2011; 33: 535–540
TWELVE TIPS
Twelve tips for implementing a patient safety curriculum in an undergraduate programme in medicine GERRY ARMITAGE1, ALISON CRACKNELL2, KIRSTY FORREST2 & JOHN SANDARS3 1
Bradford Institute for Health Research, Bradford Teaching Hospitals, NHS Foundation Trust; and School of Health, University of Bradford, Bradford, UK, 2Leeds Teaching Hospital, NHS Trust, Leeds, UK, 3University of Leeds, Leeds, UK
Abstract Patient safety is a major priority for health services. It is a multi-disciplinary problem and requires a multi-disciplinary solution; any education should therefore be a multi-disciplinary endeavour, from conception to implementation. The starting point should be at undergraduate level and medical education should not be an exception. It is apparent that current educational provision in patient safety lacks a systematic approach, is not linked to formal assessment and is detached from the reality of practice. If patient safety education is to be fit for purpose, it should link theory and the reality of practice; a human factors approach offers a framework to create this linkage. Learning outcomes should be competency based and generic content explicitly linked to specific patient safety content. Students should ultimately be able to demonstrate the impact of what they learn in improving their clinical performance. It is essential that the patient safety curriculum spans the entire undergraduate programme; we argue here for a spiral model incorporating innovative, multi-method assessment which examines knowledge, skills, attitudes and values. Students are increasingly learning from patient experiences, we advocate learning directly from patients wherever possible. Undergraduate provision should provide a platform for continuing education in patient safety, all of which should be subject to periodic evaluation with a particular emphasis on practice impact.
Introduction Patient safety is a major priority for healthcare. Modern medicine has contributed to enormous advances in healthcare, but the incidence of medical error frequently undermines progress, and serious adverse events can cause irreparable damage to all those involved. The National Patient Safety Foundation and the Lucian Leape Institute advocate that an essential first step to improve patient safety is to reform undergraduate medical education. They highlight the need for new content, but also emphasise the need for a new focus on mentorship and the development of attitudes as well as skills (Piankiewicz et al. 2008). However, any long-term improvements in patient safety will only be achieved if the students learn the craft of medicine in organisational cultures that have patient safety as their first priority. This requires the parallel development of medical teachers and mentors, who have a strong understanding of patient safety and can equip students with the skills to reduce the risk of preventable harm (Institute of Medicine 2001). A recent in-depth survey of pre-registration health professional curricula in England and Scotland (Ashcroft et al. 2008) found that patient safety is often implicit rather than explicit, usually excluded from the assessment process, and lacks organisational context. Moreover, it would seem that curricula are not capturing the sense of reality that patient safety can
Practice points . Safer healthcare requires that undergraduate medical programmes include a patient safety curriculum. . Human factors provide a useful framework for developing a systematic curriculum planning process. . A spiral curriculum is recommended with definitive competencies and innovative assessment to reflect the realities of practice. . Patient safety education offers an opportunity to advance multi-disciplinary working and should continue beyond initial qualification.
bring to student learning which, if carefully and consistently synthesised into a programme of study, could convince students and their clinical mentors of its intrinsic value. Patient safety warrants an explicit place in the curriculum, a position also taken by UK Government in the Health Select Committee Report on Patient Safety (2009); the same position has been taken by the World Health Organisation (WHO), who has also published a Patient Safety Curriculum Guide (WHO 2009). Such guidance is particularly welcome when the UK General Medical Council emphasises the need for safe practice but adds little detail on how this might be achieved
Correspondence: G. Armitage, School of Health, University of Bradford, BD5 0BB, UK. Tel: 44 01274 383428; fax: 44 01274 382640; email:
[email protected] ISSN 0142–159X print/ISSN 1466–187X online/11/070535–6 ß 2011 Informa UK Ltd. DOI: 10.3109/0142159X.2010.546449
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Figure 1.
Building blocks for patient safety in the Leeds undergraduate medical curriculum.
(Tomorrow’s Doctors 2009). Other medical education providers, to our knowledge, have also implemented patient safety curricula, but in specific modules, in a specific year (Finn & Patey 2009). In this article, we describe how an undergraduate programme in medicine has embedded the theory and practice of patient safety in a spiral curriculum model from years one to five of the curriculum as part of a recent curriculum review. The principles we drew upon and the actions we have taken are combined to suggest 12 tips for developing an integrated patient safety curriculum for medical students.
Tip 1 Develop a multidisciplinary curriculum development team with representation from primary and secondary care The provision of safe and effective healthcare is complex and numerous personnel are involved. However, healthcare education is traditionally organised around specific departments or specialties with little inter-professional education and minimal attention to how various systems link together into an integrated whole. If we are to accept the premise that inter-professional education is a valid means of laying the foundations of good teamwork skills beyond traditional professional boundaries, i.e. ‘those who work together should train together’ (House of Commons Health Select Committee 2009, Section 196), it is self-evident that the curriculum development team reflects this broader perspective. The exact composition of the curriculum development team will vary across different contexts; the development team for the Leeds curriculum included a nurse, an anaesthetist, a medical internist and a general practitioner. Each has a passion for improving patient safety, possesses a substantial understanding of human error and importantly holds educational expertise. Although we did not include a patient in the team, we are now drawing on parallel work with a partner organisation, currently carrying out a large scale nationally funded programme of research on patient involvement in patient safety including involvement in medical education.1 536
Tip 2 Decide on content using human factors as a framework Human factors theory acknowledges that people and their behaviour are influenced by a whole range of factors. They can be organisational, environmental, arise from local conditions, relate to individual human characteristics and can sometimes lead to human error. The additional premise of accepting the natural human tendency to err is critical to understanding the human factors perspective (Reason 2008). As human factors is fast becoming the predominant approach to managing medical error across many health services, the human factors perspective should certainly be included in any undergraduate teaching. While we will employ human factors in delivering the curriculum, we also used human factors to inform our curriculum framework. In our initial planning meetings, we agreed on four domains of competence upon which to build the curriculum content: knowledge, communication and cooperation, situational awareness, decision making and accountability, all linked to a key overarching, underpinning concept of ‘systems’. Figure 1 shows the building blocks.
Tip 3 Identify learning outcomes through competencies based on human factors Knowledge for safety is the foundation for each of the domains; students should understand the language of safety (e.g. near misses, adverse events and the notion of harm), and the epidemiology of medical error. Additionally, they should recognise failure, the nature of causation, and the role of patient safety interventions. We based communication content on the principles of crew resource management – an approach grounded in human factors – to improve 1:1 and team communication processes (Helmreich & Foushee 1993). Consequently, students will be expected to demonstrate effective handover skills and use specific patient safety tools such as checklists.
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Situational awareness is also a skill-based domain; students must develop a dynamic awareness of their surrounding environment, colleagues, and time, ultimately being able to assess a given situation and how it might change. Decision making and accountability is grounded in professional responsibility. Students should recognise the importance of clinical evidence to inform their decisions and actions, and if an error occurs – acknowledge the duty to be open with colleagues about the circumstances and learn from the action taken – appreciating that patient safety is a cross-professional priority. Inculcating the students with these values through definitive competences is also designed to relieve the on-going problem of some doctors being disengaged from reporting (Evans et al. 2006; Miller et al. 2006; Evans et al. 2007; Armitage et al. 2010), and others being reluctant to recognise their limitations and seek assistance from senior colleagues (Franklin and Matthew 1994). Furthermore, we are aware that for some time, doctors have perceived a systems approach as a potential threat to clinical autonomy (Esmail 2006). However, such an approach can again engender in students a whole organisation perspective i.e. errors are seen as a product of the organisation in which they occur rather than a direct consequence of individuals’ actions (Reason 2000).
Tip 4 Consider the relationship between generic and specific safety competencies The scope of an undergraduate patient safety curriculum is vast since numerous factors interplay to produce and reduce threats to patient safety. The obvious response is to produce a lengthy and comprehensive curriculum, such as the Australian Patient Safety Education Framework (2005). Yet it is unlikely that all of the detailed curriculum statements could be implemented in an already crowded undergraduate curriculum with competing demands for importance. Generic competencies were identified from the wider undergraduate medical curriculum and we mapped how these competencies related to the patient safety curriculum. Generic competencies will be identified early in the programme with non-clinical scenarios and then applied to clinical practice, e.g. the lack of collective responsibility in the Herald of Free Enterprise disaster was also apparent in the Wayne Jowett case where vincristine was incorrectly administered into the patient’s intrathecal space. However, in line with the House of Commons Select Committee Report, we emphasise application, and transference of skills rather than a simple list of competencies required by the end of training, e.g. maintenance of a clinical pharmacy module but explicitly linked to safe prescribing skills.
Tip 5 Integrate the new curriculum within the existing curriculum The domains of competence described above are not traditionally taught in medical school but are fast becoming a
Figure 2. The IDEALS octagon ( permission to reproduce kindly given by the School of Medicine at the University of Leeds). consideration for many education providers, driven by larger scale developments. However, patient safety also links with many existing subjects, especially within the personal and professional development, and ethical themes. Examples include personal conduct, whistle blowing and taking responsibility for one’s own mistakes. For any new aspect of a curriculum to succeed, it is important that its principles are integrated and contextualised through those components of the existing curriculum that consistently evaluate well. We were fortunate in that the Leeds undergraduate curriculum was undergoing a major review of content during this time. Patient safety was situated in a new theme called IDEALS (innovation, development, enterprise, leadership and safety) that runs across the programme (Figure 2). However, many principles overlapped and it was quickly evident that close working was required to prevent unnecessary repetition and develop a truly integrated spiral curriculum.
Tip 6 Plan stepwise/spiral curriculum We chose a spiral curriculum, a description given to the process whereby topics are revisited over time with increasing levels of difficulty, new applications and ongoing practical experience. New learning is related to previous learning, to increase competence. It is based on the constructivist model of learning – that is, the learning takes place by building individual concepts that are added to or revised as new information arises. The major components of a spiral curriculum as described by Cooper and Forrest (2009) include: . revisiting clinical and professional practice, and studying at increasingly complex levels; . practising with decreasing supervision;
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Figure 3. Our current spiral, starting from year one, and continuing throughout postgraduate medical education. . building on existing levels of understanding; and . recognising that levels of expertise generally increase with practice and reflection.
the assessment process in, e.g. problem based, or action, learning sets.
Tip 9 Tip 7 Identify and train facilitators We recognise that simply filling students with knowledge will not produce junior doctors whose practice is orientated to team working. Although the curriculum framework advocated here goes beyond the delivery of knowledge, the impact on medical practice can only be realised if an equivalent safety culture exists in student placements. A recent study has demonstrated the resistance to advancing non-technical skills among surgeons (McCulloch et al. 2009). Some facilitators are then likely to require support, and this may need to be formalised, e.g. a short course in human factors and patient safety will also require expert facilitators as some aspects of the patient safety curriculum are especially challenging such as developing situational awareness and decision-making skills.
Tip 8 Involve healthcare professionals in the curriculum delivery The complexity of modern healthcare requires effective team working across a variety of different professional groups, and research on patient safety has clearly identified that many threats occur when there is a breakdown in team working (Carthey et al. 2003). Involving different healthcare professionals in the delivery of a patient safety curriculum not only provides students with a range of different perspectives but also has the potential of eroding any ritualised medical identity, engaging these professionals in improving the safety of the care that they provide. This can be achieved by joint tutor development sessions, collaborative delivery of training workshops and giving feedback as part of 538
Involve patients in the curriculum delivery It is essential to include experiences of patients in all patient safety topics to highlight the relevance and bring theory to life. Hearing first hand from a patient or relative involved in an adverse event is an effective tool for students to understand the complexities of error; reflect on the patient (and family) impact and appreciate the need for effective communication following the event. Real patients will be invited to take part in case discussions early in the curriculum, helping the student understand the importance, relevance and impact of error. Videos/DVDs and case studies of patients’ experiences are also used. They are available from such agencies as the National Patient Safety Agency (e.g. Just an Ordinary Day) and in the WHO Patient Safety Curriculum Guide (WHO 2009). The curriculum development team included a patient safety researcher who is a co-applicant in the previously mentioned research programme (Note 1), part of which will evaluate the role of patients in teaching junior doctors using personal narratives. The research findings from this programme will inform any further enhancements to patient involvement in the curriculum.
Tip 10 Develop assessments Assessment is instrumental in motivating students and is an integral part of any curriculum. Students need to be assessed on their knowledge and understanding of the generic principles of patient safety, human error and evidence-based safety interventions. Over the duration of the course, students will be expected to demonstrate an increasing level of self-awareness, critical analysis, application of theory to practice and ultimately the principles of management in acute situations. Assessments
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will mirror topics and match their learning outcomes on the spiral curriculum map (Figure 3). Introducing a new curriculum has required the design and validation of new assessment tools. In the early years, all students at Leeds will have an electronic portfolio to record reflective logs after each patient safety session and clinical situations where they have observed a patient safety incident. A structured written assignment will be attached to the eportfolio for summative assessment to demonstrate an understanding of the generic principles of patient safety. We are currently developing innovative assessments for the latter years including: root cause analysis of previous (anonymised) incidents from partnering organisations; detecting and correcting prescribing errors in complex prescribing regimes as part of a problem-based learning (PBL) exercise; managing the deteriorating patient; and further reflective assignments based on real world case studies. The prescribing and root cause analysis assignments will be led by experienced facilitators; students will be expected to identify objectives, problems, implications and solutions. There are already developed and validated novel OSCE assessments for the final MBChB Assessing Patient Safety Skills Essential for Professional Practice, including: clinical handover; safe prescribing; record keeping; and open disclosure. These involve simulated patients and video components; they elicit and test a range of abilities such as decision making, practical skills and professionalism. To advance the multi-disciplinarity of the curriculum, we will also include a range of different health professionals and academic staff in assessing the PBL and the root cause analysis assignments.
Tip 11 Map on to local postgraduate patient safety provision Dynamic undergraduate medical education should provide a suitable platform for subsequent postgraduate education and a seamless transition between the two. The Leeds University curriculum has attempted to do this by developing the IDEALS theme referred to above; patient safety being appropriately embedded in IDEALS across 5 years. However, in order to realise the maxim of life-long learning, local medical deaneries should also be mindful of postgraduate patient safety education, thereby continually re-enforcing safety as a core attitude (Ellis 2009). We advocate a regional approach based on our previously argued emphasis on human factors and interprofessional learning. Such an approach has recently been launched in the Yorkshire and Humber Deanery – in conjunction with the authors of this article, the Bradford Institute for Health Research, and the Strategic Health Authority.2
Tip 12 Evaluate the curriculum An essential aspect of evaluating the patient safety curriculum is to consider its impact on improving patient safety. A widely used approach to evaluate any training intervention considers
its impact at several levels: reaction, learning, behaviour and results (Kirkpatrick 1998). Reaction is the level of satisfaction that participants feel about the training and is the most commonly used method. Evaluating the learning is usually a self-perception of change in knowledge, skills or attitudes. Measurement of knowledge, such as by a multiple choice test, can be performed but an important aspect of patient safety education is to increase awareness and produce a cultural change that recognises that patient safety is paramount in any clinical interaction. A validated questionnaire has recently been developed to measure the attitudes to patient safety of both students and tutors (Carrruthers et al. 2009). This questionnaire will be used to measure attitudinal change. It would also be helpful to know whether a curriculum actually changes the way that professionals behave in clinical practice, but such an evaluation would be inevitably complex as a consequence of the many variables that impact on the delivery of care. The ultimate aim of a patient safety curriculum is to reduce the massive extent of harm and potential harm that is associated with healthcare, but this may, of course, take several years to achieve. However, combined with new inter-professional postgraduate training we could envisage a critical mass of patient safety advocates in the near future.
Conclusion The curriculum we designed between 2008 and 2009 is being implemented from September 2010. Future students will be likely to share the goals of their many predecessors – passing the final examinations and working as a doctor. Although these goals are eminently understandable, the curriculum proposed here, using patient safety as a vehicle, seeks to develop students who, from the early years of training, will begin to understand the inevitability of human error, recognise the need for constant vigilance, and practice as part of a clinical team and not as individuals. We are now also aware that both the curriculum content and process we have described has considerable overlap with the WHO Patient Safety Curriculum Guidance, which we view as strength. Both curricula deliver a specific knowledge base but also the acquisition of particular skills; perhaps most importantly, we aim to inculcate the maxims of patient safety and human factors as cultural norms in contemporary practice. This curriculum is not an isolated initiative and has been developed as part of a region-wide initiative to improve patient safety education for future and existing medical practitioners and their professional colleagues.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Notes on contributors GERRY ARMITAGE, BSc (Hons) MSc PhD FIHE RN, is a senior fellow at the Bradford Institute for Health Research. He is a nurse by background, has led and taught higher education programmes, and spent the last 7 years
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carrying out and publishing patient safety research. Gerry is a member of the Clinical Human Factors Group. ALISON CRACKNELL, MBChB (Hons), MRCP (UK), is a consultant geriatrician at Leeds Teaching Hospitals NHS Trust and also teaches on the undergraduate medical curriculum at Leeds; Alison is actively involved in both patient safety education and research. KIRSTY FORREST, FAcadMed, MMEd, FRCA, MBChB, BSc Hons, is a consultant anaesthetist who actively teaches on the undergraduate medical curriculum at Leeds University; she leads a patient safety and human factors programme for qualified staff at the Leeds Teaching Hospitals NHS Trust. Kirsty’s articles are widely published in medical education. JOHN SANDARS, MBChB (Hons), MSc, MD, MRCP (UK), FRCGP, NHS, is a general practitioner and senior lecturer at Leeds Institute of Medical Education. John has an international profile in patient safety and works extensively in advancing patient safety education in the developing world. He has published widely on patient safety, medical education and elearning.
Notes 1. Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust. Patient Involvement in Patient Safety. A five-year programme of study funded by the National Institute for Health Research 2009–2014. 2. Training and action for patient safety (TAPS): training specialty teams across healthcare economies to learn about safety, find solutions to local problems and measure any improvement.
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