Chapter 6

Teaching patient safety the project consisted of an online survey of ESA members to determine what aspects of professional practice (Wacker, Staender)

Ten years ago, the Helsinki Declaration on Patient Safety in Anaesthesiology stated that Education has a key role to play in improving patient safety….^1,214 Moreover, it called for improvement through research and innovation.¹ Teaching patient safety aims to improve patient outcomes – but the scientific evidence of such beneficial impact remains sparse.²¹⁵ This fact is of particular importance for this chapter, which describes approaches to teaching patient safety to medical students.

For the design and successful implementation of curricula, evidence-based contents are needed. Practical conditions, local structures and limited resources often restrict the optimal realisation of such courses. In due consideration of these limitations, this chapter presents a narrative review of published evidence, and of practical experiences with teaching patient safety. A short perspective on particular aspects of patient safety education beyond medical school is included. Hence, this chapter addresses physicians and other healthcare professionals interested in teaching patient safety to medical students. Articles were identified by searches in PubMed, and complemented by selective searches in Google Scholar as well as by a Web of Science cited reference search for articles citing the latest systematic review on the topic.^215,216 Readers interested in simulation-based skills training are referred to other chapters, and to the specific literature.

Education as a patient safety intervention

The concept of ‘patient safety’ used in this chapter follows a definition provided by Charles Vincent: The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare.²¹⁷ Acknowledging that not all adverse outcomes or harm may be inevitable, preventable harm should be the target of patient safety interventions.^218,219 From a public health perspective, formalised patient safety education programmes or curricula represent patient safety interventions.²²⁰ The target is significant: according to a recent systematic review, harm occurs in 20% of surgical and 34% of intensive care patients, and about 50% of this harm was considered preventable, in line with earlier reports.^219,221,222

Origins, advancement and development of dedicated patient safety education

At the turn of the millennium, several national reports pointed to an alarming number of patient harmed in medicine, among them the IOM report ‘To Err is Human’ published in the United States in 2000, and the report ‘An organisation with a memory’ published by the UK Department of Health in 2000.^223,224 Consistently, the IOM report identified the need of integrating a curriculum on patient safety into professional training and certification requirements of healthcare professionals.²²³ Subsequently, ideas about the contents and teaching formats of such curricula were developed in many countries.²²⁵ The following trendsetting examples are just a small selection from the multitude of initiatives.

Examples of initiatives leading to patient safety education frameworks

The UEMS recognised in its 2001 Basel Declaration on continuing professional development that education is a safety mechanism.²²⁶ In 2006, the Council of Europe passed a patient safety recommendation underscoring the importance of developing patient safety education programmes for all healthcare personnel. These programmes should be developed and implemented by educational institutions as well as accrediting, certifying, licensing, diploma appraisal and revalidation bodies.^227,228

The Australian Council for Safety and Quality in Healthcare endorsed a National Patient Safety Education Framework in 2005.^229,230 This framework, also called ‘APSEF’ (Australian Patient Safety Education Framework), is an evidence-based description of the knowledge, skills and behaviours required by healthcare professionals to ensure safe patient care, and for developing educational curricula and training programmes for all healthcare workers, across all levels of responsibility.^229–231

In 2008, the Canadian Patient Safety Institute developed Safety Competencies, a framework of interprofessional patient safety competencies (defined as ‘important observable knowledge, skills and attitudes’) for education and continuing professional development.^232,233 Based on the internationally acknowledged CanMEDS framework of physician competencies, and following principles of outcome-based education, the Safety Competencies framework is designed to help develop locally adapted teaching curricula.^232–234

WHO: patient safety curriculum guides

The WHO World Alliance for Patient Safety sponsored the development of a universal patient safety curriculum guide for medical schools worldwide.²³¹ A team from the University of Sydney and Monash University, assisted by an Expert Consensus Working Group representing the six WHO regions, developed the curriculum guide based on the Australian APSEF as an evidence-based foundation.²³¹ From 22 topics in the APSEF, 16 were included in the curriculum guide topics. After regrouping, the guide finally contained 11 topics.²³¹ APSEF topics not included in the curriculum guide were those that would already be covered in medical school curricula, for example, consent, evidence-based practice, learning and teaching, and information technology (because of disparity in the access to technology).²³¹ As teaching formats, the curriculum guides suggest lectures, clinical placements, online activities, on the ward activities, small group tutorial teaching, problem-based learning, simulation/skills laboratories and traditional tutorials. Subsequently, after revision of the 2009 curriculum guide by experts from dentistry, midwifery, nursing and pharmacy, a multiprofessional edition of the WHO Patient Safety Curriculum Guide maintaining the basic 11 topics (Table 12) was finally published in 2011. Importantly, the WHO curriculum guides offer freely available and comprehensive programmes for teaching patient safety as well as resources and practical hints for implementation (https://www.who.int/patientsafety/education/mp_curriculum_guide/en/). However, these guides need to be tailored to existing local professional curricula, and to the local requirements.

 

After grouping the 11 topics into three major areas, the guides provide an overview of general topics like the extent of patient harm in health care, human factors, complexity of systems, teamwork and error (topics 1 to 6); methodical approaches like quality improvement or communication with patients and families (topics 7 to 8); and topics of specific clinical interest, namely infection control, safety of invasive procedures and medication safety (topics 9 to 11). The multiprofessional edition of the curriculum guide also covers all topics. Except for some of the topics of specific clinical interest, these topics are also covered (but to varying extent) by the APSEF, and by the Canadian Safety Competencies.^229,230,233

Teaching patient safety to medical students

Implementation of patient safety curricula

Apparently, implementation of formal patient safety teaching into medical school curricula has been sporadic rather than straightforward. While the WHO curriculum guide for Medical Schools was designed to provide a universally applicable comprehensive educational approach, some local medical school curricula already contain patient safety topics, and most are filled beyond capacity.²³¹ Lack of time in the curricula schedules and limited availability of adequately trained faculty may pose problems.²³⁵ In view of limited evidence of the beneficial impact of defined patient safety education interventions on patient outcomes, it may also be helpful for patient safety educators to learn from successfully established patient safety courses or curricula.

Medical student’s view

How do students see undergraduate medical patient safety education? Medical students themselves have indicated a need for more attention to patient safety and quality of care.²³¹ A survey conducted among medical students in Hong Kong found that students knew about the risk of medical errors, but were less aware of the importance of a multidisciplinary approach to the management of incidents.²³⁶ These students also supported an initiative for a formal curriculum on patient safety.²³⁶ In North Carolina, more than 70% of students thought patient safety and quality improvement were equally or more important than basic science or clinical skills.²³⁵ Regarding teaching and learning styles, this survey of medical students in North Carolina found that respondents clearly preferred ‘hands-on’ teaching in clinical settings about patient safety and quality improvement rather than lectures and independent studies.²³⁵ Medical students surveyed in Singapore regarding their preferred learning style favoured discussions of real-life near misses (75.3%) and internet-based learning (69.9%).²³⁷ Potentially, due to cultural reasons, the latter finding contrasts with the survey results from North Carolina, where computer modules were not rated being helpful.²³⁵

Practical experience: the Patient Safety Module for medical students at the University of Zurich

National background in Switzerland

The following account describes a course that has been successfully run for 7 years in Switzerland, and with which the authors of this chapter are involved as faculty. In 2007, a report by the Swiss Academy of Medical Sciences pointed out that the University of Geneva was the only one among the five universities in Switzerland to offer a structured module about medical errors within their medical curriculum.²³⁸ The report called for considerable efforts in Switzerland to promote patient safety education for healthcare professionals, and stated the particular need of integrating these learning targets into the relevant curriculum: the “Swiss Catalogue of Learning Objectives for Undergraduate Medical Training” (hereafter “Swiss Catalogue”).^238,239 The second edition of this “Swiss catalogue” (2008) was enhanced by a revised chapter about ‘General Objectives’ based on the CanMEDS 2005 Framework and on the British Curriculum for the Foundation years in Postgraduate Education and Training.^232,239 This revised chapter of the “Swiss Catalogue” chapter lists many particular learning objectives related to patient safety and quality improvement.²³⁹

Conception and development of the module

Against this national background in Switzerland, preparation of a dedicated educational unit for medical students on patient safety was started at the University of Zurich in 2010.²⁴⁰ Concepts and contents were adapted from the WHO curriculum and the APSEF.^229,231 The course concept is also based on the idea that developing and fostering safety culture should start early during medical education.^227,238 Run without interruption since 2012, this course is performed semi-annually and continually as an elective curricular module for approximately 20 second to fourth-year medical and dentistry students.²⁴⁰ The 28 hours of lessons are taught in 4-h morning sessions distributed over several weeks.²⁴⁰ A high value was set on interprofessional and interdisciplinary approaches, and the course faculty includes representatives from surgery, anaesthesiology, nursing, internal medicine, infection control, clinical pharmacy, psychology, risk management and aviation.²⁴⁰

The course covers all topics of the WHO patient safety curriculum guide, and conveys basic knowledge such as patient safety concepts, epidemiology of patient harm, complexity of health systems, human factors, communication; clinical patient safety issues including medication errors, surgical errors, nosocomial infections and hygiene, diagnostic errors, handover-related patient harm and communication failures; and approaches like critical incident reporting and root-cause analysis, open disclosure, dealing with the so called second victim, clinical risk management and principles of interdisciplinary teamwork, and the ‘art’ of ‘speak-up’, among others.²⁴⁰ Hands-on and simulation-based experiences are important teaching methods, for example, one morning session is performed in collaboration with Swiss International Airline (SWISS) at the Lufthansa Aviation Training Centre Switzerland (https://www.swiss.com/corporate/de/unternehmen/ueber-uns/lufthansa-aviation-training-switzerland#), and benefits from their long lasting team training experience.²⁴⁰ This scenario is designed to provide a team learning experience of communicating under stress, multitasking and reaching limits of human performance.²⁴⁰

Evaluation and practice experience

The implementation and educational effectiveness of the course were monitored systematically throughout the initial semesters.²⁴⁰ Pre–post surveys of the students before and after the course documented explicit learning success regarding systems thinking, self-efficacy of applying learned knowledge, knowledge about latent errors and attitudes about patient safety. As a longitudinal assessment, students were also briefly interviewed after each session. Notably, individual student feedbacks were suggestive of fears or concerns that might have been triggered by the course topics. Although not formally evaluated for this course, providing encouraging feedback and nurturing competencies that help students with their autonomous management of such concerns may be an important educational objective for undergraduate patient safety curricula.

Beyond learning success, task sharing among faculty was also evaluated. Review of the session contents revealed multiple overlaps that were adapted to reduce redundancies. Future advancement of the course could include enhanced integration into the undergraduate medical curriculum to reach more students. Meanwhile, the current concept has attracted interest in the patient safety community: in 2014, the course was awarded the third prize of the German patient safety award offered by the German Coalition for Patient Safety (https://www.aps-ev.de/archiv-dpfps). The justification for the award stated that the novel patient safety teaching module for medical students had resulted in measurable improvements in participants’ safety consciousness. In addition, the experience gained at the University of Zurich with this course concept was incorporated into a proposal for a corresponding curriculum at German Universities.²⁴¹

Perspective beyond medical school: teaching patient safety to residents and to specialist physicians

Interdisciplinary and multiprofessional patient safety education in professional practice

The core contents of the WHO curriculum guides are also very useful for the diverse and less formalised ways of teaching patient safety to residents during specialist training, and to specialist physicians during continuous medical education. However, most important patient safety challenges have an interdisciplinary and multiprofessional nature, and some patient safety education frameworks specifically address multiprofessional audiences.²²⁹ For example, the APSEF addresses everyone working in the Australian healthcare system, irrespective of their position or role within an organisation.²²⁹ Practically, the comprehensive synopsis provided by patient safety education frameworks needs to be adapted and tailored to the circumstances of the local education structures, and to the priorities of individual healthcare professions. Intrinsically, the interprofessional dimensions of patient safety challenges call for interprofessional patient safety education interventions, faculty, and multiprofession course audiences, respectively.^240,242,243 Locally established traditional education structures and differing curricula and certification requirements of different professions may make such approaches more difficult.

Examples of patient safety education interventions addressing interdisciplinary challenges

Many patient safety interventions or courses address patient safety issues that have an interdisciplinary and/or multiprofessional nature. As outlined above, this does not always imply that courses are given for multiprofessional audiences. The first example is teaching communication algorithms, for example, to anaesthesia providers, to enable them to speak up.²⁴⁴ According to a recent review, educational interventions are essential to improve speak up behaviour, but the interventions as such are not enough, and other institutional changes need to occur as well.²⁴⁵ As a second example, educational interventions have been used to improve event reporting by residents and medical students in anaesthesia.²⁴⁴ Although such interventions have been found to improve reporting, the duration of this effect remained unclear.²⁴⁴ As a third example, team training interventions are widely used. For instance, the TeamSTEPPS intervention has been related to significant decreases in medication and transfusion errors,²⁴⁴ and the Veteran’s Affairs Medical Team-Training to a reduction in mortality.^244,246 As a fourth example, evaluations of teaching clinical handovers have yielded inconsistent results: such interventions have resulted in improved quality of handovers, improved information transfer, and in reductions of selected complications in the ICU.^247–250 However, a systematic review concluded that more methodologically robust studies were needed to establish the effectiveness of handover interventions for improving patient outcomes.²⁴⁸

Patient safety education provided by professional societies: European Society of Anaesthesiology

Professional societies are particularly important for realising patient safety education activities.²²³ Their activities complement courses and curricula organised by teaching institutions (e.g. fellowship programmes), hospitals and many other organisations.²⁵¹ As a supranational society, and in line with the Helsinki Declaration on Patient Safety in Anaesthesiology, the ESA has a longstanding commitment to organising respective teaching activities through its PSQC (https://www.esahq.org/about/committees/patient-safety-and-quality-committee/). Among these activities, the European Patient Safety Course has been run for many years; a new version is in preparation.²¹⁴ As an online learning resource, ESA offers the Patient Safety Starter Kit (http://html.esahq.org/patientsafetykit/resources/index.html). In addition to an extensive scientific patient safety education programme during ‘Euroanaesthesia’ (the annual congress of ESA), the fifth edition of the ESA Patient Safety and Quality Masterclass has been held in 2019 (https://www.esahq.org/patient-safety/patient-safety/european-patient-safety-and-quality-masterclass). In collaboration with the ASA, ESA organises the semi-annual International Forum on Perioperative Safety & Quality (ISQ: https://www.asahq.org/ifpsq).

Outside Europe, the Anesthesia Patient Safety Foundation (APSF) Stoelting Conference in Phoenix, Arizona, is an important, focussed meeting on anaesthesia-related patient safety issues (https://www.apsf.org/event/apsf-stoelting-conference-2019/). Other patient safety education events have been summarised before.²²⁵

Examples of innovative teaching concepts in undergraduate and postgraduate patient safety education

In view of changing the learning habits of new generations of medical students, the use of serious games has been proposed as being helpful for identification of gaps in patient safety training, and to raise patient safety awareness.²⁵²

Furthermore, a patient safety teaching tool for medical students during paediatric clerkships called ‘Patient Safety Morning Reports’ was developed: students were asked to write up patient encounters that included a patient safety concern or an adverse event. These observations were discussed in a safe environment with faculty experienced in patient safety and quality improvement, and led to improved knowledge and ability to identify lapses, and to propose potential solutions.²⁵³

As an example for ‘teach the teachers’ approaches, residents have been successfully integrated as teachers in a patient safety curriculum for medical students.²⁵⁴ The preclinical students in this setting valued the interaction with residents as teachers as a ‘near-peer involvement’, while simultaneously the residents gained experience in teaching and leadership.²⁵⁴ Senior doctors have been successfully recruited to engage in teaching patient safety to trainees during ‘lessons learnt’ sessions using incident analysis. Their preparation consisted of a half day course in patient safety theory, RCA and small group facilitation.²⁵⁵

Evaluations of patient safety education interventions and curricula

Assessing learning outcomes

Patient safety education interventions ultimately aim at improving patient outcomes, but not all studies investigating the effectiveness of such interventions can be funded and designed to finally measure patient outcomes in clinical practice. Learning outcomes can be evaluated using Kirkpatrick’s levels of evaluation in the modified version adopted by the Best Evidence Medical Education collaboration (Table 13).^215,256

Formal evaluations of patient safety teaching curricula

An evaluation study followed the implementation of the WHO curriculum guide for medical schools after its publication.²⁵⁷ Investigating ten medical schools in all WHO regions, the study found that parts of the WHO curriculum guide had been implemented in medical school curricula across the world within 18 months, that the WHO guide was an important resource for faculty, and had led to improved knowledge and attitudes among students.²⁵⁷ However, it also pointed to the importance of time requirements, and found that in many cases the teaching was delivered by the lead tutor alone or with few additional faculty.²⁵⁷ Another study assessed the learning effect of teaching interventions among nurses.²⁵⁸ Despite significant increases in subscales, no impact of the educational intervention on participants’ knowledge and attitudes was observed.²⁵⁸ A ‘strengths, weaknesses, opportunities and threats’ analysis of integrating the WHO curriculum guide into undergraduate medical education in Pakistan identified a lack of a patient safety culture as the primary obstacle, and called for regulatory support.²⁵⁹ A Chinese study investigating the effects of a patient safety course compiled from the WHO curriculum guide for medical schools and elements related to frequent adverse events in Chinese clinical practice found no significant effect on safety attitudes, but remarkable influence on knowledge.²⁶⁰ A survey-based evaluation in 2016 found that implementation of the WHO curriculum guide for medical schools and of the multiprofessional edition in low-income and middle-income countries were at consideration or planning stages, rather than actually implemented.²⁶¹ As common barriers, the study identified obstacles at the faculty level, for example, lack of collaboration and of sufficient training to address implementation challenges, lack of governmental and institutional support which resulted in lack of on-going financial support, among others.²⁶¹ Furthermore, it would be important to know more about the cost-effectiveness of patient safety education interventions to justify their costs. Cost-effectiveness has been analysed for Crew Resource Management training.²⁶² However, with the current literature search, no comparable studies of patient safety education interventions for medical schools could be found.

Systematic reviews

Nie et al.²⁶³ included seven studies investigating patient safety education for undergraduate medical students. They reported mostly positive effects on knowledge, skills, and attitudes, but pointed to the limited design of most studies.²⁶³ Wong et al.²⁶⁴ investigated effects of 41 quality improvement and patient safety curricula for medical students, residents or both. They reported that most curricula were well accepted and improved knowledge, 32% of curricula implemented local change in care delivery, and 17% even improved processes of care.²⁶⁴ The review also identified sufficient faculty as a ‘facilitator’ for implementation.²⁶⁴ Kirkman et al.²¹⁵ reviewed 26 studies of patient safety education interventions for trainee physicians and medical students. Most of the training courses were well accepted and improved knowledge, skills and attitudes, and some courses also resulted in positive behaviours. However, no patient benefits were reported.²¹⁵ Implementation was affected by availability of faculty, competing curricula or service demands, as well as by institutional culture. The authors concluded that more evidence of the impact of patient safety education interventions on actual patient outcomes is needed.²¹⁵

Current challenges, ideas for improving patient safety education, and research agenda

As long as an evidence-based gold standard for teaching patient safety is missing, debates about the optimal course contents and formats will likely continue. Current controversies include new developments in health care which may create new risks, and so the inclusion of new topics into patient safety curricula must be constantly considered. For example, while digital health care may open new opportunities, new sources of error may also lead to new risk potentials.²⁶⁵ There are manifold ideas about priorities regarding the conceptual contents and practical realisation of patient safety education: On the one hand, there are voices calling for better evidence of a beneficial impact of patient safety education interventions on actual patient outcomes,²¹⁵ and for emphasising preventable harm as an educational topic.²¹⁹ On the other hand, integration of the Safety-II approach into patient safety education is promoted: in a recent publication, Sujan et al.²⁶⁶ suggested revising the WHO curriculum using resilient healthcare principles and Safety-II thinking either by adding a dedicated module to the curriculum, or by integrating these principles systematically into a revised version. Concerns have been raised regarding gaps between course contents and the realities of every day clinical practice that may interfere with optimal learning.^264,267 Such gaps may be caused by the unclear roles of learners, rotational models of training and a shortage of expert faculty: an expert conference called for better integration of patient safety and quality education with clinical care delivery.²⁶⁷ Many questions of course accreditation and certification are subject to local or national regulations. To our knowledge, and despite the existence of well established patient safety education frameworks and local or national courses, there is no generally accepted or multinational modular course system related to patient safety education for medical students, for example, like the Advanced Cardiac Life Support certificate course.²⁶⁸ Methodologically sound research is needed to establish additional evidence of impact on patient outcomes, and of the sustainability of such interventions.²¹⁵

Conclusion

Teaching patient safety is one strategy to reduce preventable patient harm. It remains an exciting area where improvements can be pioneered, and where close collaboration between teachers and learners is necessary. Several curricula for medical schools have improved learning outcomes, but evidence supporting beneficial impact on patient outcomes is still largely missing. In view of this limited evidence, developing patient safety curricula adapted to the local medical requirements as well as measuring learning effects locally remains important. The on-going quest for improving patient safety education should prioritise evidence-based contents as much as possible.

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