying bibliography can also be
approach: literature review, development of learning accessed online at
areas and learning topics, classification into learning http://www.health.gov.au/internet/safety/publishin
domains, and conversion into a performance-based g.nsf/Content/C06811AD746228E9CA2571C600
format. An extensive consultation and validation 835DBB/$File/framewkbibli0705.pdf
process was undertaken in Australia and
internationally. Published in 2005, the Framework is Australian Patient Safety Education
a simple, flexible and accessible template Framework learning areas and topics
describing the knowledge, skills and behaviours There are 7 learning areas (categories) and 22
that all health-care workers need to ensure safe learning topics in APSEF. Table 1 sets out the
patient care. The Framework is divided into level of Curriculum Guide topics and the relationship with
knowledge, skills and behaviours depending on a APSEF.
7 Learning Categories
22 learning
* 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 among
university medical schools and health services.
7
2. How were the Curriculum Guide topics selected?
Recognizing, reporting and managing adverse events and near misses yes Topics 6,7
8
2. How were the Curriculum Guide topics selected?
There were three main stages in the development knowledge, skills or behaviours and attitudes.
of the Framework content and structure:
1. Initial review of knowledge and development The final step in this stage was to allocate each
of framework outline. activity to the appropriate level corresponding to
2. Additional searching for content and the degree of responsibility of particular categories
assignment of knowledge, skills, behaviours of health-care workers for patient safety:
and attitudes.
3. Development of performance-based format. Level 1 (Foundation) identifies the knowledge,
skills, behaviours and attitudes that every health-
Stage 1—Review of knowledge and care worker needs to have.
development of framework outline
Level 2 is designed for health-care workers who
A search was conducted to identify the current provide direct clinical care to patients and work
body of knowledge relating to patient safety (as under the supervision of, and for those with
described in the next section). The literature, books, managerial, supervisory and/or advanced clinical
reports, curricula and web sites collected were then responsibilities.
reviewed to identify the major activities associated Level 3 is for health-care workers who have
with patient safety that had a positive effect on managerial or supervisory responsibilities or are
quality and safety. These activities were then senior clinicians with advanced clinical
grouped into categories termed learning areas. responsibilities.
Each learning area was analysed and further broken Level 4 (Organizational) identifies the knowledge,
down into major subject areas, termed learning skills, behaviours and attitudes required for
topics. See below for details of the literature review clinical and administrative leaders with
process and the Framework content structure. organizational responsibilities. Level 4 is not part
of the progressive learning that underpins the first
The rationale for the inclusion of each learning three levels.
area and topic has been articulated in the body of
the Framework and is summarized below. The learning areas and topics were endorsed by
the Reference Group and Steering Committee.
Stage 2—Additional searching for content and Extensive consultation with the wider health
assignment of knowledge, skills, behaviours and system and community within Australia as well as
attitudes internationally completed the review and
endorsement process for the learning areas and
Each learning topic formed the basis for a more topics and their content.
extensive search, including additional terms such as
education, programmes, training, adverse events, The outcome of this stage is shown in Table 2.
errors, mistakes and organization/institution/health This example is taken from the learning topic
facility/health service. All the activities (knowledge, “involving patients and carers as partners in health
skills, behaviours and attitudes) for each topic were care”.
listed until no more activities were forthcoming and
the sources exhausted. This list was then culled for
duplication, practicality and redundancy. The
remaining activities were then categorized into
9
2. How were the Curriculum Guide topics selected?
Learning objectives Provide patients and Use good Maximize opportunities Develop strategies for
carers with the communication and for staff to involve staff to include patients
information they need know its role in patients and carers in and carers in planning
when they need it effective health-care their care and and delivering health-
relationships treatment care services
Knowledge
Skills
Behaviours and attitudes
The completed context matrix was translated into a Topic 1: What is patient safety?
performance-based format, which takes full Health professionals are increasingly being
advantage of the modular nature of the Framework. required to incorporate patient safety principles
The most extensive consultation occurred at this and concepts into everyday practice. In 2002,
stage of the Framework’s development. Individual WHO Member States agreed on a World Health
health-care workers were interviewed about aspects Assembly resolution on patient safety because
of every performance element in the Framework and they saw the need to reduce the harm and
the entire Framework document was distributed suffering of patients and their families as well as
across the health-care sector for feedback. the compelling evidence of the economic benefits
of improving patient safety. Studies show that
The Curriculum Guide topics additional hospitalization, litigation costs,
1. What is patient safety? infections acquired in hospitals, lost income,
2. What is human factors and why is it important disability and medical expenses have cost some
to patient safety? countries between US$ 6 billion and US$ 29
3. Understanding systems and the impact of billion a year [2,3].
complexity on patient care
4. Being an effective team player. A number of countries have published studies
5. Understanding and learning from errors. highlighting the overwhelming evidence showing
6. Understanding and managing clinical risk. that significant numbers of patients are harmed
7. Introduction to quality improvement methods. due to their health care, either resulting in
8. Engaging with patients and carers. permanent injury, increased length of stay (LOS) in
9. Minimizing infection through improved hospitals or even death. We have learnt over the
infection control. last decade that adverse events occur not
10. Patient safety and invasive procedures. because bad people intentionally hurt patients but
11. Improving medication safety. rather that the system of health care today is so
10
2. How were the Curriculum Guide topics selected?
complex that the successful treatment and Topic 3: Understanding systems and the
outcome for each patient depends on a range of impact of complexity on patient care
factors, not just the competence of an individual Students are introduced to the concept that a
health care provider. When so many people and health-care system is not one but many systems
different types of health-care providers (doctors, made up of organizations, departments, units,
nurses, pharmacists and allied health) are services and practices. The huge number of
involved, it is very difficult to ensure safe care relationships between patients, carers, health-
unless the system of care is designed to facilitate care providers, support staff, administrators,
timely and complete information and bureaucrats, economists and community
understanding by all the health professionals. This members as well as the relationships between the
topic presents the case for patient safety. various health- and non-health-care services add
to this complexity. This topic gives medical
Topic 2: What is human factors and why is it students a basic understanding of complex
important to patient safety? organizations using a systems approach. The
Human factors, engineering or ergonomics is the lessons from other industries are used to show
science of the interrelationship between humans, students the benefits of a systems approach.
their tools and the environment in which they live
and work [3]. Human factors engineering will help When students think in systems they will be better
students understand how people perform under able to understand why things break down and
different circumstances so that systems and have a context for thinking about solutions.
products can be built to enhance performance. It Medical students need to understand how an
covers the human–machine and human-to-human individual doctor or nurse working in a hospital
interactions such as communication, teamwork can do their very best in treating and caring for
and organizational culture. their patients but alone that will not be enough to
provide a safe and quality service. This is because
Other industries such as aviation, manufacturing patients depend on many people doing the right
and the military have successfully applied thing at the right time for them; in other words,
knowledge of human factors to improve systems they depend on a system of care.
and services. Students need to understand how
human factors can be used to reduce adverse Topic 4: Being an effective team player
events and errors by identifying how and why Medical students’ understanding of teamwork
systems break down and how and why human involves more than identification with the medical
beings miscommunicate. Using a human factors team. It requires students to know the benefits of
approach, the human–system interface can be multidisciplinary teams and how effective
improved by providing better-designed systems multidisciplinary teams improve care and reduce
and processes. This involves simplifying errors. An effective team is one in which the team
processes, standardizing procedures, providing members communicate with one another as well
backup when humans fail, improving as combining their observations, expertise and
communication, redesigning equipment and decision-making responsibilities to optimize
engendering a consciousness of behavioural, patient care [4].
organizational and technological limitations that
lead to error. The task of communication and flow of
information between health providers and patients
11
2. How were the Curriculum Guide topics selected?
can be complicated due to the spread of clinical than a person approach, which seeks to blame
responsibility among members of the health-care people for individual mistakes. Leape’s seminal
team [5,6]. This can result in patients being article in 1994 showed a way to examine errors in
required to repeat the same information to health care, that focused on learning and fixing
multiple health providers. More importantly, errors instead of blaming those involved [19].
miscommunication has also been associated with Although his message has had a profound impact
delays in diagnosis, treatment and discharge as on many health-care practitioners, there are still
well as failures to follow up on test results [7-11]. many embedded in a blame culture. It is crucial
that students begin their vocation understanding
Students need to know how effective health-care the difference between blame and systems
teams work, as well as techniques for including approaches.
patients and their families as part of the health-
care team. There is some evidence that Topic 6: Understanding and managing
multidisciplinary teams improve the quality of clinical risk
services and lower costs [12-14]. Good teamwork Clinical risk management is primarily concerned
has also been shown to reduce errors and with maintaining safe systems of care. It usually
improve care for patients, particularly those with involves a number of organizational systems or
chronic illnesses [15-17]. This topic presents the processes that are designed to identify, manage
underlying knowledge required to become an and prevent adverse outcomes. Clinical risk
effective team member. However, knowledge management focuses on improving the quality
alone will not make a student a good team player. and safety of health-care services by identifying
They need to understand the culture of their the circumstances and opportunities that put
workplace, and how it impacts upon team patients at risk of harm and acting to prevent or
functioning. control those risks. Risk management involves
every level of the organization so it is essential that
Topic 5: Understanding and learning from medical students understand the objectives and
errors relevance of the clinical risk management
Understanding why health-care professionals strategies in their workplace. Managing
make errors is necessary for appreciating how complaints and making improvements,
poorly designed systems and other factors understanding the main types of incidents in the
contribute to errors in the health-care system. hospital or clinic that are known to lead to adverse
While errors are a fact of life, the consequences of events, knowing how to use information from
errors on patient welfare and staff can be complaints, incident reports, litigation, coroners’
devastating. Medical students and other health- reports and quality improvement reports to control
care professionals need to understand how and risks [20] are all examples of clinical risk
why systems break down and why mistakes are management strategies.
made so they can act to prevent and learn from
them. An understanding of health-care errors also
provides the basis for making improvements and
implementing effective reporting systems [18].
Students will learn that a systems approach to
errors, which seeks to understand all the
underlying factors involved, is significantly better
12
2. How were the Curriculum Guide topics selected?
Topic 7: Introduction to quality improvement has shown that there are fewer errors and better
methods treatment outcomes when there is good
Over the last decade, health care has successfully communication between patients and their carers,
adopted a variety of quality improvement methods and when patients are fully informed and
used by other industries. These methods provide educated about their medications [23-30]. Poor
clinicians with the tools to: (i) identify a problem; (ii) communication between doctors, patients and
measure the problem; (iii) develop a range of their carers has also emerged as a common
interventions designed to fix the problem; and (iv) reason for patients taking legal action against
test whether the interventions worked. Health- health-care providers [31,32].
care leaders such as Tom Nolan, Brent James,
Don Berwick and others have applied quality Topic 9: Minimizing infection through
improvement principles to develop quality improved infection control
improvement methods for health clinicians and WHO has a global campaign on infection control.
managers. The identification and examination of We thought it important that this area be included
each step in the process of health-care delivery is in the Curriculum Guide not only for consistency
the bedrock for this methodology. When students but also because along with surgical care and
examine each step in the process of care they medications these areas constitute a significant
begin to see how the pieces of care are percentage of adverse events suffered by
connected and measurable. Measurement is patients. The problem of infection control in
critical for safety improvement. This topic health-care settings is now well established, with
introduces the student to improvement methods health care-associated infections being a major
and the tools, activities and techniques that can cause of death and disability worldwide. There are
be incorporated into their practice. numerous guidelines available to help doctors and
nurses minimize the risks of cross-infection.
Topic 8: Engaging with patients and carers Patients who have surgery or an invasive
Students are introduced to the concept that the procedure are known to be particularly prone to
health-care team includes the patient and/or their infections and account for about 40% of all
carer, and that patients and carers play a key role hospital-acquired infections. The topic sets out
in ensuring safe health care by: (i) helping with the the main causes and types of infections to enable
diagnosis; (ii) deciding about appropriate medical students to identify those activities that
treatments; (iii) choosing an experienced and safe put patients at risk of infection and to prepare
provider; (iv) ensuring that treatments are students to take the appropriate action to prevent
appropriately administered; and (v) identifying transmission.
adverse events and taking appropriate action
[21,22]. The health-care system underutilizes the Topic 10: Patient safety and invasive
expertise patients can bring such as their procedures
knowledge about their symptoms, pain, WHO has a project on safe surgery. One of the
preferences and attitudes to risk. They are a main causes of errors involving wrong patients,
second pair of eyes if something unexpected sites and procedures is the failure of health-care
happens. They can alert a health-care worker if providers to communicate effectively (inadequate
the medication they are about to receive is not processes and checks) in preoperative
what they usually take, which acts as a warning to procedures. Other examples of wrong
the team that checks should be made. Research site/procedure/patient are: (i) the wrong patient in
13
2. How were the Curriculum Guide topics selected?
the operating room (OR); (ii) surgery performed on regarding the name of the medication; and (vi)
the wrong side or site; (iii) wrong procedure poor history taking [37].
performed; (iv) failure to communicate changes in
the patient’s condition; (v) disagreements about References
stopping procedures; and (vi) failure to report 1. Walton MM et al. Developing a national patient safety
education framework for Australia. Quality & Safety in
errors.
Health Care, 2006, 15(6):437–442.
2. Chief Medical Officer. An organisation with a memory.
Minimizing errors caused by misidentification London, UK Department of Health, Report of an expert
involves developing best-practice guidelines for group on learning from adverse events in the National
Health Service, 1999.
ensuring the correct patient receives the right
3. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is
treatment [6]. Students can learn to understand human: building a safer health system. Washington,
the value of all patients being treated in DC, Committee on Quality of Health Care in America,
accordance with the correct Institute of Medicine, National Academy Press, 1999.
4. Greiner AC, Knebel E, eds. Health professions
site/procedure/patient policies and protocols.
education: a bridge to quality. Washington, DC,
Such learning would include the benefit of National Academy Press, 2003.
protocols as well as knowledge of the underlying 5. Gerteis M et al. Through the patient’s eyes:
principles supporting a uniform approach to understanding and promoting patient centred care.
San Francisco, Jossey-Bass Publishers, 1993.
treating and caring for patients.
6. Chassin MR, Becher EC. The wrong patient. Annals of
Internal Medicine, 2002, 136(11):826–833.
One study of hand surgeons found that 21% of 7. Baldwin PJ, Dodd M, Wrate RM. Junior doctors
surgeons surveyed (n=1050) reported performing making mistakes. Lancet, 1998, 351:804–805.
8. Baldwin PJ, Dodd M, Wrate RM. Young doctors: work,
wrong site surgery at least once during their
health and welfare. A class cohort 1986–1996.
careers [33]. London, Department of Health Research and
Development Initiative on Mental Health of the National
Topic 11: Improving medication safety Health Service Workforce, 1998.
9. Anderson ID et al. Retrospective study of 1000 deaths
An adverse drug reaction has been defined by
from injury in England and Wales. British Medical
WHO [34] as any response to a medication that is Journal, 1988, 296:1305–1308.
noxious, unintended and occurs at doses used for 10. Sakr M et al. Care of minor injuries by emergency
prophylaxis, diagnosis or therapy. Patients are nurse practitioners or junior doctors: a randomised
controlled trial. Lancet, 1999, 354:1321–1326.
vulnerable to mistakes being made in any one of
11. Guly HR. Diagnostic errors in an accident and
the many steps involved in ordering, dispensing emergency department. Emergency Medicine Journal,
and administering medications. 2001, 18:263–279.
12. Baldwin D. Some historical notes on interdisciplinary
and interpersonal education and practice in health care
Medication errors have been highlighted in studies
in the US. Journal of Interprofessional Care, 1996,
undertaken in many countries, including Australia, 10:173–187.
which [35] show that about 1% of all hospital 13. Burl JB et al. Geriatric nurse practitioners in long term
admissions suffer an adverse event related to the care: demonstration of effectiveness in managed care.
Journal American Geriatrics Society, 1998, 46(4):506–
administration of medications. The causes of
510.
medication errors include a wide range of factors 14. Wagner EH et al. Quality improvement in chronic illness
including: (i) inadequate knowledge of patients care: a collaborative approach. Joint Commission
and their clinical conditions; (ii) inadequate Journal on Quality Improvement, 2001, 27(2):63–80.
15. Wagner EH. The role of patient care teams in chronic
knowledge of the medications; (iii) calculation
disease management. British Medical Journal, 2000,
errors; (iv) illegible handwriting; (v) confusion 320(7234):569–572.
14
2. How were the Curriculum Guide topics selected?
16. Silver MP, Antonow JA. Reducing medication errors in communication skills for malpractice prevention.
hospitals: a peer review organisation collaboration. Journal of Law, Medicine and Ethics, 2000, 28(3):258.
Joint Commission Journal on Quality Improvement, 31. Levinson W et al. Physician–patient communication:
2000, 26(6):332–340. the relationship with malpractice claims among primary
17. Weeks WB et al. Using an improvement model to care physicians and surgeons. Journal of the American
reduce adverse drug events in VA facilities. Joint Medical Journal, 1997, 277(7):553–559.
Commission Journal on Quality Improvement, 2001, 32. Joint Commission on Accreditation of Healthcare
27(5):243–254. Organizations. Guidelines for implementing the
18. An organisation with a memory. London, UK universal protocol for preventing wrong site, wrong
Department of Health, 2000 procedure and wrong person surgery. Chicago,
(http://www.npsa.nhs.uk/admin/publications/docs/org. JCAHO, 2003.
pdf, accessed October 2004). 33. Meinberg EG, Stern PJ. Incidence of wrong-site
19. Walshe K. The development of clinical risk surgery among hand surgeons. Journal of Bone Joint
management. In: Vincent C, ed. Clinical risk Surgery, 2003;85(A(9)):193–197.
management: enhancing patient safety, 2nd ed. London, 34. World Health Organization. International drug
British Medical Journal Books, 2001:45–61 monitoring—the role of the hospital WHO Report. Drug
20. Vincent C, Coulter A. Patient safety: what about the Intelligence and Clinical Pharmacy, 1970, 4:101–110.
patient? Quality & Safety in Health Care, 2002, 11:76– 35. Runciamn WB et al. Adverse drug events and
80. medication errors in Australia. International Journal for
21. National Patient Safety Agency. Seven steps to patient Quality in Health Care, 2003, 15(Suppl. 1):i49–i59.
safety: your guide to safer patient care. London, 36. Smith J. Building a safer NHS for patients: improving
NPSA, 2003 (www.npsa.nhs.uk, accessed October medication safety. London, UK Department of Health,
2004). 2004.
22. Coiera EW, Tombs V. Communication behaviours in a
hospital setting: an observational study. British Medical
Journal, 1998, 316(7132):673–676.
23. Clinical Systems Group, Centre for Health Information
Management Research. Improving clinical
communications. Sheffield, University of Sheffield,
1998.
24. Lingard L et al. I. Team communications in the
operating room: talk patterns, sites of tension and
implications for novices. Academic Medicine, 2002,
77(3):232–237.
25. Gosbee J. Communication among health
professionals. British Medical Journal, 1998,
316–642.
26. Parker J, Coeiro E. Improving clinical communication:
a view from psychology. Journal of the American
Medical Informatics Association, 2000, 7:453–461.
27. Smith AJ, Preston D. Communications between
professional groups in a National Health Service Trust
hospital. Journal of Management in Medicine, 1669,
10(2):31–39.
28. Britten N et al. Misunderstandings in prescribing
decisions in general practice: qualitative study. British
Medical Journal, 2000, 320:484–488.
29. Greenfield S, Kaplan SH, Ware JE Jr. Expanding
patient involvement in care. Effects on patient
outcomes. Annals of Internal Medicine, 1985,
102(April):520–528.
30. Lefevre FV, Wayers TM, Budetti PP. A survey of
physician training programs in risk management and
15
3. Aims of the Curriculum Guide
The aims of the Curriculum Guide are to: rigorous medical programme. Many are experts in
• prepare medical students for safe practice in their particular disciplines and usually keep up to
the workplace; date using the accepted professional pathways
• inform medical schools of the key topics in for their area. Patient safety knowledge requires
patient safety; additional learning that falls outside these
• enhance patient safety as a theme traditional routes. To be an effective patient safety
throughout the medical curriculum; teacher, health professionals need to be provided
• provide a comprehensive curriculum to assist with the knowledge, tools and skills necessary for
teaching and integrating patient safety implementing patient safety education in their
learning; institutions. This is why a Teacher’s Guide (Part A)
• further develop capacity for patient safety has been developed to accompany the
educators in medical schools; Curriculum Guide. It provides practical advice and
• promote a safe and supportive environment information for each stage of curriculum
for teaching students about patient safety; development and renewal, from assessing
• introduce or strengthen patient safety capacity to staff development to programme
education in medical schools worldwide; design and implementation.
• raise the international profile of patient safety
teaching and learning; A flexible curriculum to meet individual
• foster international collaboration on patient needs
safety education research in the higher We recognize that the curriculum of most medical
education sector. programmes is already filled beyond capacity. This
is why we have designed each topic as stand
Underpinning principles alone, thus allowing for wide variations in patient
safety education implementation. The topics are
Capacity-building is integral to also designed so they can be integrated into
curriculum change existing curricula, particularly in the doctor–patient
The main reason that WHO embarked on this stream. The topics in the Curriculum Guide have
project was to assist medical schools to develop each been designed with enough content for a
patient safety education in their medical schools. 60–90 minute educational session and feature a
The requirement of medical schools to develop variety of ideas and methods for teaching and
and integrate patient safety learning into the assessing so that educators can tailor material
medical curricula is a challenge for many medical according to their own unique needs, context and
schools because of the limited education and available resources. There is no requirement to
training of faculty staff in patient safety concepts absolutely follow the outline provided. Teachers
and principles. One cannot expect medical need to pay attention to the local environment,
schools to develop new curricula or review culture and student learning experiences and then
existing curricula if they are unfamiliar with the select the most appropriate teaching method for
requirements of the discipline of patient safety. the content selected.
Medical educators come from many backgrounds Easily understood language for a
(clinicians, clinician educators, non-clinician targeted yet global audience
educators, managers, health professionals) and The Teacher’s Guide (Part A) of the Curriculum
their collective experience is necessary to deliver a Guide is written for medical educators (those with
16
3. Aims of the Curriculum Guide
17
4. Structure of the Curriculum Guide
18
5. Implementing the Curriculum Guide
How to use this Curriculum Guide experiences in the hospitals and/or the different
This Curriculum Guide provides you with clinical environments. It may be that students are
resources for teaching medical students about already experiencing some patient safety
patient safety. It identifies the topics to be taught, education in the hospitals and clinics that is not
how it might be taught and how you can assess written down. The curriculum may already cover
the different topics in the curriculum. Case some aspects of this patient safety curriculum
examples have been selected are available at the such as the importance of protocols in
end of each topic. These cases can be used to handwashing to avoid infection transmission.
demonstrate a particular aspect of the topic under Getting a picture of existing material in the
discussion. We recognize that the best learning medical curriculum is necessary to identify those
occurs when the case study used reflects local opportunities for enhancing patient safety
experiences, therefore, we encourage teachers to teaching.
modify the cases so that they reflect the
experiences of the health-care providers and The patient safety curriculum we have designed is
locally available resources. described in Part B of this document. We have
identified the topics, resources, teaching
How to review your curriculum for strategies and assessment methods that will
patient safety learning make patient safety teaching easier to introduce
and integrate into the curriculum.
• Identify the learning outcomes
To start the process of curriculum development or • Build on what is already in the curriculum
renewal it is important to first identify the learning A good approach to patient safety education is to
outcomes for patient safety. Part B contains the enhance existing parts of the medical curriculum
topics that have been chosen for this Curriculum rather than see patient safety as a new subject to
Guide; whereas learning outcomes are further teach. There are elements of patient safety that
discussed in Part A. are new and will be additional to the existing
curriculum, but there are many aspects of patient
• Know what is already in the medical safety that can be added onto or achieved with
curriculum further development of a subject or topic that
We use the word curriculum to refer to the broad already exists.
spectrum of teaching and learning practices,
including the strategies for developing skills and We have found that mapping topics or areas in
behaviours as well as using appropriate the existing curriculum will help identify
assessment methods to test whether the learning opportunities to include patient safety concepts
outcomes have been achieved. Medical students and principles. Areas such as clinical skills
are guided in their learning by a medical curriculum development, professional and personal
that sets out the requisite knowledge, skills and development, patient–doctor and community–
behaviours required to demonstrate competency doctor themes, health law, medical ethics, clinical
at the completion of their medical degree. ethics and communication are all suitable for
including patient safety concepts and principles.
Before new material is introduced into a The University of Sydney developed a template to
curriculum it is important to know what curriculum review their medical curriculum and offer it as an
already exists as well as students’ clinical example that can be followed (see Table 3).
19
5. Implementing the Curriculum Guide
Table 3. Map of patient safety content in the existing medical programme (example)
Session/area of Year Where is the Potential How is patient How is patient Comments
the curriculum patient safety patient safety safety being safety being
content? learning taught? assessed?
Ethics 1 Respect for Honesty after Lecture Ethics essay, Many patient safety
patient an adverse MCQ, OSCE principles have an
autonomy event ethical basis that
can be used to
make explicit the
patient safety
lesson
Mapping medical curriculum will also help identify teaching and make sure they are included in the
the opportunities for including patient safety survey. The mapping exercise described above will
concepts in an integrated fashion. help identify those people who currently teach and
in a position to integrate patient safety concepts.
How to assess the capacity of faculty The survey could include questions in relation to
to integrate patient safety teaching into interest or knowledge of patient safety and practice
the existing curriculum in patient safety methods. This process could also
One of the biggest challenges facing all medical identify those people who may be interested in
schools is the growing shortage of clinician forming a group or committee to oversee the
teachers generally. There are few who know how development of the patient safety curriculum.
to integrate patient safety principles and concepts
into their clinical teaching. Many good clinicians Focus group
intuitively adopt patient safety methods into their Run a focus group of clinicians to find out what
practice but may not know how to articulate what the current state of knowledge is about patient
they do. Perhaps this is because they view any safety. This will also provide information about the
discussions about “systems” as the province of clinicians’ attitudes towards including patient
administrators and managers. Others may not safety learning in the curriculum.
think patient safety teaching important or relevant
to their practice. Engaging clinicians in the area Face-to-face meetings
will be the first challenge for you. Building capacity Individual meetings with clinicians will help to
of the faculty can take time, but there are a convey a clear message about patient safety
number of steps that can be taken to engage education. This provides an opportunity to explain
clinicians in patient safety teaching. the basis and urgency for patient safety education
as well as establish a relationship for later work.
Survey
One way to find out who is interested in teaching Convene a round table
patient safety is to conduct a survey of the Invite a select group of clinicians who you think
clinicians who teach medical students. In some may be interested and those who are possible
institutions there may be hundreds of teachers and champions of a round table discussion about
in others not so many. Identify the clinicians who patient safety education for medical students.
are in the best position to incorporate patient safety (The benefit of a round table format is that there is
20
5. Implementing the Curriculum Guide
no one expert obviously in charge and the group as a result of previous contacts or meetings about
seeks to discuss and resolve the issues together patient safety. It is also a good idea to check the
in a collegial fashion.) availability of experts from other faculties and
disciplines such as nursing, engineering (human
Conduct a seminar on patient safety factors knowledge), psychology (behavioural
Seminars are typical venues for building new psychology, process and improvement theories)
knowledge. Seminars can be good for exposing and pharmacy (medication safety).
clinicians new to the area to experts or respected
clinicians who know about patient safety. Techniques to find out where patient
Seminars can either be a half day or a full day. safety could fit into the medical
Topics that could be included in such a seminar curriculum
include: (i) what is patient safety; (ii) the evidence Brainstorming is a technique that requires and
of why patient safety is important; (iii) how to encourages everyone to suggest ideas for solving
develop a curriculum for patient safety; (iv) how to a problem. The problem being how to best
teach patient safety; and (v) how to assess patient introduce patient safety learning into the
safety. It is important to remember to maintain curriculum. Each medical school will be different;
context of the programme, which is to build they will have different resources, capacity and
capacity for faculty staff and clinicians to teach interest in patient safety. Patient safety may not
patient safety to medical students. yet be a community or government concern so
the urgency to include patient safety education
How to identify like-minded colleagues may not be a priority.
or associates
If you undertake the activities set out above in Convening introductory workshops on the
relation to building capacity this will help identify Curriculum Guide for medical students will provide
like-minded people interested in teaching patient an opportunity for members of the faculty to
safety. Another way is to convene a meeting and become familiar with the core topics in patient
send an open invitation to faculty staff and safety. It will also allow them to express any
clinician teachers. Make sure to schedule the reservations they have about the programme and
meeting at a time convenient for as many people clarify any concerns or questions.
as possible in order to attract maximum
attendance (for example, clinicians who see Patient safety is best considered in the context of
patients during the day may want to come but multidisciplinary learning. Staff should be
cannot because of work demands). Another way encouraged to reflect on the feasibility of
is to put an article in the faculty newsletter or combining some of the patient safety sessions
university news. This will let people know about with other health professionals. While this
patient safety, and even if they are not interested Curriculum Guide has been designed for medical
in getting involved, the article will raise awareness students, it can easily be adapted to other health-
of the need to include patient safety education in care students. Other professions and disciplines
the curriculum. have much to contribute, particularly in teaching
some of these topics. Engineers may be able to
Patient safety teaching requires the engagement teach about systems, safety cultures and human
of interested and knowledgeable staff who either factors engineering. Psychologists and
self-select, or have been appointed or nominated behavioural scientists, nursing and pharmacy
21
5. Implementing the Curriculum Guide
Reaching agreement
As in all discussions about curriculum there will be
different views about what should be included and
what should be left out. The important thing is to
start and build on that. This means that
compromise may be better in the long run—
getting something started rather than debating
and discussing the issues for lengthy periods of
time. Another technique is to introduce new
topics into the curriculum using a pilot, which
could identify any problems and be used as a
guide for future topics. It also allows faculty staff
members who are unsure of the value of patient
safety learning to get used to the idea.
22
6. How to integrate patient safety into your medical
school curriculum
Box 1. Linking patient safety education with traditional medical school subjects
An example of how a patient safety topic such as correct patient identification has specific applications in numerous
disciplines in medicine:
Discipline Patient safety application
Obstetrics How are newborn babies identified as belonging to their mother so that babies are not
accidentally 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 they
receive the correct blood type?
Ethics How are patients encouraged to speak up if they do not understand why the doctor is doing
something to them that they were not expecting?
Box 2. Linking patient safety education with new knowledge and performance elements
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 is
delivered by a team. Learning what situations increase the likelihood of a patient mix-up such as
having two patients with the same condition, patients who cannot communicate and staff being
interrupted 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 strategies
used 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 you
John Smith?”
23
6. How to integrate patient safety into your medical school curriculum
The field of patient safety is also very broad. Given In this setting, clinical application and
this breadth and the need for contextualizing performance elements of patient safety may be
patient safety principles, there are likely to be best introduced in the later years of the course.
many opportunities in your curriculum to However, broad knowledge of patient safety
incorporate effective patient safety education into principles can still be effectively introduced in the
existing sessions. However, some areas of patient early years.
safety are relatively new to medicine and may not
be so easy to graft onto an existing session and • Is it an integrated curriculum? Basic,
hence are likely to need their own time slot in the behavioural and clinical sciences and clinical
curriculum. skills are covered in parallel throughout the
course and learning is integrated.
How to establish best fit using generic
curriculum structures In this setting, there are advantages to vertical
Once you have reviewed your existing curriculum, integration of knowledge, application and
determined what patient safety areas are already performance elements of patient safety education
taught and decided what patient safety topics you throughout the course.
want to teach, it is time to think about how to
incorporate the new content into your curriculum. Knowledge and performance requirements
of patient safety:
When thinking about your medical school’s • Are ideally learnt in the context of the clinical
curriculum consider the following questions: setting; relevance is more apparent once
• How is your overall curriculum structured? students understand how health care is
• When and where in the curriculum are delivered and are more familiar with the
particular subjects and topics taught that workplace environment.
might lend themselves to inclusion of patient • Will be more likely to change practice if
safety content? students have the opportunity to use what
• How are individual topics structured in terms they have learnt shortly after it is covered in
of learning objectives, delivery methods and the curriculum.
assessment methods?
• How is your curriculum delivered? When teaching a patient safety topic, there are
advantages if the knowledge and performance
Once you have answered these questions it will requirements are covered together. A clear
become more apparent where and how patient understanding of the scope of a problem inpatient
safety can be included in your curriculum. safety will provide motivation and insight when
learning about performance requirements.
How is your overall curriculum structured?
• Is it a traditional curriculum? Students first Students are also less likely to feel demoralized
learn about the basic and behavioural about the risks facing patients from the health-
sciences and once these are complete, care system they will soon be a part of; if they
concentrate on the clinical disciplines. explore solutions (applications) and learn practical
Education tends to be discipline-specific strategies (performance elements) to make them
rather than integrated. safer doctors at the same time, they will be more
positive. For logistical reasons it may not be
24
6. How to integrate patient safety into your medical school curriculum
possible to cover the knowledge and performance public health, epidemiology, ethics or other
requirements of a patient safety topic at the same behavioural science-based subjects. Suitable
time. For example, there is a lecture on medication topics for early introduction include: (i) what is
error in the second year but the students do not patient safety; (ii) introduction to human factors
practise safe drug administration techniques until a engineering; and (iii) systems and complexity in
clinical skills workshop in the fourth year. If this is health care.
the case, it will be helpful to inform students in the
second year that they will learn safe drug If your curriculum is integrated and students are
administration in the fourth year, and then in the taught clinical skills from the first year, then patient
fourth year, refer back to the lecture they had in safety topics are best introduced early and
the second year on medication error. This way vertically integrated throughout the entire course.
motivation for safe practice will not be lost and This makes patient safety a constant theme and
students will feel more confident about their provides opportunities to reinforce and build upon
potential to graduate as a safe practitioner. earlier learning. Ideally, students should be
exposed to patient safety education prior to and
If your curriculum is traditional, then knowledge upon entering the clinical environment.
and performance requirements of patient safety
are best taught in later years when students have When and where in the curriculum are
more knowledge of the clinical disciplines, particular subjects and topics taught that
exposure to patients and clinical skills training. The might lend themselves to inclusion of patient
context for the knowledge and performance safety teaching?
requirements should match the students’ ability to Box 3 sets out opportunities for examining
put into practice their new knowledge. integration of patient safety topics.
Introductory patient safety knowledge can still be
included in the early years in subjects such as
25
6. How to integrate patient safety into your medical school curriculum
Any clinical discipline can potentially house a How is your curriculum delivered?
patient safety topic if a sample case is part of the • lectures
session and is relevant to that discipline. For • clinical placements
example, a case involving a medication error in a • online activities
child could be used as the starting point for • on the ward activities
teaching about understanding and learning from • small group tutorial teaching
errors while studying paediatrics. Similarly, during • problem-based learning (PBL)
the surgical rotation a clinician could teach the • simulation/skills laboratories
topic “patient safety and invasive procedures”. • traditional tutorials.
Medicine or obstetrics could house the topic of
“understanding and learning from errors” if the It will probably be easier to incorporate patient
case was relevant to that particular discipline. The safety topics into pre-existing educational delivery
learning, however, is generic and relevant for all methods familiar to students and staff.
disciplines and all students.
Examples of models for implementation
How are individual curriculum topics Example 1: Patient safety as a stand alone subject
structured in the following areas? in a traditional curriculum occurring in the final
• learning objectives years. See chart 1.
• delivery methods • educational methods could consist of a
• assessment methods. combination of lectures, small group
discussions, project work, practical
Implementation of new patient safety content into workshops or simulation-based exercises;
your curriculum will be more efficient if the • adding a layer of patient safety to prior
associated learning objectives, delivery and knowledge before entering the workforce.
assessment methods are consistent with the
structure of objectives, delivery and assessment
methods of existing subjects.
26
6. How to integrate patient safety into your medical school curriculum
Example 2: Patient safety as a stand alone subject Patient safety could be a stand alone subject with
in an integrated curriculum. See chart 2. links to other subjects, e.g. lectures at the start of
term that relate to topics that will come up in
tutorials or on placement over the course of the year.
27
6. How to integrate patient safety into your medical school curriculum
Example 3: Integrating patient safety into pre- In the fourth year there could be a lecture on
existing subjects—example A. See chart 3. medication safety as part of therapeutics, a
workshop on safe drug administration in the
A number of subjects could set aside some clinical skills programme and a PBL case that
sessions where the main objective of the tutorial demonstrates the multifactorial nature of error
or lecture is to cover a patient safety topic. using a case of medication error.
Chart 3: Implementation of patient safety as a stand alone subject in an pre-existing subjects (A)
Year 1 PBL Patient
safety
case
Clinical Patient
skills safety
activity
Lecture Patient
Safety
topic
Clinical Patient
skills safety
activity
Lecture Patient
Safety
topic
Clinical Patient
skills safety
activity
Lecture Patient
Safety
topic
Clinical Patient
skills safety
activity
Lecture Patient
Safety
topic
28
6. How to integrate patient safety into your medical school curriculum
Example 4: Integrating patient safety into pre- the session is not a patient safety topic, elements
existing subjects—example B. See Chart 4. of patient safety education are weaved into the
session. For this to occur, session objectives
Work together with subject leaders to incorporate should include an element of patient safety. See
elements of patient safety into selected Box 4 for examples.
educational sessions. Although the main focus of
Chart 4: Implementation of patient safety as a stand alone subject in an pre-existing subjects (B)
Year 1 PBL Patient safety Patient safety
case case
Clinical skills Patient safety Patient safety Patient safety Patient safety Patient safety Patient safety
activity activity activity activity activity activity
Clinical skills Patient safety Patient safety Patient safety Patient safety Patient safety Patient safety
activity activity activity activity activity activity
Clinical skills Patient safety Patient safety Patient safety Patient safety Patient safety Patient safety
activity activity activity activity activity activity
Clinical skills Patient safety Patient safety Patient safety Patient safety Patient safety Patient safety
activity activity activity activity activity activity
29
6. How to integrate patient safety into your medical school curriculum
Box 4. Examples of how patient safety topics can be weaved in with pre-existing sessions
Pre-existing session Patient safety education component
Clinical skills tutorial at the bedside Patients are always provided with an explanation and
consent to being part of the educational process at the start
of 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 have
information 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 of
the lecture.
Verification protocols to ensure correct patient.
PBL on pulmonary embolism where the index case is Students are encouraged to discuss the importance of
commenced on an oral anticoagulant patient education when prescribing potentially dangerous
medication.
The more patient safety topics are integrated into combination of the above approaches is more
the established curriculum, the easier it will be to appropriate for your setting.
incorporate the performance requirements in a
meaningful way, and provide context for patient Once you have an overall plan of what, where and
safety concepts. how you want to incorporate patient safety into
your curriculum, it will be easier to add to the
However, there should be a word of caution: the curriculum in a piecemeal fashion, topic by topic
more that patient safety is integrated into the over time, rather than trying to add every aspect
existing curriculum, the more it is dispersed, of your plan at once. This way you can learn as
dependent on a greater number of teachers and it you go, and start achieving small goals early.
becomes harder to coordinate effective delivery.
You will need to find the balance between Integration of patient safety into a
integration of the new material and ability to problem-based learning programme
coordinate its delivery. It is a good idea to keep a Many medical schools use PBL as a major
detailed record of what patient safety is integrated component for delivering curriculum. One of the
into the existing curriculum, how it is being taught many benefits of PBL is the integration of basic,
and how it is being assessed. From an behavioural and clinical science material in the
educational perspective, integration of patient context of solving a clinical problem. If the clinical
safety is ideal; however, this aim needs to be problem also includes aspects of the realities of
balanced by the practicalities of implementation. the health-care delivery system then there will be
When asked by a university or accrediting body opportunities to explore issues relating to patient
where and how patient safety is taught to medical safety. PBL is well suited to patient safety
students the faculty needs to have information teaching and learning. This section provides ideas
that is sufficiently detailed to allow an observer to to help you effectively include patient safety
attend such a session and see patient safety material into your PBL programme.
education being delivered. It may be that a
30
6. How to integrate patient safety into your medical school curriculum
There are many variations of the PBL process. How learning issues emerge from the
The relevance of some of the ideas we present problem-based learning case
will depend on which PBL model your school has For a PBL session to achieve its aims the clinical
adopted. In this section, PBL is assumed to have case needs to be written in a way that promotes
the following characteristics: curiosity and discussion.
• small group learning with a facilitator (tutor or
teacher) present; Example of a PBL case:
• a clinical case is used as the starting point for Jeremy So is a 15-year-old boy who arrives at the
learning; local medical clinic with noisy breathing and itch.
• as students attempt to understand the case His father says he was fine 30 minutes ago and
through group discussion, issues and that he just became unwell quite suddenly. On
problems arise that will form the basis of examination, Jeremy looks distressed and
further study; nervous. He has a puffy face, his lips are huge
• students undertake self-directed study and he can hardly open his eyes as they are so
(resources may be provided to help guide swollen. He has red blotches on his skin and he is
students with their study); scratching his body. Every time he breathes in he
• students come together as a group to share makes a noise.
their learning and collectively improve their
understanding of the issues that arose from From this case a number of questions may arise
the clinical case; in the minds of the students:
• PBL sessions have specified learning • What is the most likely diagnosis? What else
objectives and PBL learning is assessable. could it be?
• What could have caused the problem?
The nature of the PBL process is aligned with • How does the diagnosis explain all the clinical
strategies that promote patient safety in the features?
workplace such as: • What is the underlying pathophysiology of the
• collaborative learning; condition—can the features be explained by
• reviewing cases, identifying problems and understanding the pathophysiology?
issues as a group; • What is likely to happen to Jeremy if he does
• sharing the workload and not get treatment?
exploring/researching problems as an • What is the treatment?
individual;
• learning from and teaching peers; Example of the same case written to elicit
• group problem solving; discussion of medical error as well as answers
• respecting roles and responsibilities; to the above questions:
• showing respect to colleagues.
Jeremy is a 15-year-old boy who arrives at the
Many of the skills developed in the PBL process local medical clinic with noisy breathing and itch.
will assist students to be effective future members His father says he was fine 30 minutes ago and
of health-care teams involved in continuous that he just became unwell quite suddenly. On
quality improvement in the workplace. examination, Jeremy looks distressed and
nervous. He has a puffy face, his lips are huge
and he can hardly open his eyes as they are so
31
6. How to integrate patient safety into your medical school curriculum
In addition to a well-written case, clearly stated A case may include a nurse (or medical student)
learning objectives help keep students’ discussion noticing some important information that the
on the intended path. It may be that only the doctor has overlooked. The case can describe the
teacher has access to the learning objectives and nurse being assertive (speaking up), the doctor
can guide students in the right direction if need being receptive to the nurse and the patient’s care
be. So, in this sample case, as well as objectives being improved as a result.
that relate to the pathophysiology, clinical
manifestations and treatment of severe allergic The patient safety issue may be a major or minor
reactions, one or two of the objectives could be component of the case.
focused on patient safety issues. • If your school has learning objectives for each
PBL case, include patient safety knowledge
32
6. How to integrate patient safety into your medical school curriculum
33
6. How to integrate patient safety into your medical school curriculum
For example: Correct patient identification when making in action and knowing the environment.
taking a blood sample. How to label sample tubes Similar to other forms of experiential learning, there
to minimize chance of misidentification: label at are opportunities to practise the performance
the bedside, check patients name with an open- requirements demonstrating safe practice.
ended question, make sure the patient’s name
matches the label on the sample tube and the Note: Immersive scenario-based teaching using
label on the request form, i.e. perform a “three- simulation can be a highly effective way for
way check”. students to learn, but can also be quite
confronting for students and not always a
A variety of educational methods can be used to comfortable way to learn. Attention to creating a
introduce the broad patient safety topics as they safe and supportive learning environment is very
apply to performing invasive procedures—for important if this educational method is used. See
example, lectures, readings, group discussion, the section on underpinning educational principles
tutorials, online activities and even PBL. for more details on creating a safe and supportive
learning environment.
The best time to learn the knowledge and
performance requirements of a patient safety topic Clinical skills training programme
is when learning the steps of the procedure. This Clinical skills training includes learning how to take
may occur in a practical tutorial at the bedside, a history, how to perform a physical examination,
using simulation in a skills laboratory or as a tutorial clinical reasoning, test ordering and interpretation,
without a “hands-on” component. Students could procedural skills and communication skills such
be asked to read a particular article or guidelines as providing information, counselling and
prior to attending the teaching session. obtaining informed consent.
Tutorials on particular procedures provide an A range of methods are used to teach clinical
excellent opportunity to reinforce generic skills such as bedside tutorials, practising with
principles, to detail patient safety applications for simulated patients, practising with peers,
a particular procedure and for students to practise observing videos of expert performance,
performance elements of patient safety. participation in the clinical environment and
presenting cases.
If your school utilizes immersive scenario-based
simulation training, for example, to learn basic and Consider when and how your school delivers its
advanced life support, there is an opportunity to clinical skills programme.
incorporate team training into that programme.
The advantages of this type of training for A number of patient safety topics will be
incorporating patient safety issues are the realistic appropriate for inclusion in a clinical skills
situations that mirror many real-life challenges that programme. And since the programme may offer
can emerge from the scenario. For example, opportunities to practise performance elements of
knowing what to do in an emergency situation is patient safety, it is important that good habits be
different from actually doing it, especially when developed early. Note that bedside tutorials offer
working as part of a team. The real elements rich opportunities for tutors to role model safe
introduced are time pressure, stress, teamwork, practice—for example, patient-centred
communication, equipment familiarity, decision- communication and hand hygiene.
34
6. How to integrate patient safety into your medical school curriculum
Clinical skills training may provide opportunities for • invite guest speakers to promote patient safety;
students to learn about and practise the following • engage/excite teachers about the inclusion of
patient safety performance elements: patient safety in the curriculum;
• communicating risk; • parallel patient safety education in the
• asking permission; postgraduate setting;
• accepting refusal; • clearly state patient safety learning objectives in
• being honest with patients; tutor notes;
• empowering patients—helping patients be • provide tutors notes on patient safety topics;
active participants in their own care; • assess patient safety content in exams.
• keeping patients and relatives informed;
• hand hygiene; Using case studies
• patient-centred focus during history taking
and physical examination; Build local case studies
• clinical reasoning—diagnostic error, Case studies can either demonstrate how not to do
consideration of risk benefit ratio of something (learning from a person’s negative
procedures, investigations and management experience) or how to do something right (learning
plans. from a person’s positive experience). For example, if
a case study is being developed for the topic “being
How to collaborate with ward-based an effective team player”, then the local case study
teachers and teachers of clinical skills would have elements of teams that are familiar to
For patient safety principles to be integrated the local institutions, local clinics or hospitals.
broadly throughout the curriculum, the
cooperation of many individual teachers will need The following steps will assist in building local cases
to occur, particularly if patient safety education is relevant to the topic being taught.
to be delivered in small group settings such as • Review the sections of each topic in this
PBL and clinical skills tutorials. Curriculum Guide outlining:
- the relevance of the topic to the workplace;
We mentioned in the beginning of this section that - the learning objectives for the topic.
many teachers will not be familiar with patient • Write down the activities that are captured in
safety concepts and specific knowledge and the objectives.
performance requirements will be new. For • Obtain case studies from:
example, students may see clinicians in the - the Curriculum Guide; or
workplace asking patients their name in a hurried - ask doctors and nurses in the hospital or
and disrespectful manner, taking shortcuts that may clinic to provide cases that can be identified.
compromise patient safety or display a “blame and • Develop a story that contains the elements set
shame” attitude when things go wrong. Tutors will out in the objectives.
need to reflect on their own practice if they are to
be effective patient safety teachers and role models. The context of the case study should be familiar to
the students and clinicians. For example, if there are
The following strategies may assist to engage no intensive care units (ICUs) locally available, then
clinical teachers in patient safety teaching: the case studies should avoid mentioning ICUs or
• conduct a patient safety workshop or lecture placing the case study in an ICU.
series for teachers;
35
6. How to integrate patient safety into your medical school curriculum
36
7. Educational principles essential for patient safety
teaching and learning
Use examples that are realistic for your Box 5. Practical application example
setting
Think about the sort of work most of your While observing a surgical operation a
students will be doing after they graduate and medical student notices that the surgeon is
have this in mind when choosing clinical contexts closing the wound and there is still a pack
in which to incorporate patient safety education. inside the patient. The student is not sure if
Including a case about malnutrition, morbid the surgeon is aware of the pack and is
obesity or malaria is not particularly useful if these wondering whether to say something.
conditions are extremely uncommon in your
clinical practice setting. Use situations and Give students the opportunity to practise
settings that are common and relevant for the applying their patient safety knowledge and
majority of your graduates. skills
By giving students the opportunity to practise
Identify practical applications “safe practice”, it will hopefully become habitual,
Help students identify the situations in which they and students will be more inclined to approach
can apply their patient safety knowledge and clinical situations with a patient safety mindset.
skills. This way they are more likely to recognize
opportunities for safe practice in the workplace as Practising “safe practice” can occur as soon as
they arise. For example, correct patient students commence their medical training—for
identification is important in: example, in:
• sending off blood samples; • tutorials or private study, e.g. brainstorming
• administering medication; solutions for hazardous situations;
• putting labels on imaging request forms; • a simulation setting, e.g. skills laboratory,
37
7. Educational principles essential for patient safety teaching and learning
simulation laboratory, role play; Suggestions for helping to create a safe and
• the clinical environment, e.g. hand hygiene supportive learning environment:
when seeing patients, correct patient • Introduce yourself to students and ask the
identification when drawing blood from a students to introduce themselves. Show an
patient; interest in them as individuals as well as
• patient interactions—when advising, students showing an interest in their learning.
can practise encouraging patients to be • At the start of your teaching session, explain
informed, ask questions and be proactive in how the session will run. This will let the
ensuring care progresses as planned. students know what to expect, and also what
is expected of them.
Create an effective learning environment • Orient learners to the environment you are
Aspects of the learning environment can also teaching in. This is especially important if you
have a bearing on the effectiveness of teaching are in the clinical environment or a simulation
and learning. An ideal learning environment is one environment. Students need to know what is
that is safe, supportive, challenging and engaging. expected of them if they are in a new setting.
Simulation environments can be confusing as
Safe and supportive learning environments some aspects are real, some aspects are not,
A safe and supportive learning environment is one and the learner is asked to pretend that some
in which: aspects are real. Make sure the learners
• students feel comfortable to ask “stupid” know the level of immersion required for the
questions; role play, and how realistically you expect
• volunteer what they do not understand; them to treat the situation. It may be
• share what they do understand in an honest embarrassing for a student to talk to an
and open way. intravenous (IV) cannulation insertion practice
arm as if it were a real patient when the
Students who feel safe and supported tend to be teacher’s intention was just to use the IV
more open to learning, enjoy being challenged insertion practice arm for practising the
and are more prepared to actively participate in manual aspects of the task.
learning activities. • Invite students to ask questions and speak
up if there is anything they do not
If students feel unsafe and not supported they will understand. This sends the message that not
tend to be reluctant to disclose knowledge deficits knowing is okay.
and less likely to engage actively for fear of feeling • Never criticize or humiliate a student for lack
embarrassed or being humiliated in front of their of knowledge or poor performance. Rather,
teachers and peers. The student’s primary aim this should be viewed as a learning
becomes self-preservation rather than learning. opportunity.
Attention to creating a safe and supportive • If active participation is required, ask for
learning environment not only makes learning volunteers rather than singling people out
more enjoyable, but also, importantly, makes yourself.
learning more effective. The teacher has a • Consider demonstrating how to do something
significant role in making the learning environment yourself before asking students to have a turn.
a comfortable place for students. For example, when teaching about how to
create a sterile field before doing a lumbar
38
7. Educational principles essential for patient safety teaching and learning
39
7. Educational principles essential for patient safety teaching and learning
process. Ideally, the task would help develop equally or more effective in particular
critical reflection skills. For example, if students circumstances. The ability to be flexible is
are required to attend morbidity and mortality encouraged. It may be that you will need to adjust
meetings, they could have some pre-set your usual methods to fit in with the overall
questions to address based on their observations. curriculum delivery design at your school.
40
7. Educational principles essential for patient safety teaching and learning
41
7. Educational principles essential for patient safety teaching and learning
References
1. 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 teaching
methods. Medical Teacher, 2001, 23(6):610–612.
3. Harden RM, Crosby J. Association for Medical
Education in Europe Guide No 20: the good teacher is
more 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 acceptance
of medical error: the case for a teaching programme.
Medical education, 1998, 32(1):3–7.
42
8. How to assess patient safety
43
8. How to assess patient safety
Table 4. A blueprint showing end-of-course assessments for components of the patient safety
curriculum
Assessable learning Year that curriculum modules are first assessed in a typical programme
outcomes
Year 1 Year 2 Year 3 Year 4
Health law X
Health-care systems X
Communication X
Safe patient care X
Quality improvement X
Select appropriate test methods appropriate. One of the most well known of these is
It is important to emphasize that assessment in Miller’s triangle, which suggests that a student’s
patient safety is aligned with the agreed learning performance is made up of four levels (see Figure 2):
outcomes. It is unlikely that any particular • knows
assessment format is suitable to assess everything • knows how
required. It is best to be aware of the range of • shows how
assessment methods and make a decision based • does.
on an understanding of their strengths and
limitations. Let the purpose of the assessment, for For example, “showing how” is related to specific
example, “to assess knowledge of health-care law in competencies that are appropriate for the level of
the unconscious patient” drive the choice of format, expertise of the student. These can be examined
in this case a modified essay question (MEQ) or a by, for example, an objective structured clinical
multiple choice question (MCQ). examination (OSCE) station.
44
8. How to assess patient safety
Figure 2. Miller’s triangle There are some strengths and weaknesses with
all of these formats and which need to be
}
considered when choosing the right assessment
Dir ect observation in
real-li f e contexts
(emerging technology)
for a particular learning outcome within a patient
}
Does safety curriculum.
Dir ect observation in
simulated contexts
(e.g. OSCE)
Shows how
Written
}
Various (w ritten or
computer-based) selected
Knows how and constructed response
questions (item writing
technology) Multiple choice question/extended matching
Knows question
MCQ and EMQ are very attractive formats in that
they can test a wide sample of the curriculum,
Source: Miller GE. The assessment of clinical
skills/competence/performance. Academic Medicine,
can be machine marked and give reliable scores
(Supplement), 1990, 65:S63-S67. of a student’s ability. However, their main
drawback in testing aspects of clinical
Again, looking at Figure 2, one can see that competence, such as patient safety, is that they
knowledge (knows) can be tested by MCQs, for tend to test knowledge only. This is appropriate
example. with, for example, health-care law and aspects of
patient safety in public health. It is not appropriate
Typical assessment formats within a medical in testing, for example, ethical reasoning. An
school might include: example of an MCQ is given in Appendix 2. The
EMQ has been designed to address the issue of
Written: guessing in multiple choice exams.
• multiple choice items (1 from 4/5);
• extended matching questions (EMQ); Modified essay questions/key feature
• structured short answer questions; The traditional essay is used in some places.
• modified essay question (MEQ); There is great advantage in allowing students to
• extended written work (e.g. project reports, evidence their critical thinking, reasoning and
posters); problem solving skills. However, marking essays
• portfolio/log books. for large classes are resource intensive and
subject to much variability in judges marks.
Clinical/practical: However, MEQs or key feature formats are
• multiple station exams; designed to be answered in 5–10 minutes, and
• direct observation of performance (e.g. encourage short note responses to appropriate
observed long cases, mini clinical evaluation scenarios. Providing a model answer and marking
exercise [Mini-CEX]); scheme helps examiners maintain some
• 360 degree or multisource feedback (MSF); standardization. Several MEQs on a range of
• structured reports (e.g. attachment different subjects can be asked in the time it takes
assessments); to write one essay sampling just one area of the
• oral presentations (e.g. projects, case-based curriculum. An example is given in Appendix 2.
discussion);
• structured oral exams.
45
8. How to assess patient safety
46
8. How to assess patient safety
Matching assessment to expected learning A sample of patient safety outcomes have been
outcomes modified from the Australian Junior Doctor
It is always important to match assessments to Curriculum Framework. The Framework has been
intended learning outcomes. Most medical aligned with many sources, including the
curricula will have learning outcomes, some more Australian Patient Safety Education Framework,
detailed than others. In Table 5, the complete list and shows that patient safety concepts are
of learning outcomes for patient safety can be completely integrated.
easily matched with appropriate assessments.
Table 5. Sample of typical end of medical programme learning outcomes for patient safety showing
typical assessment formats
Competencies Assessment
format
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 local Portfolio
requirements
47
8. How to assess patient safety
Communication Assessment
format
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
Treat patients courteously and respectfully showing awareness and sensitivity to different backgrounds OSCE/mini-CEX
Provide clear and honest information to patients and respect their treatment choices OSCE/mini-CEX
Ensure relevant family/carers are included appropriately in meetings and decision-making Portfolio
Ensure patients are supported and cared for after an adverse event OSCE
48
8. How to assess patient safety
Multisource feedback
Archer J, Norcini J, Davies H. Use of SPRAT for
peer review of paediatricians in training. British
Medical Journal, 2005, 330(1251–1253).
49
9. How to evaluate patient safety curricula
50
9. How to evaluate patient safety curricula
Hospital administrators/clinical staff Does teaching patient safety to interns result in a decreased
number of adverse events?
University faculty How can this patient safety curriculum best be implemented
in our institution?
Individual teachers Am I delivering the curriculum effectively? Are students
enjoying it? Are they learning?
What form(s) of evaluation is/are most terms of primary purpose of the evaluation, the
appropriate? stage of programme/curriculum implementation
Evaluation types or forms can be categorized as you are at, the kinds of questions you are asking
follows: proactive, clarificative, interactive, and the key approaches required. Table 7
monitoring and impact [2]. The forms differ in provides a summary of each form of evaluation.
Component Objectives-based
Responsiveness
Evaluability analysis Needs-based
Needs assessment Action research
assessment Devolved Goal-free
Key approaches Review of the Developmental
Logic development performance Process-outcome
literature Empowerment
Accreditation assessment Realistic
Quality review
Systems analysis Performance audit
51
9. How to evaluate patient safety curricula
- Is the
- Has the
programme
programme
reaching the
been
target
- What are the implemented as
population?
intended planned?
- Is
outcomes and - Have the stated
implementation
how is the goals been
- What is the meeting stated
programme achieved?
programme objectives and
designed to - Have the needs
trying to benchmarks?
achieve them? of students,
achieve? - How is
- What is the teachers
- How is it going? implementation
- Is there a need underlying andothers
- Is the delivery going between
for the rationale for the served by the
working? sites?
programme? programme? programme
- Is delivery - How is
- What do we - What elements been achieved?
consistent with implementation
know about the need to be - What are the
the programme now compared
Types of problem that the modified to unintended
plan? to a month/6
questions programme will maximize outcomes?
- How could months/1 year
address? intended - How do
delivery be ago?
- What is outcomes? differences in
changed to - Are our costs
recognized as - Is the implementation
make it more rising or falling?
best practice? programme affect
effective? - How can we
plausible? programme
- How could this finetune the
- Which aspects outcomes?
organization be programme to
of the - Is the
changed to make it more
programme are programme
make it more efficient? More
amenable to more effective
effective? effective?
subsequent for some
- Are there any
monitoring or participants than
programme sites
impact for others?
that need
evaluation? - Has the
attention to
programme
ensure more
been cost-
effective
effective?
delivery?
52
9. How to evaluate patient safety curricula
Collection Questionnaires
There are a number of data sources and Questionnaires are easily the most common
collection methods to consider in an evaluation of method of data collection, providing information
patient safety curricula or any other evaluation on people’s knowledge, beliefs, attitudes and
object. How many and which ones you use behaviour [4]. If you are interested in research,
depends on your evaluation’s purpose, form, and publishing the evaluation results, it may be
scope and scale. Potential data sources include: important to use a previously validated and
• students (prospective, current, past, published questionnaire. This will save you both
withdrawn); time and resources, and will allow you to compare
• self (engaging in self-reflection); your results with those from other studies using
• colleagues (teaching partners, tutors, the same instrument. It is always useful as a first
teachers external to the course); step to search the literature for any such tools that
• discipline/instructional design experts; may already be in existence.
• professional development staff;
• graduates and employers (e.g. hospitals); More often than not, however, teachers/faculties/
• documents and records (e.g. teaching universities choose to develop questionnaires for
materials, assessment records). their own individual use. Questionnaires may be
comprised of open- and/or closed-ended
Data may be collected from the above listed questions and can take a variety of formats such
sources in a variety of ways, including self- as tick-box categories, rating scales or free text.
reflection, questionnaires, focus groups, individual Good questionnaire design is integral to the
interviews, observation and documents/records. collection of quality data, and much has been
written about the importance of layout and how to
Self-reflection construct appropriate items [3-5]. You may wish
Self-reflection is an important activity for a medical to consult one of the references or resources
or clinical educator and has an important role in provided prior to developing your questionnaire
evaluation. An effective method for reflection for evaluation of patient safety teaching or
involves: curricula.
• writing down your experience of teaching (in
this case, patient safety education) or Focus groups
feedback received from others; Focus groups are useful as an exploratory method
• describing how you felt and whether you and means of eliciting student or tutor
were surprised by those feelings; perspectives [6]. They often provide more in-
• re-evaluating your experience in the context depth information than questionnaires and allow
of assumptions made: [3] for more flexible, interactive exploration of
- Were they good assumptions? Why, or attitudes towards and experiences of curriculum
why not? change. They can be used in conjunction with
questionnaires or other data collection methods
Engaging in self-reflection will allow for the as a means of checking or triangulating data, and
development of new perspectives and a greater can vary in terms of structure and delivery from
commitment to action in terms of improving or the conversational and flexible to the strictly
53
9. How to evaluate patient safety curricula
54
9. How to evaluate patient safety curricula
Resources References
You may find the following resources useful for 1. Owen J. Program evaluation: forms and approaches,
3rd ed. Sydney, Allen & Unwin, 2006.
various stages of your evaluation planning and
2. Boud D, Keogh R, Walker D. Reflection, turning
implementation: experience into learning. London, Kogan Page. 1985.
3. Boynton PM, Greenhalgh T. Selecting, designing and
Centre for the Advancement of Learning and developing your questionnaire. British Medical Journal,
2004,328:1312–1315
Teaching, University of Tasmania. Project
4. Leung WC. How to design a questionnaire. Student
evaluation toolkit, 2005 British Medical Journal, 2001, 9:187–189.
(http://www.utas.edu.au/pet/index.html, accessed 5. Taylor-Powell E. Questionnaire design: asking
15 May 2008). questions with a purpose. University of Wisconsin-
Extension, 1998
(http://learningstore.uwex.edu/pdf/G3658-2.pdf, 15
DiCicco-Bloom B, Crabtree BF. The qualitative May 2008).
research interview. Medical Education, 2006, 6. Barbour RS. Making sense of focus groups. Medical
40:314–321. Education, 2005, 39:742–750.
7. Brinko K. The practice of giving feedback to improve
teaching: what is effective? Journal of Higher
Learning Technology Dissemination Initiative, Education, 1993, 64(5):574–593.
Hariot Watt University. The evaluation cookbook,
1999 (http://www.icbl.hw.ac.uk/ltdi/cookbook/,
accessed 15 May 2008).
55
10. Web-based tools and resources
56
11. Activities to assist patient safety understanding
Don’t tell students when you can show them, and Lectures are often structured as follows, with
don’t show them when they can do it themselves. three principal elements (set, body, close):
• the set, or introduction, is the initial period of
Lowman has outlined some teaching strategies the lecture when the lecturer explains why the
for increasing the effectiveness of active learning, topic is important and outlines the objectives
including: [3] of the session;
• use information that is of interest to learners • the body is the main content part of the
and involves real-life events; lecture;
• present dramatic or provocative material; • the conclusion should revisit the objectives
• reward learners; and the key points of the presentation.
• tie themes together with as many topics as
possible;
57
11. Activities to assist patient safety understanding
Benefits: Challenges:
• able to convey information to large numbers • lack of time due to work pressures;
of students at one time; • lack of knowledge of how to incorporate
• useful for providing an overview of broad patient safety topics into bedside teaching;
topics, to impart factual information and • opportunistic—not possible to prepare and
introduce theoretical concepts; difficult to deliver a uniform curriculum.
• provide up-to-date information and ideas that
are not easily accessible in texts or papers; Examples:
• can explain or elaborate on difficult concepts • hand hygiene issues on the ward;
and ideas and how these should be • patient identification processes.
addressed.
Resource:
Challenges: Teaching on the run series
• keeping large numbers of students actively (http://www.meddent.uwa.edu.au/go/about-the-
engaged; faculty/education-centre/teaching-on-the-run/teac
• junior staff generally prefer more experiential hing-resources).
techniques;
• presentation skills; Small group activities—learning with others
• usually there is some dependence on Learning done in the setting of a small group,
technology; usually with a tutor. The main feature is student
• content (medical harm) can be discouraging. participation and interactivity, used in relation to a
particular problem, with more onus on the
Examples: students to be responsible for own learning, e.g.
• introduction to patient safety; PBL, project work.
• introduction to human factors.
Benefits:
Learning on the run during clinical • sharing own stories;
placements • learning from peers;
Teaching that occurs in the context of ward • multiple perspectives;
rounds or in bedside teaching sessions. • learning teamwork and communication skills.
Benefits: Challenges:
• ward-based teaching provides one of the • group dynamics;
best opportunities to teach and observe • resource implications in terms of tutor time;
history and examination skills as well as • expertise of the tutor.
communication and interpersonal skills—the
teacher can also role model safe, ethical, Examples:
professional practice; • human factors considerations of commonly
• patient safety issues are everywhere in the used clinical equipment;
clinical environment; • teamwork in the clinical environment.
• contextualized;
• real—hence highly relevant;
• interesting and often challenging.
58
11. Activities to assist patient safety understanding
Resources: Benefits:
University of Colorado, Denver, Health Sciences • fun, enjoyable;
Programme • challenging;
http://www.uchsc.edu/CIS/SmGpChkList.html. • can illustrate teamwork, communication.
Scottish Council for Postgraduate Dental and
Medical Education Challenges:
http://www.nes.scot.nhs.uk/Courses/ti/SmallGrou • relating the game to the workplace;
ps.pdf. • clearly defining the purpose of the game
upfront.
Case discussion
A group of students—often with a tutor—discuss Resource:
a clinical case. • Examples of teamwork generating games
http://wilderdom.com/games/InitiativeGames.
Benefits: html
• can use an actual or made-up case to
illustrate patient safety principles; Independent study
• contextualized—makes concepts real and Study undertaken by the student on their own,
relevant; e.g. assignment work, essays.
• learn to solve problems as they arise in the
workplace; Benefits:
• enables linking of abstract concepts to the • student can proceed at own pace;
real situation. • student can focus on own knowledge gaps;
• opportunity for reflection;
Challenges: • cheap, easy to schedule;
• choosing/developing realistic cases that • flexible for learner.
encourages students to become actively
engaged in the discussion; Challenges:
• using the case effectively to challenge • motivation;
thinking and generate thoughtful learning; • lack of exposure to multiple inputs;
• encouraging students to generate the • may be less engaging;
problem solving themselves. • marking the work and providing the feedback
is time consuming for the teacher.
Resources:
• incident analyses from parent hospital; Buddying a patient in hospital (patient
• agency for health-care research and quality tracking)
weekly morbidity and mortality cases; A student follows the course of an individual
• http://webmm.ahrq.gov/ patient throughout their hospital stay. Includes
accompanying the patient for all investigations
Games and procedures.
Encompasses a spectrum from computer games
to situational role play. Benefits:
• includes the opportunity to learn about the
health-care system;
59
11. Activities to assist patient safety understanding
60
11. Activities to assist patient safety understanding
occur and reach their conclusion (in real life a • act—what needs to happen next to continue
more capable clinician would have to intervene); the improvement process?
• identical scenarios can be presented to
different clinicians or teams; Benefits:
• the underlying causes of the situation are PDSA approaches encourage clinicians to develop
known; and be actively engaged in strategies that they
• with mannequin-based simulators clinicians hope will lead to improvement. It also promotes
can use actual medical equipment, exposing evaluation of these changes once the strategies
limitations in the human–machine interface; have been implemented. Therefore, this can be a
• with full recreations of actual clinical very useful approach to have students involved at
environments complete interpersonal a ward or clinical unit level, ideally as part of a
interactions with other clinical staff can be multidisciplinary team approach to patient safety.
explored and training on teamwork, Most quality improvement projects by their very
leadership and communication provided; nature have a patient safety element to them.
• intensive and intrusive recording of the • motivating
simulation session is feasible, including • empowering
audiotaping and videotaping; there are no • learn about change management
issues of patient confidentiality—the • learn to be proactive
recordings can be preserved for research, • learn to problem solve.
performance assessment or accreditation.
Challenges:
Challenges: • sustaining momentum and motivation
• some modalities are very expensive; • time commitment.
• specialized expertise required for teaching
and for upkeep of some of the training Example:
devices. • hand hygiene issues in a clinical environment.
Resource: Resources
Society for Simulation in Healthcare Teaching Quality Improvement Presentation,
(www.ssih.org). Institute for Healthcare Improvement
http://www.ihi.org/NR/rdonlyres/60C85294-F1F9-
Improvement projects 49D9-8D89-F3DFBD2376A5/1150/TeachingQuali
Quality improvement is a continuous cycle of tyImprovementPresentation.pdf
planning, implementing strategies, evaluating the
effectiveness of these strategies and reflection to Bingham JW. Using a health-care matrix to
see what further improvements can be made. assess patient care in terms of aims for
Quality improvement projects are typically improvement and core competencies. Joint
described in terms of the PDSA cycle [8] as follows: Commission Journal on Quality and Patient
• plan—the change, based on perceived ability Safety, 2005, 31(2:February):98–105.
to improve a current process;
• do—implement the change; AHRQ mortality and morbidity web site
• study—analyse the results of the change; (http://www.webmm.ahrq.gov/).
61
References
1. 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. San
Francisco, Jossey-Bass, 1995.
4. Dent JA, Harden, RM. A practical guide for medical
teachers. 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 medical
education: an ethical imperative. Academic Medicine,
2003, 78(8):783–788.
7. Gaba, DM. Anaesthesiology as a model for patient
safety in healthcare. British Medical Journal, 2000,
320(785–788).
8. Cleghorn GD, Headrick L. The PDSA cycle at the core
of learning in health professions education. Joint
Commission Journal on Quality Improvement, 1996,
22(3):206–212.
62
12. How to foster and engage in a transnational
approach to patient safety education
Patient safety impacts on all countries The World Federation of Medical Education has
In 2002, WHO Member States agreed on a World also published standards for international best
Health Assembly resolution on patient safety practice in medical school accreditation.
because they saw the compelling evidence of the
need to reduce the harm and suffering of patients There is evidence that developing countries that
and their families, and the economic benefits of have invested heavily in future generations of
improving patient safety. The extent of patient harm health-care workers have seen their assets
from their health care has been exposed by the stripped by the predations of the health-care
publication of international studies from a number systems of richer developing nations during times
of countries including Australia, Canada, Denmark, of workforce shortages [2].
New Zealand, the United Kingdom and the United
States of America. The concerns of patient safety The globalization of health-care delivery has
are international, and it is widely recognized that forced medical education to recognize the
adverse events are considerably underreported. challenges of preparing medical students who are
While the bulk of patient safety research might be not only able to work in their country of training,
done in Australia, the United Kingdom and the but also work in other health-care systems.
United States, patient safety advocates wish to see Harden [3] described a three-dimensional model
patient safety adopted in all countries around the of medical education based on the:
world, not just those that have had the resources • student (local or international);
to study and publish their patient safety initiatives. • teacher (local or international);
This internationalization of patient safety requires • curriculum (local, imported or international).
novel approaches to the education of future
doctors and health-care practitioners. In the traditional approach to teaching and
learning patient safety, local students and local
Globalization teachers use a local curriculum. In the
The global movements of doctors in training have international medical graduate or overseas
produced many opportunities for enhancing student model, students from one country pursue
postgraduate medical education and training. The in another country a curriculum taught and
mobility of students and teachers, and the developed by teachers in the latter. In the branch-
international interconnectedness of experts in campus model, students, usually local, have an
curriculum design, instructional methods and imported curriculum taught jointly by international
assessment, married with local campus and and local teachers.
clinical environments, have led to a concordance
in what constitutes good medical education. A second important consideration in the
There have been initiatives to attack the problems internationalization of medical education is the
of variable standards across the world in the affordability of e-learning technologies that allow a
outputs of medical schools. The International global interconnectivity where the provider of a
Institute of Medical Educators has identified the teaching resource, the teacher of that resource and
Global Minimum Education Requirements with the the student do not all have to be on campus, in a
express purpose of defining the minimum hospital or out in a community at the same time.
competencies that all physicians must have,
regardless of where they receive their general The old style of curriculum emphasizes the
medical education or training [1]. mobility of students, teachers and curriculum
63
across the boundaries of two countries, by mutual included in this curriculum);
agreement, with a high expectation that the • a research section that would both facilitate
country of practice would provide much of the and encourage international collaboration;
training when the student graduates. • a curriculum map that identifies common areas
of global interest in patient safety—it is vital that
The new way is a transnational approach in which staff and students are able to customize
internationalization of patient safety education is programmes to meet their local and individual
integrated and embedded within a curriculum and needs;
involves collaboration between a number of • a collaboration section that includes online
schools in different countries. In this approach, discussions among students from different
the principles of patient safety are taught in the countries who participate as part of a
global context rather than the context of a single collaborative learning environment in an
country. international community of learners; a place for
teachers to share experiences;
This model offers a range of considerable • an “ask-the-expert” facility with online access
challenges and opportunities for international to patient safety experts from different
collaboration in patient safety education. This countries;
Curriculum Guide serves as an excellent base in • a bank of virtual patient safety cases with
this regard. It is important that the standards of emphasis on a ethical hazards, disclosure and
international medical education bodies, for apology;
example, the World Federation of Medical • an approach to patient safety that includes
Education, are reviewed to ensure that the cultural awareness and respects competences;
principles of patient safety are included. Similarly, • an assessment bank of patient safety items for
a dialogue is held with national accrediting bodies sharing—for example, the Hong Kong
of medical schools around the world to ensure International Consortium for Sharing Student
that patient safety principles are included in their Assessment Banks is a group of international
accreditation checklists. medical schools that maintains a formative and
summative bank of assessment items across
At a more local level, it is important for countries to all aspects of medical courses.
customize and adapt materials. A good example of
a transnational approach to medical education is the Content experts in patient safety and educational
experience with international virtual medical schools developers are in limited supply and often work in
[4]. Here a number of international universities have isolation. This impedes the sharing of information,
collaborated to form a virtual medical school, innovation and development and often results in
dedicated to enhanced learning and teaching. This unnecessary duplication of resources and learning
model could be adaptable to patient safety. activities. A transnational approach to patient
safety education will ensure that there is true
Common components of a transnational virtual international capacity-building in patient safety
patient safety curriculum could be: education and training. It is one way that
• a virtual library that would provide access to developed nations can assist developing nations
up-to-date resources, tools and learning by sharing their substantial curriculum
activities and access to international patient development resources.
safety literature (for example, the topics
64
References
1. Schwarz MR, Wojtczak A. Global minimum essential
requirements: a road towards competency-oriented
medical education. Medical Teacher, 2002, 24:125–
129.
2. Karle H. Global standards and accreditation in medical
education: a view from the WFME. Academic
Medicine, 2006, 81(12).
3. Harden RM. International medical education and future
directions: a global perspective. Academic Medicine,
2006, 81(12):S22–S29.
4. Harden RM, Hart IR. An international virtual medical
school (IVIMEDS): the future for medical education?
Medical Teacher, 2002, 24:261–267.
65
PART B: CURRICULUM GUIDE TOPICS
Why do medical students need patient safety By getting students to focus on each individual
education? patient, having them treat each patient as the
unique human being they are, practising their
Health-care outcomes have significantly improved knowledge and skills for the patient’s benefit
with the scientific discoveries of modern medicine. alone, students themselves can be role models for
But we also know as a result of studies undertaken others in the health-care system. Most medical
in many countries that along side these benefits students have high aspirations when they enter
are significant risks to patient safety. We know medicine, nevertheless the reality of the system of
that hospitalized patients and patients on health care sometimes deflates their optimism.
medications have increased risks of adverse We want students to be able to maintain their
events. A major consequence of this knowledge optimism and believe that they can make a
has been the development of patient safety as a difference, both to the individual lives of patients
specialized discipline. Patient safety is not a and the system of health care.
traditional stand alone discipline; rather, it is one
that integrates into all areas of medicine and How to approach patient safety
health care. teaching: managing the barriers
Effective student learning depends on teachers
Medical students as the future clinicians and using a range of educational methods such as
leaders in health care will need to know about imparting knowledge, demonstrating skills,
patient safety: how systems impact on the quality instilling attitudes—all are essential for patient
and safety of health care, how poor safety education. Teachers of patient safety
communication can lead to adverse events and should use:
much more. Students need to learn how to • problem-based teaching (facilitated group
manage these challenges. learning);
• simulated-based learning (role plays and
The WHO World Alliance for Patient Safety aims games);
to implement patient safety worldwide. Patient • lecture-based teaching (interactive/didactic);
safety is everyone’s business—health • mentoring and coaching (role models).
professionals, cleaners and catering staff,
managers, bureaucrats, consumers and Patients judge their doctors not by how much
politicians. As medical students are among the they know but by how they perform. The
future leaders in health care, it is vital that they are challenge for medical students when they
knowledgeable and skilful in their application of progress into the clinical environment is to apply
patient safety principles and concepts. This their scientific generalized knowledge to a specific
Curriculum Guide equips medical students with patient. In doing so, the student is going beyond
essential patient safety learning so they can “what” they know to knowing “how” to apply their
practise safely in all their clinical activities. knowledge. The best way for students to learn
“‘how” is by doing. Patient safety practice requires
The time to build students’ patient safety students to act safely—to check names, to seek
knowledge is right at the beginning of their entry information about medications, to ask questions.
into medical school. Students need to practise The best ways for students to learn about patient
their patient safety skills and behaviours as soon safety are by having hands-on experience or
as they enter a hospital, clinic or health service. practice in a simulated environment. The student
67
Introduction to the Curriculum Guide topics
needs expert coaching rather than a situation and the readiness of the medical
knowledgeable physician talking about profession for change. In some societies, patient
underpinning theories. When teachers observe safety concepts might not easily fit in with the
and give feedback about student performance the cultural norms. These barriers are explored in
student will continuously improve and eventually more depth in the following section.
master many of the patient safety skills.
The barriers most evident to students are those
Mentoring and coaching is also particularly that surface in hospitals and clinics. These mainly
relevant to patient safety education. Students relate to senior doctors and nurses who are
naturally try to copy and model their behaviour on unable to adapt to the new health care
their teachers and senior doctors; how they challenges, or who are able but actively
behave will be very influential on how students discourage any change. Their voices can change
behave or will behave when they qualify. Most a student from an advocate for patient safety to a
students come to medicine with high ideals— passive learner of textbook medicine. The way the
wanting to be a healer, to show compassion and different health professionals, such as nurses,
to be an ethical health professional. However, social workers or physiotherapists, maintain their
what they frequently see is rushed care, rudeness own cultures and continue to work in silos is also
to colleagues and professional self-interest. a significant barrier.
Slowly, their high ideals are compromised and
become more pragmatic and they just try to fit in As teachers become familiar with this curriculum,
with the medical culture around them. they will quickly realize that what they are teaching
may not be practised in the real world—this is
Patient safety education recognizes these strong particularly the case with patient safety. Some
influences and factors. These negative influences clinicians may feel that teaching patient safety to
can be moderated and their impact on students medical students is an unachievable goal because
minimized by talking with students about the of the many barriers. Yet, when barriers are
culture and the impact of such cultures on the named and talked about, they do not seem so
quality and safety of patients. Recognizing the daunting. Even discussion within the student
barriers and talking about them will give the group about the realities and the barriers can
student a sense of the system as a problem (and inform and teach. At the very least, it will allow a
not the people) and that it is possible to change it critique of the system.
for the better. The barriers are not the same for
every country, culture or even hospital or clinic How the topics relate to clinical
within one region. The country barriers might be practice
the laws and regulations governing the health Table 8 shows how the Curriculum Guide can be
system. These laws may prevent some of the integrated into clinical care using handwashing as
patient safety concepts being implemented. an example. The same principles apply to many
Different cultures have their own approaches to other areas of health care such as teamwork,
hierarchies and the ways conflicts are resolved. medication safety and engaging with patients.
The extent to which students are encouraged to This example is used because getting health
be assertive in the presence of senior doctors, professionals to stop the transmission of infection
particularly in circumstances where a patient by washing their hands using the correct
might be at risk of harm, will depend on the techniques seems such an obvious and easy
68
Introduction to the Curriculum Guide topics
thing to achieve. But despite hundreds of problem and hospital-acquired infection rates are
campaigns to educate staff about universal climbing worldwide.
precautions we do not appear to have fixed this
Problem area: minimizing the spread of infection Curriculum Guide topic and relevance to practise
Problem caused by poor infection control. Topic 1 “What is patient safety?” describes the
evidence of the harm and suffering caused by
adverse events. Patients suffering an infection die
or spend extended time in hospital or are
permanently disabled as a result of their infection.
Infections can be avoided and minimized when
patients apply correct handwashing techniques
and when health professionals comply with
universal precautions. Knowing the causes of
infections (adverse events) and the steps that can
be taken to minimize any opportunity for
transmission is the first step to prevention.
People know that infection is a problem, however, Topic 2 “What is human factors and why is it
just knowing does not seem to change practice. important to patient safety?” explains how and
People tend to use correct handwashing why humans work they way they do, which
techniques for a while, but then they forget. includes making errors. An understanding of
human factors will assist people to identify
opportunities for errors and know how they can be
avoided or minimized. Understanding the factors
involved in errors and their root causes will assist
people to understand the context of their actions.
Telling people to try harder (wash their hands
correctly) will not change anything. They need to
see their own actions in context of the environment
they work in and the equipment they use. When
health-care workers believe that a patient’s
infection was caused by their actions they are
more likely to change practise and use universal
precautions.
69
Introduction to the Curriculum Guide topics
Problem area: minimizing the spread of infection Curriculum Guide topic and relevance to practise
People want to maintain proper infection control Topic 3 “Understanding systems and the impact of
but there are too many patients to care for and not complexity on patient care” shows how patient
enough time to wash hands properly. care comprises multiple steps and multiple
relationships. Patients depend on health
professionals treating them in the right way; they
depend on a system of health care. Medical
students need to know that good health care is a
team effort and not just one person. They need to
understand that washing hands is not an optional
extra but an important step in caring for the
patient. Understanding how one’s actions, and
each component of care, fit together in a
continuous process that has either good
outcomes (the patient gets better) or bad
outcomes (the patient suffers an adverse event) is
an important patient safety lesson. When they
understand that the actions of one person on the
team can undermine the patient’s treatment goals,
they quickly see their work in a different context—a
patient safety context.
There are no alcohol rubs or cleaning agents on Topic 4 “Being an effective team player” is integral
the wards because the clerk forgot to order them. to the work of doctors. If no alcohol rubs are
available it is up to every member of the team to
notify the appropriate person to ensure availability.
Just complaining that one cannot wash because
someone forgot to order alcohol rubs does not
help the patients get better. Being mindful at work
and looking for opportunities to assist patients and
the team is part of being professional and a team
player. Adverse events are often caused by many
seemingly trivial things—not washing hands, no
medication chart available, delayed attendance of
a doctor. Reminding someone to order the alcohol
rubs is not trivial in the context that it can prevent
an infection.
70
Introduction to the Curriculum Guide topics
Problem area: minimizing the spread of infection Curriculum Guide topic and relevance to practise
A surgeon left the theatre briefly to answer a Topic 5 “Understanding and learning from errors”
mobile phone. He returned to theatre and shows that blaming people does not work, and
continued the operation wearing the same gloves. that if people fear being blamed no one will report
The patient experienced a postoperative wound or learn from the event. A systems approach to
infection. errors seeks to find out the underlying causes of
errors and make sure they are not repeated. An
examination of the causes of the infection may
show that the surgeon left the theatre and did not
maintain a sterile environment. Blaming him will
achieve nothing. Further analysis may show that
the surgeon and the rest of the team had been
routinely violating infection control guidelines
because they did not think infection was a
problem. Without the data they were lulled into a
false sense of security.
The patient above who received the infection Topic 6 “Understanding and managing clinical risk”
made a written complaint to the hospital about shows students the importance of having systems
their care and management. in place to identify problems and fix them before
they happen. Complaints can tell a doctor, nurse
or hospital manager if there are particular
problems. This patient’s letter of complaint about
their infection may be the tenth letter in a month,
which could tell the hospital that there may be a
problem with infection. Reporting incidents and
adverse events is also a systematic way of
gathering information about the safety and quality
of care.
The hospital decides that it has a problem with Topic 7 “Introduction to quality improvement
infection in a particular theatre and wants to know methods” identifies two major methods for
more about the problem. measuring and making improvements in clinical
care—students need to know to measure
processes of care and measure whether the
changes led to an improvement.
71
Introduction to the Curriculum Guide topics
Problem area: minimizing the spread of infection Curriculum Guide topic and relevance to practise
The hospital now knows that one of the theatres Topic 8 “Engaging with patients and carers” shows
has a higher infection rate than the others. Patients students the importance of honest communication
are complaining and the hospital was recently in with patients after an adverse event and the
the media about its infection problem. importance of giving complete information to
patients about their care and treatment. Engaging
with patients is necessary to maintain trust of the
community.
The hospital decides that infection is a particular Topic 9 “Minimizing infection through improved
problem and that everyone needs to be reminded infection control” describes the main types and
of the importance of complying with universal causes of infections as well as covers the relevant
precautions. steps and protocols for minimizing the
transmission of infection.
The hospital decides to review infection control in Topic 10 “Patient safety and invasive procedures”
theatres because surgical site infections comprise demonstrates to students that patients having
a significant percentage of the adverse events surgery or an invasive procedure are at a higher
being reported by staff. risk of infection or receiving the wrong treatment.
An understanding of the failures caused by poor
communication, lack of leadership, inadequate
attention to processes, non-compliance with
guidelines and over work will help the students to
appreciate the multiple factors that are at play in
surgery.
In reviewing surgery using a quality improvement Topic 11 “Improving medication safety” is relevant
method (one that asks “what happened” instead of to students because medication errors cause a
“who did it”) it was discovered in the search for an significant proportion of adverse events. The scale
intervention that might assist lower the infection of medication error is immense and students need
rate that the appropriate administration of to identify factors that lead to errors and know the
prophylactic antibiotics can prevent infections. But steps to take to minimize them. Medication safety
this protocol also required that a complete would ensure that students know about the
medication history was available for each patient to potential for adverse drug reactions and that one
make sure other medications they were taking has to consider each medication and its potential
were safe. interaction with other medications as well as the
predicted side-effects of a single medication.
72
Introduction to the Curriculum Guide topics
Confronting the real world: helping repercussions for them or the doctors involved.
students to become patient safety Over-reliance on supervisors for teaching and
leaders assessment may encourage students to conceal
One of the main challenges to patient safety their mistakes and to perform clinical tasks when
reform is the preparedness of the hospital or clinic requested knowing they are not competent in
to be open to new ways of delivering health care. those tasks.
Change can be very difficult for organizations and
practitioners who are used to treating patients in a Students may be reluctant to talk to their
particular way. They do not necessarily see supervisors about patient safety or express their
anything wrong with how they deliver care, and concerns about an ethical issue. This may also
are not convinced they need to change. They include a reluctance to advise their supervisors
may feel threatened or challenged when about a patient safety issue particularly if it
someone, particularly a junior person, sees things involves a critique of the actions of a senior
differently and may even do things differently. In clinician. They may be fearful of receiving an
these circumstances, unless students are unfavourable report or being seen as “lacking in
supported with positive coaching and discussion commitment” or “having a bad attitude”. Students
about their experiences, much of the teaching may hold founded or unfounded fears that
and learning about patient safety at medical speaking up for a patient or disclosing errors may
school will be undermined. lead to unfavourable reports, decreased
employment opportunities, reduced chances for
Medical students learn very quickly about how gaining access to training programmes, or all
doctors behave and what is expected of them, three.
and because they are novices they wish to fit in as
soon as possible. Many students and junior Discussions about medical errors are difficult for
doctors think their survival of the early years and doctors in all cultures. Openness to learning from
their careers depends on their fitting in. The errors will often depend on the personalities of the
system of medical progression relies on reports senior people. In some cultures and hospitals,
from supervising clinicians about the performance openness about errors may be new and so it will
and development of students and young doctors. be very difficult for doctors. In these cases, it may
Medical students are low in the medical hierarchy be appropriate for the students to talk about
and very dependent upon supervisors for their errors in a student teaching session. In other
instructions and learning. places, error discussions may occur in closed
meetings and in more advanced hospitals the
For students, maintaining the confidence of a team may talk about errors openly and have many
supervisor is paramount. Their progression policies in place to assist health-care workers
depends on favourable reports from supervisors navigate their way through an error. But eventually
based on informal and formal feedback and every country will have to confront the human
subjective and objective assessments about their suffering caused by human and system errors.
competence and commitment. Patient safety Once the suffering is openly acknowledged by
requires that doctors talk about their mistakes and hospitals and clinics it is difficult to stay the same.
learn from them, but students may fear that Many will adopt different approaches to
disclosing their own mistakes or the mistakes of hierarchies and patient care services. These
senior clinicians to supervisors may have approaches view the team as the main instrument
73
Introduction to the Curriculum Guide topics
of health-care delivery; envisaging a flatter Modern societies want safe quality care and this
hierarchy in which everyone caring for the patient requires health care to adopt a safety culture. This
can appropriately contribute. safety culture has started to permeate health-care
workplaces around the world and students will
It may help students if they can understand why the encounter both traditional attitudes and attitudes
expectations and attitudes of some senior staff that stem from a safety culture. The challenge for
seem at odds with what they have learnt about all students, irrespective of their culture and
patient safety. Health care has not been designed country, is to practise safe health care, even when
with patient safety in mind, it has evolved over time those around them do not.
with many aspects of care being a consequence of
tradition rather than what we would consider safe, It is helpful to be able to differentiate between old
efficient and effective care appropriate to approaches that may negatively impact on patient
contemporary health care. Many attitudes within care and new ways that foster patient-centred
medicine are deeply rooted in a professional culture care. It is also important to acknowledge that this
that originated in a time when hierarchical structures cultural shift may create some tension for the
were common place in society, when medicine was student or trainee who is keen to practice with
seen as a life vocation that involved a 24 hours a safety in mind, but whose direct senior is not aware
day commitment, when doctors were considered of, or in favour of, new approaches. It is important
infallible, good doctors did not make mistakes, that students talk to their supervisors before they
training was through apprenticeship, patient start practising the suggested new ways.
outcomes (good and bad) were due to the doctor’s
skills—not the team. Doctors were not We do not expect students to put themselves or
professionally accountable to anyone other than their careers at risk in the interest of changing the
themselves and non-paying patients in some places system. But we do encourage students to think
were predominantly viewed as learning material. about how they might approach their training and
Although much has changed, some remnants of maintain a patient safety perspective at the same
the old culture have persisted and shaped the time. Table 9 provides a framework that gives
attitudes of staff who trained in the days before students some ideas for managing the conflicts
safety and quality became an important outcome they may experience while they are in supervised
measure of successful health care. placements in hospitals or clinics.
74
Introduction to the Curriculum Guide topics
Medical hierarchies: Doctor does not clean Student says nothing and (1) Seek clarification of the correct
handwashing hands between patients. conforms to inadequate technique for handwashing with the
technique. Imitate senior doctor or other senior person.
doctor.
(2) Say nothing but use safe
handwashing techniques.
Medical hierarchies: Surgeon does not Adopt the approach of the (1) Actively help the rest of the team to
site of surgery participate in checking surgeon and do not complete the checking protocol.
the correct site for participate in checking—
surgery or verifying the decide that checking is too
correct patient. menial a task for a doctor
The surgeon is resentful anyway.
of the preoperative
checking protocol,
believing it to be a waste
of time, and pressures
the rest of the team to
hurry up.
Medical hierarchies: Student knows that a Say nothing for fear of being (1) Immediately share concern about
medication patient has a known seen to disagree with a allergy with the doctor. Student views
serious allergy to senior doctor’s decision. this as being a helpful part of the team
penicillin and observes a Presume that the doctor and also their responsibility as a
senior doctor prescribe must know what they are patient advocate.
penicillin. doing anyway.
Paternalism: Student asked to get Accept task. Do not let (1) Decline the task and suggest that a
consent consent from a patient senior staff know level of doctor with some familiarity with the
for a surgical procedure ignorance about procedure. procedure would be more appropriate
the student has never Talk to the patient about the for this task.
heard of before. procedure in a vague and
superficial way so as to get (2) Accept the task, but explain you
the patient’s signature on know little about the procedure so will
the consent form. need some teaching about it first and
request that one of the doctors comes
along to help/supervise.
75
Introduction to the Curriculum Guide topics
Paternalism: The patients are ignored Accept the situation and do (1) Take the lead in greeting the
role of patients in during the ward round nothing. Assume that this is patient: “Hello Mr Ruiz, we are
their care and not engaged in the way things are done reviewing all of our patients this
discussion about their around here. Conform to morning. How are you feeling today?”
situation. behaviours that do not
include or engage with (2) If there is time pressure to keep
Family members are patients and their families. moving, explain to the patient and their
asked to leave the family, “I will come back to talk to you
bedside when the after the ward round”.
doctors are doing their
ward rounds. (3) Find out your patients’ concerns
before the round and raise them with
the senior doctors on the round at the
bedside, e.g. “Mr Cartlon is hoping to
avoid the surgery, is this an option for
him?”
Infallibility of doctors: A junior doctor on the Admire the doctor for their (1) Ask the doctor how they feel and
hours of work ward announces with stamina and commitment to whether it is wise or even responsible
pride that they have their work. to still be working?
been at work for the last
36 hours. (2) Ask the doctor when they are due
to finish and how they are going to get
home? Are they safe to even drive a
car?
Infallibility of doctors: Mistakes are only made Accept the culture that says (1) Understand that everyone will make
attitude to mistakes by people who are doctors who make mistakes mistakes at some time and that the
incompetent or are “bad” or “incompetent”. causes of errors are multifactorial
unethical. Good doctors Try harder to avoid making a involving latent factors not immediately
do not make mistakes. mistake. Remain silent, or obvious at the time the error was
find someone or something made. Look after your patients,
else to blame when you yourself and your colleagues in the
have made a mistake. event of an error and actively promote
Look at the mistakes others learning from error.
make and tell yourself you
would not be that stupid.
76
Introduction to the Curriculum Guide topics
Infallibility of doctors: Senior doctor makes a Accept that the way to (1) Talk to a supervisor about open
making mistakes mistake and tells patient handle a mistake is to disclosure to patients and whether the
it was a complication. rationalize that it was a hospital or clinic has a policy about
Doctors do not talk problem associated with the providing information to a patient after
about their mistakes in patient rather then their an adverse event.
peer review meetings. health care. Quickly learn
that doctors do not disclose (2) Ask the patient if they would like
errors to patients or their more information about their care and
colleagues and model if so advise the doctor that the patient
behaviour of senior doctor. would like more information.
Infallibility of doctors: A doctor who acts “god Aspire to be like this doctor (1) Recognize the arrogance in such
omniscience like” and looks down on and admire how everyone attitudes and model behaviour on
other health bows down to them. doctors who work in teams and share
professionals and their knowledge and responsibilities.
patients.
Blame/shame A doctor who makes a Say nothing and model (1) Offer support and understanding to
mistake is ridiculed or behaviour on other doctors a colleague who is involved in an
humiliated by his who talk negatively about a incident.
supervisor. health professional involved
in an incident. (2) Talk to colleagues and supervisor
A hospital disciplines a about better ways to understand
staff member for an mistakes than just blaming the person
error. involved.
Teamwork: Students and junior Change behaviour to reflect (1) Be mindful that the team from a
my team is the doctors identify only that of the rest of the patient’s perspective is everyone who
medical team other doctors as being doctors and identify only cares for and treats the patient—
part of their team. with the medical members nurses, ward staff, allied health,
of the team. including the patient and their family
The doctors in the ward members.
do their rounds without a
member of the nursing (2) Always suggest including other
staff present. members of the health-care team in
conversations and discussions about a
patient’s care and treatment.
77
Definition of terms
International Classification for Patient Safety (v.1.0) for Use in Field Testing in 2007–2008
78
Definition of terms
Key to Icons
1 Slide Number
T6
Topic Number
Groups
Lecture
Simulation exercises
Books
Web
DVD
79
Topic 1: What is patient safety?
Why is patient safety relevant 1 safety by engaging with patients and their families,
to health care? checking procedures, learning from errors and
There is now overwhelming evidence that significant communicating effectively with the health-care
numbers of patients are harmed from their health team. Such activities can also save costs because
care either resulting in permanent injury, increased they minimize the harm caused to patients. When
length of stay (LOS) in hospitals and even death. We errors are reported and analysed they can help
have learnt over the last decade that adverse events identify the main contributing factors.
occur not because bad people intentionally hurt Understanding the factors that lead to errors is
patients but rather that the system of health care essential for thinking about changes that will
today is so complex that the successful treatment prevent errors from being made.
and outcome for each patient depends on a range
of factors, not just the competence of an individual Keywords
health-care provider. When so many people and Patient safety, system theory, blame, blame
different types of health-care providers (doctors, culture, system failures, person approach,
nurses, pharmacists, social workers, dieticians and violations and patient safety models.
others) are involved this makes it very difficult to
ensure safe care, unless the system of care is Learning objective 2
designed to facilitate timely and complete The objective of this module is to
information and understanding by all the health understand the discipline of patient safety and
professionals. its role in minimizing the incidence and impact
of adverse events, and maximizes recovery
Patient safety is an issue for all countries that from them.
deliver health services, whether they are privately
commissioned or funded by the government. Learning outcomes: 3 4
Prescribing antibiotics without regard for the knowledge and performance
patient’s underlying condition and whether Patient safety knowledge and skills covers many
antibiotics will help the patient, or administering areas: medication safety, procedural and surgical
multiple drugs without attention to the potential skills, effective teamwork, accurate and timely
for adverse drug reactions, all have the potential communication and more. The topics in this
for harm and patient injury. Patients are not only Curriculum Guide have been selected based on the
harmed by the misuse of technology, they can evidence of relevance and effectiveness. This topic
also be harmed by poor communication between takes an overview of patient safety and sets the
different health-care providers or delays in scene for deeper learning in some of these areas.
receiving treatment. For example, we introduce the term “sentinel event”
in this topic but we go deeper into its meaning and
Patient safety is a broad subject incorporating the relevance to patient safety in topic 6.
latest technology such as electronic prescribing
and redesigning hospitals and services to washing What students need to do
hands correctly and being a team player. Many of (performance requirements):
the features of patient safety do not involve • apply patient safety thinking in all clinical
financial resources; rather, they involve activities;
commitment of individuals to practise safely. • demonstrate ability to recognize the role of
Individual doctors and nurses can improve patient patient safety in safe health-care delivery.
80
Topic 1: What is patient safety?
What students need to know caused by other factors not related to such
(knowledge requirements): negligence. They concluded that many patients
• the harm caused by health-care errors and were injured as a result of poor medical
system failures; management and substandard care. Bates et al.
• the lessons about error and system failure [11] found that adverse drug events were common
from other industries; and that serious adverse drug events were often
• the history of patient safety and the origins of preventable. They further found that medications
the blame culture; harmed patients at an overall rate of about 6.5 per
• the difference between system failures, 100 admissions in large US teaching hospitals.
violations and errors; Although most resulted from errors at the ordering
• a model of patient safety. stage, many also occurred at the administration
stage. They suggested that prevention strategies
WHAT STUDENTS NEED TO KNOW should target both stages of the drug delivery
(KNOWLEDGE REQUIREMENTS) process. Their research, based on self-reports by
nurses and pharmacists and daily chart review, is a
The harm caused by health-care errors conservative figure because doctors do not
and system failures 5 routinely self-report medication errors.
Even though the extent of adverse events in
the health system has long been recognized [1-8] , Many studies confirm that medical error is
the degree to which they are acknowledged and prevalent in our health system and that the costs
managed varies greatly across health systems and are substantial. In Australia [13], medical error in
across health professions. Poor information and one year resulted in as many as 18 000
understanding about the extent of harm, unnecessary deaths and more than 50 000
and the fact that most errors do not cause any disabled patients. In the United States [14],
harm at all, may explain why it has taken so long to medical error resulted in at least 44 000 (and
make patient safety a priority. In addition, mistakes perhaps as many as 98 000) unnecessary deaths
affect one patient at a time and staff working in one each year and one million excess injuries.
area may only experience or observe an adverse
event infrequently. Errors and system failures do not In 2002, WHO Member States agreed on a
all happen at the same time or place, which can World Health Assembly resolution on patient
mask the extent of errors in the system. safety because they saw the need to reduce the
harm and suffering of patients and their families
The collection and publication of patient outcome and the compelling evidence of the economic
data is not yet routine for all hospitals and clinics. benefits of improving patient safety. Studies show
However, the significant number of studies that that additional hospitalization, litigation costs,
have relied upon patient outcome data [7,9,10] infections acquired in hospitals, lost income,
show that most adverse events are preventable. In disability and medical expenses have cost some
a landmark study by Leape et al. [10] found that countries between US$ 6 billion and US$ 29
more than two thirds of the adverse events they billion a year [12,14].
studied were preventable, 28% were due to the
negligence of a health professional and 42% were
81
Topic 1: What is patient safety?
The extent of patient harm from health care has confirm the high numbers of patients involved and
been exposed by the publication of the show the adverse event rate in four countries.
international studies listed in Table 10. They
Table 10: Data on adverse events in health care from several countries
Study Study focus Number of Number of Adverse
(date ofadmissions) hospital adverse event rate
admissions events (%)
Source: World Health Organization, Executive Board 109th session, provisional agenda item 3.4, 5 December 2001, EB 109/9.
a Revised using the same methodology as the Quality in Australian Health Care Study (harmonising the four methodological discrepancies
between the two studies).
b Revised using the same methodology as Utah–Colorado Study (harmonising the four methodological discrepancies between the two studies).
Studies 3 and 5 present the most directly comparable data for the Utah–Colorado and Quality in Australian Health Care studies.
The studies listed in Table 10 used retrospective To assist management of adverse events many
medical record reviews to record the extent of health systems categorize adverse events by level
patient injury as a result of health care [15-18]. of seriousness. The most serious adverse events
Since then, Canada, England and New Zealand are called sentinel events, which cause serious
have published similar adverse event data [19]. injury or death. Some countries call these the
While the rates of injury differ in the countries that “should never be allowed to happen” events.
publish data, there is unanimous agreement that Many countries now have or are putting in place
the harm is of significant concern. The catastrophic systems to report and analyse adverse events.
deaths that are reported in the media, while horrific Some countries have even mandated reporting of
for the families and health professionals involved, sentinel events. The reason for categorizing
are not representative of the majority of adverse adverse events is to ensure that the most serious
events in health care. Patients are more likely to ones with the potential to be repeated are
suffer less serious but nevertheless debilitating analysed by a quality improvement method to
events such as wound infections, decubitus ulcers make sure that the causes of the problem are
and unsuccessful back operations [19]. Surgical uncovered and steps taken to prevent another
patients are more at risk than others [20]. incident. These methods are covered in topic 7.
82
Topic 1: What is patient safety?
Table 11 sets out the types of sentinel events that are required reporting by governments in Australia and
the United States.
Table 11. Sentinel events reported in the Australia and the United States [19]
Type of adverse event USA (% of 1579) Australia (% of 175)
Suicide of in patient or within 72 hours of discharge 29 13
Surgery on wrong patient or body part 29 47
Medication error leading to death 3 7
Rape/assault/homicide in an in patient setting 8 N/A
Incompatible blood transfusion 6 1
Maternal death (labour, delivery) 3 12
Infant abduction/wrong family discharge 1 -
Retained instrument after surgery 1 21
Unanticipated death of a full-term infant - N/A
Severe neonatal hyperbilirubinaemia - N/A
Prolonged fluoroscopy - N/A
Intravascular gas embolism N/A -
N/A indicates that this category is not on the official reportable Sentinel Event list for that country
Human and economic costs eighth leading cause of death in the United
There are significant economic and human costs States. The Institute of Medicine also estimated
associated with adverse events. The Australian that preventable errors cost the nation about
Patient Safety Foundation estimated for the state US$ 17 billion annually in direct and indirect costs.
of South Australia the costs of claims and
premiums on insurance for large medical The human costs of pain and suffering include
negligence suits to be about $18 million loss of independence and productivity for both
(Australian) in 1997–1998 [21]. The National patients and the families and carers remains
Health Service in the United Kingdom pays out un-costed. While debates [24-27] within the
around £400 million in settlement of clinical medical profession about the methods used to
negligence claims every year [22]. The US Agency determine the rates of injury and their costs to the
for Healthcare Research and Quality (AHRQ) health system continue, many countries have
reported in December 1999 that preventing accepted that the safety of the health-care system
medical errors has the potential to save is a priority area for review and reform.
approximately US$ 8.8 billion per year [23]. Also
reporting in 1999, the Institute of Medicine report, Lessons about error and system
To err is human—building a safer health system, failure from other industries 6
estimated that between 44 000 and 98 000 The large-scale technological disasters in
people die each year from medical errors in spacecraft, ferries, off-shore oil platforms, railway
hospitals alone, thus making medical errors the networks, nuclear power plants and chemical
83
Topic 1: What is patient safety?
installations in the 1980s led to the development organizational culture tolerates violations of rules
of organizational frameworks for safer workplaces and procedures is critical. This was a feature
and safer cultures. The central principle present in the events preceding the Challenger
underpinning efforts to improve the safety in these crash* [3]. That investigation showed how
industries was that accidents are caused by violations had become the rule rather than the
multiple factors, not single factors in isolation: exception. Vaughan analysed the Challenger
individual situational factors, workplace conditions crash findings and described how violations are
and latent organizational and management the product of continued negotiations between
decisions were commonly involved. experts searching for solutions in an imperfect
environment with incomplete knowledge**. This
Analysis of these disasters also showed that the process of identifying and negotiating risk factors,
more complex the organization, the greater he suggested, leads to the normalization of risky
potential for a larger number of system errors in assessments.
the organization or operation.
Reason [35] took these lessons from industries to
Sociologist Barry Turner, who examined make sense of the high number of adverse events
organizational failures in the 1970s was the first to inside health care. He stated that only a systems
appreciate that tracing the “chain of events” was approach (as opposed to the more common
critical to an understanding of the underlying “person” approach—of blaming an individual
causes of accidents [28,29]. Reason’s work on the doctor or nurse) will create a safer health-care
cognitive theory of latent and active error types and culture because it is easier to change the
risks associated with organizational accidents built conditions people work in than change human
on his work [30,31]. Reason analysed the features actions. To demonstrate a systems approach he
of many of the large-scale disasters occurring in used examples from the technological hazard
the 1980s and noted that latent human errors were industries that show the benefits of built-in
more significant than technical failures. Even when defences, safeguards and barriers***. When a
faulty equipment or components were present, he system fails, the immediate question should be
observed that human action could have averted or why it failed rather than who caused it to fail; e.g.
mitigated the bad outcome. which safeguards failed? Reason created the
“Swiss cheese” Model [36] to explain how faults in
An analysis of the Chernobyl catastrophe [32] the different layers of the system can lead to
showed that organizational errors and violations of accidents/mistakes/incidents.
operating procedures that were typically viewed
as evidence of a “poor safety culture” [33] at Figure 3 uses Reason’s Swiss cheese model and
Chernobyl were really organizational shows the steps and multiple factors (latent
characteristics that contributed to the incident. factors, error producing factors, active failures and
The lesson learnt from the Chernobyl investigation defences) that are associated with an adverse
was that the extent to which a prevailing event.
*The viton O-ring seals failed in the solid rocket boosters shortly after launch. The Rogers Commission also found that other flaws in shuttle
design and poor communication may have also contributed to the crash.
**For nearly a year before the Challenger’s last mission the engineers were discussing a design flaw in the field joints. Efforts were made to
redesign a solution to the problem but before each mission, both NASA and Thiokol officials (a company that designed and built the
boosters) certified the solid rocket boosters were safe to fly. (See Challenger: a major malfunction by Malcolm McConnell, Simon & Schuster,
19877. Challenger had previously flown nine missions before the fatal crash.
***Engineered defensive systems include automatic shut-downs (alarms, forcing functions, physical barriers). Other defensive mechanisms
are dependent on people such as pilots, surgeons, anaesthetists, control room operators. Procedures and rules are also defensive layers.
84
Topic 1: What is patient safety?
The diagram shows that a fault in one layer of the the time of the incident and hold them
organization is usually not enough to cause an accountable. This act of “blaming” in health care
accident. Bad outcomes in the real world usually has been a common way for resolving health-care
occur when a number of faults occur in a number problems. We refer to this as the “blame culture”.
of layers (for example, rule violations, inadequate Since 2000, there has been a dramatic increase in
resources, inadequate supervision, inexperience) the number of references to the “blame culture” in
and momentarily line up to permit a trajectory of the health literature [37]. This is possibly due to
accident opportunity. For example, if a junior the realization that system improvements cannot
doctor was properly supervised in a timely way, be made while we focus on blaming individuals.
then a medication error may not occur. To combat Our willingness to “blame” is thought to be one of
errors at the sharp end, Reason invoked the the main constraints on the health system’s ability
“defence in-depth” principle [36]. Successive to manage risk [36,38-41] and improve health
layers of protection (understanding, awareness, care. Putting this into the context of health care, if
alarms and warnings, restoration of systems, a patient is found to have received the wrong
safety barriers, containment, elimination, medication causing an allergic reaction we look
evacuation, escape and rescue) are designed to for the person—be they medical student, nurse or
guard against the failure of the underlying layer. doctor—who gave the wrong drug and blame that
The organization is designed to anticipate failure person for the patient’s condition. Individuals who
thus minimizing the hidden “latent” conditions that are identified as responsible are also shamed. The
allow actual or “active” failures to cause harm. person responsible may receive remedial training,
a disciplinary interview or told never to do it again.
Figure 3. Swiss cheese model 7 We know that simply insisting the health-care
workers just “try harder” does not work. Policy
Latent factors
Organisational processes - workload, handwritten prescriptions
and procedures may also change to tell health-
Management decisions - staffing leveIs, culture of lack of support for interns
Error-producing factors
care workers how to avoid an allergic reaction in a
Environmental - busy ward. Interruptions
Team - lack of supervision patient. The focus is still on the individual staff
Individual - limited knowledge
Task - repetitious, poor .medication chant design
Patient - complex communication difficulties
members rather than on how the system failed to
Active failures
Error - slip, lapse
protect the patient and prevent a wrong
Violation
medication being administered.
Defences
Inadequate - AMH confusing
Missing - no pharmacist
Why do we blame?
A demand for answers as to why “the event”
occurred is not an uncommon response. It is
Source: Coombes ID et al. Why do interns make prescribing
errors? A qualitative study, Medical Journal of Australia, 2008, human nature to want to blame someone and far
188(2): 89–94. Adapted from Reason’s model of accident
more “satisfying” for everyone involved in
causation.
investigating an incident if there is someone to
blame. Social psychologists have studied how
History of patient safety and the origins
people make decisions about what caused a
of the blame culture 8
particular event, explaining it as attribution theory.
The way we have traditionally managed
The premise of this theory is that people naturally
failures and mistakes in health care has been
want to make sense of the world, so when
called the person approach—we single out the
unexpected events happen, we automatically start
individuals directly involved in the patient care at
figuring out what caused it.
85
Topic 1: What is patient safety?
Pivotal to our need to blame is the belief that • Human actions are almost always
punitive action sends a strong message to others constrained and governed by factors beyond
that errors are unacceptable and that those who an individual’s immediate control. (A medical
make them will be punished. The problem with student working in a surgical ward is
this assumption is that it is predicated on a belief constrained by the hospital’s management of
that the offender somehow chose to make the the theatres.)
error rather than adopt the correct procedure: that • People cannot easily avoid those actions that
the person intended to do the wrong thing. they did not intend to perform. (A medical
Because individuals are trained and/or have student may not have intended to obtain
professional/organizational status, we think that consent from a patient for an operation but
they “should have known better” [42]. Our notions was unaware of the rules in relation to
of personal responsibility play a role in the search informed consent.)
for the guilty party. Expressions such as “the buck • Errors have multiple causes: personal, task-
stops here” or “carrying the can” are widely used. related, situational and organizational factors.
Professionals accept responsibility for their (If a medical student entered the theatre
actions as part of their training and code of without correct scrubbing it may be because
practice. It is easier to attribute legal responsibility the student was never shown the correct
for an accident to the mistakes or misconduct of way, has seen others not comply with
those in direct control of the operation then on scrubbing guidelines, the cleaning agent had
those at the managerial level [42]. run out, there was an emergency that the
student wanted to see and there was no
Charles Perrow [43] in 1984 was one of the first to time, etc.)
write about the need to stop “pointing the finger” • Within a skilled, experienced and largely well-
at individuals when he observed that between intentioned workforce, situations are more
60% and 80% of system failures were attributed amenable to improvement than people. (If
to “operator error” [1]. The prevailing cultural staff were prevented from entering theatres
response to mistakes, at that time, was to punish until appropriate cleaning techniques were
individuals rather than address any system followed, then the risk of infection would be
problems that may have contributed to the diminished.)
error(s). Underpinning this practice was the belief
that, since individuals are trained to perform tasks, Reason warned against being wise after the
then a failure of that task must relate to the failure event—so-called “hindsight bias”—because most
of individual performance, thus deserving people involved in serious accidents do not intend
punishment. Perrow believed that these something to go wrong and generally do what
sociotechnical breakdowns are a natural seems like the “right” thing to do at the time,
consequence of complex technological systems though they “may be blind to the consequences
[31]. Others [44] have added to this theory by of their actions” [31].
emphasizing the human factor at an individual and
institutional level. Today most complex industrial/high technological
managers realize that a blame culture will not
Reason [36], building on the earlier work of bring safety issues to the surface [45]. While many
Perrow [43] and Turner [29], provided this health-care systems are beginning to recognize
rationale for managing human error: this we are yet to move away from the person
86
Topic 1: What is patient safety?
87
Topic 1: What is patient safety?
88
Topic 1: What is patient safety?
WHAT STUDENTS NEED TO DO has said at this point, it is a good idea to check
(PERFORMANCE REQUIREMENTS) with a clinical teacher how they usually introduce
students to patients beforehand, especially the
Apply patient safety thinking in all first time you are working and learning with a
clinical activities particular clinical teacher. Students must explain
There are many opportunities for students in their and make it clear to patients and their families
clinical work to incorporate patient safety that they are medical students studying to
knowledge into practice. become doctors. 12
89
Topic 1: What is patient safety?
Avoid blaming when an error occurs fail. Important information can be missed or
It is important that medical students support each incorrect. This can lead to inadequate care or
other and health professionals when they are errors. The continuity of care chain is broken,
involved in an adverse event. Unless students are leaving the patient vulnerable to a poor outcome.
open about errors there will be little opportunity to
learn from them. However, often medical students Student awareness of the importance of
are excluded from meetings where discussions self-care
about adverse events occur. Also, the hospital or Students should be responsible for their own well-
clinic may not hold such meetings to discuss being and that of their peers and colleagues.
adverse events. This does not necessarily mean Medical students should be encouraged to have
that clinicians want to hide their errors; it may their own doctor and be aware of their own health
mean they are unfamiliar with patient safety status. If a student is in difficulty (mental illness or
strategies to learn from them. They may also drug or alcohol impairment), they should be
worry about medico-legal fears and possible encouraged to seek professional help.
interference from administrators. Even so, as
patient safety concepts become more widely Act ethically everyday
known and discussed in health care, more Learning to be a good doctor requires
opportunities are arising for reviewing care and observation of respected senior clinicians as well
making the improvements necessary to minimize as practical clinical experience involving patients.
errors. Students can ask their supervisors if the One of the privileges medical students have is the
hospital conducts mortality and morbidity opportunity as students to learn medicine “at the
meetings or other peer review forums where bedside” and treating “real patients”. Most
adverse events are reviewed. Students, patients understand that medical students have to
irrespective of level of training and education must learn and that the future of medicine depends on
appreciate the importance of reporting their own training. Yet, it is also important that students
errors to their supervisors. remember that their opportunity to interview and
examine patients is a privilege that is granted by
Practise evidence-based care each individual. In most situations, patients
Students should learn how to apply evidenced- cannot be examined by a student unless they give
based practice. They should be aware of the role their consent. Students should always ask
of guidelines and appreciate how important it is to permission from each patient before they
follow them. When a student is placed in a clinic physically touch or seek personal information from
or hospital they should seek out information about them. They should also be aware that patients
the common guidelines and protocols that are may withdraw this privilege at any time and
used. request that the student stop what they doing.
Maintain continuity of care for patients It is important that clinical teachers advise patients
The health system is made up of many parts that that their cooperation in educational activities is
interrelate to produce a continuum of care for entirely voluntary. Clinical teachers and medical
patients and families. Understanding the journey students must obtain verbal consent from patients
that patients make through the health-care before students interview or examine them. When
system (of which a hospital or clinic is just a part) a patient is being asked to allow a student to
is necessary to understand how the system can examine them they should be told that the
90
Topic 1: What is patient safety?
examination is primarily for educational purposes. confident enough to raise such matters with their
An appropriate form of words is, “Would you mind supervisors and are unsure of how to act. Raising
if these students ask you about your illness and/or this in teaching about patient safety is very
examine you so that they can learn more about important. This role confusion can lead to student
your condition?” stress and can have a negative impact on morale
and the development of the students’
It is important that all patients understand that professionalism. It can also place patients at risk.
their participation is voluntary and that a decision Learning how to report concerns about unsafe or
not to participate will not compromise their care. unethical care is fundamental to patient safety and
Verbal consent is sufficient for most educational relates to the capacity of the system to support
activities but there will be times when a written reporting.
consent is required. Students should be
requested to make inquiries if they are in doubt Students should be aware of their legal and
about the type of consent required. ethical obligations to put the interests of patients
first [8]. This may include refusal to comply with an
Particular care should be taken when involving inappropriate instruction or direction. The best
patients in teaching activities because the benefit way to resolve the conflict (or at least gain a
to the patient is secondary to the educational different perspective) is for the student to speak
needs of the students. Patient care and treatment privately with the clinician or responsible staff
is usually not dependent on student engagement. person concerned. The patient concerned should
not be part of this discussion. The student should
Explicit guidelines for clinical teachers and medical explain the problem(s) and why they are unable to
students provide protection for everyone. If no comply with the instruction or direction. If the
guidelines exist it is a good idea to request that clinician or responsible staff person ignores the
the faculty develop a policy on the relationship issues raised and continues to instruct the
between students and the patients they are medical student to proceed, then discretion
allowed to treat in their role as students. Properly should be used to proceed or withdraw from the
designed guidelines will protect patients, promote situation. If it is decided to continue, then patient
high ethical standards and avoid consent must be confirmed. If the patient does
misunderstandings. not consent, the student must not proceed.
Most medical schools are aware of the problem of If a patient is unconscious or anaesthetized, the
the “hidden curriculum” in medical education. student should explain why they cannot proceed.
Studies show that students on clinical placements It may be necessary to point out the requirement
have felt pressured to act unethically [52], and of the faculty to comply with these guidelines. It
they report that these situations are difficult to may also be appropriate to discuss the situation
resolve. All students and doctors in training with another person in the faculty or clinical
potentially face similar ethical dilemmas. On the school. If medical students are uncertain about
rare occasion in which a clinical supervisor directs the appropriateness of any behaviour by any other
medical students to participate in patient person involved in patient care, they should
management that is perceived to be unethical or discuss the matter with a senior colleague of
misleading to the patient, faculty staff should deal choice, usually the associate dean.
with the matter. Many students may not even be
91
Topic 1: What is patient safety?
All students who feel that they have been this may generate some interest in the topic.
subjected to unfair treatment because of a refusal (Reporting and incident management are
to do something that seems to be wrong should covered in topics 3, 4 and 6.)
seek advice from senior colleagues.
HOW TO TEACH THIS TOPIC
Demonstrates ability to recognize the
role of patient safety in safe health- Teaching strategies/formats
care delivery 14 The prevalence data used in this topic have been
The timing of a medical student’s entry into published in the literature and cover a number of
a hospital or clinical environment varies across countries but not all of them. Some teachers may
universities—some medical students are exposed wish to put the case for patient safety using
from their first year, other students are exposed prevalence data from their country. If it is not
later in their medical training and education. Prior available, then another way would be to access
to entering a clinical environment students should: databases maintained by the health service and
see if some of the data can be used to
• Ask questions about other parts of the demonstrate the potential or real harm to patients
health system that are available to the from their health care. For example, the Institute for
patient Healthcare Improvement (IHI) in the United States
The success of a patient’s care and treatment has published Trigger tool for measuring adverse
depends on understanding of the total health events, which is designed to assist health-care
system available to the particular patient. If a professionals measure their adverse event rates. If
patient comes from a poor area where there is there are no measures available to a country or
no refrigeration, then sending a patient home hospital, then try to obtain data for one area of care
with insulin that needs refrigeration will not such as infection rates. Infection rates in a
assist the patient. An understanding of particular country may be available and this could
systems (topic 3) will help the student be used to demonstrate the extent of transmission
appreciate how different parts of the health of infection that is a potentially preventable.
system are connected and how continuity of
care for the patient is dependent on all parts This topic can be broken up into sections to be
of the system communicating effectively and included in existing curricula or can be taught in
in a timely way. small groups or as a stand alone lecture. If the
topic is being delivered as a lecture, then the
• Ask for information about the hospital slides at the end of the topic may be helpful for
or clinic processes that are in place to presenting the information.
identify adverse events
Most hospitals or clinics will have a reporting Part A of the Curriculum Guide sets out a range of
system to identify adverse events. It is teaching methods for patient safety since giving a
important that students are aware of these lecture is not always the best approach.
events and understand how the hospital
manages them. If there are no reporting A small group discussion session
requirements in the hospital, then the student A teacher could use any of the activities
can ask the appropriate people how the listed below to stimulate discussion about patient
hospital manages such events. At the least, safety. Another way is to have one or more
92
Topic 1: What is patient safety?
students prepare a seminar on the topic of patient someone talk about errors and how they impact
safety using the information in this topic. They on patients and staff is a powerful introduction of
could then lead a discussion about the areas patient safety to students. Students can react to
covered in the topic. The students could follow the presentation. The teacher can then go through
the headings as outlined below and use any of the the information in this topic to demonstrate to
activities below to present the material. The tutor students how and why attention to patient safety
facilitating this session should also be familiar with is essential for safe clinical practice. The slides can
the content so information can be added about be PowerPoint or converted to overhead slides for
the local health system and clinical environment. a projector. Start the session with the case study
and get the students to identify some of the issues
Harm caused by health-care errors and system presented in the story. Use the accompanying
failures: slides at the end of this topic as a guide.
• use examples from the media (newspapers
and television) that have been Other ways to present different sections in this
published/broadcasted; topic are listed below.
• use de-identified case examples from your
own hospitals and clinics; Lessons about error and system failure from
• use a case study to construct a flowchart of other industries:
the patient’s journey; • invite a staff member from another discipline
• use a case study to brainstorm all of the such as engineering or psychology to talk
things that went wrong and the times when about system failures, cultures of safety and
an action might have prevented the adverse role of error reporting in safety;
outcome for the patient; • invite someone from the aviation industry to
• invite a patient who has experienced an talk about their response to human errors.
adverse event to talk to the students.
History of patient safety and the origins of the
Difference between system failures, violations blame culture:
and errors: • invite a senior respected clinician to talk
• use a case study to analyse the different about the damage of “blaming” in the context
avenues for managing an adverse event; of medical care;
• participate or be an observer in a root cause • invite a quality and safety officer to talk about
analysis. systems in place to minimize errors and
manage adverse events.
An interactive/didactic session
Invite a respected senior clinician and/or Simulation
other health-care professionals from within your Different scenarios could be developed
country to talk about health-care errors in the about adverse events and the need to report and
workplace. If no one is available, then use a video analyse errors.
of an influential and respected physician talking
about errors and how the system of health care Teaching and learning activities
exposes everyone to them. A search of the There are many other opportunities for students
internet will locate video clips of speeches that to learn about patient safety such as during their
have been made by patient safety leaders. Having clinical placements in hospitals or clinics. The
93
Topic 1: What is patient safety?
following are some examples of activities that third child in an uncomplicated caesarean delivery.
students could perform, either alone or in pairs; Dr A was the obstetrician and Dr B was the
anaesthetist who set the epidural catheter. On 11
• follow a patient on their journey through the April, Caroline reported that she felt a sharp pain
health-care service; in her spine and on the night before the epidural
• ask students to spend a day with another was removed she accidentally bumped the
health professional (nurse, physiotherapist, epidural site. During this time, Caroline repeatedly
social worker, pharmacist, dietician and complained of pain and tenderness in the lumbar
interpreter) and to identify the main role and region. The anaesthetist, Dr B, examined her and
functions of that profession; diagnosed “muscular” pain. Still in pain and
• ask students when they have student–patient limping, Caroline was discharged (transferred)
encounters to routinely seek information about from the city hospital on 17 April.
the illness or condition from the patient’s
perspective; For the next seven days Caroline remained at her
• ask students to make inquiries of their hospital home in the country. She telephoned her
or health service about whether there are obstetrician, Dr A, about her fever, shaking,
processes or teams to investigate and report on intense low back pain and headaches. On 24
adverse events—if there are avenues, ask the April, the local medical officer, Dr C, examined
students to seek permission from the relevant Caroline and her baby and recommended they
supervisor for them to observe or take part; both be admitted to the district hospital for back
• ask students to find out if the hospital conducts pain and jaundice, respectively.
mortality and morbidity meetings or other peer
review forums where adverse events are The admitting doctor at the district hospital, Dr D,
reviewed; recorded that Caroline’s back pain appeared to be
• require the students to talk among themselves situated at the S1 joint rather than at the epidural
about errors they have observed in the hospital site. On 26 April, the baby’s jaundice had
using a no blame approach; improved, but Caroline had not yet been seen by
• ask the students to select a ward or clinic the general practitioner, Dr E, who admitted he
where they are placed and inquire about a main had forgotten about her. The medical registrar, Dr
protocol used by the staff; get the students to F, examined Caroline and diagnosed sacroiliitis. He
ask how the guideline was written and how staff discharged her with prescriptions for oxycodone,
know about it and how to use it and when to paracetamol and diclofenac. He also informed
deviate from it. Caroline’s obstetrician, Dr A, of his diagnosis.
94
Topic 1: What is patient safety?
Her condition was critical by this stage and she environment at the city hospital.
was rushed by ambulance to the district hospital.
It was clear that Caroline would be managed by
By the time she arrived at the district hospital, others after her discharge; however, she was not
Caroline was unresponsive and needing involved as a partner in her health care by being
intubation. Her pupils were noted to be dilated given instructions about the need to seek medical
and fixed. Her condition did not improve and on 4 attention if her back pain worsened. Similarly, no
May she was transferred by ambulance to a referral letter or phone call was made to her local
second city hospital. At 13:30 on Saturday, 5 May, medical officer, Dr C.
she was determined to have no brain function and
life support was withdrawn. It was the coroner’s opinion that each of the
doctors who examined Caroline after she returned
A postmortem examination revealed an epidural to the country was hasty in reaching a diagnosis,
abscess and meningitis involving the spinal cord mistakenly believing that any major problem
from the lumbar region to the base of the brain would be picked up by someone else down the
with cultures revealing a methicillin-resistant track. Her local medical officer, Dr C, only made a
staphylococcus aureus (MRSA) infection. very cursory examination of Caroline as he knew
Changes to the liver, heart and spleen were she was being admitted to the district hospital.
consistent with a diagnosis of septicaemia. The The admitting doctor, Dr D, thought there was a
coronial investigation concluded that Caroline’s 30% chance of Caroline having an epidural
abscess could and should have been diagnosed abscess but did not record it in the notes because
earlier than it was. he believed it was obvious. In a major departure
from accepted medical practice, Dr E agreed to
The following discussion of the coroner’s report see Caroline and simply forgot about it.
into the death of Caroline highlights many of the
issues addressed in the topics outlined in this The last doctor to examine Caroline at the district
Curriculum Guide. The observation that surfaced hospital was the medical registrar, Dr F, who
again and again in this story was the inadequacy discharged her with prescriptions for strong
in recording detailed and contemporaneous analgesics without fully investigating his
clinical notes and the regular incidence of notes provisional diagnosis of sacroiliitis, which he
being lost. The anaesthetist, Dr B, was so thought could have been postoperative or
concerned about Caroline’s unusual pain that he infective. With regards to medicating safely, Dr F’s
consulted the medical library, but he did not handwritten notes to Caroline were considered
record this in her clinical notes. He also failed to vague and ambiguous in instructing her to
communicate the risk of what he now thought to increase the dose of oxycodone if the pain
be “neuropathic” pain to Caroline or ensure that increased, while at the same time monitoring
she was fully investigated before being specific changes. The notes Dr F made on a
discharged. There were also concerns that piece of paper detailing his examination and the
evidence-based guidelines were not followed with possible need for magnetic resonance imaging
respect to Dr B scrubbing prior to the epidural (MRI) were never found.
insertion as it was the view of an independent
expert that the bacteria that caused the abscess The one doctor who the coroner believed could
was most likely to have originated from the staff or have taken global responsibility for Caroline’s care
95
Topic 1: What is patient safety?
was her obstetrician, Dr A. He was phoned at least Emanuel L et al. What exactly is patient safety? A
three times after her discharge from the city hospital definition and conceptual framework. Agency
with reports of her continuing pain and problems, for Health Care Quality and Research, Advances
but failed to realize the seriousness of her condition. in Patient Safety: from Research to
Implementation, 2008 (in press).
From the birth of her child to her death 25 days
later, Caroline was admitted to four different
hospitals and there was a need for proper Making health care safer: a critical
continuity of care in the handover of analysis of patient safety practices. Evidence
responsibilities from each set of medical and Report/Technology Assessment, No. 43, AHRQ
nursing staff to another. The failure to keep Publication No. 01-E058. Rockville, MD, Agency
adequate notes with provisional/differential for Healthcare Research and Quality, July 2001
diagnoses and investigations and provide (http://www.ahrq.gov/clinic/ptsafety/summary.htm).
discharge summaries and referrals led to a delay
in the diagnosis of a life-threatening abscess and Kohn LT, Corrigan JM, Donaldson MS, eds. To err
ultimately Caroline’s death. is human: building a safer health system.
Washington, DC, Committee on Quality of Health
Care in America, Institute of Medicine, National
Reference Academy Press, 1999
Inquest into the death of Caroline Barbara (http://psnet.ahrq.gov/resource.aspx?resourceID=
Anderson, Coroner’s Court, Westmead, Sydney 1579).
Australia, 9 March 2004. (Merrilyn Walton was
given written permission by Caroline’s family to Crossing the quality chasm: a new health system
use in teaching medical students and other health for the 21st century. Washington, DC, Committee
professionals so that they could learn about on Quality of Health Care in America, Institute of
patient safety from the perspective of patients and Medicine, National Academy Press, 2001
families.)
HOW TO ASSESS THIS TOPIC
TOOLS AND RESOURCES
A range of assessment methods are suitable for
Reason JT. Human error. Reprinted. New this topic including essay, MCQ paper, short best
York: Cambridge University Press, 1999. answer question paper (SBA), case-based
discussion and self-assessment. Students can be
Reason JT. Managing the risks of organizational encouraged to develop a portfolio approach to
accidents, 1st ed. Aldershot, UK, Ashgate patient safety learning. The benefit of a portfolio
Publishing Ltd, 1997. approach is that at the end of the student’s
medical training they will have a collection of all
Runciman B, Merry A, Walton M. Safety and their patient safety activities. Students will be able
ethics in health care: a guide to getting it right, 1st to use this to assist job applications and their
ed. Aldershot, UK, Ashgate Publishers Ltd, 2007. future careers.
Vincent C, Safety. P. Patient Safety, Edinburgh, The assessment of knowledge of the potential
Elsevier, 2006. harm to patients, the lessons from other
96
Topic 1: What is patient safety?
industries, violations and the blame free approach 4. Barr D. Hazards of modern diagnosis and
and models for thinking about patient safety is all therapy-the price we pay. Journal of
assessable using any of the following method: American Medical Association
• portfolio; 1956;159:1452-6.
• case-based discussion; 5. Couch NP, Tilney NL, Rayner AA, Moore FD.
• OSCE station; The high cost of low-frequency events: the
• written observations about the health system anatomy and economics of surgical mishaps.
and the potential for error (in general); New England Journal of Medicine
• reflective statements (in particular) about: 1981;304:634-37.
- the hospital and clinical environment and 6. Friedman M. Iatrogenic disease: Addressing a
the potential for patient harm; growing epidemic. Post Graduate Medicine
- the consequences of adverse events on 1982;71:123-9.
patient trust in health care; 7. Dubois R, Brook R. Preventable deaths: who,
- the systems in place for reporting how often, and why? Annals of Internal
medical errors; Medicine 1988;109:582-9.
- the role of senior clinicians in managing 8. McLamb J, Huntley R. The Hazards of
adverse events; Hospitalization. Southern Medical Association
- the role patients have in the health-care Journal 1967;60:469-72.
system. 9. Bedell S, Deitz DK, Leeman D, Delbanco T.
Incidence and characteristics of preventable
The assessment can be either formative or iatrogenic cardiac arrests. Journal of
summative; rankings can range from unsatisfactory American Medical Association
to giving a mark. See examples of some of these 1991;265:2815-20.
assessment methods in Appendix 2. 10. Leape L, Lawthers A, Brennan T, Johnson W.
Preventing medical injury. Quality Review
HOW TO EVALUATE THIS TOPIC Bulletin 1993;8:144-9.
Evaluation is important in reviewing how a 11. Bates DW, Cullen D, Laird N, Petersen LA,
teaching session went and how improvements Small SD, Servi D, et al. Incidence of adverse
can be made. See the Teacher’s Guide (Part A) for drug events and potential adverse drug events:
a summary of important evaluation principles. implications for prevention. Journal of American
Medical Association 1995;274:29-34.
References 12. Chief Medical Officer. An organisation with a
1. Steel K, Gertman PM, Crescenzi C, Anderson memory. Report of an expert group on
J. Iatrogenic illness on a general medical learning from adverse events in the NHS.
practice service at a university hospital. New London: Department of Health. United
England Journal of Medicine 1981;304:638-42. kingdom, 1999.
2. Schimmel E. The hazards of hospitalization. 13. Weingart SN et al. Epidemiology of medical
Annals of Internal Medicine 1964;60:100-10. error. British Medical Journal, 2000,
3. US Congress House Sub Committee on 320(7237):774–777.
Oversight and Investigation. Cost and quality 14. Kohn LT, Corrigan JM, Donaldson MS. To err
of health care: Unnecessary surgery. is human: Building a safer health system:
Washington DC: USGPO, 1976. National Academy Press., 1999.
97
Topic 1: What is patient safety?
15. Davis P, Lay Lee R, Briant R, Schug S, Scott 24. Thomas E, Brennan T. Errors and adverse
A, Johnson S, et al. Adverse Events in New events in medicine: An overview. In: C
Zealand public hospitals: Principal findings Vincent, editor. Clinical Risk Management:
from a national survey. . Wellington New Enhancing patient safety. London: BMJ
Zealand Ministry of Health 2001.;Occasional Books, 2002:33.
Paper 3. 25. Haywood R, Hofer T. Estimating hospital
16. Brennan TA, Leape LL, Laird N, et al. deaths due to medical errors: preventability is
Incidence of adverse events and negligence in the eye of the reviewer. Journal of
in hospitalized patients: results of the Harvard American Medical Association 2001;286:415-
Medical Practice Study I. New England 20.
Journal of Medicine 1991;324 270-6. 26. Thomas E, Studdert D, Brennan T. The
17. Wilson RM, Runciman WB, Gibberd RW, reliability of medical record review for
Harrison BT, Newby L, Hamilton JD. The estimating adverse event rates. Annals of
Quality in Australian Health Care Study. Internal Medicine 2002;136:812-16.
Medical Journal of Australia 1995;163:458- 27. McDonald C, Weiner M, Sui H. Deaths due to
71. medical errors are exaggerated in Institute of
18. G. Ross Baker, Peter G. Norton, Virginia Medicine report. Journal of the American
Flintoft, Régis Blais, Adalsteinn Brown, et al. Medical Association 2000;248:93-5.
The Canadian Adverse Events Study: the 28. Turner BA. The organizational and inter
incidence of adverse events among hospital organisational development of disasters.
patients in Canada. Canadian Medical Administrative Science Quarterly
Association Journal 2004;170(11). 1976;21:378-97.
19. Runciman B, Merry A, Walton M. Safety and 29. Turner BA. Man made disasters. London:
Ethics in Health Care : A guide to getting it Wykeham Science Press, 1978.
right. 1 ed. London: Ashgate Publishers, 30. Reason J. The contribution of latent human
2007. failures to the breakdown of complex
20. Andrews LB, et al. An alternative strategy for systems. Philosophical Transactions of the
studying adverse events in medical care. Royal Society of London. Series B Biological
Lancet 1997;349(9048):309-13. Sciences. 1990 1990;327:475-84.
21. Runciman W. Iatrogenic Injury in Australia: A 31. Reason JT. Human Error. reprinted ed. New
report prepared by the Australian Patient York: Cambridge University Press, 1999.
Safety Foundation. Adelaide: Australian 32. Pidgen N. Safety culture: transferring theory
Patient Safety Foundation and evidence from major hazards industries.
http://www.apsf.net.au/, 2001:24. Department of Transport Behavioral Research
22. Expert group on learning from adverse events in Road Safety: Tenth Seminar. 2001.
in the NHS. An Organisation with a Memory. 33. International Atomic Energy Agency. The
London: Department of Health United Chernobyl Accident: Updating of INSAG-1.
Kingdom., 2000. INSAG-7: International Nuclear Safety Group
23. Eisenberg JM Statement on Medical Errors,. (INSAG), 1992:24.
Senate Appropriations Subcommittee on Labor 34. Vaughan D. The Challenger Launch Decision:
Health and Human Services, and Education Risky technology, Culture and Deviance at
December 13. Washington DC, 1999. NASA. Chicago: Chicago University Press,
1996.
98
Topic 1: What is patient safety?
35. Reason J. Human error: models and 49. Emanuel L, Berwick D, Conway J, Combes J,
management. British Medical Journal Hatlie M, Leape L, et al. What exactly is
2000;320:768-70. patient safety? A definition and conceptual
36. Reason JT. Managing the Risks of framework. Agency for Health care Quality
Organisational Accidents. Aldershot, and Research, Advances in Patient Safety:
Hampshire, England: Ashgate Publishing Ltd, From Research to Implementation 2008;in
1997. press.
37. Gault WG. Experimental exploration of implicit 50. Vincent C, Safety. P. Patient Safety: Elsevier,
blame attribution in the NHS: Grampian 2006.
University Hospitals NHS Trust, 2004. 51. Carayon P, Hundt A, Karsh B, Gurses A,
38. Millenson ML. Breaking bad news. Quality Alvarado C, Smith M, et al. Work system
and Safety in Health Care 2002;11:206-7. design for patient safety: the SEIPS model.
39. Gault W. Blame to aim, risk management in Quality and Safety in Healthcare
the NHS. Risk Management Bulletin 2006;15(Suppl 1):i50-i58.
2002;7(1):6-11. 52. Hicks LK, Lin Y, Robertson DW, Robinson
40. Berwick D M. Improvement, trust and the DL, Woodrow SI. Understanding the clinical
health care workforce. Quality and Safety in dilemmas that shape medical students’
Health Care 2003;12 ( suppl 1):i2-i6. ethical development: questionnaire survey
41. Walton M. Creating a 'no blame' culture: have and focus group study. British Medical
we got the balance right? Quality and Safety Journal 2001;322:709-10.
in Health Care 2004;13:163-4.
42. Maurino DE, Reason J, Johnson N, Lee RB.
Beyond aviation human factors. Aldershot SLIDES FOR TOPIC 1: WHAT IS
UK: Ashgate, 1995. PATIENT SAFETY?
43. Perrow C. Normal Accidents: Living with
high-technologies. 2nd edition ed. Princeton Didactic lectures are not usually the best way to
New Jersey: Princeton University Press, teach students about patient safety. If a lecture is
1999. being considered, it is a good idea to plan for
44. Douglas M. Risk and Blame: essays in student interaction and discussion during the
cultural theory: Routledge, 1992. lecture. Using a case study is one way to generate
45. Helmreich RL, Merritt AC. Culture at work in group discussion. Another way is to ask the
aviation and medicine. Aldershot UK: students questions about different aspects of health
Ashgate, 1998. care that will bring out the issues contained in this
46. Strauch B. Normal accidents-Yesterday and topic such as the blame culture, nature of error and
today. In: Hohnson CW, editor. Investigating how errors are managed in other industries.
and Reporting of Accidents. Washington DC
20594 USA: National Transportation Safety The slides for topic 1 are designed to assist the
Board, 2002. teacher deliver the content of this topic. The slides
47. Walton M. Creating a "no blame" culture: can be changed to fit the local environment and
have we got the balance right? . Quality and culture. Teachers do not have to use all of the
Safety in Health Care 2004;13:163-4. slides and it is best to tailor the slides to the areas
48. Reason J. Managing the risks of organizational being covered in the teaching session.
accidents. 1st ed: Ashgate publishers, 1997.
99
Topic 2: What is human factors and why is it important to
patient safety?
Why human factors is important 1 (as it is sometimes called) are used to describe
Human factors examines the relationship interactions between three interrelated aspects:
between human beings and the systems with individuals at work, the task at hand and the
which they interact [1] by focusing on improving workplace itself.
efficiency, creativity, productivity and job
satisfaction, with the goal of minimizing errors. A Human factors is an established science that uses
failure to apply human factors principles is a key many disciplines (such as anatomy, physiology,
aspect of most adverse events in health care. physics and biomechanics) to understand how
Therefore, all health-care workers need to have a people perform under different circumstances.
basic understanding of human factors principles. We define human factors as: the study of all the
Health-care workers who do not understand the factors that make it easier to do the work in the
basics of human factors are like infection control right way.
professionals not knowing about microbiology.
Another definition of human factors is the study of
Keywords the interrelationship between humans, the tools
Human factors, ergonomics, systems, human and equipment they use in the workplace, and the
performance. environment in which they work [1].
100
Topic 2: What is human factors and why is it important to patient safety?
environment, and industries such as aviation, these tasks were made easier for the health-care
manufacturing and the military have applied practitioner, then they would be able to provide
knowledge of human factors to improve systems safer health care. These tasks require design
and services for many years now [2]. 6 solutions that include software (computer order
entry systems), hardware (IV pumps), tools
The lessons and examples from other industries (scalpels, syringes, patient beds) and the
show that by using human factors principles we physical layout, including
can also improve work processes in health care. lighting of work environments. 10 11
For example, the underlying causes of many
adverse events relate to the miscommunications The technological revolution in health care has
and actions of the people in the system. Many increased the relevance of human factors in errors
people think that communication difficulties among because the potential for harm is great when
the health-care team relate to the fact that each technology is mishandled [3]. 12
person has a number of tasks that have to be
performed at one time. Human factors engineering In its broadest sense human factors incorporates
research shows that what is important is not the the human–machine interactions (including
number of tasks but the nature of the tasks being equipment design) and human–human
attempted. A doctor may be able to tell a student interactions such as communication, teamwork
the steps in a simple operation while he is doing and organizational culture. Human factors
one but if it was a complicated case he may not be engineering seeks to identify and promote the
able to do that because he has to concentrate. An best fit between people and the world within
understanding of human factors and adherence to which they live and work, especially in relation to
human factors principles is now fundamental to the the technology and physical design features in
discipline of patient safety [3]. 7 their work environment. 13
Human factors experts help make it easier for the Human factors recognize that the workplace
widest range of health-care providers to perform needs to be designed and organized to minimize
at their best while caring for patients. This is the likelihood of errors occurring and the impact
important because the goal of good human of errors when they do occur. While we cannot
factors design is to accommodate all the users in eliminate human fallibility, we can act to moderate
the system. This means not just thinking about and limit the risks. 14 15
design issues as though the task was to be
accomplished not only by a calm, rested Note that human factors is not as directly about
experienced clinician, but also for an “humans” as the name might suggest. But it is
inexperienced health-care worker who might be about understanding human limitations and
stressed, fatigued and rushing. 8 9 designing the workplace and the equipment we
use to allow for variability in humans and human
Human factors experts use evidence-based performance.
guidelines and principles to design ways to make
it easier to safely and efficiently do things such as: Knowing how fatigue, stress, poor communication
(i) order medications; (ii) hand off (hand over) and inadequate knowledge and skill affect health
information; (iii) move patients; and (iv) chart professionals is important because it helps us
medications and other orders electronically. If understand predisposing characteristics that may
101
Topic 2: What is human factors and why is it important to patient safety?
102
Topic 2: What is human factors and why is it important to patient safety?
The relationship between stress levels and receiving a wrong dosage or drug. Students
performance has also been confirmed through should look for pictures and diagrams of the steps
research. While high stress is something that involved in a treatment process or procedure.
everyone can relate to, it is important to recognize Checking one’s actions against a picture diagram
that low levels of stress are also can reduce the load on the working memory and
counterproductive, as this can lead to boredom this frees the student to focus on the tasks in real
and failure to attend to a task with appropriate time such as taking a history or ordering the drugs
vigilance. 29 from the hospital pharmacy.
The aviation industry requires individual pilots to This is a major reason that protocols are so
use a number of personal checklists to monitor important in health care—they reduce reliance on
their performance—an approach that health-care memory. On the other hand, having too many
workers could easily emulate. All health-care protocols is unhelpful, especially if they are not
workers should consider using a series of updated in a timely manner. Students should ask
personal error reduction strategies to ensure that about the main protocols used by a ward or clinic
they perform optimally at work. 30 so that they are familiar with them. It is important
to check when the protocols were last reviewed—
The acronym IM SAFE (illness, medication, stress, finding out more about the process by which
alcohol, fatigue, emotion) that was developed in protocols are updated reinforces the important
the aviation industry is useful as a self- point that to be effective, protocol must be a living
assessment technique to determine when document.
entering the workplace each day whether a
person is Make things visible
safe for work. 31 Students will observe that many wards and clinics
have equipment that is necessary in patient
treatments—e.g. infusion pumps. Many students
WHAT STUDENTS NEED TO DO will be required to use such equipment. Again, the
(PERFORMANCE REQUIREMENTS) use of pictures and notices about the steps
involved in switching the machine on and off and
Apply human factors thinking to your reading the displays will help the student master
work environment[8] the skill. Another good example of making the
Medical students are able to apply human factors right thing to do more visible is the use of pictorial
thinking as soon as they enter a hospital or clinic reminders to staff and patients about
environment. In addition, the following tips are handwashing—this has proven to be effective in
known to limit the potential errors caused by improving handwashing compliance and
humans. technique.
103
Topic 2: What is human factors and why is it important to patient safety?
104
Topic 2: What is human factors and why is it important to patient safety?
105
Topic 2: What is human factors and why is it important to patient safety?
106
Topic 2: What is human factors and why is it important to patient safety?
HOW TO EVALUATE THIS TOPIC Didactic lectures are not usually the best way to
teach students about patient safety. If a lecture is
Evaluation is important in reviewing how a being considered, it is a good idea to plan for
teaching session went and how improvements student interaction and discussion during the
can be made. See the Teacher’s Guide (Part A) for lecture. Using a case study is one way to
a summary of important evaluation principles. generate group discussion. Another way is to ask
the students questions about different aspects of
References health care that will bring out the issues contained
1 Kohn LT, Corrigan JM, Donaldson MS, eds. in this topic.
To err is human - building a safer health The slides for topic 2 are designed to assist the
system. Washington, DC, Committee on teacher deliver the content of this topic. The slides
Quality of Health Care in America, Institute of can be changed to fit the local environment and
Medicine, National Academy Press, 1999. culture. Teachers do not have to use all of the
2 Cooper N, Forrest K, Cramp P. Essential slides and it is best to tailor the slides to the areas
guide to generic skills. Malden, MA, Blackwell being covered in the teaching session.
2006.
3 Walton M. National Patient Safety Education
Framework. Canberra, Commonwealth of
Australia, 2005.
4 Runciman W, Merry A, Walton M. Safety and
ethics in healthcare: a guide to getting it right,
1st ed. Aldershot, UK, Ashgate Publishing,
Ltd, 2007.
5 Vincent C. Clinical risk management—
enhancing patient safety, London, British
Medical Journal books, 2001.
6 Flin R, O’Connor P, Crichton M. Safety at the
sharp end: a guide to non-technical skills.
Aldershot, UK, Ashgate Publishing Ltd, 2008.
7 Dawson D, Reid K. Fatigue, alcohol and
performance impairment. Nature, 1997,
388(6639):235–237.
107
Topic 3: Understanding systems and the impact of
complexity on patient care
108
Topic 3: Understanding systems and the impact of complexity on patient care
A complex system is one in which there are so Students visiting patients on the wards quickly
many interacting parts that it is difficult, if not understand that each individual patient requires
impossible, to predict the behaviour of the system care and treatment tailored to their specific
based on a knowledge of its component parts [3]. conditions and circumstances. A student can
The delivery of health care fits this definition of a quickly see that when all the individualized health
complex system, especially in a hospital setting. services are combined they form a system of care.
Hospitals are made up of many interacting parts,
including humans (patients and staff), Many health services present as a system—
infrastructure, technology and therapeutic buildings, people, processes, desks, equipment
agents—the various ways they interact with one telephones—yet unless the people understand its
another and how they collectively act is highly purpose and aim it will not operate as a whole
complex and variable [3]. unified system. People are the glue that binds and
maintains the system.
Health-care professionals need to have an
understanding of the nature of complexity in An understanding of the health system requires
health care, as it is important in preventing students to think beyond the individualized
hazards from occurring and helpful in terms of service. For the health system to work effectively,
analysing when things go wrong. Otherwise, there the doctors, nurses and other health professionals
can be a tendency to blame only the individuals need to understand each other’s roles and
directly involved in a situation, without realizing responsibilities. It also requires their understanding
there are usually many other contributory factors. about the impact of complexity on patient care
Health care is complex because of:[3] and that complex organizations such as health
• the diversity of tasks involved in the delivery care are prone to errors. Until relatively recently,
of patient care; we viewed the hundreds of services provided to
• the diversity of patients, clinicians and other patients as separate distinct services. The work of
staff; doctors was separate from the tasks of nurses or
• the huge number of relationships between physiotherapists. Units and departments were
patients, carers, health-care providers, also seen as distinct entities.
support staff, administrators and community
members; If the emergency department was not able to see
• the vulnerability of patients; urgent patients quickly enough, we thought that
• variations in physical layout of clinical by fixing the broken bit—the emergency
environments; department—without any attention to other
• variability or lack of regulations; services that relate to it then we could solve the
• implementation of new technology; problem. Perhaps the emergency department
• increased specialization of health-care was not able to transfer the patients to the wards
professionals—while specialization allows a in a timely manner because there were no beds to
wider range of patient treatments and put the patients in. The staff may have had too
services, it also provides more opportunity for many conflicting priorities that impeded their
things to go wrong and errors to be made. abilities to be responsive to patient needs.
109
Topic 3: Understanding systems and the impact of complexity on patient care
even understand the multiple components and • move away from blaming to understanding;
relationships that are prone to dysfunctionality, • improve the transparency of the processes of
they have difficulty in thinking in terms of systems care rather than focus solely on the single act
because, typically, they are not trained to think in of care.
the concepts or language of systems theory, nor
do they use its tools to make sense of the The traditional approach when things
systems in which they work. go wrong in health care—blame and
shame 8 9
Knowledge about the complexity of health care In such a complex environment it is no
will enable health-care professionals to surprise that many things go wrong on a regular
understand how the organizational structure and basis. When something does go wrong, the
the work processes can contribute to the overall traditional approach is to blame the health-care
quality of patient care. Much of the knowledge worker most directly involved in the patient care at
about complex organizations comes from other the time—often the nurse or junior doctor—
disciplines such as organizational psychology. The example, a wrong drug has been administered by
Institute of Medicine report To err is human a junior nurse or medical student. While the
highlighted that organizational processes such as tendency to blame an individual (the “person
simplification and standardization are recognized approach”) [4] is a strong one—and a very natural
safety principles, yet were rarely applied to health- one—it is unhelpful, and actually
care delivery systems. counterproductive for a number of reasons.
Whatever role that the “blamed” health-care
Systems thinking helps us make sense of worker may have had in the evolution of the
complex organizations by enabling us to look at incident, it is very unlikely that their course of
health care as a whole system with all its action was deliberate in terms of patient harm (if
complexity and interdependence. It removes the the action was deliberate this is termed a
focus from the individual to the organization. It violation—see topic 5 “Understanding and
forces us to move away from a blame culture learning from errors” and topic 6 “Understanding
towards a systems approach. Using a system and managing clinical risk”).
approach, a nurse will be able to tell a doctor that
there may be a problem with fulfilling an order
T5 T6
immediately because of other competing
demands. The doctor and the nurse can then Most health-care workers involved in an adverse
work out a solution to the problem together, thus event are very upset by the prospect that their
foreseeing and avoiding a problem later on. action (or inaction) may have been in some way a
contributory episode. The last thing they need is
In summary, a systems approach enables us to: punishment—Wu described the health-care
• examine organizational factors that underpin worker as the “second victim” in such
dysfunctional health care and circumstances [5]. The natural tendency in such
accidents/errors (poor processes, poor situations is to limit reporting because no one
designs, poor teamwork, financial restraints would report future incidents for fear that they
and institutional factors) rather than focus on would be blamed if anything untoward ever
the people who are associated with or happened. If such a blame “culture” is allowed to
blamed for the blunders or negligence; persist a health-care organization will have great
110
Topic 3: Understanding systems and the impact of complexity on patient care
111
Topic 3: Understanding systems and the impact of complexity on patient care
medical students and patients are part of the culture, regulations and policies, levels of
system. This demonstrates that “systems hierarchy and supervisor span of control.
thinking” does not exclude individual contributions
to safety, or a lack thereof. The Swiss cheese model 14
Task factors
These are characteristics of the tasks or jobs Reason’s “Swiss cheese”
model of accident causation
health-care providers perform, including the tasks
Some holes due
themselves, as well as characteristics such as to active failures Hazards
112
Topic 3: Understanding systems and the impact of complexity on patient care
workers plus inadequate procedures plus faulty possible to achieve consistently safe and effective
equipment) and momentarily line up to permit a performance despite high levels of complexity and
“trajectory” of accident opportunity (indicated by unpredictability in the work environment. HROs
the arrow). demonstrate to health-care organizations that they
too can improve safety by focusing on the system.
To prevent these adverse events occurring,
Reason proposed the need for multiple The differences between HROs and health-care
“defences” in the form of successive layers of organizations are significant and go to the very
“protection” (understanding, awareness, alarms heart of the existing problems we have. In health
and warnings, restoration of systems, safety care, we do not routinely think that health care will
barriers, containment, elimination, evacuation, fail. It is not part of the way of thinking unless it is
escape and rescue) designed to guard against the to do with specific treatments. We do not provide
failure of the underlying layer. The advantage of health care being mindful that health professionals
the systems approach to investigating situations might miscommunicate, or that the surgeon may
is that this approach considers all the layers to be extremely tired having worked all night or that
see if there are ways that any of them can the doctor’s handwriting was illegible so the
be improved. 15 student gave the wrong dose. Any one of these
may be a factor in an adverse event. Doctors are
Reason’s - Defences
used to talking about risks to individual patients in
Potential
adverse
relation to knowing side-effects and
events
complications, but they do not apply the same
Patient
113
Topic 3: Understanding systems and the impact of complexity on patient care
Health-care organizations can learn from HROs The surgical incision was performed. Six minutes
even though they are different from health care. later the antibiotics were delivered to the OR and
We can examine their successes and study what immediately injected into the patient. This injection
factors made them work. We can also learn from happened after the time of incision, which was
their failures—how do disasters occur and what counter to protocol that requires antibiotics to be
factors are typically present. administered prior to the surgical incision in order
to avoid surgical site infections.
Summary 20
Analysis of adverse events demonstrates Case from the WHO Patient Safety Curriculum
that multiple factors are usually involved in their Guide for Medical Schools working group.
causation. Therefore, a systems approach to Supplied by Lorelei Lingard, University of Toronto,
considering the situation—as distinct from a Toronto, Canada.
person approach—will have a greater chance of
setting in place strategies to decrease the
likelihood of recurrence.
114
Topic 3: Understanding systems and the impact of complexity on patient care
115
Topic 3: Understanding systems and the impact of complexity on patient care
Miscommunication to a patient about the Case from the WHO Patient Safety Curriculum
type of anaesthesia to expect for surgery Guide for Medical Schools working group.
This example highlights system complexities that Supplied by Lorelei Lingard, University of Toronto,
reach outside of the immediate operating room Toronto, Canada.
setting and includes communication between
individuals not immediately involved in the current
surgical procedure, both between and across TOOLS AND RESOURCES
professions.
IHI clinical microsystem assessment tool
A patient arrived in the operating room for an Batalden PB et al. Microsystems in health care:
inguinal hernia repair. Although the procedure had Part 9. Developing small clinical units to attain
been booked as a general anaesthesia case, the peak performance. Joint Commission Journal on
anaesthetist discussed a local anaesthetic with Quality and Safety, 29 November 2003,
the patient. During his pre-operative anaesthesia 29(11):575–585
consultation, it had been established that the (http://www.ihi.org/IHI/Topics/Improvement/Impro
patient would receive a local anaesthetic. vementMethods/Tools/ClinicalMicrosystemAssess
mentTool.htm).
When the surgeon entered the room several
minutes later, the patient told him that he wanted Learning to improve complex systems of care
to have a local anaesthetic. The surgeon Headrick LA. Learning to improve complex
examined the hernia and reported that the hernia systems of care. In: Collaborative education to
was too big for a local anaesthetic and would ensure patient safety. Washington, DC,
require either a spinal or general anaesthesia. The HRSA/Bureau of Health Professions, 2000, 75–88
surgeon was irritated and said that, “if (the (http://www.ihi.org/NR/rdonlyres/15FB8A41-
anaesthetist who did the pre-op consult) wants to D6B0-4804-A588-6EC429D326E9/0/final11700v
do the procedure under a local that’s fine, but I do ersion.pdf).
not”. The patient and the anaesthetist discussed
the side-effects of a spinal and the patient asked Organization strategy
the surgeon which one he would recommend. Runciman B, Merry A, Walton M. Safety and
The surgeon suggested general anaesthesia and ethics in health care: a guide to getting it right, 1st
the patient agreed to this. ed. Aldershot, UK, Ashgate Publishing Ltd, 2007.
After the patient had been induced and intubated Kohn LT, Corrigan JM, Donaldson MS, eds. To err
the surgeon asked the anaesthetist to tell the is human: building a safer health system.
other anaesthetists that they should not speak to Washington, DC, Committee on Quality of Health
patients in pre-admit about local versus general Care in America, Institute of Medicine, National
anaesthesia because they had not examined the Academy Press, 1999
patient. It has happened three or four times that (http://psnet.ahrq.gov/resource.aspx?resourceID=
the pre-admit anaesthetists have told patients 1579).
something different in their pre-op consult than
what the surgeon has recommended. The
anaesthetist agreed to speak to his colleagues
and the chief of anaesthesia.
116
Topic 3: Understanding systems and the impact of complexity on patient care
Teaching activities
• Follow a patient from the time they enter
the service to the time they are discharged
and discuss all the steps and types of
health-care workers involved.
• Keep a track of the people from the different
parts of the health system and discuss their
roles and functions in health care.
• Visit unfamiliar parts of the organization.
• Participate or observe a root cause analysis
process.
117
Topic 3: Understanding systems and the impact of complexity on patient care
118
Topic 4: Being an effective team player
119
Topic 4: Being an effective team player
teams that work closely together in one place; (iv) distributed as in a multidisciplinary cancer team or
teams that are geographically distributed; (v) primary health-care team.
teams with constant membership; and (vi) teams
with constantly changing membership. Teams can include a single discipline or involve
the input from multiple practitioner types including
Regardless of the type and nature of the team doctors, nurses, pharmacists, physiotherapists,
they can be said to share certain characteristics. social workers, psychologists and potentially
These include: administrative staff. The role these practitioners
• team members have specific roles and interact play will vary between teams and within teams at
together to achieve a common goal; [3] different times. Roles of individuals on the team
• teams make decisions; [4] are often flexible and opportunistic such as the
• teams possess specialized knowledge and leadership changing depending on the required
skills and often function under conditions of expertise or the nurse taking on the patient
high workloads; [5,6] education role as they are the ones that have the
• teams differ from small groups in as much as most patient contact.
they embody a collective action arising out of
task interdependency [7]. In support of patient-centred care and patient
safety, the patient and their carers are increasingly
Salas defines teams as a “distinguishable set of being considered as active members of the
two or more people who interact dynamically, health-care team. As well as being important in
interdependently, and adaptively towards a terms of issues such as shared decision making
common and valued goal/objective/mission, who and informed consent, engaging the patient as a
have been each assigned specific roles or team member can improve the safety and quality
functions to perform, and who have a limited of their care as they are a value information
lifespan of membership” [8]. source being the only member of the team who is
present at all times during their care.
Examples of teams include choirs, sporting
teams, military units, aircraft crew and emergency 8 9
response teams.
The TeamSTEPPS™ [9] programme developed in
What different types of teams are found the United States identifies a number of different
in health care? 7 but interrelated team types that support and
There are many types of teams in health deliver health care:
care. They include labour and delivery units, ICUs,
medical wards, primary care teams in the 1.Core teams
community, teams assembled for a specific task Core teams consist of team leaders and members
such as an emergency response team or who are involved in the direct care of the patient.
multiprofessional teams such as multidisciplinary Core team members include direct care providers
cancer care teams that come together to plan (from the home base of operation for each unit)
and coordinate a patient’s care. and continuity providers (those who manage the
patient from assessment to disposition, for
Teams in health care can be geographically co- example, case managers). The core team, such
located, as in an ICU or surgical unit, or as a unit-based team (physician, nurses,
120
Topic 4: Being an effective team player
121
Topic 4: Being an effective team player
The link between non-technical skills such as cancer care [14]. Teamwork has also been
teamwork and adverse events is now well associated with reduced medical errors [15,16].
established [10,11], as is the increasing burden of As summarized in Table 12, improving teamwork
chronic disease, co-morbidities and ageing can have benefits beyond improving patient
populations that require a coordinated and outcomes and safety that include benefits for the
multidisciplinary approach to care [12]. individual practitioners in the team, the team as a
whole as well as the organization in which the
Baker et al. [1], in a major review of team training, team resides (adapted from Mickan, 2005) [12].
contended that the training of health professionals
as teams “constitutes a pragmatic, effective How do teams form and develop? 11
strategy for enhancing patient safety and reducing Considerable research into how teams form
medical errors”. and develop has been conducted in other high
stakes industries. As detailed in Table 13,
Teamwork has been associated with improved Tuckmann [17] identified four stages of team
outcomes in areas such as primary care [13] and development: forming, storming, norming and
Individual benefits
Efficient use of health-care Acceptance of treatment Greater role clarity Better accessibility for
services patients
Enhanced communication Improved health outcomes Reduced medical errors Enhanced well-being
and professional diversity and quality of care
Stage Definition
Forming Typically characterized by ambiguity and confusion when the team first forms. Team members may not
have chosen to work together and may be guarded, superficial and impersonal in communication, as well
as unclear about the task.
Storming A difficult stage when there may be conflict between team members and some rebellion against the tasks
assigned. Team members may jockey for positions of power and frustration at a lack of progress in the task.
Norming Open communication between team members is established and the team starts to confront the task at
hand. Generally accepted procedures and communication patterns are established.
Performing The team focuses all of its attention on achieving the goals. The team is now close and supportive, open
and trusting, resourceful and effective
122
Topic 4: Being an effective team player
123
Topic 4: Being an effective team player
• utilizing resources to maximize performance; TeamSTEPPS™ [9] programme and can be found
• resolving team conflicts; at http://www.ahrq.gov/qual/teamstepps/.
• balancing the workload within a team;
• delegating tasks or assignments; SBAR
• conducting briefs, huddles, debriefs; SBAR is a technique for communicating critical
• empowering team members to speak freely information about a patient’s concern that
and ask questions; requires immediate attention and action. The
• organize improvement activities and training technique is intended to ensure the correct
for the team; information and level of concern is communicated
in an exchange between health professionals.
• inspire “followers” and maintain a positive
group culture.
Situation
What is going on with the patient?
Including the patient as a member of the health-
“I am calling about Mrs Joseph in room 251. Chief
care team is a new concept in health care.
complaint is shortness of breath of new onset.”
Traditionally the role of the patient has been more
passive as being a receiver of health care. But we
Background
know that patients bring their own skills and
knowledge about their condition and illness. What is the clinical background or context?
Medical student can begin showing leadership in “Patient is a 62-year-old female post-op day one
this area by trying to include the patient or their from abdominal surgery. No prior history of
family as much as possible. Establishing eye cardiac or lung disease.”
contact with patients, checking and confirming
information and seeking additional information can Assessment
all be done in the context of a ward round. What do I think the problem is?
Including the patient is a safety check to ensure “Breath sounds are decreased on the right side
the correct information and complete information with acknowledgement of pain. Would like to rule
is available to everyone on the team. out pneumothorax.”
124
Topic 4: Being an effective team player
Check-back
Handover or handoff
This is a simple technique for ensuring information Handover or handoff are crucial times where
conveyed by the sender is understood by the errors in communication can result in adverse
receiver, as intended:
outcomes. " I pass the baton" is a strategy to
• sender initiates message;
assist timely and accurate handoff.
I Introduction Introduce yourself, your role and job and the name of the patient.
S Safety concerns Critical lab values/reports, socioeconomic factors, allergies and alerts(falls,
isolation and so on).
The
A Actions What actions were taken or are required? Provide brief rationale.
Resolving disagreement and However, it is important for all members of the team
conflict 16 to feel they can comment when they see something
Key to successful teamwork is the ability to that they feel will impact on the safety of a patient.
resolve conflict or disagreement in the team. This
can be especially challenging for junior members The following protocols have been developed to
of the team, such as medical students, or in help members of a team express their concern in
teams that are highly hierarchical in nature. a graded manner.
125
Topic 4: Being an effective team player
Medical hierarchies
Medicine is strongly hierarchical in nature and this
is counterproductive in terms of establishing and
effectively running teams where all members’
126
Topic 4: Being an effective team player
views are accepted and the team leader is not Assessing team performance 19
always the doctor. While there has been a Assessing the performance of a team is an
growing acknowledgement that teamwork is important step in improving team performance.
important in health care this has not necessarily
been translated into changed practices, especially A number of teamwork assessment measures are
in emerging and developing nations where cultural available [18,25, 26]. Assessment of teams can
norms of communication may mitigate against be carried out in a simulated environment, by
teamwork. direct observation of their actual practice or
through the use of teamwork exercises such as
Individualistic nature of medicine described in the section below on teaching
The practice of medicine is based on the teamwork.
autonomous one-on-one relation between the
doctor and patient. While this relationship remains Assessment of teams can either be done at the
a core value, it is challenged by many concepts of level of individual performance within the team or
teamwork and shared care. This can be at many at the level of the team itself. Assessment can be
levels including doctors being unwilling to share performed by an expert or through peer rating of
the care of their patients through to medico-legal performance.
implications of team-based care.
An analysis of the learning styles or problem
Instability of teams solving skills individuals bring to teamwork can be
As already discussed, health-care teams are often useful following the assessment of team
transitory in nature, coming together for a specific performance [27].
task or event (such as cardiac arrest teams). The
transitory nature of these teams places great
emphasis on the quality of training for team Summary 20
members, which raises particular challenges in Teamwork does not just happen. It requires
medicine where education and training is often an understanding of the characteristics of
relegated at the expense of service delivery. successful teams, knowledge of how teams
function and ways to maintain effective team
functioning. There are a variety of team tools that
Accidents in other industries 18 have been developed to promote team
Reviews of high-profile incidents such as the communication and performance and these
crash of Pan Am flight 401 have identified three include SBAR, call-out, check-back and I Pass
main teamwork failings as contributing to the Baton.
accidents, namely: [18,24]
• roles not being clearly defined; WHAT STUDENTS NEED TO DO
• lack of explicit co-ordination; (PERFORMANCE REQUIREMENTS)
• miscommunication/communication.
Using teamwork principles 21
Medical students can use teamwork
principles as soon as they start their medical
courses. Many medical degrees are based on a
problem based learning (PBL) format and require
127
Topic 4: Being an effective team player
students to work together in teams to build patients that they take the time to engage with the
knowledge and solve clinical problems. They can patient. This can include discussing with the
begin to understand how those teams function patient the procedure they are undergoing or any
and what makes an effective PBL group. Learning anxieties or concerns the patient or their carers
to share information, textbooks and lecture notes may have. They can actively include patients in
is a forerunner to sharing information about ward rounds by either inviting them at the time to
patients. participate or by discussing with the team how
patients might be included in ward round
Be mindful of how one’s values and discussions.
assumptions affect interactions with other
team members Using mutual support techniques and
Students learn by observing how different health resolving conflicts, using communication
professionals interact with each other. They will techniques and changing and observing
realize that even though a team can be made up behaviours 22 23
of many personalities and practice styles, this Medical students can practise all of
does not necessarily make the team less effective. these competencies either in their work with their
Rather, it can show how the strengths and peers in study groups or within health-care teams
weaknesses of different members of the team can as they move through their programme and are
assist deliver quality and safe care. increasingly involved. As detailed below, many
teamwork activities can be used with groups of
Be mindful of the role of team members and students and practitioners to explore leadership
how psychosocial factors affect team styles, conflict resolution and communication
interactions, recognize the impact of change skills.
on team members
It can often be difficult for medical students (and A number of practical tips exist to help medical
indeed practising clinicians) to appreciate the students improve their team communication skills.
different roles that health-care professionals play They can start practising good teamwork at the
in teams, or how teams respond to change or very beginning of their medical course. The
psychosocial factors. Students can be following activities and steps will promote good
encouraged to make structured observations of teamwork in any situation whether as a medical
teams to observe what roles are played by student or a hospital senior doctor.
different individuals and how this relates to factors • Always introduce yourself to the team or
such as their personal characteristics as well as those you are working with even if it is for a
their profession. Students can be encouraged to few minutes.
talk to different team members around their • Reading back and closing the communication
experience of working in a team. Faculty can loop in relation to patient care information.
themselves ensure that students are included in • Stating the obvious to avoid confusion.
teams and assigned roles so they can observe
these processes from the inside. Nurse: Mr Brown is going to have
an X-ray.
Include the patient as a member of the team Student: So, we are taking Mr Brown to have
Medical students can ensure that when they are an X-ray now.
taking histories or performing procedures on
128
Topic 4: Being an effective team player
• Asking questions and continually clarifying. • When conflict occurs, concentrate on “what”
• Delegating tasks to people—look at them is right for the patient not on establishing
and check they have the information to “who” is right or wrong.
enable them to do the task. Talking into the
air is an unsafe practice because the person
may not think that it is they who have the CASE STUDIES
responsibility of the task.
• Clarifying your role in different situations. Right action, wrong result
Nurse: Mr Brown is going to have A doctor was coming to the end of his first week
an X-ray. in the emergency department. His shift had ended
Student: So, we are taking Mr Brown to have an hour before, but the department was busy and
an X-ray now. his registrar asked if he’d see one last patient.
Nurse: Yes. The patient was an 18-year-old man. He was with
Student: Who is taking Mr Brown for his parents who were sure he’d taken an
his X-ray? overdose. His mother had found an empty bottle
of paracetamol that had been full the day before.
• Using objective language not subjective He had taken overdoses before and was under
language. the care of a psychiatrist. He was adamant he’d
• Learning the names of people who are in the only taken a couple of tablets for a headache. He
team and using them. Some doctors do not said he’d dropped the remaining tablets on the
bother to learn the names of the nurses and floor so had thrown them away. The parents said
other allied health-care workers thinking they they’d found the empty bottle six hours ago and
are not as important. However, doctor better felt sure that he couldn’t have taken the
relationships with other team members if they paracetamol more than ten hours ago. The doctor
use people’s names rather than referring to explained that a gastric lavage would be of no
them by their profession, such as “nurse”. benefit. He took a blood test instead to establish
• Being assertive when required. This is paracetamol and salicylate levels. He asked the
universally difficult, yet if a patient is at risk of lab to phone the emergency department with the
serious injury then the health professionals, results as soon as possible. A student nurse was
including students, must speak up. Senior at the desk when the lab technician phoned. She
clinicians will be grateful in the longer term if one wrote the results in the message book. The
of their patients avoids a serious adverse event. salicylate level was negative. When it came to the
• If something does not make sense, ask for paracetamol result, the technician said, “two”
clarification. paused, and then, “one three”, “two point one
• Briefing the team before undertaking a team three” repeated the nurse, and put down the
activity and performing a debriefing phone. She wrote “2.13” in the book. The
afterwards. technician didn’t say whether this level was toxic
and he didn’t check whether the nurse had
This encourages every member of the team to understood. When the doctor appeared at the
contribute to discussions about how it went and desk, the nurse read out the results. The doctor
what can be done differently or better next time. checked a graph he’d spotted earlier on the
notice board. It showed when to treat overdoses.
129
Topic 4: Being an effective team player
There was also a protocol for managing reserved. The NPSA authorises healthcare
paracetamol overdoses on the notice board, but it organisations to reproduce this material for
was covered by a memo. The graph showed that educational and non-commercial use.
2.13 was way below treatment level. The doctor
thought briefly about checking with the registrar, but A failure to relay information between staff
she looked busy. Instead, he told the student nurse and to confirm assumptions, resulting in
that the patient would need admitting overnight so adverse patient outcome
that the psychiatrist could review him the next day. This example highlights how the dynamics
The doctor went off duty before the printout came between surgical trainees and staff and the flow of
back from the lab. It read “paracetamol level: 213”. staff in and out of the operating room
The mistake wasn’t discovered for two days, by can allow adverse events to happen.
which time the patient was starting to experience
the symptoms of irreversible liver failure. It wasn’t Before a roux-en-y gastric bypass patient was
possible to find a donor liver for transplant and the brought into the operating room, allow nurse
patient died a week later. If he’d been treated when reported to a second nurse that the patient was
he arrived at the emergency department, he might allergic to “morphine and surgical staples”. This
not have died. information was repeated again to the staff
surgeon and the anaesthetist before the start of
The doctor was told what had happened by his the procedure.
consultant on Monday when he started his next
shift and, while still in a state of shock, explained As the surgery was coming to an end, the staff
that he had acted on what he thought was the surgeon left the operating room, leaving a surgical
correct result. He had not realised, he admitted, fellow and two surgical residents to complete the
that paracetamol levels are never reported with a procedure. The surgical fellow then also left the
decimal point. Because he had not seen the operating room, leaving the two residents to close
protocol he had also not appreciated that it might the incision. The two surgical residents stapled a
have been appropriate to start treatment before long incision closed along the length of the
the paracetamol level had come back anyway, patient’s abdomen. They stapled the three
bearing in mind that the history, although laparoscopic incisions closed as well. When the
contradictory, suggested the patient might well residents began the stapling, a medical student
have taken a considerable number of tablets. It removed a sheet of paper from the patient chart
would be unfair to blame the doctor or the and took it over to the residents. The medical
student nurse individually. The real weakness is student tapped one of the residents on the
the lack of safety checks in the system of shoulder, held the paper up for her to read and
communicating test results. In fact, no-one made told her that the patient was allergic to staples.
a really big mistake. At least three people made a The resident looked at it and said “you cannot be
series of small ones, and the system failed to pick allergic to staples.”
these up.
The staff surgeon returned to the operating room
Reference as the residents were completing the stapling. He
National Patient Safety Agency 2005. Copyright saw that the residents had stapled the incisions
and other intellectual property rights in this and informed them that the patient did not want
material belong to the NPSA and all rights are staples. He told them that they would have to
130
Topic 4: Being an effective team player
take all the staples out and suture the incision. He heart rate or rhythm. The patient did not seem to
apologized for neglecting to inform them of this be breathing. The heart monitor came on and
allergy. One of the residents asked whether you showed ventricular fibrillation.
could be allergic to staples and the staff surgeon
said: “It does not matter. The patient is convinced “Pads and 50 joules”, called Simon. The nurses
that she is.” The staff surgeon told the residents look at him and say, “What?” “Pads and 50 joules,
they would have to remove all the staples and stat!” Simon replie. “Call a doctor, any doctor, to
sew the incisions. This took an additional 30 come and assist me now!” he yelled. They could
minutes. not revive the patient.
131
Topic 4: Being an effective team player
132
Topic 4: Being an effective team player
Reflective activities around experiences of Remember, one of the most important parts of any
teamwork team building exercise is the debrief at the end of
A simple way to introduce teamwork concepts to the exercise. The purpose of the debrief is to
medical students is to get them to reflect on • reflect on what worked well for the team so
teams they may have participated in during school that effective team behaviours are reinforced;
or university. This may include sporting teams, • reflect on what was difficult and what
work teams, choirs and so on. Reflective challenges the team face—strategies to
exercises can include the creation of simple manage the challenges should be explored
surveys that can be used to draw out questions and then practised in subsequent sessions.
around teamwork.
Free team building games can be found on the
Reflective exercises can also be built around following web site.
examples of teamwork failures or successes that http://www.businessballs.com/teambuildinggame
may be topical and/or current within the local s.htm
community. This may include the development of
quizzes or group discussions about newspaper Building newspaper towers: an example of a
articles describing failures in sporting teams team building exercise (taken from the web site
associated with teamwork failures or high-profile above)
examples of medical errors due to failures in An interactive exercise that requires no physical
teamwork. The case studies provided within the contact that can be varied depending on the
framework could also be used to reflect on group size, dynamics and available time.
failures in teamwork.
Basic exercise:
High-profile examples of teamwork failures and Split the group into smaller groups of 2–6 people.
successes outside of health care such as plane Issue each group with an equal number of
crashes or nuclear power station failures are often newspaper sheets (the fewer the more difficult,
used in the teaching of teamwork principles. A 20-30 sheets is fine for a 10-15 minute exercise),
133
Topic 4: Being an effective team player
and a roll of sticky tape. The task is to construct Newspaper construction exercises are terrifically
the tallest free-standing tower made only of flexible and useful. Once you decide the activity
newspaper and sticky tape in the allotted time. The purpose and rules, the important thing is to issue
point of the exercise is to demonstrate importance the same quantity of materials to each team.
of planning (time, method of construction,
creativity) and the motivational effect of a team Other tips for newspaper construction activities:
task. The facilitator will need a tape measure. • Building tips: it does not matter how big the
sheets are, but large double pages offer the
Instructions need to be very clear. For instance, greatest scope for the towers.
does the tower have to be free standing or can it • Think about how much paper is issued as it
be braced? It does not matter which, it matters changes the type of challenge: lots of paper
only that any issues affecting a clear result are makes it much easier and places less
clarified. emphasis on planning. Very few sheets, or
even just one sheet, increases the
Tips for newspaper constructions exercises requirement for planning.
You can allocate as many sheets as you wish, • The main trick (do not tell the participants
depending on the main purpose of the exercise, before the exercise) is to make long thin
and to an extent the duration and how many team round-section struts by rolling the sheets and
members per team. As a general rule, the fewer fixing with sticky tape—Sellotape or Scotch
the sheets the smaller the teams and the shorter tape, or narrow masking tape instead. The
the exercise. Short timescales, big teams, lots of struts can then be connected using various
sheets = lots of chaos. This may be ideal for techniques, rather like girders.
demonstrating the need for leadership and • Round struts (tubes), and any other design of
management. Unless the primary purpose is struts or sections, lose virtually all their
leadership and managing the planning stage, strength if flattened or bent. Very few
avoid small numbers of sheets with large teams. newspaper exercise builders understand this
Small teams do not need lots of sheets unless fundamental point, and some fail to realize it
you make a rule to use all materials in order to put even after completing the exercise, so it is
pressure on the planning and design stage. worth pointing out during the review.
• Square sections are not very strong.
Examples of main purposes and numbers of Triangular or circular sections work best,
sheets: although the former are difficult to make.
• very strong emphasis on preparation and • It is possible to make a very tall tower (8–10
design; feet) using a telescopic design, which
• 1-5 sheets in pairs or threes; requires many sheets to be stuck together
• design, planning, preparation, teamworking: end-to-end, rolling together and then pulling
5–10 sheets in team of three or four; out from the centre.
• team building, time management, warm up, • Most people make the mistake of forming big
ice-breaker, with some chaos management: square section lengths or spans, which are
20 sheets in teams of four, five or six; inherently very weak and unstable. This is
• managing a lot of chaos: 30 sheets and why the newspaper constructions are such
upwards in teams of six or more. good exercises—each one needs thinking
about and planning and testing or people fall
134
Topic 4: Being an effective team player
into traps and make simple mistakes. namely the teamwork, leadership and
• The best way of finding answers is to try it— communication issues that emerge as the
you should be doing that anyway if you are scenario unfolds [18].
facilitating and running the session. You will
be amazed at how strong paper can be if it is As with the non-health-care team building
folded and/or rolled and assembled with a bit exercises discussed above, it is vital that a
of thought. structured debriefing is conducted that explores
the way the teams performed in the exercise:
Simulated health-care environments what worked well and why, what was difficult and
Simulation is being increasingly used to learn and why, and what could be done to improve
practise teamwork in health care. This is an ideal performance on subsequent occasions. If different
learning environment for medical students, as it health-care students are working together in the
combines safety—there is no “real” patient—and simulation, the different roles, perspectives and
the ability to increase or decrease the speed of challenges of each profession can be discussed
evolution of the scenarios to optimize learning, during the debriefing as well.
especially if using mannequin-based simulation
techniques. This is ideal for teamwork exercises The major constraint with simulation exercises is
as the importance of sound teamwork behaviours that they can be resource intensive, especially if
is particularly manifest in “emergency”, time- using a computerized mannequin and attempting
critical situations. In addition, students get a to make a teaching setting look like a clinical
chance to experience what it is like to manage a environment.
situation in “real” time.
Participating in health-care teams
Ideally, simulated environments may be used to Students, particularly in their later years, should
explore teamwork using mixed groups of health- be encouraged to participate in a number of
care professionals. When exploring teamwork the different types of health-care teams at every
focus should not be on the technical skills of the opportunity. Just because the doctors and nurses
students but rather their interactions and from a particular ward or clinic maintain the
communication with one another. The best way to traditional silo approach to health care does not
ensure this remains the focus of the exercise is to prevent medical students working with other
allow the students to learn and practise the health professionals as part of a team.
technical aspects of the scenario together prior to
the actual scenario, usually through an initial The faculty should identify teams where students
procedural workshop. If the team struggle with will be welcomed and ideally given some form of
basic knowledge and skills then the opportunity to participatory role. These teams may include well-
discuss teamwork may be lost as there may be so established multidisciplinary care planning teams
many important medical and technical issues to such as found in mental health or oncology or
discuss. However, if the students are well drilled more fluid teams as found in emergency
on the technical aspects of the scenario departments. They should also include primary
beforehand, the challenge for them is to put what health-care teams in the community.
they know into action as a team. The simulation
then becomes a powerful opportunity to explore It is important to get students to reflect on team-
the “non-technical” aspects of the scenario, based experiences in health care and share these
135
Topic 4: Being an effective team player
experiences with other students and faculty staff. different groups of students together to
This will allow then to discuss both the positive appreciate and respect the different roles of health
and negative aspects of their experience. professionals before they have joined a
Students should be asked to identify model teams professional group themselves.
and why they believe they can be identified as
such. They should be encouraged to ask While there is a compelling argument that
questions such as: undergraduate IPE should improve subsequent
• What were the strengths of the team? teamwork in practice, the research to support this
• What professions were represented on the argument is not yet conclusive.
team and what was their role?
• Did the team have clear goals? Universities have taken different approaches to
• Was there a clear leader? introducing IPE depending on available resources,
• Were all team members permitted to the available undergraduate programmes and the
participate? degree of support for the concept at a senior
• How did members of the team communicate level. Approaches have ranged from a full re-
with one another? engineering and alignment of all health curricula
• How could the student see the team being through to inserting IPE modules and activities
improved? into existing curricula on a relatively opportunistic
• Was the patient part of the team? basis.
Students should be asked to explore and reflect The resources and activities included in this guide
on areas of teamwork where errors are know to are intended to be useful either for programmes
occur such as communication between primary teaching only medical students or for those
and secondary care or during handover/hand off. teaching multiprofessional student groups.
It may also be possible for students to take part in Below we include further reading on IPE and links
a panel discussion with an effective to universities that have introduced IPE into their
multidisciplinary team to discuss how the team curricula.
functions and works together.
Resources
Interprofessional education Institute for Healthcare Improvement. Health
While the focus of this Curriculum Guide is on profession education: a bridge to quality.
medical schools, teamwork in health care cannot Washington DC, National Academies Press,
be discussed without discussing the important 2003.
role of interprofessional education (IPE) in Almgren, G et al. Best practices in patient safety
undergraduate health education. education: module handbook. University of
Washington, Seattle, Center for Health Sciences
At the heart of IPE is the preparation of future Interprofessional Education, 2004.
practitioners for effective team-based practice
through bringing students from different
disciplines together during undergraduate
education to learn from and with each other.
Undergraduate education is a good time to bring
136
Topic 4: Being an effective team player
137
Topic 4: Being an effective team player
138
Topic 4: Being an effective team player
139
Topic 4: Being an effective team player
140
Topic 5: Understanding and learning from errors
141
Topic 5: Understanding and learning from errors
an error has occurred. Indeed, most errors in former situation is a so-called error of execution
health care do not lead to harm for patients and may be further described as being either a
because they are recognized before harm occurs “slip”—if the action is observable—or a “lapse” if it
and the situation is retrieved. There is no doubt is not. An example of a slip is accidentally pushing
that the nature of the outcome usually influences the wrong button on a piece of equipment; an
our perception of the error, often due to example of a lapse is some form of memory failure
phenomenon of “hindsight bias” in which such as failing to administer a medication (see
knowledge of the outcome of a situation Figure 6).
influences our perception (usually unfavourably) of
the standard of care before and during the Figure 6. Summary of the principal error types
incident in question [2]. 11
One only has to consider one’s last “silly mistake” Attentional slips
of action
in everyday life to be reminded of the inevitability Skill-based slips
of error as a fundamental facet of the “human and lapses
Lapses of
condition” (see topic 2 “What is human factors memory
and why is it important to patient safety?”). Errors
T2
Rule-based
mistakes
The challenging reality for health-care workers is
Mistakes
that the same mental processes that lead us to
Knowledge-based
make “silly mistakes” away from the workplace mistakes
The unique feature in health care-associated Slips, lapses and mistakes are all serious and can
errors is that when failure occurs (omission or potentially harm patients, though again it all
commission) it is the patient or patients who depends on the context in which the error occurs.
suffer.
Situations that increase the likelihood of error as
Errors occur because of one of two main types of well as personal error reduction strategies are
failures: either actions do not go as intended or described in topic 2 “What is human factors and
the intended action is the wrong one [3]. The why is it important to patient safety?” Some other
142
Topic 5: Understanding and learning from errors
general error reduction principles are outlined pharmacists and nurses who have habitual
below. Reason has also promoted the concept of checking routines built into their discipline.
“error wisdom” [4] for frontline workers as a Medicine has not had such a long tradition of
means to assess the risk in different contexts using techniques to help minimize errors.
depending on the current state of the individual Checking is a simple thing that students can start
involved, the nature of the context and the error practising immediately when they are placed into
potential of the task at hand. the clinical environment.
T2
143
Topic 5: Understanding and learning from errors
preparedness of medical students for clinical the first to measure the effects of sleep
practice has been studied. Most reveal that many deprivation on medical errors. They found that
graduating medical students in their early intern interns working in the medical intensive unit and
year have deficiencies in basic clinical skills. This coronary care unit of Brigham and Women’s
may be because of a reluctance to ask for help as Hospital (Boston, United States) made
students. Inadequate understanding of the crucial substantially more serious mistakes when they
signs of acute illness, airway obstruction and worked frequent shifts of 24 hours or more than
basic life support were examples of specific areas when they worked shorter shifts. Other studies
where new doctors had inadequate knowledge show that sleep deprivation can have similar
and skills. symptoms to alcohol intoxication [6].
Many students think that if they can regurgitate Stress, hunger, illness
the medical information stored in textbooks they When students feel stressed, hungry or ill they will
will be good doctors. However, this is not the not function as well as when they have none of
case. The amount of information that a doctor is these issues. It is very important for students to
required to know today is far beyond that which is begin to monitor their own status and well being,
capable of being memorized. Today, educational being mindful that if they are feeling unwell or
outcomes are more about performance than stressed that they are more likely to make errors.
retention of information. This is because
educationalists recognize that the human brain is Language or cultural factors
a limited organ that is only capable of The potential for communication errors caused by
remembering a finite amount of information. language and cultural factors is obvious but there
Students should not rely on memory, particularly are many patient–doctor interactions that occur
when there are a number of steps involved. without an interpreter or understanding of the
Guidelines and protocols were developed to language. Students should appreciate the
assist clinicians to provide care following the best problems caused by language barriers and
available evidence. Students should get into the misunderstanding of cultural norms.
habit of using checklists and not relying on their
memory. Topic 7 has a section on guidelines. T7 Hazardous attitudes
Medical students who perform procedures on
Fatigue patients without supervision might be said to
Memory is affected by fatigue. Fatigue is a known display a hazardous attitude. The student may be
factor in errors involving junior doctors. In more interested in practising or getting experience
recognition of the problems caused by fatigue rather than any concern for the well-being of the
many countries have or are reforming the patient. Students should always appreciate that
excessive hours worked by doctors. The accessing patients in a privilege and one that
connection between sleep deprivation of interns should not be taken for granted.
due to long hours and circadian interruption and
well-being was made three decades ago, yet it is
only recently that governments and regulators
have been serious about limiting hours.
A 2004, study by Landrigan et al. [5] was one of
144
Topic 5: Understanding and learning from errors
There are many easy to remember incident—are criticized for their role in the
mnemonics to assist students monitor evolution of the incident. As mentioned above,
themselves. HALT is one such aid. 14 15 this situation is often exacerbated by the
phenomenon of hindsight bias. The person
Do not forget if you are approach is counterproductive at several levels
H H ungry (see topic 3 “Understanding systems and the
A A ngry impact of complexity on patient care”). T3 18
L L ate
or The frequency of reporting and the manner in
T T ired which incidents are analysed—using a systems
approach rather than a person approach—are
Another tool is IM SAFE heavily dependent on the leadership and “culture”
I Illness within an organization. More attention is being
M Medication (prescription alcohol and others) paid to the importance of organizational culture in
health care in recent years [7], reflecting lessons
S Stress learnt in other industries in relation to system
A Alcohol safety. It is likely that there is a correlation in health
F Fatigue care between organizational culture in a health
E Emotion service and patient safety.
145
Topic 5: Understanding and learning from errors
Other successful strategies in terms of incident that focuses on prevention not blame or
reporting and monitoring include: [6] 21 punishment. Other processes are used when
• anonymous reporting; people are required to be accountable for their
• timely feedback; actions. The focus is on systems level
• open acknowledgement of successes vulnerabilities and not individual performance. The
resulting from incident reporting; model examines multiple factors such as
• reporting of near misses is useful in that “free communication, training, fatigue, scheduling,
lessons” can be learnt, i.e. system rostering, environment, equipment, rules, policies
improvements can be instituted as a result of and barriers. 24
the investigation but at no cost to a patient.
The defining characteristics of root cause analysis
include: [10]
Root cause analysis • review by an interprofessional team
knowledgeable about the processes involved
See also topic 7 “Introduction to quality in the event;
improvement methods”. 22 T7 • analysis of systems and processes rather
than individual performance;
The Veterans Affairs National Center for Patient • deep analysis using “what” and “why” probes
Safety of the US Department of Veterans Affairs until all aspects of the process are reviewed
has developed a structured approach called root and contributing factors are considered;
cause analysis to evaluate, analyse and develop • identification of potential improvements that
system improvements for the most serious could be made in systems or processes to
adverse events [9]. improve performance and reduce the
likelihood of such adverse events or close
Reporting an incident requires the following basic calls in the future.
information: [1] 23
• What happened? Practise strategies to reduce errors 25
• Who was involved? Medical students can immediately start
• When did it happen? practising error reduction behaviours by looking
• Where did it happen? after their own health. Being aware when they are
• The severity of the actual or potential harm. tired, becoming familiar with the environment they
• The likelihood of reccurrence. work in, and being prepared for the usual knowing
• The consequences. that unusual things can happen. We know that it
is impossible for any one individual to know
Root cause analysis focuses on the system and everything so it is important that medical students
not the individual worker and assumes that the get used to asking questions if they do not know
adverse event causing harm to a patient is a something relevant and important to the patients.
system failure. The VA system uses a severity
assessment code to help triage the reported Some personal error reduction strategies for
incidents to ensure those indicating the most students are to
serious risk to the organization are dealt with first. • know yourself (eat well, sleep well and look
after yourself):
The root cause analysis model is a tested model • know your environment;
146
Topic 5: Understanding and learning from errors
Learning from error can occur at both an individual United States, November 2005
and organizational level through incident reporting A 21-year-old male was being treated for non-
and analysis. Barriers to learning from error include Hodgkin’s lymphoma. A syringe containing
a blame culture that institutes a person approach vincristine for another patient had been
to investigation and the phenomenon of hindsight accidentally delivered to the patient’s bedside. A
bias. A broadly based system approach is physician administered vincristine via a spinal
required for organizational learning and the route, believing it was a different medication. The
possibility of system change to occur. error was not recognized and the patient died
three days later.
147
Topic 5: Understanding and learning from errors
148
Topic 5: Understanding and learning from errors
149
Topic 5: Understanding and learning from errors
patient safety: a curriculum guide for teaching reflections. Academic Medicine, 2002,
medical students and family practice residents, 77(10):993–1000.
(http://www.nymc.edu/fammed/medicalerrors.pdf, 7. Flin R et al. Measuring safety climate in health
accessed May 2008). care. Quality and Safety in Health Care, 2006.
8. Reason JT. Managing the risks of
HOW TO ASSESS THIS TOPIC organisational accidents, 3rd ed. Aldershot,
UK, Ashgate Publishing Ltd, 2000.
Assessment strategies/formats 9. Root cause analysis. Washington, DC,
A range of assessment strategies are suitable for this Veterans Affairs National Center for Patient
topic including MCQs, essays, SBA, case-based Safety, US Department of Veterans Affairs
discussion and self-assessment. Having a student, (http://www.va.gov/NCPS/curriculum/RCA/in
or a group of students, lead an adverse event dex.html, accessed May 2008).
investigation or even a “mock” root cause analysis is 10. Best practices in patient safety education
a highly engaging way to elicit understanding. module handbook. Seattle, University of
Washington Center for Health Sciences,
HOW TO EVALUATE THIS TOPIC 2005.
11. Kohn LT, Corrigan JM, Donaldson MS, eds.
Evaluation is important to review how a teaching To err is human - building a safer health
session went and how improvements can be made. system. Washington, DC, Committee on
Quality of Health Care in America, Institute of
References Medicine, National Academy Press, 1999.
1. Runciman W, Merry A, Walton M. Safety and
ethics in healthcare: a guide to getting it right, Slides for topic 5: Understanding and
1st ed. Aldershot, UK, Ashgate Publishing learning from errors
Ltd, 2007.
2. Reason JT. Human error. New York: Didactic lectures are not usually the best way to
Cambridge University Press 1990. teach students about patient safety. If a lecture is
3. Reason JT. Human error: models and being considered, it is a good idea to plan for
management. British Medical Journal, 2000, student interaction and discussion during the
320:768–770. lecture. Using a case study is one way to
4. Reason JT. Beyond the organisational generate group discussion. Another way is to ask
accident: the need for “error wisdom” on the the students questions about different aspects of
frontline. Quality and Safety in Health Care, health care that will bring out the issues contained
2004, 13:28–33. in this topic such as the blame culture, nature of
5 Landrigan CP et al. Effect of reducing interns' error and how errors are managed in other
working hours on serious medical errors in industries.
intensive care units. New England Journal of
Medicine, 2004, 351:1838–1848. 7 Dawson The slides for topic 5 are designed to assist the
D, Reid K. Fatigue, alcohol and performance teacher deliver the content of this topic. The slides
impairment. Nature, 1997, 388:235. can be changed to fit the local environment and
6. Larson EB. Measuring, monitoring, and culture. Teachers do not have to use all of the
reducing medical harm from a systems slides and it is best to tailor the slides to the areas
perspective: a medical director’s personal being covered in the teaching session.
150
Topic 6: Understanding and managing clinical risk
Why clinical risk is relevant to patient medication errors and the strategies in place to
safety 1 2 manage and avoid them.
Risk management is routine in most
industries and has traditionally been associated Research shows that nurses are more likely to
with limiting litigation costs. Many corporations try report an incident than other health professionals,
to avoid financial loss, fraud or a failure to meet certainly more so than doctors. This may be
production expectations by implementing because the blame culture in medicine is a strong
strategies to avoid such events. Hospitals and deterrent to reporting. Today, most risk
health organizations use a variety of methods for management programmes aim to improve safety
managing risks. The success of a risk and quality in addition to minimizing the risk of
management programme, however, depends on litigation and other losses (staff morale, loss of
the creating and maintaining safe systems of care, staff, diminished reputation), but the degree of
designed to reduce adverse events and improve their success depends on many factors. 3
human performance [1]. Many hospitals have
well-established systems in place for reporting Clinical risk management specifically is concerned
patient falls, medication errors, retained swabs with improving the quality and safety of health-
and misidentification of patients. Nevertheless, care services by identifying the circumstances and
they are only beginning to focus on all aspects of opportunities that put patients at risk of harm and
clinical care to see opportunities for reducing risks then acting to prevent or control those risks. The
to patients. following simple four-step process is commonly
used to manage clinical risks:
A medical student, along with everyone else who 1. identify the risk;
works in a hospital or clinic has a responsibility to 2. assess the frequency and severity of the risk;
take the correct action when they see an unsafe 3. reduce or eliminate the risk;
situation or environment. Taking steps to ensure a 4. assess the costs saved by reducing the risk
slippery floor is dry and preventing a patient from or the costs if the risk eventuates.
falling over is as important as ensuring that the
medication a patient is taking is the correct one. Medical students, along with all other health
In the event of a patient falling on a slippery floor professionals will be mainly concerned about the
or receiving the wrong medication, it is equally risk to patients. The first topic in this Curriculum
important for a student to report these events so Guide outlines the extent of the harm done by
that steps can be taken to avoid future incidents. health care. It is against this backdrop that
organizations are concerned about managing
Effective risk management involves every level of clinical risks. Clinical risk management allows
the health service, so it is essential that all health- identification potential errors. Health care itself is
care workers understand the objectives and inherently risky and although it would be
relevance of the risk management strategies and impossible to eradicate all harm, there are many
their relevance to their own workplace. activities and actions that can be introduced that
Unfortunately, even though a hospital may have a will minimize opportunities for errors. Clinical risk
policy of reporting incidents such as medication is relevant to medical students because it
errors, the actual reporting of them is often recognizes that clinical care and treatment are
sporadic. Students can begin to practise reporting risky and incidents may to occur during clinical
by talking with the health-care team about care and treatment. Students (as well as all other
151
Topic 6: Understanding and managing clinical risk
health-care professionals) must actively weigh up • respond appropriately to patients and families
the anticipated risks and the benefits of each after an adverse event;
clinical situation and only then take action. • respond appropriately to complaints.
Students should seek out information about past
risks and actively participate in efforts to prevent WHAT STUDENTS NEED TO KNOW
them recurring. For example, compliance with a (KNOWLEDGE REQUIREMENTS)
handwashing protocol so that the spread of
infection is minimized. In this sense students are What are the activities for gathering
acting proactively to avoid problems and not information about risk? 7
merely reacting to a current problem. Medical students working in hospitals may
not be immediately aware of a risk management
Keywords programme in their hospital or clinic.
Clinical risk, reporting near misses, reporting Nevertheless, most countries today will have a
errors, risk assessment, incident, incident range of mechanisms to measure the harm to
monitoring. patients and staff as well as avoid known
problems. Some countries have well-developed
Learning objective 4 state and national data sets of incidents. In
Know how to apply risk management Australia, the Advanced Incident Management
principles by identifying, assessing and reporting System is a comprehensive approach to reporting
hazards and potential risks in the workplace. incidents and analysing the various types of
incidents. The Veterans Affairs Administration of
Learning outcomes: knowledge and the US Department of Veterans Affairs has
performance established a National Center for Patient Safety
that uses a structured approach called root cause
What students need to know (knowledge analysis to evaluate, analyse and treat the
requirements): 5 problems. See topics 5 and 7 for more
• the activities for gathering information information about the root cause analysis
about risk; methodology. T5 T7
• fitness-to-practice requirements;
• personal accountability for managing clinical The principle underpinning root cause analysis is
risk. that the actual (root) cause of a particular problem
is rarely (immediately) recognizable at the time of
What students need to do (performance the mistake or incident. A superficial and biased
requirements): 6 assessment of any problem usually does not fix
• know how to report known risks or the problem and more incidents will occur
hazards in the workplace; involving others in similar situations. An essential
• keep accurate and complete medical part of any root cause analysis is the
records; implementation of the findings of the root cause
• know when and how to ask for help from a analysis process. Many hospitals and
supervisor, senior clinician and other health- organizations fail to complete the process
care professionals; because either the recommendations involve
• participate in meetings that discuss risk resources that are not available or there is no
management and patient safety; commitment by the senior hospital management to
152
Topic 6: Understanding and managing clinical risk
carry through the recommendations. make a report again. Even when this happens,
Some health-care organizations that mandate students should be encouraged by faculty staff to
reporting of incidents can become so overloaded continue to report. One day the student will be a
with reported incidents with the consequence that senior doctor and their actions will be highly
many remain unanalysed due to inadequate influential on younger doctors and students.
resources. Even the introduction of a triage system Facilitated monitoring is designed to identify a
to distinguish serious incidents from others has not greater proportion of incidents and to produce
resolved this dilemma in some systems. Many reports that are aimed at improving care. This type
systems now have borrowed from the Veteran of monitoring is a continuous activity of the clinical
Administration and introduced a severity team involving the following actions:
assessment code to help identify those incidents • discussion about incidents is a standing item in
that indicate the most serious risk to the the weekly clinical meetings;
organization. • there is a weekly review of areas where errors
are know to occur;
Below are some common activities used to manage • a detailed discussion about the facts of an
clinical risk. incident and follow-up action required is done
with the team;
Incident monitoring • the discussion is always educational rather
Incident reporting has existed for decades. Many then attributing blame;
countries now have national databases of adverse • identifies the system issues so they can be
events pertaining to different specialties such as addressed and other staff made aware of the
surgery, anaesthesia, maternal and child health. WHO potential difficulties.
defines an incident as an event or circumstance that
could have or did lead to unintended and/or As well as reporting actual incidents, some
unnecessary harm to a person and/or a complaint, organizations encourage the reporting of “near
loss or damage. The main benefit of incident reporting misses” because of the value they bring about new
lies in the information about prevention rather than the problems and the factors that contribute to them,
frequency of the incident; other quantitative methods and how they may be prevented, before serious
are required for that. harm is done to a patient. A near miss is an incident
that did not cause harm. Some people call “near
Facilitated incident monitoring refers to the misses” “near hits” because the actions may have
mechanisms for identifying, processing, analysing caused an adverse event, but corrective action was
and reporting incidents with a view to preventing taken just in time or the patient had no adverse
their reccurrence [2]. The key to an effective reaction to the incorrect treatment. Talking about
reporting system is to have staff routinely reporting “near misses” may be easier in some environments
incidents or near misses. However, unless staff trust where there is a strong blame culture because no
that the organization will use the information for one will be able to be blamed because there was
improvement and not to blame individuals, they will no adverse outcome to the patient. See Table 14
not report. Trust includes the belief that the for more analysis of incident monitoring.
organization will also act upon the information. If a
medical student reported an incident to a senior Sentinel events 8
nurse or doctor who dismissed their effort and told A sentinel event is an unexpected
them not to bother, then the student is less likely to occurrence involving death or serious physical or
153
Topic 6: Understanding and managing clinical risk
Falls 29
Injuries other than falls (e.g. burns, pressure injuries, physical assault, self-harm) 13
Medication errors (e.g. omission, overdose, underdose, wrong route, wrong medication) 12
Clinical process problems (e.g. wrong diagnosis, inappropriate treatment, poor care) 10
Equipment problems (e.g. unavailable, inappropriate, poor design, misuse, failure, malfunction) 8
Documentation problems (e.g. inadequate, incorrect, not completed, out of date, unclear) 8
Logistic problems (e.g. problems with admission, treatment, transport, response to emergency) 4
Administrative problems (e.g. inadequate supervision, lack of resource, poor management decisions) 2
Nutrition problems (e.g. fed when fasting, wrong food, food contaminated, problems when ordering) 1
Colloid or blood product problems (e.g. omission, underdose, overdose, storage problems) 1
Oxygen problems (e.g. omission, overdose, underdose, premature cessation, failure of supply) 1
a
More than one type of incident may be assigned to a report.
psychological injury to a patient and includes any The role of complaints in improving care 9
process variation for which a recurrence would A complaint is defined as an expression of
carry a significant chance of serious adverse dissatisfaction with their health care by a patient or
outcome [4]. The current trend in many countries a family member. Because medical students will be
in analysing adverse events is to rank the treating patients under supervision they may be
seriousness of the event. A sentinel event is named in a complaint from a patient or family
reserved for the most serious ones. member. Students may feel exposed when this
happens and may feel that they will be blamed for
Many hospitals and clinics have mandated the their actions. Students and all health professionals
reporting of these types of events or events may feel embarrassed, remorseful, angry or
because of the risk of a repeat. These are often defensive if they are the subject of a complaint.
called “never events” that should never be allowed While complaints from patients or their families may
to happen because of the potential for death or be uncomfortable to deal with, they are a very good
significant harm. Catastrophic event is another opportunity for improving clinical practice [5] and
term used and these make up half of all the restoring a trusting relationship between the patient,
sentinel events reported in the United States and their family and the health-care team. Complaints
over two thirds of those reported in Australia [3]. often highlight problems that need addressing such
154
Topic 6: Understanding and managing clinical risk
as the common problems of poor communication Complaints and concerns where the
or suboptimal clinical decision-making. individual is responsible
Communication problems are common causes of From a patient’s perspective individual patients
complaints as are problems with treatment and should be able to have their concerns examined
diagnosis. Students are learning about clinical to see if there has been a departure from
decision-making and patient management and are professional standards. After examination or
seeing just how complex these tasks can be. So it investigation it may be that system issues are at
is not surprising that miscommunication or the heart of the problem but the treating doctor or
suboptimal care may sometimes occur. Patient health-care team may also have been at fault—for
complaints help to identify areas in the processes of example by cutting corners and breaching
care that could be improved. The information from accepted protocols. The standard of care may be
complaints can also used to educate and inform low resulting in suboptimal care. Guidelines may
health professionals about problem areas. not have been followed or hospital rules broken.
Other benefits of complaints include that they: [5] An example is failure of a staff member to wash
• assist to maintain standards; their hands, resulting in transmission of infection
• reduce the frequency of litigation; from one patient to another. While the initial
• help maintain trust in the profession; approach to the investigation should adopt a
• encourage self-assessment; systems-based view, individuals are also required
• protect the public. to meet their professional responsibilities—it may
be that the staff member was indeed directly at
Students should be aware that most doctors will fault through failing to adhere to accepted
receive complaints in their careers and that it is standards of care. Reason [6] defined a violation
not an indication of incompetence—even the as a deviation from safe operating procedures,
most conscientious and skilful clinicians can and standards or rules.
do make mistakes. Medical error is a subset of
human error; all humans make mistakes. Legal Coronial Investigations
and ethical obligations are reinforced when a Most countries have some system for establishing
complaint is in the hand. cause of death. Specifically appointed people,
often called coroners, are responsible for
If a student is involved in a complaint, or if they investigating deaths in situations where the cause
receive one when they are doctors, they should of death is uncertain, or thought to be due to
be open to discussing the complaint with the unethical or illegal activity. Coroners often have
patient or family. It is a good idea to have a more broader powers than a court of law and after
senior person present during these discussions. If reporting the facts will make recommendations for
a student is required to provide a written addressing any system-wide problems.
statement about their actions, it is important that
the statement is factual and relates directly to the Fitness-to-practise requirements 10
student’s or doctor’s involvement. It is important Medical students and all health professionals
to always check with a supervisor if a written are accountable for their actions and conduct in
complaint is received and a statement required. the clinical environment. They are responsible for
The hospital or clinic will most likely have in place their actions according to the circumstances in
a policy for managing complaints. which they find themselves. Related to
155
Topic 6: Understanding and managing clinical risk
accountability is the concept of “fitness to Hospitals and health-care organizations also have
practise”. Why is fitness to practise an important responsibilities to ensure that only competent and
component of patient safety? qualified doctors treat patients. They are required
to check that a doctor has the right qualifications
Of the many factors underpinning adverse events and experience to practise in the area they
one factor relates to the competence of clinicians. nominate. The processes for doing this follow.
Many mistakes leading to adverse events are
associated with the fitness of a doctor to practise. Credentialling
Are they competent? Are they practising beyond Credentialling is the process of assessing and
their level of experience and skill? Are they unwell, conferring approval on a person’s suitability to
suffering from a stress or a mental illness? Most provide specific consumer/patient care and
countries will have a system for registering doctors, treatment services, within defined limits, based on
dealing with complaints and maintaining standards. an individual’s licence, education, training,
It is important that medical students understand experience and competence (Australian Council on
why it is important to be vigilant about their own Healthcare Standards). Many hospitals have
fitness and that of their colleagues. Medicine as a credentialling processes in place to check whether
profession places duties and obligation upon a doctor has the required skills and knowledge to
doctors with the aim of keeping patients safe. undertake specific procedures or treatments.
Hospitals will restrict the type of procedures offered
Selecting the right students to study medicine is at a hospital if there are no qualified personnel or if
the first step in making sure that the people who the resources are not available or appropriate for
are choosing medicine as a career have the the particular condition or treatment.
professional attributes for safe and ethical
practice. Many medical schools now have OSCE- Accreditation
type (Objective Structured Clinical Examination) Accreditation is a formal process to ensure
processes to help identify those students who in delivery of safe, high-quality health care based on
addition to their examination results also have the standards and processes devised and developed
attitudes and behaviours best suited to medicine by health-care professionals for health-care
and patient safety. Doing medicine because of services. It can also refer to public recognition of
family expectations or a desire for high status or achievement by a health-care organization of
money is often insufficient to sustain a career in requirements of national health care standards.
medicine. Attributes such as compassion,
empathy, a vocational aspiration to do good and Registration
to provide benefits to society are the sustaining Most countries require medical practitioners to be
qualities. registered with a government authority or under a
government instrument. The principal purpose of
The duties of a doctor (and medical student) a registration authority is to protect the health and
extend to reporting a peer or colleague who is safety of the public by providing mechanisms
unsafe because of either incompetence or designed to ensure that medical practitioners are
unprofessional or unethical behaviour. Some fit to practise medicine. It achieves this by
countries require mandatory reporting of ensuring that only properly trained doctors are
practitioners if they are unfit, while others rely on registered, and that registered doctors maintain
individuals to use their conscience in this regard. proper standards of conduct and competence.
156
Topic 6: Understanding and managing clinical risk
157
Topic 6: Understanding and managing clinical risk
shifts. Other studies show that sleep overtime that have been noted to have an
deprivation can have similar symptoms to association with increased errors. The factors
alcohol intoxication [11]. underpinning these errors can range from lack of
supervision to tiredness. Students should be extra
Stress and mental health problems vigilant during these times.
Students are also prone to stress caused by
examinations, part-time work, family and Supervision
workplace concerns. Good supervision is essential for every student
• Strong evidence suggests physicians are prone and the quality of the supervision will determine to
to mental health problems [12], particularly a large extent how successfully a student
depression, in their first postgraduate years as integrates and adjusts to the hospital or clinical
well as in later years. Students also suffer from environment.
stress and associated health problems that • The failure of senior clinicians to supervise or
they carry with them when they start practising arrange adequate supervision for medical
as doctors; students and interns and residents makes
• While rates of depression and mental health them more vulnerable to making mistakes
problems among doctors are higher than either by omission (failing to do something) or
those experienced by the general population, commission (doing the wrong thing).
the literature shows that when interns and • Students should always request supervision if
residents are supported by fellow house it is the first time they are attempting a skill or
officers and senior clinicians, and are procedure on a patient. They should also
members of well-functioning teams, they are advise the patient that they are students and
less likely to feel isolated and suffer stress; request their permission to proceed to treat
• Performance is also affected by stress; them or perform the procedure.
• There is strong evidence indicating that • Poor interpersonal relationships between
inadequate sleep contributes to stress and students, other health-care professionals,
depression, rather than the number of hours interns, residents and supervisors have also
worked; been identified as factors in errors. If a
• Other stressors identified in the literature student is having a problem with a supervisor,
include financial status, educational debt and they should seek help from another faculty
term allocation and emotional pressures member who may be able to meditate or help
caused by demands from patients, time the student with techniques to improve the
pressures and interference with social life. relationship.
• The literature also shows that students who
Work environment and organization have problems with inadequate skills
Hospitals and clinics can be very stressful places acquisition also have poor supervision. Many
to the newcomer. Unfamiliar work practices and health professionals have learnt a procedure
rosters can make it very difficult in the early phase while unsupervised and were judged by
of a new workplace. In addition, long hours cause supervisors to have poor technique and
fatigue. inadequate mastering of procedures. Students
should never perform a procedure on a patient
There are well-known situations such as change- without sufficient preparation and supervision.
overs of shift, shift work, nights, week ends and
158
Topic 6: Understanding and managing clinical risk
Know how to report known risks or Know when and how to ask for help
hazards in the workplace from a supervisor, senior clinician or
Students should seek information on the incident other health professional
reporting system used in the hospital where they Many medical students fear that if they admit to
are practising or placed. There will usually be a not knowing something that their teachers will
specific method for reporting—either an electronic think less of them. It is important for students to
or paper form. Students should be familiar with recognize the limitations caused by their lack of
the system in place and seek information about knowledge and the importance of seeking help or
how to report an incident. asking for information. Students should be clear
about who they report to in the hospital or in the
clinic. This person will be able to assist them if they
get into a situation beyond their current knowledge
and skills. It is essential that students ask for help
even if they feel uncomfortable about doing so.
Supervisors and senior clinicians do not expect
medical students or junior doctors to have the
depth of learning required to independently treat
159
Topic 6: Understanding and managing clinical risk
160
Topic 6: Understanding and managing clinical risk
The tutor facilitating this session should also be maintaining continuity of care.
familiar with the content so information can be Brian was being treated by a new specialist and
added about the local health system and clinical needed his records from the orthopaedic surgeon
environment. who operated on his knee two years earlier. When
the records finally arrived, Brian’s new doctor
Simulation exercises informed him that they were not “up to scratch”.
Different scenarios could be developed
about adverse events and the techniques for The records were poorly documented with no
minimizing the opportunities for errors such as meaningful notes concerning the consent
• practising the techniques of briefings, discussion for Brian’s operation. There were also
debriefings, and assertiveness to improve gaps in the information recorded in the operation
communication; report and there was no documentation of the
• role play using a “person approach” and then orthopaedic surgeon’s verbal advice about the
a ”system approach” in a mortality and risks and complications of the operation. Brian
morbidity meetings; was dismayed to discover that the surgeon had
• role play a situation in theatre where a not followed up on a missed postoperative review.
medical student notices something is wrong
and needs to speak up. Reference
Case adapted from Payne S. case study:
Teaching activities managing risk in practice. United Journal, 2003,
Administration, theatre and ward activities: Spring, p. 19.
• students can observe a risk management
meeting; Acknowledgment of medical error
• students could meet with the people who This case shows the value of open disclosure.
manage complaints for the hospital or clinic—
part of the exercise would be to ask the Frank is a resident of an aged care facility. One
hospital policy on complaints and what night, a nurse mistakenly gave Frank insulin, even
usually happens if a complaint is made; though he does not have diabetes. The nurse
• students could take part in an open immediately recognised his error and brought it
disclosure process. the attention of the other staff, who in turn
informed Frank and his family. The facility took
After these activities students should be asked immediate action to help Frank and arranged his
to meet in pairs or small groups and discuss transfer to a hospital where he was admitted and
with a tutor or clinician what they observed and observed before being returned to the aged care
whether the features or techniques being facility. The nurse was commended for fully and
observed were present or absent, and whether immediately disclosing the incorrect administration
they were effective. of the insulin. Following this incident, the nurse
undertook further training in medications to
CASE STUDIES minimise the possibility of a similar error occurring.
161
Topic 6: Understanding and managing clinical risk
Inadequate complaints management This was not the first time that the nurse had
This case shows the importance of timely stolen Schedule 8 drugs for the purposes of self-
attention to complaints. administering them. A number of complaints had
been made about the nurse while working at a
162
Topic 6: Understanding and managing clinical risk
private hospital including professional misconduct, Commission for Safety and Quality, 2006.
impairment for drug addiction, lack of good http://www.health.gov.au/internet/safety/publishin
character and that which rendered the nurse unfit g.nsf/Content/2D41579F246E93E3CA2571C500
to practice. 2358A0/$File/guidecomplnts.pdf.
163
Topic 6: Understanding and managing clinical risk
summative; rankings can range from physical and mental well being of pre-
unsatisfactory to giving a mark. See the forms in registration house officers. Irish Journal of
Appendix 2 for assessment examples. Medical Sciences, 1998, 176:22–25.
10. Landrigan CP et al. Effect of reducing interns’
HOW TO EVALUATE THIS TOPIC working hours on serious medical errors in
Intensive Care Units. The New England
Evaluation is important in reviewing how a Journal of Medicine, 2004, 351:1838–1848.
teaching session went and how improvements 11. Dawson D, Reid K. Fatigue, alcohol and
can be made. See the Teacher’s Guide (Part A) for performance impairment. Nature 1997:388–
a summary of important evaluation principles. 335.
12. Tyssen R, Vaglum P. Mental health problems
References among young doctors: an updated review of
1. Reason JT. Understanding adverse events: prospective studies. Harvard Review of
the human factor. In: Vincent C, ed. Clinical Psychiatry, 2002, 10:154–165.
risk management: British Medical Journal 13. Spath PL, ed. Error reduction in health care:
Books, 2001, 9–14. systems approach to improving patient safety.
2. Barach P, Small S. Reporting and preventing San Francisco, Jossey-Bass, 1999.
medical mishaps: lessons from non-medical
near miss reporting systems. British Medical
Journal, 2000, 320:759–763. SLIDES FOR TOPIC 6:
3. Runciman B, Merry A, Walton M. Safety and UNDERSTANDING AND MANAGING
ethics in health care: a guide to getting it CLINICAL RISK
right, 1st ed. Aldershot, UK, Ashgate
Publishing Ltd, 2007. Didactic lectures are not usually the best way to
4. Joint Commission on Accreditation of teach students about patient safety. If a lecture is
Healthcare Organizations. Sentinel event being considered, it is a good idea to plan for
policy and procedures. In: JCAHO, ed. student interaction and discussion during the
Chicago, JCAHO, 1999. lecture. Using a case study is one way to generate
5. Walton M. Why complaining is good for group discussion. Another way is to ask the
medicine. Journal of Internal Medicine, 2001, students questions about different aspects of health
31(2):75–76. care that will bring out the issues contained in this
6. Reason JT. Human error: Cambridge, topic such as the blame culture, nature of error and
Cambridge University Press, 1999. how errors are managed in other industries.
7. Samkoff JS. A review of studies concerning
effects of sleep deprivation and fatigue on The slides for topic 6 are designed to assist the
residents’ performance. Academic Medicine, teacher deliver the content of this topic. The slides
1991, 66:687–693. can be changed to fit the local environment and
8. Deary IJ, Tait R. Effects of sleep disruption on culture. Teachers do not have to use all of the
cognitive performance and mood in medical slides and it is best to tailor the slides to the areas
house officers. British Medical Journal, 1987, being covered in the teaching session.
295:1513–1516.
9. Leonard C et al. The effect of fatigue, sleep
deprivation and onerous working hours on the
164
Topic 7: Introduction to quality improvement methods
165
Topic 7: Introduction to quality improvement methods
developing quality improvement methods for to apply the principles and use the tools to
health clinicians and managers. The identification undertake their own improvement project.
and examination of each step in the process of
health-care delivery is the bedrock of this What students need to know (knowledge
methodology. When students examine each step requirements): 3
in the process of care they begin to see how the • the science of improvement;
pieces of care are connected and measurable. • the quality improvement model;
Measurement is critical for safety improvement. • change concepts;
• two examples of continuous improvement
A range of quality improvement methods have methods;
been designed. Below are some more common • methods for providing information on
examples: clinical care.
• clinical practice improvement (CPI);
• root cause analysis to retrospectively examine What students need to do (performance
what went wrong; requirement): 4
• failure modes and effects analysis to • know how to perform a range of
prospectively consider what might go wrong. improvement activities and tools.
166
Topic 7: Introduction to quality improvement methods
167
Topic 7: Introduction to quality improvement methods
Purpose To discover new knowledge To bring new knowledge into daily practice
Biases Control for as many biases as possible Stabilize the biases from test to test
Data Gather as much data as possible, “just in case” Gather “just enough” data to learn and complete
another cycle
Duration Can take long periods of time to obtain results “Small tests of significant changes” accelerates
the rate of improvement
168
Topic 7: Introduction to quality improvement methods
169
Topic 7: Introduction to quality improvement methods
170
Topic 7: Introduction to quality improvement methods
171
Topic 7: Introduction to quality improvement methods
172
Topic 7: Introduction to quality improvement methods
Two continuous improvement methods The following activities will assist the team to
There are a number of examples of quality complete the diagnostic phase.
improvement methods in health care but the two 1. Team members collect and analyse quantitive
most relevant to medical students are: and qualitative data of the process being
• CPI (Clinical practice improvement) investigated to establish causes of and
methodology; potential solutions.
• root cause analysis. 2. Members discuss the different causes
interact to produce the problems.
Clinical practice improvement Slides 13 14 3. Members identify solutions using the following
activities.
CPI methodology is used by health-care
• process flowchart;
professionals to improve the quality and safety of
• brainstorming;
health care. It does this through a detailed
• consumer focus groups;
examination of the processes and outcomes in
• nominal group technique;
clinical care. The success of a CPI project
• tally chart.
depends on the team covering each of the
following five phases. An example of a completed
Members organize and prioritize information by
CPI project is provided in the second part of this
using the following tools.
topic and in the Case Study Bank in Appendix 1.
• cause and effect diagram;
Project phase: The team needs to ask • affinity diagram;
themselves what it is they wish to fix or achieve. • Pareto chart.
They do this by developing a mission statement or Members prepare graphs of current data-run
objective that describes what it is they wish to do chart, statistical process control chart.
in a few sentences. This is the time to select the
team members who should be selected on the Intervention phase: By now, the team will have
basis of their knowledge about the problem. worked out what the problems are and their
173
Topic 7: Introduction to quality improvement methods
174
Topic 7: Introduction to quality improvement methods
- composed of people who can add value the events including documenting the
because of their knowledge, position in process of questions about each event
the organization or unique perspective and expanding the chart on the basis of
they bring; the information:
- made up of some members who have • environmental factors: e.g. the work
been trained in root cause analysis, who environment and its attention to
can guide the rest of the team with just-in- safety; the type of culture in the unit
time training about the root cause analysis or locality; medico-legal issues;
process, wider system issues and factors • organizational factors: e.g. staffing
that may be associated with the event; levels; quality and attention to
- who will be committed to meeting weekly policies; morale of staff; workload and
for two to four hours at a time over a fatigue; access to essential
period of five to six weeks; equipment; administrative support,
• root cause analysis effort is directed towards attitudes to patients and their families;
finding out what happened: • team staff factors: e.g. supervision of
- documentation and review (medical junior staff; quality and effectiveness
records, incident forms, hospitals of communication between
guidelines, literature review, letters from professional groups; availability of
the patient or their family or carer); senior doctors;
- site visit—the team will benefit from • individual staff factors: e.g. level of
visiting the environment in which the knowledge or experience; fatigue and
event occurred to examine the stress; expectations of staff;
equipment, the surroundings and observe • task factors: e.g. existence of clear
the relationships of the relevant staff; protocols and guidelines; system in
• event flowchart is a key part of the place for obtaining test results;
investigation as it: definition and description of tasks;
- helps to form a common understanding • patient factors: e.g. distressed
of what happened; patients; communication and cultural
- allows the team to develop problem barriers between patients and staff;
statements to enable a cause and effect multiple co-morbidities.
diagram to be developed;
- outlines the story and defines what The VA root cause analysis process has
happened chronologically; developed a guide to staff about the possible
• the team develops a problem statement that: areas and questions they might ask to uncover
- clearly states the problem to be the possible factors involved in an incident.
addressed; • communication: Was the patient correctly
- focuses deeply about the problem(s) and identified? Was information from patient
not the solutions; assessments shared by members of the
• establishing the contributing factors or root treatment team on a timely basis?
causes are accomplished through: • environment: Was the work environment
- a brainstorming process of all possible designed for its function? Had there been an
factors; environmental risk assessment?
- the development of an event flowchart of • equipment: Was equipment designed for its
175
Topic 7: Introduction to quality improvement methods
176
Topic 7: Introduction to quality improvement methods
177
Topic 7: Introduction to quality improvement methods
Even though the actions described may differ understanding of the process and use this
from the organization’s view, it is important to knowledge to collect data, identify problems,
draw in the flowchart what actually happens focus discussions and identify resources;
because this provides a common reference point • it serves as a basis for designing new ways to
and shared language that all members of the deliver health care;
team can share. Constructing a flowchart enables • health-care workers who document the
a “real” and actual portrayal of the process. process also gain a better understanding of
each other’s role and functions.
The IHI has assembled a range of tools on the
Institute’s web page that is available to help Not all flowcharts look the same. Slide 24 shows
people with improvement projects. the flowchart developed by the team who want to
reduce colectomy patient length of stay from 13
There are two levels of flowcharts: days to 4 days within 6 months.
• high-level flowchart:
- there are only 6-12 steps described that The team also wants to understand the
gives an overview of a process; expectations of the participants. 25
- these show any major blocks of activity,
or the major system components, in a A cause and effect diagram is a tool for solving
process; problems. This diagram is also called an Ishikawa
- they are especially useful in the early or fishbone diagram. The diagram is used to
phases of a project. explore and display the possible causes of a
• detailed flowchart: certain effect. The content on each arm of the
- there are many steps described and is a diagram is generated by members of the team in
close-up view of the process; a brainstorm about possible causes. The fishbone
- it can identify loops and allows complex diagram in slide 26 is the result of a brainstorm by
causes of errors to be identified; a team of health-care professionals working on
- these are often shown using the cloud reducing length of stay post-colectomy. 26
symbol as shown in the slide below
(flowchart of process); A cause and effect diagram has a variety of
- detailed flowcharts are useful after teams benefits:
have pinpointed issues or when they are • it identifies multiple causes that may
making changes in the process. contribute to an effect;
• it graphically displays the relationship of the
Using a flowchart has a variety of benefits: causes to the effect and to each other;
• it explains the processes involved in health- • it focuses the team to the areas for
care delivery; improvement.
• it identifies the steps that do not add value to Continuing with the CPI project conducted by
the health-care service including the team at the base hospital who were trying
delays; needless storage and to reduce length of stay post colectomy, the
transportation; unnecessary work, duplication Pareto chart identifies the factors that they saw
and added expense; breakdowns in as contributing to the current time patients
communication; stayed in hospital. 27
• it helps health-care workers get a shared
178
Topic 7: Introduction to quality improvement methods
179
Topic 7: Introduction to quality improvement methods
This topic can be delivered in a number of ways. Students can implement the PDSA cycle to suit
their own personal circumstances and obtain a
An interactive/didactic lecture better understanding of the process so they can
This topic contains a lot of underpinning apply it in their professional work as medical
and applied knowledge that is suitable for an students or members of a health-care team.
interactive didactic lecture. Use the Following the steps set out above in the case
accompanying slides as a guide, covering the example, students can begin to experiment with
whole topic. The slides can be PowerPoint or the tools and see how to use them and whether
converted to overhead slides for a projector. they helped them in their project.
Simulation exercises
Different scenarios could be developed for
the students: practising the techniques of
brainstorming; designing a run chart, cause and
effect diagram or histogram.
180
Topic 7: Introduction to quality improvement methods
Resources
Langley GL et al. The improvement guide: a
practical approach to enhancing organizational
performance. Institute for Healthcare
Improvement. San Francisco, Jossey-Bass
181
Topic 7: Introduction to quality improvement methods
182
Topic 8: Engaging with patients and carers
Why engaging with patients and Many consumer organizations are now turning
families is important 1 their attention to organizational activities. The
The claim of modern health care is that it is WHO initiative Patients for patient safety [1] is for
patient centred. Yet, the reality for many patients consumers and focuses on education about
and consumers is that they have had a long- patient safety and the system of health care as a
standing battle to overturn entrenched views contributing factor to adverse events.
about the level of involvement patients should
have in their own care. The tide is turning and in Many patients having medical treatments,
many nations around the world the consumer’s particularly when hospitalized, are in a vulnerable
voice in health care is not only being heard but is psychological state even when treatment goes
being recognized by government, the professions according to plan. Symptoms akin to post-
and health-care providers. traumatic stress disorder can occur even following
procedures that strike providers as routine. When
Any health-care intervention has an element of a patient experiences a preventable adverse
uncertainty as to whether it will improve the health event, may be that the for emotional trauma is
of the patient. Every consumer has the right to particularly severe.
know what it means being a patient, and to
receive helpful information about the quality of the This topic will provide an overview of consumer
care they will receive especially if they are to have engagement activities that naturally divides into
any type of medical or surgical intervention. two dimensions: (i) learning and healing
Informed consent allows them, in collaboration opportunities after an adverse event has
with health-care professionals, to make decisions occurred; and (ii) engagement of patients in
about having the intervention and the recognized preventing harm.
risks associated with that intervention. Such
interventions may include, for example, a course Keywords
of medication or an invasive procedure. Adverse event, advisory council, apology,
communication, complaints, cultural norms,
While most health-care interventions have good disclosure, education, error, fear, informed
results or at least do no harm, poor outcomes do decisions, liability, mediation, patient and family,
happen that can include errors, both random and patient-centred, patient empowerment, patient
systemic. The quality of a health-care system can engagement, patient rights, partnership,
be judged by the way it handles those errors. When partnership councils, proactive, rapid response
health-care organizations fail to integrate consumer team, reporting, questions, Speak up campaign,
involvement in managing systemic risk, they lose stories, victims.
access to important knowledge that cannot be
gained from any other source. Learning objective: 2
The objective of this topic is to understand
The inclusion of open disclosure processes in the ways in which patients and carers can be
many hospitals today reflects the increasing involved as partners in health care, both in
importance of professionalism and honesty with preventing harm and learning and healing from an
patients and their carers. This in turn is increasing adverse event.
opportunities for partnerships with patients.
183
Topic 8: Engaging with patients and carers
184
Topic 8: Engaging with patients and carers
unimpaired and voluntary? Is it free of intrinsic information about the known risks and benefits
(stress, grief) and extrinsic (money, threat) (and uncertainties) associated with the specific
pressures? treatment or procedure to the particular concerns
and information needs of the patient or caregiver.
What a patient should know 5
Doctors are widely encouraged to use Patients need to know the range of options, not
evidence-based medicine. For many treatments, just the one favoured by the practitioner. In
there is a body of evidence on the likelihood of particular, they need to know:
success and the likelihood of harm. It is important • the proposed treatment;
that such information is communicated to patients • expected benefits;
in a way that they can understand. Where there • when treatment would start;
are printed resources to aid decision-making these • length of treatment;
should be used. Before a patient can decide • costs involved.
whether to have the treatment or not they need to
have information about the following issues. The benefits of the treatment and the risks of
not having the treatment
The diagnosis Some treatments, notwithstanding the risks, are
This includes test results and procedures. Without better than no treatment because of the very poor
a diagnosis it is difficult for a patient to come to a prognosis.
decision about whether the treatment will be
beneficial. If a treatment is exploratory, then this Information on recovery time
should be disclosed. The type of treatment or the decision to go ahead
with a treatment or procedure may be influenced
The degree of uncertainty in the diagnosis by other factors in the patient’s life: employment,
Medicine is an error ridden profession; as more family responsibilities, money, location of the
symptoms appear, the diagnosis can either be treatment.
confirmed or changed. Disclosing uncertainty is
essential. Name, position, qualifications and experience of
health workers who are providing the care and
Risks involved in the treatment treatment
To enable patients to make a decision that suits Patients are entitled to know the level of training
them, they need to know: and experience of health-care professionals. If a
• any side-effects; practitioner is inexperienced, then supervision
• complications associated with the treatment becomes more important and information about
or procedure; supervision may become part of the information
• any outcome that may affect the patient’s exchanged.
physical/mental well-being;
• nature of risks; Availability and costs of any service required after
• consequences of not having the treatment. the transfer of care (discharge) from hospital
Patients may require the services of the
One way to communicate the risks and benefits community nurse or the general practitioner.
to patients is to move from the general information
about the treatment or procedure to specific
185
Topic 8: Engaging with patients and carers
186
Topic 8: Engaging with patients and carers
187
Topic 8: Engaging with patients and carers
Open disclosure is the honest communications • compensation—for actual losses, pain and
with patients and/or their families after an adverse suffering or to provide care in the future for an
event. The requirement to be honest is an ethical injured person;
obligation and is documented in most medical • accountability—a belief that the staff or
ethical codes of practice. Basic questions would organization should have to account for their
include: “What is the right thing to do in this actions; patients wanted greater honesty an
situation?”, “What would I want in a similar appreciation of the severity of the trauma they
situation?”, “What would I want if my loved one had suffered and assurances that lessons
suffered an adverse event?” Many countries are had been learnt from their experiences.
yet to develop open disclosure guidelines for
health-care professionals. After an adverse event, patients want disclosure
of an event that including:
Do patients want disclosure of adverse • an explanation of what happened;
events or errors that produce near misses? • an admission of responsibility;
A landmark study by Charles Vincent et al. [10] • an apology;
which examined the impact of medical injury on • the assurance of prevention of similar events
patients and their relatives and the reasons for to others in the future;
taking legal action after such incidents gave • in some cases, punishment and
impetus to consideration of the role and compensation.
experience of patients. They interviewed 227 (out
of a sample population of 466 or 48.7%) patients Common barriers to honesty with patients
and relatives who were taking legal action in 1992 after an adverse event
through five firms of plaintiff medical negligence Doctors and nurses may want to provide accurate
solicitors. They found that over 70% of and timely information to patients about an adverse
respondents were seriously affected by incidents event, yet fear that such communications may
that caused them to sue with long term effects on result in legal action or, at a minimum, confronting
work, social life, and family relationships. an angry patient or family member. Targeted
The survey results showed: education about the disclosure process may better
• intense emotions were aroused and prepare doctors for such an event. Doctors may
continued for a long time; also fear causing more distress to patients, loss of
• decision to take legal action was determined reputation, job, insurance cover or shame.
by original injury and by insensitive handling
poor communication after the original event; Open disclosure principles
• where explanations were given less than 15% There are now many guidelines available to assist
were considered satisfactory. clinicians through the open disclosure process:
• crafting an effective apology (Joint
Four main themes emerged from the analysis of Commission Resources);
reasons for litigation [11]: • open disclosure (Australian Commission for
• concern with standards of care—both Safety and Quality);
patients and relatives wanted to prevent • open disclosure guidelines (New South
similar incidents in the future; Wales, Health Australia);
• they needed an explanation—to know how • disclosure of adverse event (Deptartment of
the injury happened and why; Veteran Affairs);
188
Topic 8: Engaging with patients and carers
• When things go wrong: responding to The Harvard framework for disclosure [13]: 13
adverse events (consensus statement of the 1. preparing:
Harvard hospitals). • review the facts;
We use the New South Wales open disclosure • identify and involve the appropriate
guidelines as an example, which is freely available at participants;
http://www.health.nsw.gov.au/policies/gl/2007/pd • use an appropriate setting.
f/GL2007_007.pdf (acessed May 2008) 2. initiating conversation:
• determine patient and family readiness
to participate;
Key principles of open disclosure [12] (New • assess the patient and family’s medical
South Wales, Australia) 10 literacy and ability to understand;
• openness and timeliness of • determine the patient and family’s level of
communication; medical understanding in general.
• acknowledgement of the incident; 3. presenting the facts:
• expression of regret/apology; • simple description of what happened:
• recognition of the reasonable expectations of - no medical jargon;
the patient and their support person; - speak slowly;
• support for staff; - be aware of body language;
• confidentiality. 11 12 • do not overwhelm with information or
oversimplify;
The open disclosure process has many steps that • explain what is known of the outcome at
should be taken. Senior clinicians are responsible that point;
for this process and medical students should • describe the next steps;
never be left with responsibility for telling patients • sincerely acknowledge the patient's and
and families about an adverse event. They should family’s suffering.
try to observe and sit in on the interviews with 4. actively listening:
patients so they can learn about the process and • allow ample time for questions;
the value to patients and their families. Slide 13 is • do not monopolize the conversation;
a flowchart of the open disclosure process used 5. acknowledging what you have heard.
in New South Wales, Australia, that commenced 6 responding to any questions.
in 2007. 7. concluding the conversation:
• summarize;
The 2006 consensus statement of the Harvard • repeat key questions raised;
hospitals When things go wrong [13]: responding • establish the follow-up.
to adverse events, places a much stronger 8. documentation:
emphasis on the need for emotional trauma • describe the event;
support for both patient/family and health-care • describe the discussion.
professionals involved. The importance of
documentation to facilitate transparent
communication with the patient and family and
safety improvement initiatives that follow an event
is emphasized in the Harvard framework for
disclosing adverse events to patients and families.
189
Topic 8: Engaging with patients and carers
Practising SPIKES 14
190
Topic 8: Engaging with patients and carers
must be able to listen and ask questions with Step 2: perception (P)
minimal disruptions. It is very important that the A good technique to understanding a patient is to
health professional and the patient are fully first ask the patient what they think is going on.
engaged with each other. For example, if a Then after they have talked it may be appropriate
television is on, politely ask the patient to turn it to obtain the relevant clinical information. This will
off—this helps focus the patient on what you are enable the clinician and you the student to
going to be discussing. understand where the patient is in relation to their
understanding of their situation.
Involve significant others
Patients should always be asked if they want to Step 3: invitation (I)
have a family member present to support them Many students worry about how much
and help with information. Some patients, information they should disclose to the patient.
particularly the frail and vulnerable may need a Different countries will have different rules for this
person to help them make sense of the process. A general rule that probably applies to
information. It is particularly important to let most countries and cultures is to focus on each
patients know that they can have someone with individual patient’s informational needs. Patients
them if they wish. are as varied as humanity and will differ in how
much information they want or can cope with.
Sit down Students should be guided by their supervisors in
Medical students are often alert to the problems this area. Different clinicians will provide more or
caused by doctors standing over a patient and less; it is a good opportunity for the student to
will often comment on it in their early student observe what works for the patient, and what
years. However, with time they come to accept works for different sorts of patients.
that this is normal and how things are done.
Students should practise asking the patient’s The informational needs of patients differ. If a
permission to sit down before doing so. Patients patient has a family history of heart failure, the
appreciate a doctor sitting down because it allows doctor may spend more time talking about the
for direct communication and conveys to the risks and paying attention to any anxieties the
patient that the doctor is not going to rush off. patient may have.
It is important to always appear calm and maintain A simple rule to remember about risks is that all
eye contact if this is culturally appropriate. patients should be given information about
Sometimes if a patient is crying it is best to look treatments when there is potential for significant
away and allow the patient some privacy and time harm even if the risk is tiny and when side-effects,
to compose themself. although minor, occur frequently. The application
of this rule will help most clinicians to match
Listening mode patient informational needs. This approach
An important role of a doctor is listening to the enhances communication between the patient and
patient and not interrupting them when they are the health provider by encouraging discussion.
talking. Maintaining good eye contact and
remaining quiet is a good way to show the patient Students will also observe that too much
your concern and interest. information at once can confuse patients.
191
Topic 8: Engaging with patients and carers
192
Topic 8: Engaging with patients and carers
193
Topic 8: Engaging with patients and carers
194
Topic 8: Engaging with patients and carers
the attention of the other staff, who in turn Another doctor (B) told her to return in a week to
informed Frank and his family. The facility took the hospital. While staying at home breastfeeding
immediate action to help Frank and arranged his difficulties continued and the baby’s jaundice
transfer to a hospital where he was admitted and increased. Rachael was afraid, and took the
observed before being returned to the aged care baby to the emergency room when he was 72
facility. The nurse was commended for fully and hours old. The doctor did not check the baby’s
immediately disclosing the incorrect administration weight but requested a bilirubin test. The result
of the insulin. Following this incident, the nurse was 13.5 mg; he said that it was a low level for a
undertook further training in medications to 3-day-old baby and that everything was OK, so
minimise the possibility of a similar error occurring. she should not have to come to the hospital when
the baby was a week old. He advised Rachael to
Reference return in a week from that day and said, laughing,
Open Disclosure. Case Studies—Volume 1. “Your baby is OK, do not be fearful. I know what
Sydney: Health Care Complaints Commission, I’m saying, I’m the doctor”.
2003: 16–18.
Over the next few days the baby required
The importance of listening to a mother breastfeeding every hour and a half, and
This case illustrates the importance of examining Rachael’s breasts looked empty. She
each patient as individual and not blindly following remembered having been told by the nurse while
rules. she was at the hospital not to take any
supplements in order to stimulate milk production.
Rachael, a single mother, gave birth to her first Rachael’s friends do not have children, so they
child. He was a healthy newborn of 37 weeks said, “I do not know, but if the doctor said
gestation, weighing 2700 grams. The birth was everything is OK, do not be paranoid, everything
normal and mother and baby were stable one is OK”.
hour after delivery. She was informed by the nurse
that everything was OK with both of them. Rachael took the baby to the hospital according
to doctor B’s advice, the baby was 10 days old,
Breastfeeding started six hours after delivery. The his weight had decreased 20% and his bilirubin
nurse verbally told the doctor about some difficulties test was 35 mg; during clinical examination the
with the mother’s breast and that the baby looked baby presented clear signs of bilirubin
too sleepy. The hospital rules stated that that encephalopathy.
mothers were to be discharged 36 hours after birth,
so the mother was prepared for early discharge. The hospital Advisory Board tried to understand
why a healthy baby born from a healthy mother
Rachael was told by doctor A that everything was with a normal delivery developed this terrible and
OK, that the baby has mild jaundice but that it will preventable situation.
disappear in a couple of days because there was
no incompatibility between the baby and mothers Case from the WHO Patient Safety Curriculum
blood group, and breastfeeding should improve Guide for Medical Schools working group.
the next few days in this “healthy baby”. Supplied by Jorge Martinez, Universidad Del
Salvador, Buenos Aires, Argentina.
195
Topic 8: Engaging with patients and carers
Unpicking the concerns of patients / carers even We arrived at the information office to find it was
when not fully expressed verbally is a key skill that crowded with a lot of people shouting, some of them
needs to be mastered. angry. There was only one person providing
• We should never not take the mother’s information. Lucy, the medical student said, “I do not
concerns into consideration, and should think we will get anywhere if we try to get information
always take them seriously. here”. I thought we could follow the signals I had seen
• We should never make them feel that they are at the main entrance. I said, “Let’s go”.
having inappropriate concerns.
After walking through the crowd, we arrived at the
A letter from a patient main entrance. We finally arrived at the
This letter presents a patient’s perspective of her gastrointestinal department. Lucy said, “Oh, yes, this
experience with her hospital. is the place, ask the nurse over there; I should go to
take my class, good luck”.
I’m Alice, 25 years old. I had abdominal pain for six
days and I was really frightened because my sister The nurse told me that I shouldn’t come directly to
started a year ago with similar symptoms and now the gastrointestinal department, that I should go to
has intestinal cancer and is under a very aggressive the emergency department and they would decide
treatment. about my condition. So, I had to return to the
emergency room. When I arrived, plenty of people
I decided to go alone to the hospital in order not to were waiting; they told me I would have to wait. “You
scare the whole family. I arrived at the hospital early should have come earlier”, the nurse said (I arrived
in the morning. I didn’t know exactly what to do or early!!).
who to see; it was my first time at the hospital.
Everybody looked in a hurry and they did not look A general practitioner eventually saw me and
very friendly. Some of them looked as frightened ordered X-rays and lab examinations. Nobody said
as I was. anything and no explanations were provided to me.
At that moment I was more scared than when I
I took a deep breath and asked a young lady who woke up with the pain.
looked at me and smiled as if she knew where the
gastrointestinal department was located. She I was at the hospital all day going from one place to
laughed a little and said, “I’m a medical student and another. At the end of the day, a doctor came and
I’m lost too. Lets try together to find it, I have to go told me in few words you are OK, there is nothing to
to the same place too”. She said, “Why don’t we go worry about, and I started “breathing” again.
to the information office?” I thought it was a good
idea, and all of sudden I started to feel in some way
protected. A person I considered to be a health-care
professional was with me.
196
Topic 8: Engaging with patients and carers
I would like to say to the hospital authorities that they TOOLS AND RESOURCES
should realize that every person coming to the
hospital, even if they do not have any important Key textbooks and references
disease, is feeling stressed and often unwell. We Workshop: Building the future for patient safety:
need friendly people taking care of us, ones who try developing consumer champions—a workshop
to understand our story and why we feel so bad. We and resource guide. Chicago, Consumers
need clear communication between health-care Advancing Patient Safety. Funded by Agency for
workers and patients. We need clear information on Healthcare Research and Quality (AHRQ)
how we should use the hospital facilities in order to (http://patientsafety.org/page/102503/).
make best use of them. I understand that you Patient-centred care: Expanding Patient-
cannot cure everybody--unfortunately you are not Centred Care To Empower Patients and Assist
Gods--but I am sure that you could be friendlier to Providers. Research In Action, AHRQ, Issue 5,
patients. Doctors and nurses have the incredible 2002 (http://www.ahrq.gov/qual/ptcareria.pdf).
power that only with his/her words, gestures and Medical errors: Talking about Harmful Medical
comprehension of the patient situation, they can Errors with Patients. Seattle, University of
make a patient feel secure and relieved. Washington School of Medicine
(http://www.ihi.org/IHI/Topics/PatientCenteredCar
Please do not forget this power so incredibly useful e/PatientCenteredCareGeneral/Tools/Talkingabout
for those human beings who enter your hospital. HarmfulMedicalErrorswithPatients.htm).
Open disclosure: Open Disclosure Education
With all my respect, and Organisational Support Package. Open
Disclosure Project 2002–2003, Australian Council
Alice for Safety and Quality in Healthcare
http://www.health.gov.au/internet/safety/publishin
Case from the WHO Patient Safety Curriculum g.nsf/Content/PriorityProgram-02
Guide for Medical Schools working group. Open disclosure guidelines: New South Wales
Supplied by Jorge Martinez, Universidad Del Health Australia Quality and Safety Branch Open
Salvador, Buenos Aires, Argentina. Disclosure Guidelines, May 2007
(http://www.health.nsw.gov.au/policies/gl/2007/p
df/GL2007_007.pdf).
Open disclosure: A review of the literature.
Centre for Health Communication, February 2008
(http://www.health.gov.au/internet/safety/publishin
g.nsf/Content/PriorityProgram-02)
Disclosure of adverse events: Disclosure of
adverse events to patients. VHA Directive 2005-
049, Veterans Health Administration, US
Department of Veterans Affairs, Washington, DC,
October 2005
(http://www.sorryworks.net/pdf/VA_Link.pdf).
197
Topic 8: Engaging with patients and carers
Details of patient safety assessment are given in the 1. World Health Organization, World Alliance for
Teacher’s Guide (Part A). However, a range of Patient Safety. Patients for patient safety -
assessment methods are suitable for this topic statement of case
including essay, MCQ, SBA, case-based discussion (http://www.who.int/patientsafety/patients_for
and self-assessment. Students can be encouraged _patient/statement/en/index.html).
to develop a portfolio approach to patient safety 2. Kerridge I, Lowe M, McPhee J Ethics and
learning. The benefit of a portfolio approach is that Law for the Health Professions The
at the end of the students’ medical training they will Federation press 2nd edition 2005.216-35
have a collection of all their patient safety activities. 3. Emmanuel L, Combes J, Hatlie M, Karsh B,
Students will be able to use this to assist job Lau D, Shalowitz J, Shaw T, Walton M eds,
applications and their future careers. The Patient Safety Education Project ( PSEP)
Core Curriculum 2008.
The assessment of knowledge about patient 4. Australian Council for Safety and Quality in
engagement and open disclosure can include: Healthcare. National patient safety education
• portfolio; framework. Commonwealth of Australia, 2007.
• case-based discussion; 5. Genao I et al. Building the case for cultural
• OSCE station; competence. The American journal of
• written observations about the health system medical Sciences,2003:326(3);136-40
(in general) and the potential for error; 6. Gallagher TH et al. Patients and physicians
• reflective statements (in particular) about the attitudes regarding the disclosure of medical
- role patients play in hospitals or clinics; errors. Journal of the American Medical
- consequences of paternalism; Association, 2003, 289(8):1001–1007.
- role of senior clinicians in open disclosure 7. Gallagher TH, Lucas MH. Should we disclose
process; harmful medical errors to patients? If so,
- role of patients as teachers. How? Journal of Clinical Outcomes
Management, 2005, 12(5):253–259.
The assessment can be either formative or 8. Davis RE. Jacklin R. Sevdalis N. Vincent CA.
summative; rankings can range from unsatisfactory Patient involvement in patient safety: what
to giving a mark. See the forms in Appendix 2. factors influence patient participation and
engagement Health Expectations. 10(3):259-
HOW TO EVALUATE THIS TOPIC 67, 2007 Sep.
9. Vincent CA. Coulter A. Patient safety: what
Evaluation is important in reviewing how a about the patient? Quality & Safety in Health
teaching session went and how improvements Care. 11(1):76-80, 2002 Mar.
can be made. See the Teacher’s Guide (Part A) for 10. Open Disclosure Health Care Professionals
a summary of important evaluation principles. Handbook A Handbook for health care
professionals to assist with the
implementation of the Open disclosure
Standard. Commonwealth of Australia 2003
11. Vincent CA, Young M, Phillips A. Why do
people sue doctors? Lancet, 1994,
198
Topic 8: Engaging with patients and carers
199
Introduction to cluster topics 9–11
Putting knowledge into practice: The following three topics heavily rely upon the
infection control, medication safety and implementation of appropriate and authorised
invasive procedures. guidelines. Understanding the role of guidelines
and why they are important to health care will
The following three cluster topics are best taught show students that good patient outcomes are
when the students are on placement and dependent on all the members of the health care
allocated to a clinical environment—ward or clinic. team following the same treatment plans.
Guidelines are designed to assist patient
Much of this Curriculum Guide will be new management using the best evidence available.
knowledge for the students. However, unless they Evidenced based practice uses the best evidence
apply this new knowledge in the workplace, available to lessen variation and reduce risks to
beside the bed or in the operating rooms or patients. There is plenty of evidence to show that
clinics, there will be little change to the quality of the appropriate use of clinical guidelines can
the health care being provided by students and minimize adverse events caused by overuse,
doctors or received by the patients. Students under use, and misuse of medical care [1,2].
need to practise the techniques and behaviours
described in this Curriculum Guide. The following
three topics of infection control, medication safety
and surgery and invasive procedures have been
developed from a patient safety perspective. They
are designed to maximize the student’s ability to
practise patient safety concepts and principles
while on placements in the hospitals and clinics.
Before teaching one or more of these topics it
would be helpful to have some exposure to the
concepts in the earlier topics, particularly the
topics on teamwork, system thinking and errors.
200
Topic 9: Minimizing infection through improved infection
control
This topic acknowledges the work of the WHO Box 6. WHO: health care-associated infection:
Global Patient Safety Challenge: Clean Care is scale and cost
Safer Care and the Hôpitaux Universitaires de
Genève.
• Between 5% and 10% of patients
admitted to modern hospitals in the
Why infection control is relevant to
developed world acquire one or more
patient safety 1
infections.
The spread of infection in health-care
• The risk of health care-associated
settings today affects hundreds of millions of
infection in developing countries is from 2
people worldwide. In a WHO sponsored
to 20 times higher than in developed
prevalence survey study [1] conducted in 55
countries. In some developing countries,
hospitals of 14 countries representing four WHO
the proportion of patients affected by a
regions (South-East Asia, Europe, the Eastern
health care-acquired infection can exceed
Mediterranean and the Western Pacific) it was
25%.
found that, on average, 8.7% of hospital patients
• In the United States, 1 out of every 136
suffer health care-associated infections. At any
hospital patients becomes seriously ill as a
time, over 1.4 million people worldwide suffer from
result of acquiring an infection in hospital;
infectious complications acquired while in hospital
this is equivalent to two million cases and
being treated for a medical condition. In the United
about 80 000 deaths a year.
States, about 90 000 patients die each year.
• In England, more than 100 000 cases of
Health care-associated increase suffering for the
health care-associated infection lead to
patients and keep them in hospital longer. Many
over 5000 deaths directly attributed to
suffer permanent disability and a significant
infection each year.
number die. This alarming rate has led to
• In Mexico, an estimated 450 000 cases of
increased attention by clinicians, managers,
health care-associated infection cause 32
institutions and governments to preventing
deaths per 100 000 inhabitants each year.
infection.
• Health care-associated infections in
England are estimated to cost £1 billion a
Box 6 lists some of the WHO statistics about the
year. In the United States, the estimate is
high rate of infection throughout the world.
between US$ 4.5 billion and US$ 5.7
Everybody, health professionals and patients alike,
billion per year. In Mexico, the annual cost
has a responsibility to decrease the opportunities
approaches US$ 1.5 billion.
for contamination of clothing, hands and
equipment that have been associated with
transmission routes. This topic sets out the main
areas where cross-infection occurs and identifies Keywords
the activities and behaviours, which if routinely Infection control, hand hygiene, transmission,
practised by everyone, would lead to reduced cross-infection, health-acquired infections, drug
health care-associated infections. resistant, multidrug-resistant organisms, MRSA
(methicillin-resistant staphylococcus aureus)
infection, antiseptic handwashing agents,
bloodborne virus infections.
201
Topic 9: Minimizing infection through improved infection control
202
Topic 9: Minimizing infection through improved infection control
The CDC’s campaign to Prevent antimicrobial considered potentially infectious for HIV, HBV and
resistance aims to prevent antimicrobial resistance other bloodborne pathogens. The precautions
in health-care settings by a range of strategies require students to apply infection control
aimed at preventing infection, diagnosing and principles as set out above—correct
treating infection, using antimicrobials wisely and handwashing, using gloves, a mask, a gown and
preventing infection transmission. The campaign eyewear and handle needles safely as well as safe
is targeting clinicians who treat particular patient disposal.
groups such as hospitalized adults, dialysis
patients, surgical patients, hospitalized children A 2006 cross-sectional study of medical staff and
and long-term care patients [9]. medical students at two hospitals in Iran showed
that only 54% of students had heard about
The IHI campaign called the 5 million lives aims to universal precautions [11]. Students should be
reduce MRSA infections through the habitually applying universal precautions as soon
implementation of five key interventions: as they enter the hospital environment. It is easier
1. hand hygiene; to learn how to do something right the first time
2. decontamination of environment, equipment; than trying to undo bad habits.
3. active surveillance cultures;
4. contact precautions for infected and The economic burden
colonized patients; The costs associated with caring and treating
5. compliance with central venous catheter and patients suffering from infections are significant
ventilator bundles. and have added a substantial economic burden
Today, health-care professionals have to be to the health-care budgets of all countries.
vigilant in applying a range of prevention methods Estimates of the cost of infections range from
designed to control a variety of pathogens in all US$ 4500–5700 million a year in the United
health-care environments, not just hospitals. States, £1000 million a year in the United
When a student works on the wards, visits a clinic Kingdom, 5% of the annual budget of a county
or does a home visit they are as capable of hospital in Trinidad and Tobago and up to 10% of
transmitting an infection as are all health-care Thailand hospital budgets and 70% of the entire
workers. Multidrug-resistant organisms do not health budget for Mexico [1].
discriminate and while they are mainly found in
acute care settings, any setting where patients are The main causes and types of
treated provides an opportunity for the infections
emergence and transmission of antimicrobial-
resistant microbes. Main types of infections
Infectious diseases are caused by pathogenic
Student knowledge of universal precautions micro-organisms such as bacteria, viruses,
The CDC [10] defines universal precautions as a parasites or fungi; the diseases can be spread,
set of precautions designed to prevent directly or indirectly, from one person to another.
transmission of human immunodeficiency virus Zoonotic diseases are infectious diseases of
(HIV), hepatitis B virus (HBV) and other animals that can cause disease when transmitted
bloodborne pathogens when providing first aid or to humans.
health care. Under universal precautions, blood
and certain body fluids of all patients are
203
Topic 9: Minimizing infection through improved infection control
204
Topic 9: Minimizing infection through improved infection control
hygiene. Applying correct hand hygiene procedures • the activities being performed;
requires medical students to understand why • the susceptibility of the patient.
hands need to be decontaminated.
How to clean hands:
Decontamination refers to the process for physical • limited studies available to test the technique
removal of blood, bodily fluids and the removal or of hand decontamination;
destruction of micro-organisms from the hands. • methods based on expert opinion:
WHO has developed easy-to-follow brochures - before clinical shift begins remove all wrist
and diagrams to help health-care workers follow and hand jewelry;
correct handwashing procedures, available on the - cuts and abrasions covered with waterproof
WHO web pages at dressings;
http://www.who.int/gpsc/tools/Five_moments/en/i - fingernails kept short clean and free from
ndex.html nail polish.
Hospitals can make it easier for staff by providing Promoting the use of hand hygiene guidelines
alcohol hand rubs beside the beds. Alcohol rubs • The use of protective equipment:
rapidly kill bacteria and have few side-effects for - assess the risks to patients, carers and self;
the staff. However, when hands are heavily soiled, - everyone should be educated about
alcohol rubs are not a substitute for soap. standard principles and trained in the use of
protective equipment;
Factors to consider to maintain clean hands: - adequate supplies of disposable aprons,
• the level of contact with the patient or single use gloves and face protections are
objects; easily available wherever care is delivered;
• the extent of the contamination that may - gowns should be available on the advice of
occur with the contact; the infection control team.
205
Topic 9: Minimizing infection through improved infection control
206
Topic 9: Minimizing infection through improved infection control
Face masks and eye protection should be worn the disease will become active and the person
when there is a risk of blood, bodily fluids, becomes infectious. Students should apply
secretions and excretions splashing into the face universal precautions at all times. Universal
and eyes. Respiratory protective equipment is to precautions are described later in this topic. If TB
be worn when caring for patients with respiratory is a major problem in your country then additional
infections transmitted by airborne particles. information about the prevalence of TB in your
country and strategies for containing the spread
4. The safe use and disposal of sharps 13 of TB would be appropriate to cover.
Students should be aware of the significant
problem for health-care workers caused by WHAT STUDENTS NEED TO DO
needle stick injuries, which are as prevalent as (PERFORMANCE REQUIREMENTS)
injuries from falls and handling and exposure to
hazardous substances. Many health-care workers Medical students have a responsibility to make
continue to be infected by bloodborne viruses every effort to minimize the spread of infection
even though they are largely preventable: and to encourage patients and other health-care
• keep handling to a minimum; workers to actively engage in practices that
• do not recap needles, bend or break after minimize the spread of infection both in the
use; community and in the hospitals and clinics.
• discard each needle into a sharps container Students need to 14
at the point of use; • practise universal precautions;
• do not overload a bin if it is full; • be immunized against Hepatitis B;
• do not leave a sharp bin where children can • use personal protection methods;
reach it. • know what to do if exposed;
• encourage others to use universal
These safety measures are repeated below in the precautions.
checklist for universal precautions.
Apply universal precautions 15
Tuberculosis (TB) WHO has developed the following checklist
The WHO web site demonstrates through its for health-care workers.
numerous reports that describe the prevalence
and the devastating effects and suffering caused Practise universal precautions [8]
by TB. In response to rising rates of TB, a major
campaign to stop the increase has been initiated Students must handwash after any direct
in many countries with some small success. contact with patients.
Students need to be aware of their own role in The WHO campaign has published techniques for
minimizing the spread of TB. TB is spread via the correct handwashing and safe health care. The
air from people who have TB affecting the lungs. It following strategies can be found on the web
is contagious. The disease is spread by coughing, pages of the WHO Clean hands are safer hands
sneezing, talking or spiting that send the TB campaign at
germs (bacilli) into the air. People then breathe in http://www.who.int/gpsc/tools/Five_moments/en/i
the bacilli. Some people will not develop an ndex.html, accessed April 2008
infection because their immune system keeps it
dormant. When the immune system fails a person
207
Topic 9: Minimizing infection through improved infection control
Before contact with each and every patient a immediately after an exposure risk to body fluids
student should clean their hands before and after glove removal. Cases of transmission
touching a patient. have been to know to occur even with gloving.
This is important to protect the patient against This is essential to limit the opportunity of the
harmful micro-organisms carried on the hands. student receiving an infection. It is also necessary
Students may have been travelling on a bus to maintain a safe health-care environment.
immediately before entering the hospital and the
ward where they intend to take a history from a Medical students will inevitably come into contact
patient. In doing so they may shake the hand of with mucous membrane and with non-intact skin,
the patient or comfort the patient as a humane as detailed in the indication “before aseptic task”.
gesture. They may also be requested to assist a Understanding the risks will help the student
patient to move from the bed to a chair, or to a practise safe health care. They will also have
sitting area for more privacy. They might be contact with medical devices or clinical samples
required to perform a physical examination, take such as drawing and manipulating any fluid
the pulse of the patient or blood pressure and sample, opening a draining system, endotracheal
abdominal palpation. tube insertion and removal.
A student should clean hands before an aseptic At times they will be required to clean up a
task. patient’s urine, faeces or vomit. Students often
It is essential that students clean their hands help out in the hospital and clinic and may find
immediately before any aseptic task. This is themselves handling waste (bandages, napkin,
necessary to protect the patient against harmful incontinence pads), cleaning of contaminated and
micro-organisms, including the patient’s own visibly soiled material or areas (lavatories, medical
micro-organisms, entering his or her body. instruments). They need to be particularly aware of
Students must protect against transmission the importance of clean hands after such activities.
through contact with mucous membrane:
oral/dental care, giving eye drops, secretion Students should wash hands after actual patient
aspiration. Often students will be treating patients contact.
who have open wounds and any contact with non- All students should clean their hands after
intact skin: skin lesion care, wound dressing, any touching a patient and his or her immediate
type of injection is an opportunity for transmission. surroundings. This should be done using one of
Medical devices are well known for harbouring the methods available to the clinic or hospital
potentially harmful micro-organisms and contact immediately after the patient contact is over. This
with devices such as catheter insertion, opening a is because in busy environments there are many
vascular access system or a draining system must distractions and busy people tend to rush onto
be done with careful preparation. Students should the next job or patient. Many people forget in the
also be diligent in preparation of food, medications rush to wash their hands. Forgetting to wash
and dressing sets. hands can lead to the student getting an infection
and increasing the chances of the micro-
After contact with each and every patient a organisms spreading throughout the environment.
student should clean hands after any risk of Saying goodbye to the patient by shaking a hand
exposure to body fluids. or touching a shoulder provides opportunities for
Students should habitually clean their hands micro-organisms to be transferred to the student
208
Topic 9: Minimizing infection through improved infection control
and vice versa. Activities in addition to those of infection with bloodborne viruses. The risk of
mentioned above that involve direct physical infection to both staff and patients depends on
contact include helping a patient to move around, the prevalence of disease in the patient population
to get washed or to give a massage, which are and the nature of the frequencies of exposures.
known routes for micro-organisms spreading to Students should:
others. Students performing clinical examination • be immunized as soon as they start seeing
such as taking pulse, blood pressure, chest patients in hospitals, clinics and the
auscultation and abdominal palpation are all community or in the homes of patients;
opportunities for cross-infection. • if possible conduct a post-vaccination test.
Students must handwash after contact with Students should use personal protection
patient surroundings methods [14]
Micro-organisms are also known to survive on • use needle stick prevention devices where
inanimate objects. So it is important to clean one’s possible;
hands after touching any object or furniture in the • let people know if supplies of personal
patient’s immediate surroundings when leaving protection are running low;
them, even without touching the patient. Students • provide feedback to the health-care team
may find themselves helping other staff and about the personal protective equipment;
change bed linen, adjust perfusion speed, monitor • seek training in use of the equipment;
an alarm, hold a bed rail or make room on a side • model practice on respected and safe senior
bed table for a patient. clinician;
• regularly perform a self-assessment of one’s
In addition: use of personal protective equipment and
• Needles should never be recapped; whether there has been any inappropriate
• All sharps should be collected and safely use.
disposed;
• Students should use gloves when in contact Students should know what to do if exposed [14]
with bodily fluids, non-intact skin and mucous If a student is inadvertently exposed or becomes
(see more about this below); infected they should immediately:
• Students should wear a face mask, eye • notify the appropriate staff in the hospital or
protection and a gown if there is the potential clinic as well as a supervisor. It is important
for blood or other bodily fluids to splash; that students receive appropriate medical
• Students should cover all cuts and abrasions attention as soon as possible.
including their own;
• Students should always clean up spills of Students should encourage others to participate
blood and other bodily fluids; in infection control 16
• Students should make themselves aware of Be a role model:
how the hospital waste management system • Students can encourage each other to use
works. correct handwashing techniques by doing so
themselves. Students can be leaders in this
Students should be immunized against respect. If another health-care provider has
Hepatitis B [14] poor technique and finishes much sooner
Students, like all health-care workers, are at risk than the student and does not wash his
209
Topic 9: Minimizing infection through improved infection control
hands but the student does, it may remind the person who fails to wash their hands, the
the health-care worker of the correct culture of the hospital and the culture of the
procedure. Sometimes people only need to society. It could be that a health-care worker
be reminded to jolt them out of a false sense was so busy that they inadvertently forgot to
of security. wash their hands. The student will have to
• Students can teach patients about the make a judgement about this based on their
importance of handwashing: They will often knowledge of the doctor’s or nurse’s habits. If
have more time with patients than fully- the student knows the person to be very
qualified colleagues. It is also a good time to attentive then it may be appropriate to raise it
practise their skills on educating patient about with the person or assist them by handing the
health care and prevention. alcohol rub or substances in use. In some
circumstances such as gatherings of
Interacting with health-care professionals: students it may be appropriate to reinforce
• Students may find themselves working in a the importance of correct handwashing
clinic or hospital where the health-care technique.
professionals including doctors do not follow
the institutional or professional guidelines for Students may routinely observe staff who
infection control. They may even observe ignore correct infection control procedures.
senior doctors not washing hands or failing to Students may wish to ask the supervisor or team
maintain sterile environments. It can be very leader to put the issue of handwashing and
difficult for students to speak up on such infection control on the agenda for discussion.
occasions. Culturally, it may not be Alternatively, they could ask the department head
conceivable that a junior member of staff if an expert can come and talk to the staff so that
would challenge a more senior member. Safe everyone is aware of the infection control
health care requires students to maintain the guidelines.
correct techniques even if there is pressure
on them to skip some steps. If a student is Summary 17
being pressured to cut corners they should • know the main guidelines in each of the
still try to maintain the proper technique. . clinical environments you are assigned;
• accept responsibility for minimizing
Students may routinely observe staff who apply opportunities for infection transmission;
inadequate technique in handwashing. • apply universal precautions;
• When this occurs students should maintain • let staff know if supplies are inadequate or
correct handwashing techniques and if depleted;
appropriate have a discussion about the • educate patients and families/visitors about
techniques used in the hospital or clinic and clean hands and infection transmission;
the reasons for the variation. However, in • ensure patients on precautions have same
many cultures this may not be appropriate. standard of care as others:
- frequency of entering the room;
Students may routinely observe staff who fail to - monitoring vital signs.
wash hands.
• How a student deals with this situation will
depend on the relationship of the student to
210
Topic 9: Minimizing infection through improved infection control
211
Topic 9: Minimizing infection through improved infection control
should observe if they do anything differently to commented that reusing the syringe on the same
other health-care workers. patient (and thus dipping a used syringe into a
common vial) was common practice.
Students could follow a patient through the peri-
operative process and observe the activities Reference
aimed at minimizing transmission of infection. Centers for Disease Control and Prevention,
Atlanta. Syringe reuse linked to hepatitis C
Students should examine and critique the outbreak. Sonner S, Associated Press
protocol used for infection control including
observations of the team’s knowledge and Bloody cuffs
adherence of it. This case illustrates the importance of adhering to
infection control guidelines. It also illustrates why
After these activities students should be asked to people should always adopt procedures that
meet in pairs or small groups and discuss with a assume a possible transmission.
tutor or clinician what they observed and whether
the features or techniques being observed were Jack, a 28-year-old male, and Sarah, a 24-year-old
present or absent, and whether they were woman, were involved in a severe motor vehicle
effective. collision when Jack’s car slammed into a cement
pillar. They were brought into the emergency
CASE STUDIES department with Jack suffering massive injuries
and Sarah with severe cuts to her upper body from
Hepatitis C: reusing needles the shattered glass of the car. Jack was bleeding
This case shows how easy it is to inadvertently profusely when he was placed in the trauma bay.
reuse a syringe. His blood pressure was taken and the cuff (made
of nylon and fabric) became completely saturated
Sam, a 42-year-old man, was booked for an with blood, so much that it could be wrung out. He
endoscopy at a local clinic. Prior to the procedure was taken to surgery but later died.
he was injected with sedatives, but after several
minutes the nurse noticed Sam seemed Sarah, with cuts to her upper body, was placed in
uncomfortable and required additional sedation. the same trauma bay where Jack had been
She used the same syringe, dipped it in the open treated. The same, unwashed, blood saturated cuff
sedative vial and re-injected him. The procedure that was used on Jack was placed on her arm.
continued as normal.
One nurse noted that the blood soaked cuff had
Several months later, Sam, suffering from swelling been used on both patients; however, other staff
of the liver, stomach pain, fatigue and jaundice, members shrugged off the incident.
was diagnosed with Hepatitis C. The Centers for
Disease Control was contacted, as 84 other A letter from the medical examiner weeks later
cases of liver disease were linked to the clinic. It revealed that Jack was HIV and HBV positive and
was believed that the sedative vial may have been that the motor vehicle collision had been a
contaminated from the backflow into the syringe suicide.
and that the virus may have been passed on from
the contaminated vial. Several health-care workers
212
Topic 9: Minimizing infection through improved infection control
213
Topic 9: Minimizing infection through improved infection control
Institute for Clinical Excellence (NICE), 2003, June, encouraged to develop a portfolio approach to
p. 257 (http://guidance.nice.org.uk/CG2, accessed patient safety learning. The benefit of a portfolio
May 2008). approach is that at the end of the student’s
Tools—surgical: Tools – surgical site infections. medical training they will have a collection of all
Boston, Institute for Healthcare Improvement their patient safety activities. Students will be able
(http://www.ihi.org/IHI/Topics/PatientSafety/Surgical to use this to assist job applications and their
SiteInfections/Tools/, accessed May 2008). future careers.
Infections—surgical: Surgical site infections
Improvement. Institute for Healthcare Improvement, The assessment of knowledge about infection
5 million lives campaign control is assessable using any of the following
(http://www.ihi.org/IHI/Topics/PatientSafety/Surgical methods.
SiteInfections/, accessed May 2008). • portfolio;
Infections: National strategy to address health care- • case-based discussion;
associated infections operational template. • OSCE station;
Australian Commission on Safety and Quality in • written observations about how a hospital or
Healthcare clinic practises infection control;
(http://www.safetyandquality.gov.au/internet/safety/p • reflective statements (in particular) about:
ublishing.nsf/Content/966A5A0D8A1E5C46CA2571 - how a hospital or clinic educates staff about
D80021E034/$File/safeusesharpsjun05.pdf, infection control;
accessed May 2008). - the role of hierarchy in the hospital
influences infection control practices;
Resources - the systems in place for reporting breaches
Pratt RJ et al. Epic 2: National evidence-based of infection control;
guidelines for preventing health care-associated - the role of patients in minimizing the
infections in NHS hospitals in England. Journal of transmission of infection;
Hospital Infection, 2007, 65S:S1–S64 - the effectiveness or the infection control
(http://www.epic.tvu.ac.uk/PDF%20Files/epic2/ep guidelines.
ic2-final.pdf, accessed May 2008).
Burke JP. Patient safety: infection control - a The assessment can be either formative or
problem for patient safety. New England Journal summative; rankings can range from
of Medicine, 2003, 348(7):651–656 unsatisfactory to giving a mark. See the forms in
(http://www.ihi.org/IHI/Topics/PatientSafety/Surgic Appendix 2.
alSiteInfections/Literature/PatientSafetyInfectionC
ontrolAProblemForPatientSafety.htm, accessed HOW TO EVALUATE THIS TOPIC
May 2008).
Evaluation is important in reviewing how a
HOW TO ASSESS THIS TOPIC teaching session went and how improvements
can be made. See the Teacher’s Guide (Part A) for
A range of assessment methods are suitable for a summary of important evaluation principles.
this topic including observational reports,
reflective statements about surgical errors,
essays, MCQ paper, SBA, case-based discussion
and self-assessment. Students can be
214
Topic 9: Minimizing infection through improved infection control
215
Topic 10: Patient safety and invasive procedures
Why patient safety is relevant to Although the principles described in this topic are
surgery and invasive procedures 1 important for both surgical and invasive
There is now plenty of evidence to show that procedures, most of the evidence in the literature
patients who undergo a surgical or an invasive relates to surgical care.
procedure are at increased risk of suffering an
adverse event [1-3]. This is not because the Learning outcomes: knowledge and
surgeons and proceduralists are careless or performance
incompetent, rather it is because we now know
about the many opportunities for things to go What does a student need to know
wrong because of the many steps involved in (knowledge requirements): 3
surgical procedures. In addition, there are the • the main types of adverse events
problems caused by surgical site infections that associated with surgical and invasive
account for a significant proportion of all health procedures care;
care-associated infections. This topic will assist • the verification processes for improving
students to understand how patient safety surgical and invasive procedures care.
principles can assist in minimizing adverse events
associated with invasive procedures. There are What a student needs to do (performance
many validated guidelines now available to assist requirements): 4
the health-care team deliver safe surgical care. • follow a verification process to eliminate
There may not be many opportunities for students wrong patient, wrong side and wrong
to implement many of these steps to improve procedure;
surgical outcomes. Nonetheless they can observe • practise operating room techniques that
how the health professionals communicate with reduce risks and errors (time-out, briefings,
one another and what techniques they use to debriefings, stating concerns);
make sure they are operating on the correct person • participate in an educational process for
or doing the procedure on the correct body part. reviewing surgical and invasive procedures
They can also observe what happens when health- mortality and morbidity.
care professionals appear not to follow a protocol.
Does this make their job harder or easier? WHAT STUDENTS NEED TO KNOW
(KNOWLEDGE REQUIREMENTS)
Keywords
Surgical and procedural site infections, The main types of adverse events
surgical/procedural errors, guidelines, associated with surgical and invasive
communication failures, verification processes, procedural care 5
teamwork. The traditional way of explaining adverse
events associated with surgery and invasive
Learning objective 2 procedures is usually related to the skills of the
The objective of this topic is to understand surgeons and the age and physical conditions of
the main causes of adverse events in surgical and the patients. Vincent and colleagues [1] believed
invasive procedural care and how the use of that adverse surgical (and other procedural)
guidelines and verification processes can facilitate outcomes are associated with many other factors
the correct patient receiving the correct procedure such as quality of the design-interface, teamwork
at the appropriate time and place. and organizational culture. Students should have
216
Topic 10: Patient safety and invasive procedures
learnt about a system approach in topic 3 as well there are more adverse events associated with
as the topics on teamwork and infection control surgery when compared to other hospital
all of which is particularly relevant to this topic. departments.
A systems approach to surgical and procedural The main adverse events associated with surgical
adverse events requires us to examine both latent care include:
factors such as teamwork and inadequate • infections and postoperative sepsis;
leadership and sharp end factors such as • cardiovascular complications;
communication during handoffs and poor • respiratory complications;
history taking. T3 T4
• thromboembolic complications.
T9
The three main causes of adverse events in When these events have been analysed, a range
surgical care are: T9 (Infection control) of pre-existing conditions (latent factors) have
been identified. Some of these are:
1. Poor infection control methods • inadequate implementation of protocols or
The Harvard Medical Practice Study II [2] found guidelines;
that surgical-wound infections constituted the • poor leadership;
second-largest category of adverse events and • poor teamwork;
confirmed the long-held belief that hospital-based • conflict between the different departments
staphylococcal infections constituted a great risk and the organization;
for hospitalized patients, particularly those • inadequate training and preparation of
receiving surgical care. The implementation of staff;
safer infection control practices such as the • inadequate resources;
appropriate administration of prophylactic • lack of evidenced-based practice;
antibiotics has reduced postoperative infections. • poor work culture;
In addition, increased attention to the risks of • overwork;
transmission show health-care workers how they • lack of a system for managing
as individuals and members of teams can performance.
minimize the risks of cross-infection. In addition to latent factors, individuals working at
the sharp end of peri-operative care are prone to
Everyone has a responsibility to decrease the the following types of errors known to cause
opportunities for contamination of clothing, hands adverse events, including:
and equipment that have been associated with • communication failures:
transmission routes. Infection control is studied in - information is provided too late to be
more detail in topic 9. Students during their effective;
training will be present during an operation or - information is inconsistent or inaccurate;
invasive procedure. They must at all times comply - key people are excluded from the
with the infection control guidelines and practise information;
universal precautions. - there are unresolved issues in the team;
• failure to take precautions to prevent
2. Inadequate patient management accidental injury;
The operating room and environment involves • wound infections, other wound problems,
intensely complex activities that may explain why technical problems and bleeding;
217
Topic 10: Patient safety and invasive procedures
218
Topic 10: Patient safety and invasive procedures
Table 17. Types of communication failure with illustrative examples and notes
Occasion Problems in the situation or context The staff surgeon asks the anaesthetist whether the
of the communication event antibiotics have been administered. At this point, the
procedure has been under way for over an hour.
Content Insufficiency or inaccuracy apparent in As the case is set up, the anaesthesia fellow asks the staff
the information being transferred surgeon if the patient has an ICU bed reserved. The staff
surgeon replies that the “bed is probably not needed, and
there is not likely one available anyway, so we’ll just go ahead”.
Audience Gaps in the composition of the group The nurses and the anaesthetist discuss how the patient
engaged in the communication should be positioned for surgery without the participation of
a surgical representative.
Purpose Communication events in which During a living donor liver resection, the nurses discuss
purpose is unclear, not achieved or whether ice is needed in the basin they are preparing for the
inappropriate liver. Neither knows. No further discussion ensues.
219
Topic 10: Patient safety and invasive procedures
Good guidelines share the following identify the best way to treat patients. Often
characteristics: guidelines may not be accessible to the team who
• they define the most important questions is required to use them; they may not even be
relating to clinical practice in a particular field; aware of them. It is not unusual for a health-care
• they attempt to identify all possible decision organization to publish a guideline but then not
options and the known consequences of make sure that everyone knows about it.
those decisions; Sometimes there are so many guidelines to follow
• they identify each decision point followed by that people turn off and do not see the relevance
the respective courses of action according to or importance of them. Being aware of the
the clinical judgement and experience of the importance of using appropriate guidelines is a
health professionals. first step to students asking about them and then
using them.
The extent of variation of practice in health care
has been identified as a major problem. Institute Safe care requires that all the staff know what is
of Medicine [6]. Variation caused by overuse, expected of them in relation to implementing a
underuse and misuse of medical care can be guideline. The guidelines need to be accessible (are
addressed by evidence-based practice, which they in a written form or are they online?) and
uses the best evidence available with the goal of applicable to the workplace where they are to be
lessening variation and reducing risks to patients. used. (Do the guidelines acknowledge the
Health professionals working in hospitals and differences in resources and the readily available
clinics do not have the time, resources or the health professionals?) For a guideline to be
available experts to each produce their own set of effective the staff must know about it, trust it, be
guidelines. Instead, clinicians are encouraged to able to access it easily and be able to implement it.
adapt already established guidelines and then
modify them to suit their local practice and For various reasons to do with resources, locality
environment. and type of patients it may be that some steps in
a guideline are impractical or inappropriate. In
Guidelines are necessary because the complexity such cases, the team may need to change the
of health care plus the level of specialization has guideline to fit the environment or circumstances.
made personal opinion or professional and When this occurs everyone needs to know about
organizational subjective preferences redundant the changes so they can apply them.
and unsafe. There are now hundreds of validated
guidelines to assist clinicians practise safe surgery If a guideline is not followed consistently by all the
such as preventing wrong site, wrong procedure, team, if people routinely skip steps, the guideline
wrong person surgery and prevention of surgical will not be effective in protecting patients from
site infections. adverse events. It is important that everybody,
including medical students, abides by the
Medical students are not always told about the protocol. Commitment of the whole team is
guidelines that are used in a particular area of necessary for successful implementation of
medicine. Nonetheless, they should be aware that guidelines or protocols.
in many areas of clinical practice, particularly that
associated with the management of chronic Some physicians may question the value of a
illness, there are established guidelines that guideline particularly when they think their
220
Topic 10: Patient safety and invasive procedures
autonomy is being compromised and questioned. The JCAHO Universal Protocol™ for preventing
They may feel their clinical discretion is being wrong site, wrong procedure, wrong person
removed with a team approach. Sharing surgery in 2003 is one example and sets out the
knowledge and information with others in the process and approach for including every
team is absolutely necessary for continuity of care member of the team as well as the patient. The
and achieving the best outcomes for the patients. WHO recently released guidelines for surgical
care advocating the use of a checklist to
Guidelines in surgical care enhance safety [7].
The main protocols in surgical care are about
improved communication to ensure that the right WHAT STUDENTS NEED TO DO
person is having the right procedure in the right (PERFORMANCE REQUIREMENTS)
place and by the right health-care team. A quick
review of the processes involved in surgery show Follow a verification process to
the many steps requiring active face-to-face eliminate wrong patient, wrong side
conversations particularly for consent, marking and wrong procedure
and or identifying the appropriate drugs and Most medical students will have an opportunity to
equipment to be used. The operating team— visit operating rooms and observe how surgical
surgeons, assistants, anaesthetists, scrub teams work together. They will also observe how
nurses, circulating nurses (scout nurses) and the team manages the processes involved—
others in the operating room—all have to know before, during and after the surgery. During a
the nature of the planned procedure, so that surgical rotation students should:
everyone is aware of the management plans, • locate the main protocols used in a particular
expectations of the different staff and anticipated surgical unit;
outcomes for the patients. For this reason, many • understand how the guideline was developed
sites now schede “time out” that takes place in and whether the processes align with
the operating room where the procedure will be evidenced-based practice;
performed, just before the procedure is to • read and understand why the guideline is
commence. necessary;
• be able to identify the steps in the verification
Safe surgery requires that every member of the process including selection of the right
surgical team knows the main protocols used in patient, right site and right procedure;
an area of practice. It would be very unusual for • identify how conflicts are resolved in
no protocols to be in place. If this is the case, the team. T4
then a member of the team should request
discussion about whether a protocol is required Practise operating room techniques
at a team meeting. that reduce risks and errors (time-out,
briefings, debriefings, stating
There is universal agreement that the best concerns) 7
approach to minimizing errors caused by Topic 4 on teamwork provides a detailed
misidentification of patients is the implementation analysis of how effective teams work and the
of best-practice guidelines for ensuring the actions that team members can take to effectively
correct patient receives the correct treatment. contribute to improved performance and safety. In
There are many guidelines addressing this issue. the surgical environment there are particular
221
Topic 10: Patient safety and invasive procedures
222
Topic 10: Patient safety and invasive procedures
confidential forum for auditing surgical the incident/area have the ability to report?
complications and are necessary for improving • Are juniors, including students, encouraged
practice in a surgical department. The meetings to attend and participate in mortality and
may be held weekly, fortnightly or monthly and morbidity meetings? These sessions provide
provide a good opportunity for learning about an excellent opportunity for students to learn
errors in surgery. Because patient safety is a about errors and the processes for improving
relatively new discipline, many of these meetings particular treatments and procedures.
are yet to adopt a systems approach (blame free) • Are all deaths involving a surgical procedure
for discussions about errors. Instead, some at the site identified and discussed?
remain focused on the person who made an error • Is a written summary of the discussions kept,
and use a punitive approach to discussing including any recommendations made for
adverse events. When meetings adopt a “person improvement or review?
approach” to discussions about errors they are
often closed to other members of the operating Summary 9
team, junior doctors and medical students and This topic outlines the value of guidelines in
only include the surgeons. reducing errors and minimizing adverse events.
But a guideline is only useful if the people using
Notwithstanding some of the problems associated the guideline trust them and understand why
with the past, mortality and morbidity meetings are using a guideline is better for patient care.
excellent places to learn about errors and discuss Protocols can prevent the wrong patient receiving
ways to prevent them in the future. Medical the wrong treatment as well as facilitate better
students should find out if the hospital has such communication among the team.
meetings and ask the appropriate senior surgeon if
they can attend. If this is possible, students should HOW TO TEACH THIS TOPIC
observe to see if the following basic patient safety
principles are demonstrated: Teaching strategies/formats
• Is the meeting structured so that the
underlying issues and factors associated with An interactive/didactic lecture
the adverse event are the focus, rather then Use the accompanying slides as a guide
the individuals involved? covering the whole topic. The slides can be
• Is there an emphasis on education and PowerPoint or converted to overhead slides for a
understanding, rather than apportioning projector. Start the session with the case study
blame to individuals? and get the students to identify some of the
• Is the goal of the discussion prevention of issues presented in the story.
similar things occurring again? This requires a
timely discussion of the event when Panel discussions:
memories are still fresh. Invite a panel of surgeons and theatre nurses to
• Are these meetings considered a core give a summary of their efforts to improve patient
activity for the entire surgical team, including safety and to talk about their roles and
the technicians and managers as well as the responsibilities. This can help students appreciate
clinicians (medical, nursing, pharmacy, the role of teamwork in surgery and invasive
allied health)? procedures. Students could also have a pre-
• Does everyone who had any involvement with prepared list questions about adverse event
223
Topic 10: Patient safety and invasive procedures
prevention and management and have time the later years of the programme. Nevertheless
scheduled for their questions. there is no reason why students could not be
exposed to them from the very first year of study.
A small group discussion session • Students could attend a surgical procedure
The class can be divided up into small and observe and record the activities
groups and three students in each group be undertaken by the team to ensure that the
asked to lead a discussion about one category of patient being operated on is the right patient,
adverse events associated with surgery. Another that they are having the right procedure and
student can focus on the tools and techniques at the right time.
available to minimize opportunities for errors and • Students could observe a surgical team,
another could look at the role of mortality and identifying who is on the team, how they
morbidity meetings. functioned and how they interacted with the
patient.
The tutor facilitating this session should also be • Students can attend a mortality and morbidity
familiar with the content so information can be meeting and write a brief report as to whether
added about the local health system and clinical the basic patient safety principles were
environment. applied during the meeting.
• Students could follow a patient through the
Simulation exercises peri-operative process and observe the
Different scenarios could be developed activities or tasks that focused on the
about adverse events in surgery and the patient’s safety.
techniques for minimizing the opportunities for • Students should examine and critique the
errors. These could mainly involve junior staff protocol used for the patient verification
having to speak up to more senior staff to avert process including observations of the team’s
an incident such as the wrong patient being knowledge and adherence of it.
operated on or the wrong limb being prepared. • Students should observe how patient
information is communicated from the wards
Different scenarios could be developed for the to the operating rooms and back to the
students: wards.
• practising the techniques of briefs, debriefs
and assertiveness to improve communication After these activities, students should be
in theatres; asked to meet in pairs or small groups and
• role play using a “person approach” and then discuss with a tutor or clinician what they
a “system approach” in a mortality and observed and whether the features or
morbidity meetings; techniques being observed were present or
• role play a situation in theatre where a absent, and whether they were effective.
medical student notices something is wrong
and needs to speak up.
CASE STUDIES
Operating room and ward activities
This topic offers many opportunities for integrated Arthroscopy performed on wrong knee
activities during the time when students are This demonstrates the role of the team in ensuring
assigned to a surgical ward. This will often be in the correct procedure is performed and how
224
Topic 10: Patient safety and invasive procedures
Brian injured his left knee while exercising and Anaesthesia was induced at 08:35 but it was not
was referred by his general practitioner to an possible to insert the laryngeal mask airway. Two
orthopaedic surgeon. The orthopaedic surgeon minutes later, the patient’s oxygenation began to
obtained consent to perform an examination of deteriorate and she looked cyanosed (turning
the left knee under anaesthetic as a day surgery blue). Her oxygen saturation at this time was 75%
procedure. Two registered nurses confirmed as (anything less than 90% is significantly low) and
part of the ordinary preoperative processes that her heart rate was raised.
his signature appeared on the consent form for
his left knee. At 08:39, her oxygen saturation continued to
deteriorate to a very low level (40%). Attempts to
The surgeon talked to Brian before he entered the ventilate the lungs with 100% oxygen using a face
operating theatre, but did not confirm which knee mask and oral airway proved extremely difficult.
was to be operated on. Brian was taken into the The anaesthetist, who was joined by a consultant
operating theatre and anaesthetized. The colleague tried unsuccessfully to achieve tracheal
anaesthetic nurse saw a tourniquet draped over intubation to overcome the problems with the
his right leg and applied it. The enrolled nurse airway. By 08:45, there was still no airway access
checked the intended side on the operating list so and the situation had become “cannot intubate,
she could set up and when she saw the cannot ventilate”, a recognized emergency in
orthopaedic surgeon preparing the right leg, she anaesthetic practice for which guidelines are
told him that she thought the other leg was the available. The nurses present appear to have
intended operative site. The doctor was heard by recognized the severity of the situation, one
both the enrolled nurse and scrub nurse to fetching a tracheotomy tray, another going to
disagree and the right (incorrect) knee was arrange a bed in ICU.
operated on.
The doctors’ intubation attempts continued using
Reference different laryngoscopes, but these were also
Case studies. Professional Standards unsuccessful and the procedure was abandoned
Committees, Health Care Complaints with the patient transferred to the recovery room.
Commission, New South Wales, Annual Report Her oxygen saturation had remained at less than
1999–2000, p. 64. 40% for 20 minutes. Despite being subsequently
transferred to ICU, she never regained
A routine operation. consciousness and died 13 days later as a result
The case illustrates the risks of anaesthetics. of severe brain damage.
225
Topic 10: Patient safety and invasive procedures
Wrong kidney removed despite a student’s the patient’s allergy to penicillin and the surgeon
warning suggested clindamycin as an alternative
This case demonstrates the relevance of using a preoperative antibiotic. The anaesthetist went into
protocol to ensure correct patient correct site the sterile corridor to retrieve the antibiotics but
correct procedure. returned and explained to the circulating nurse
that he could not find any suitable antibiotics in the
A male patient aged 69 was admitted for removal sterile corridor. The circulating nurse got on the
of his chronically diseased right kidney phone to request the preoperative antibiotics. The
(nephrectomy). Due to a clerical error, the anaesthetist explained that he could not order
admission slip stated “left”. The operating list was them because there were no order forms (he
transcribed from the admission slips. The patient looked through a file folder of forms). The
was not woken from sleep to check the correct circulating nurse confirmed that the requested
side on the preoperative ward round. The side antibiotics “were coming””
was not checked in from the notes or the consent
form. The error was compounded in the operating The surgical incision was performed. Six minutes
theatre when the patient was positioned for a left later the antibiotics were delivered to the operating
nephrectomy and the consultant surgeon put the room and immediately injected into the patient.
correctly labelled X-rays on the viewing box back This injection happened after the time of incision,
to front. The senior registrar surgeon began to which was counter to protocol that requires
remove the left kidney. antibiotics to be administered prior to the surgical
incision in order to avoid surgical site infections.
A medical student observing the operation Subsequently a nurse raised a patient concern
suggested to the surgeon that he was removing and effected a change in operative planning.
the wrong kidney but was ignored. The mistake
was not discovered until two hours after the Case from the WHO Patient Safety Curriculum
operation when the patient had not produced any Guide for Medical Schools working group.
urine. He later died. Supplied by Lorelei Lingard, University of Toronto,
Toronto, Canada.
Reference
British Medical Journal, 31 January 2002, p. 246;
Telegraph, 13 June 2002. TOOLS AND RESOURCES
A failure to administer preoperative antibiotic Universal protocol for preventing wrong site, wrong
prophylaxis in a timely manner according to procedure, wrong person surgery™: Carayon P.
protocol Schultz K. Hundt AS. Righting wrong site surgery.
This case illustrates the importance of preplanning [Case Reports. Journal Article. Research Support,
and checking prior to a procedure and how Non-U.S. Government. Research Support, US
protocols can minimize the risk of infection. Government, P.H.S.] Joint Commission. Journal
on Quality & Safety, 2004, 30(7):405–10
The anaesthetist and the surgeon discussed the (http://www.jointcommission.org/NR/rdonlyres/E3
preoperative antibiotics required for the C600EB-043B-4E86-B04E-
laparoscopic cholecystectomy that was about to CA4A89AD5433/0/universal_protocol.pdf,
begin. The anaesthetist informed the surgeon of accessed May 2008).
226
Topic 10: Patient safety and invasive procedures
5 step correct patient, correct site, correct HOW TO ASSESS THIS TOPIC
procedure: ACT Health (Australia), issued
September 2005 A range of assessment methods are suitable for
(http://www.health.act.gov.au/c/health?a=sendfile&ft this topic including observational reports,
=p&fid=1127862008&sid, accessed 29 April 2008). reflective statements about surgical errors,
Surgical events toolkit: Joint Commission essays, MCQ, SBA, case-based discussion and
International Center for Patient Safety, 2007 self-assessment. Students can be encouraged to
http://www.ccforpatientsafety.org/ accessed 29 develop a portfolio approach to patient safety
April 2008). learning. The benefit of a portfolio approach is
Correct site surgery toolkit: Association of peri that at the end of the student’s medical training
operative Registered Nurses (AORN) they will have a collection of all their patient safety
(http://www.aorn.org/PracticeResources/ToolKits/ activities. Students will be able to use this to
CorrectSiteSurgeryToolKit/, accessed 29 April assist job applications and their future careers.
2008).
Perioperative patient “hand-off’ toolkit: The assessment of knowledge about surgical care
Association of Perioperative Registered Nurses and the potential harm to patients, about system
(AORN) and the U.S. Department of Defense approach to improving surgical outcomes and the
Patient Safety Program techniques for minimizing opportunities for
(http://www.aorn.org/PracticeResources/ToolKits/ surgical errors are all assessable using any of the
PatientHandOffToolKit/, accessed 29 April 2008). following methods:
Ensuring correct surgery and invasive • portfolio;
procedures: Veterans Health Administration, US • case-based in discussion;
Department of Veterans Affairs, Washington, DC • OSCE station;
(http://www1.va.gov/vhapublications/ViewPublica • written observations about the perioperative
tion.asp?pub_ID=1106, accessed 29 April 2008). environment (in general) and the potential for
WHO safe surgery saves lives: The Second error;
Global Patient Safety Challenge. • reflective statements (in particular) about:
(http://www.who.int/patientsafety/safesurgery/en/i - theatres and the role of teamwork in
ndex.html). minimizing errors;
- the role of hierarchy in the theatre and the
Resources impact on patient safety;
Calland JF et al. Systems approach to surgical - the systems in place for reporting surgical
safety. Surgical Endoscopy, 2002, 16:1005–1014 errors;
(http://www.springerlink.com/content/wfb947ub7 - the role of surgeons in learning from errors
ut3re9n/fulltext.pdf, accessed 29 April 2008). and making improvements;
Vincent C et al. Systems approaches to surgical - role of patients in the surgical process;
quality and safety: from concept to measurement. - the effectiveness or otherwise of mortality
Annals of Surgery, 2004, 239:475–482 and morbidity meetings.
Cuschieri A. Nature of human error: Implications
for surgical practice. Annals of Surgery 2006, The assessment can be either formative or
244:642–648 summative; rankings can range from unsatisfactory
(http://www.pubmedcentral.nih.gov/articlerender.f to giving a mark. See the forms in Appendix 2
cgi?artid=1856596, accessed 29 April 2008).
227
HOW TO EVALUATE THIS TOPIC SLIDES FOR TOPIC 10: PATIENT
Evaluation is important in reviewing how a SAFETY AND INVASIVE PROCEDURES
teaching session went and how improvements
can be made. See the Teacher’s Guide (Part A) for Didactic lectures are not usually the best way to
a summary of important evaluation principles. teach students about patient safety. If a lecture is
being considered, it is a good idea to plan for
References student interaction and discussion during the
lecture. Using a case study is one way to
1. Vincent C et al. Systems approaches to generate group discussion. Another way is to ask
surgical quality and safety: from concept to the students questions about different aspects of
measurement. Annals of Surgery, 2004, health care that will bring out the issues contained
239:475–482. in this topic such as the blame culture, nature of
2. Leape L et al. The nature of adverse events error and how errors are managed in other
in hospitalized patients: results of the industries.
Harvard Medical Practice Study II. New
England Journal of Medicine, 1991, The slides for topic 10 are designed to assist the
323:377–384. teacher deliver the content of this topic. The slides
3. Kable AK, Gibberd RW, Spigelman AD. can be changed to fit the local environment and
Adverse events in surgical patients in culture. Teachers do not have to use all of the
Australia. International Journal for Quality in slides and it is best to tailor the slides to the areas
Heath Care, 2002, 269–276. being covered in the teaching session.
4. Joint Commission on Accreditation of
Healthcare Organizations. Guidelines for
implementing the universal protocol for
preventing wrong site, wrong procedure and
wrong person surgery: Chicago, JCAHO,
2003.
5. Lingard L et al. Communication failures in the
operating room: an observational
classification of recurrent types and effects.
Quality & Safety in Health Care, 2004,
13:330–334.
6 Crossing the Quality Chasm: a New Health
System for the 21st Century. Washington DC:
National Academy Press, 2001.
7. WHO safe surgery saves lives: The Second
Global Patient Safety Challenge.
(http://www.who.int/patientsafety/safesurger
y/en/index.html) accessed January 2009.
228
Topic 11: Improving medication safety
229
Topic 11: Improving medication safety
Adverse reaction
Unexpected harm arising from a justified action Steps in using medication 9
where the correct process was followed for the There are a number of discrete steps in using
context in which the process occurred [1]. For medication: prescribing, administration and
example, an unexpected allergic reaction in a monitoring are the main three. Doctors, patients
patient taking a medication for the first time. and other health professionals can all have a role
in these steps. For example, a patient may self-
Error prescribe over-the-counter medication, administer
Failure to carry out a planned action as intended their own medication and monitor themself to see
or application of an incorrect plan.[1] if there has been any therapeutic effect.
Alternatively, for example, in the hospital setting,
230
Topic 11: Improving medication safety
one doctor may prescribe a medication, a nurse Understand that using medications has
will administer the medication and a different associated risks
doctor may end up monitoring the patient’s
progress and make decisions about the ongoing Prescribing 10 11 12 13 14
drug regimen.
Sources of error in prescribing:
The main components of each step are outlined • Inadequate knowledge about drug
below. indications, contraindications and drug
interactions. This has become an increasing
Prescribing: problem as the number of medicines in use
• choosing an appropriate medication for a has increased. It is not possible for a doctor
given clinical situation, taking individual to remember all the relevant details necessary
patient factors into account such as allergies; for safe prescribing. Alternative ways of
• selecting an administration route, dose, time accessing drug information are required.
and regimen; • Not considering individual patient factors that
• communicating the plan with whoever will would alter prescribing such as allergies,
administer the medication. This pregnancy, co-morbidities like renal
communication may be written, verbal or both; impairment and other medications the patient
• documentation. may be taking.
• Prescribing for the wrong patient, prescribing
Administration: the wrong dose, prescribing the wrong drug,
• obtaining the medication and having it in a prescribing the wrong route or the wrong
ready-to-use form. This may involve counting, time. These errors can sometimes occur due
calculating, mixing, labelling or preparing in to lack of knowledge, but more commonly
some way; are a result of a “silly mistake” or “simple
• checking for allergies; mistake”, referred to as a slip or a lapse.
• giving the right medication to the right patient, These are the sorts of errors that are more
in the right dose, via the right route, at the likely to occur at 04:00, or if the doctor is
right time; rushing or bored and not concentrating on
• documentation. the task at hand.
• Inadequate communication can result in
Monitoring: prescribing errors. Communication that is
• observing the patient to determine if the ambiguous can be misinterpreted. This may
medication is working, being used correctly be a result of illegible writing or simple
and not harming the patient; misunderstanding in verbal communication.
• documentation. • Mathematical error when calculating doses
can cause errors. This can be a result of
There is potential for error at every step of the carelessness, but could also be due to lack of
process. There are a variety of ways that error can training and unfamiliarity with how to
occur at each step. manipulate volumes, amounts,
concentrations and units. Calculation errors
involving medications with narrow therapeutic
window can cause major adverse events. Not
231
Topic 11: Improving medication safety
232
Topic 11: Improving medication safety
233
Topic 11: Improving medication safety
234
Topic 11: Improving medication safety
235
Topic 11: Improving medication safety
a new set of challenges. [6] are aware of what processes are in place in your
Some useful maxims regarding checking: area to maximize learning from error and progress
• Unlabelled medications belong in the bin. in medication safety.
• Never administer a medication unless you are
100% sure you know what it is. Safe practice skills for medical
students to develop practice 38
Encourage patients to be actively Although medical students are generally not
involved in their own care and the permitted to prescribe or administer medication
medication use process: 36 until after graduation, there are many aspects of
• Educate your patients about their medication safety that students can start
medication and any associated hazards; practising and preparing for. It is hoped that the
• Communicate plans clearly with patients. following list of activities can be expanded upon at
Remember that the patient and their family multiple stages throughout a medical student’s
are highly motivated to avoid problems, so if training. Each task on its own could form the
they are made aware that they have an basis of an important educational session (lecture,
important role to play in the process, they can workshop, tutorial). Thorough coverage of these
contribute significantly to improving the safety topics is beyond the scope of an introductory
of medication use; session to medication safety.
• Information can be both verbal and written
and should cover the following aspects: An understanding of the inherent hazards of using
- name; medicines will affect how a clinician performs
- purpose and action of the medication; many daily tasks. Below are examples of what a
- dose, route and administration schedule; safety conscious clinician will do.
- special instructions, directions and • Prescribing: Consider the 5 Rs, know the
precautions; drugs you prescribe well, tailor your treatment
- common side-effects and interactions; decisions to individual patients, consider
- how the medication will be monitored. individual patient factors that may affect
• Encourage patients to keep a written record choice or dose of medication, avoid
of the medications that they take and details unnecessary use of medicines and consider
of any allergies or problems with medications risk benefit ratios;
in the past. This list should be presented • Documentation : Clear, legible,
whenever they interact with the health-care unambiguous documentation. Those who
system. struggle to write neatly should print. Consider
the use of electronic prescribing if available.
Report and learn from medication Include patient, dose, drug, route, time and
errors 37 schedule as part of documentation;
Discovering more about how and why • Use of memory aids: Have a low threshold
medication errors occur is fundamental to to look things up, be familiar with available
improving medication safety. Whenever an memory aids, look for and use technological
adverse drug event or near miss occurs there is solutions if available and effective;
an opportunity for learning and improving care. It
will be helpful for your students if they understand
the importance of talking openly about errors and
236
Topic 11: Improving medication safety
237
Topic 11: Improving medication safety
There are a variety of ways to teach medical Teaching and learning activities
students about medication safety and a
combination of approaches is likely to be most Practical workshops
effective. Suggested topics include:
• drug administration;
Options include: interactive lectures, small group • prescribing;
discussions, PBL, practical workshops, tutorials, • drug calculations.
project work including tasks to be undertaken in
the clinical environment and at the bedside, online Project work:
learning packages, reading and case analysis. Suggested topics include:
• interview a pharmacist to find out what errors
Lecture presentation and/or group they commonly see;
discussion • accompany a nurse on a drug round;
The PowerPoint presentation included in this • interview a nurse or doctor who administers a
package is designed for use as an interactive lot of medication (e.g. an anaesthetist) about
introductory lecture to medication safety or a their experience and knowledge of
teacher-led small group discussion. It can be medication error and what strategies they use
readily adjusted to be more or less interactive, to minimize the chance of making a mistake;
and can potentially be adapted to your clinical • research a medication that has a reputation
setting if you include local examples, local issues for being a common cause of adverse events
and local systems. There are a series of questions and presenting what has been learnt to fellow
interspersed throughout the presentation to students;
encourage students to actively engage with the • prepare a personal formulary of medications
topic and also short cases with questions and likely to be commonly prescribed in the early
answers that could be embedded in the lecture or postgraduate years;
provided for the students as a separate exercise. • perform a thorough medication history on a
patient on multiple medications—do some
Below are listed some other educational methods homework to learn more about each of the
and ideas to consider using for teaching on medications, then consider potential side-
medication safety. effects, drug interactions and if there are any
medications that could be ceased for your
Problem-based learning patient; discuss your thoughts with a
Use cases that raise issues relevant to pharmacist or doctor and share what you
medication safety. have learnt with fellow students;
• find out what is meant by the term
Online activities “medication reconciliation” and talk to
Suggested activities include: hospital staff to find out how this is achieved
• responding to reflective questions after at your hospital; observe and, if possible,
reading through a case; participate in the process during admission
238
Topic 11: Improving medication safety
and discharge of a patient and consider how of the patient is called to speak with the patient’s
the process may prevent errors and also son.
whether there are any gaps or problems with
the process. If the nurse explains the chain of events, takes
responsibility for and admits her error, the patient’s
Role plays son is not placated and retorts, “Is that the level of
Supplied by Amitai Ziv, The Israel Centre for care my father has been receiving?”, “What kind
Medical Simulation, Sheba Medical Centre, Tel of nurses work in this ward?”, “I won’t have it, I
Hashomer, Israel. will take action!”, “I demand to speak to the chief
or head physician immediately!”, “I demand to see
Scenario I this event’s report!”. Needless to say, if the nurse
Erroneous administration of drugs does not explain the error and its details, the
patient’s son is upset and unwilling to accept any
Description of event kind of explanation.
During the early hours of the morning shift, the
morning shift nurse administered subcutaneous A physician passing by overhears the
regular insulin 100 units, instead of 10 units as conversation and enters the room.
was written in the physician’s order. The error
stemmed from the physician’s illegible The physician will enter the room if the actor asks
handwriting. him to. If the actor does not request the physician,
the physician will enter the room after
The patient suffered from dementia, was approximately 8 minutes (12-minute scenario).
uncooperative and seemed to be asleep. During The physician will enter the room and ask about
the nurse’s regular checkup, she discovered the last night. The nurse will update him as to this
patient to be completely unresponsive. A blood morning’s events and her conversation with the
test confirmed that the patient was in a state of patient’s son (either in his presence or not,
hypoglycemic shock. The on-call physician was depending on the physician and nurse).
called, and the error was discovered.
Role playing actor: description
The patient was treated with an infusion of RY, 45 years old, is a well-dressed lawyer. He
glucose 50% IV. A crash cart was brought to the visits with his father whenever possible. He does
patient’s room to be on hand. The patient not attend to his father; rather, he hovers over him
recovered within a few minutes, woke up and with unrest. He is interested in everything going
began behaving normally. on around him, but is having difficulty accepting
his father’s new medical state: confused,
Role playing actor neglected and a bit sunken. He really wants to
Later on in the morning shift, the patient’s son, a help, but does not know with what. A
lawyer, comes to visit his father. Looking agitated, conversation with the social worker reveals that
he turns to the nurse asking, “What happened to previously there was never a need for him to care
my father?” His father’s room-mate told him there for his father, but ever since his mother fell and
was a problem and there were many people at his broke her leg and his father’s situation has
father’s bedside at the beginning of the morning deteriorated, the burden of their care rests on his
shift. The nurse responsible for the error and care shoulders alone.
239
Topic 11: Improving medication safety
Actor tips The nurse who copied the order mistook the letter
The actor must intervene; complain to the head “D” to mean “dose”, while the physician who
physician of a cover-up and omission of facts; wrote the order actually meant “day”. Over the
threaten with negative publicity (going to the next 10 days, the patient received 240 mg of
press) (i.e. “You almost killed him! You’re lucky it Garamycin, three times daily.
didn’t end that way!”)
During that time, the patient began showing signs
Scenario II of renal failure and hearing impairment. On the
Death due to erroneous medical care tenth day of treatment, as the head nurse was
taking stock of the drugs administered, the error
Description of event was discovered. The treatment was stopped, but
ST, 42 years old, was admitted for the re-section the patient’s general status deteriorated due to
of a localized, non-metastatic malignant duodenal acute renal failure progression; 10 days later, the
tumour. patient died of generalized organ failure.
ST was otherwise healthy, without any family history The patient’s family was critical of the nursing staff
of malignancy. The patient had consented to throughout the hospitalization, blaming them for
surgery and any other treatment deemed necessary malpractice. They expressed their anger to the
afterwards, according to pathology results. head nurse and the department chief.
On the morning of surgery, the patient said After the patient died, her husband asks to speak
goodbye to her husband and two young children to the head nurse. He blames the nurses for the
(ages 13 and 8). A small localized mass was re- error and malpractice that culminated in his wife’s
sected in its entirety. The mass was sent to death. He claims to have already discovered
pathology for diagnosis. Two hours into surgery, which nurse copied the order, and threatens to
the patient showed signs of decreased saturation, suit her.
tachycardia and hypotension. The patient
received IV fluids and young, while the surgeon Role playing actor: description
re-checked the re-section site for signs of The patient’s husband is a hard-working man,
haemorrhage, a tear or an embolism. After finding working in a store. He has difficulty providing for
nothing, the surgeon sutured the site according to his family and is struggling to make ends meet.
protocol. He is an angry and restless man who has not yet
come to terms with his wife’s cancer diagnosis.
Upon return to the ward, the patient quickly He is angry with everyone and especially with the
developed a high fever, which remained nursing staff, after his wife told him she received
unchanged for a week. A medical order for too many antibiotics because “the nurse couldn’t
antibiotics was written: do math”. He wants to know what killed his wife,
IV. GARAMYCIN 80 MGR X 3 P/D who is at fault and who is going to pay for it. He
wants top hospital management involved, and
The nurse copied the following order: wants help for his children. He is very upset, and
IV. GARAMYCIN 80 MGR X 3 P/DOSE shouts a lot.
240
Topic 11: Improving medication safety
The on-call physician is in the vicinity, but does In a heated discussion, the patient’s son accuses
not intervene and continues caring for other the nurses of malpractice, “You’re killing my father.
patients (some of which are near the nurses’ You do not care about him because he’s old. You
station where the event is taking place). were drinking coffee and didn’t answer my father’s
calls…” His anger is directed towards the nurse-
241
Topic 11: Improving medication safety
in-charge of the shift and the nurse in charge of beta-blocker for the angina. After commencing
ED’s care. the new medication, the patient develops
bradycardia and postural hypotension.
Role playing actor: description Unfortunately, the patient has a fall three days
GD, the patient’s son, is a 34-year-old taxi driver later due to dizziness on standing. He fractures
living with his parents. He was not close to home his hip in the fall.
when he learnt what had happened and,
therefore, was only able to reach the hospital five Case 2 with questions for discussion:
to six hours after the event. He enters the ward an administration error
and immediately asks to see his father and the A 38-year-old woman comes to the hospital with
nurse responsible for his fall. He has already been 20 minutes of itchy red rash and facial swelling.
updated by other members of his family as to his She has a history of serious allergic reactions. A
father’s complications after surgery. nurse draws up 10 mls of 1:10,000 adrenaline
(epinephrine) into a 10 ml syringe and leaves it at
Actor tips the bedside ready to use (1 mg in total) just in
You and your father are very close. You are a very case the doctor requests it. Meanwhile, the
uptight man. Your taxi driver friends usually think doctor inserts an IV cannula. The doctor sees the
that medicine is not to be trusted. 10 ml syringe of clear fluid that the nurse has
drawn up and assumes it is normal saline. There
TOOLS AND RESOURCES is no communication between the doctor and the
Activities that can be included as part of the nurse at this time.
PowerPoint presentation, to help make the
presentation more interesting, engaging and The doctor gives all 10 mls of adrenaline
effective. 40 41 42 43 44 45 46 (epinephrine) through the IV cannula thinking he is
using saline to flush the line. The patient suddenly
47 48 49 50 51 52 53 54 55
feels terrible, anxious, becomes tachycardic and
then becomes unconscious with no pulse. She is
discovered to be in ventricular tachycardia, is
Case 1 with questions for discussion: resuscitated and fortunately makes a good
a prescribing error recovery. Recommended dose of adrenaline
A 74-year-old man sees a community doctor for (epinephrine) in anaphylaxis is 0.3–0.5 mg IM. This
treatment of new onset stable angina. The doctor woman received 1 mg IV.
has not met this patient before and takes a full
past history and medication history. He discovers Case 3 with questions for discussion:
the patient has been healthy and only takes a monitoring error
medication for headaches. The patient cannot A patient is commenced on oral anticoagulants in
recall the name of the headache medication. The hospital for treatment of a deep venous
doctor assumes it is an analgesic that the patient thrombosis following an ankle fracture. The
takes whenever he develops a headache. But the intended treatment course is three to six months.
medication is actually a beta-blocker which he However, neither patient nor community doctor
takes every day for migraine. A different doctor are aware of the planned duration of treatment.
prescribed this medication. The doctor Patient continues medication for several years,
commences the patient on aspirin and another being unnecessarily exposed to the increased risk
242
Topic 11: Improving medication safety
of bleeding associated with this medication. The It consists of a doctor, a nurse and a pharmacist
patient is prescribed a course of antibiotics for a talking about serious medication errors they have
dental infection. Nine days later the patient been involved in. This DVD is available for
becomes unwell with back pain and hypotension, purchase through the Institute for Safe Medication
a result of a spontaneous retroperitoneal Practices—Preventing Medication Errors at
haemorrhage, requiring hospitalization and a www.ismp.org
blood transfusion. Blood coagulation test reveals
a grossly elevated result; the antibiotics have WHO Learning from error workshop includes a
potentiated the therapeutic anticoagulant effect. DVD depiction of a medication error – the
administration of intrathecal vincristine. The DVD
TOOLS AND RESOURCES illustrates the multifactorial nature of error.
243
Topic 11: Improving medication safety
244
APPENDICES
Modified essay question example Outline the components of consent for the
unconscious patient and conscious patient:
An accident
246
APPENDIX 1: Assessment method examples
247
APPENDIX 1: Assessment method examples
Station No.
248
APPENDIX 1: Assessment method examples
Station No.
249
APPENDIX 1: Assessment method examples
Station No.
250
APPENDIX 1: Assessment method examples
Station No.
Student name:
Greet the student and give the written instructions to the student.
Remember to ask the student for the identity label and affix it to the top of the mark sheet.
Please circle the appropriate mark for each criterion. The standard expected is that of a new pre-
registration house officer (PRHO).
251
APPENDIX 2: Link to the Australian Patient Safety
Education Framework
252
Acknowledgements
Developed by the Medical Education Team within the World Alliance for Patient Safety under the editorial
leadership of Merrilyn Walton with support and contributions from:
Brendan Flanagan, Monash University, Victoria,Australia Julia Harrison, Monash University, Victoria,
Australia Tim Shaw, University of Sydney, New South Wales, Australia Chris Roberts, University of Sydney,
New South Wales, Australia Stewart Barnet, University of Sydney, New South Wales, Australia
Samantha Van Staalduinen, University of Sydney, New South Wales, Australia Medical curriculum working
group members Bruce Barraclough (Chairperson), New South Wales Clinical Excellence Commission,
Sydney, Australia Merrilyn Walton, University of Sydney, New South Wales, Australia
Ranjit De Alwis, International Medical University, Kuala Lumpur,Malaysia Mohamed Saad Al-Moamary, King
Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia Anas Eid, International Federation
of Medical Students’ Associations (IFMSA) Rhona Flin, University of Aberdeen, Old Aberdeen,
United Kingdom Pierre Claver Kariyo, School of Medicine, Bujumbura, Burundi Lorelei Lingard, University
of Toronto, Toronto, Canada Jorge Martinez, Universidad Del Salvador, Buenos
Aires, Argentina Chit Soe, Ministry of Health, Myanmar Lee Young-Mee, Korea University College of
Medical Education, Seoul, Republic of Korea Mingming Zhang, Sichuan University, Chengdu,
China Amitai Ziv , The Israel Centre for Medical Simulation, Sheba Medical Centre, Tel Hashomer,Israel
Education:
Bruce Barraclough, Felix Greaves, Benjamin Ellis, Ruth Jennings, Helen Hughes, Itziar Larizgoitia, Claire
Lemer, Douglas Noble, Rona Patey, Gillian Perkins, Samantha Van Staalduinen, Merrilyn Walton, Helen
Woodward
253
International Classification for Patient Safety
Martin Fletcher, Edward Kelley, Itziar Larizgoitia, Fiona Stewart-Mills
Radiotherapy:
Michael Barton, Felix Greaves, Ruth Jennings, Claire Lemer, Douglas Noble, Gillian Perkins, Jesmin Shafiq,
Helen Woodward
Technology:
Rajesh Aggarwal, Lord Ara Darzi, Rachel Davies, Gabriela Garcia Castillejos, Felix Greaves, Edward Kelley,
Oliver Mytton, Charles Vincent, Guang-Zhong Yang
Vincristine
Felix Greaves, Claire Lemer, Helen Hughes, Douglas Noble, Kristine Stave, Helen Woodward
254
World Health Organization Email
20 Avenue Appia patientsafety@who.int
CH - 1211 Geneva 27 Please visit our website at:
Switzerland www.who.int/patientsafety/en/
Tel. +41 (0) 22 791 50 60 http://www.who.int/patientsafety/activities/
technical/medical_curriculum /en/index.html