Perspectives on Safety

Patient Safety in Medical, Nursing, and Other Clinical Education

Background

Figure 1: Common Patient Safety Curriculum Topics

  • The impact of culture on patient safety and factors that contribute to a culture of patient safety.
  • The role of human error and human factors in patient safety and opportunities to reduce it.
  • How to collect and learn from error reporting data.
  • Using quality improvement principles, predominantly measurement, to track and target patient safety improvement efforts.
  • Applying clinical reasoning to understand and manage patient risk.
  • Specific consideration for infection prevention and control practices.

Despite improvements over the past two decades, patient safety and quality of care still need to be enhanced across the continuum of medical, nursing, and other clinical education — from undergraduate to continuing education and practice. Safer and more reliable care can be linked to the initial education received by medical and nursing professionals. However, these efforts have not been developed in a coordinated way across the continuum of education or across professions of medicine and nursing. Historically, the approach to medical and nursing education has focused on establishing an understanding of body systems and the technical processes associated with diagnosis and treatment, with training often incorporating extensive memorization and practice of procedures until knowledge and basic proficiency is acquired. Over the past two decades, the competency-based evolution in education has shifted the focus to outcomes or healthcare professionals’ competencies in patient safety education and systems-based practice. Areas of focus include knowledge of common causes of errors and how to avoid them, attitudes towards collaboration and a culture of safety, and behaviors linked to teamwork and safety practices (Figure 1). Findings from studies published on PSNet in 2019 provide specific considerations for developing or optimizing a patient safety curriculum. Institutions should review these findings for applicability to their own educational practices.

Developing a Patient Safety Curriculum

Figure 2: Summarized Sample Tactics for Improving QIPS Education Recommended by AAMC[a]

  • Transform student, resident, and new-physician orientation to focus on patient safety. 
  • Engage patients and families in QIPS efforts.
  • Use simulation-based education for especially high-risk, infrequent events.
  • Include medical educators on sentinel event task forces or committees. 
  • Frequently review safety metrics for trends and needs and ask: how can these quality and safety needs inform and be supported by the educational programs?
  • Collaborate closely with colleagues working in quality and safety areas to improve reporting practices.
  • Integrate root cause analyses (RCA) into morbidity and mortality (M&M) conferences and daily huddles.
  • Share QIPS medical education success stories in leadership forums.
  • Integrate opportunities to reward safe practices and reporting of near misses or “good catches.”

In 2019, the Association of American Medical Colleges (AAMC) released the Quality Improvement and Patient Safety Competencies Across the Learning Continuum report, focusing not only on the core competencies that medical education should include, but also on tactics for improving quality improvement and patient safety (QIPS) educational programs (Figure 2)[a]. Medical and nursing school curricula undergo continuous quality improvement, and educators should frequently consider how patient safety is taught and assessed and how to improve practices in this area.

When creating a patient safety curriculum, it is essential to consider competencies for patient safety, such as the AAMC QIPS, American Association of Colleges and Nursing Quality and Safety Education for Nurses, World Health Organization (WHO), and diagnosis quality and safety competencies. Researchers note that competencies can provide critical direction and highlight areas to prioritize for a curriculum.  Competencies can also help to identify where and how safety principles can be integrated into existing course materials. A careful review of the existing overall curricula for ways the competencies are already being taught and assessed is a good first step before considering gaps and opportunities to increase patient safety education.

Approaches to Enhance Student Understanding of Patient Safety Concepts

The format and delivery of education to medical and nursing students can greatly impact comprehension and retention. In 2019, several articles addressed effective strategies for teaching patient safety concepts.  Recommendations from these articles, as well as from adult learning theory and research, include:

  • Wherever possible, consider multifaceted programs that incorporate several different learning approaches and authentic experiences with patients and their caregivers. Courses that include both didactic and “learn by doing” components are successful at teaching students core competencies. In this study, authors described a program that successfully taught medical students to recognize and report errors. The program incorporated an introductory workshop, facilitated discussion about errors and the importance of reporting, and required the completion of a simulated error report.
  • With the rise of remote learning and the growth in capabilities for online courses and instruction, medical and nursing education students have numerous opportunities to take classes outside the classroom or in a blended fashion. One study found that e-learning is an effective method for increasing patient safety knowledge that may be used in combination with, or in place of, face-to-face instruction. However, systematic reviews have reached varied conclusions regarding the effectiveness of e-learning so reliance on e-learning should be carefully monitored and coupled with other authentic performance-based approaches.[1],[2],[3],[4]
  • Simulation-based education continues to be widely used for teaching patient safety, and novel ways to teach large, interprofessional and interdisciplinary students and residents are emerging.[5]
  • Other novel approaches that make patient safety concepts relevant and meaningful to novice learners includes animated stories. Students in large groups found the animated, personal stories of medical error presented to be an engaging way of learning about patient safety with the potential to impact future practice.  

Regardless of the approach chosen, organizations such as AAMC and the WHO have emphasized that teaching approaches and examples should strive to be meaningful to students and have clear relevance to the workplace in order to be effective.[6],[7]   

Lessons Learned from Other Industries

Many successful healthcare improvement innovations have roots in other industries, including in education and the use of simulation training.[8] For example, the airline industry is frequently cited as one that has made tremendous strides in improving safety, utilizing approaches that the medical community could appropriate and learn from.[9],[10], [11] One article emphasized how strategies to promote effective error reduction practices from other industries (such as car manufacturing) can be incorporated into the design of patient safety curriculum. Another news article noted that analogies from other industries may be helpful to demonstrate and simplify complex topics. Specifically, the article discussed how methods used to diagnose automobile problems can be used to teach diagnostic decision making to medical students. However, while other industries may offer some lessons learned for healthcare education, any transfer of best practices requires nuanced consideration of how they can appropriately be applied.    

Considerations and Future Directions

This essay reviews teaching considerations from recent research that institutions may implement to enhance incorporation of patient safety in medical and nursing education. While progress has been made, experts call for better integration of patient safety teaching concepts into clinical care. A new report released in November 2019 by AAMC further notes the need for a coordinated approach to improvement across the continuum of physician development, from undergraduate through continuing medical education and practice.[12] However, the report also provides some concrete recommendations that may support educators in the improvement of patient safety education. Notably, AAMC offers cross-continuum patient safety competencies designed to supplement existing specialty competencies and serve as a more detailed guide for patient safety curriculum and professional development. Examples of QIPS competencies include those that focus on:

  • Improving individual safety practices, such as practicing infection-control standard precautions, focusing on self-care whenever necessary, and engaging in the collection and analysis of clinical findings to inform clinical practice.
  • Reporting safety events, such as defining and differentiating unsafe conditions related to events and near misses to improve patient safety and demonstrate knowledge of how to properly report patient safety events.
  • Enhancing system safety, such as recognizing types of human error and understanding the importance of culture in safety performance.
  • Engaging with patients and families to share information, disclose errors and improve care.

The incorporation of competencies aligned with these recommendations may support improved integration of patient safety concepts into curricula and the clinical learning environment, while at the same time encouraging collaborative patient safety discussions and initiatives across disciplines.[12]

 

Dr. Howley is an employee of AAMC. In this role she establishes and maintains partnerships with healthcare affiliates within and outside of medicine to further advance the organizations strategic partnerships.

Lisa Howley, PhD, MD
Senior Director, Strategic Initiatives and Partnerships

Association of American Medical Colleges

Washington, DC

Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health

IMPAQ International

Columbia, MD

Eleanor Fitall, MPH
Research Associate, IMPAQ Health

IMPAQ International

Washington, DC

References


[1] Vaona A, Banzi R, Kwag KH, et al. E-learning for health professionals. Cochrane Database Syst Rev. 2018;1:CD011736. [PubMed]

[2] Pei L, Wu H. Does online learning work better than offline learning in undergraduate medical education? A systematic review and meta-analysis. Med Educ Online. 2019;24(1):1666538. [PubMed]

[3] Feng JY, Chang YT, Chang HY, Erdley WS, Lin CH, Chang YJ.  Systematic review of effectiveness of situated e-learning on medical and nursing education. Worldviews Evid Based Nurs. 2013;10(3):174-183. [PubMed]

[4] Fontaine G, Cossette S, Maheu-Cadotte MA, et al. Efficacy of adaptive e-learning for health professionals and students: A systematic review and meta-analysis. BMJ Open. 2019;9(8):e025252. [PubMed]  

[5] Krishnan DG, Keloth AV, Ubedulla S. Pros and cons of simulation in medical education: A review. Int J Med Health Res. 2017;3(6):84-87. [full text]

[6] Walton M, Woodward H, Van Staalduinen S, et al. The WHO patient safety curriculum guide for medical schools. Qual Saf Health Care. 2010;19(6):542-6. [PSNet

[7] Hendrick LA, Baron RB, Pingleton SK, et al. Teaching for Quality: Integrating Quality Improvement and Patient Safety across the Continuum of Medical Education. aamc.org website. https://www.aamc.org/system/files/c/2/494316-teachingforqualityintegratingqualityimprovementandpatientsafety.pdf Accessed January 23, 202.

[8] Macrae C, Stewart K. Can we import improvements form industry to healthcare? BMJ.2019;364:I1039. [PSNet]

[9] Murphy K. What Pilots Can Teach Hospitals About Patient Safety. nytimes.com website. https://www.nytimes.com/2006/10/31/health/31safe.html. Published October 31, 2006. Accessed January 23, 2020. [PSNet]

[10] Patient safety: What can medicine learn from aviation? amednews.com website. https://amednews.com/article/20100614/profession/306149945/4/. Published June 14, 2010. Accessed January 23, 3030. [PSNet]

[11] Pronovost PJ, Goeschel CA, Olsen KL, et al. Reducing health care hazards: Lessons from the commercial aviation safety team. Health Aff. 2009;28(3):w479-89. [PSNet]

[12] Association of American Medical Colleges. New and Emerging Areas in Medicine Series: Quality Improvement an Patient Safety Competencies Across the Learning Continuum. Washington, DC: Association of American Medical Colleges. Available at https://store.aamc.org/downloadable/download/sample/sample_id/302/. Accessed January 23, 2020.