Who Patient Safety Curriculum Guide for Medical Schools

WORLD ALLIANCE FOR PATIENT SAFETY

WHO PATIENT SAFETY CURRICULUM GUIDE FOR MEDICAL SCHOOLS

A SUMMARY

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Printed in the United Kingdom Curriculum Guide: a summary

Background advantages to introducing both of these With the growing recognition of the simultaneously. The number of topics harms caused by health care comes the covered may be increased over time to need for medical students to learn how ease implementation. to deliver safer care. The Curriculum Guide aims to support medical schools Some aspects of patient safety link in worldwide in implementing patient safety well with existing subjects and can be education by providing a comprehensive incorporated into existing sessions. curriculum for patient safety, to promote Others are relatively new and are likely to and enhance the status of patient safety dedicated sessions. A balance must be worldwide and ultimately to prepare struck between integration of material students for safe practice. into existing curriculum and ability to coordinate delivery effectively. The Australian Patient Safety Education Principles of patient safety teaching Framework was used to derive 11 topics and learning for the Curriculum Guide. Topics within the Curriculum are designed to stand Patient safety education can be alone, each with content for 60-90 integrated into procedural skills training minutes’ teaching and include a variety programmes. A number of different of ideas for implementation and patient safety topics may be relevant in assessment. any given procedure, and those taught for one procedure often also apply Implementation generally. Early steps include identifying learning outcomes, mapping patient safety to Patient safety education can be made existing curriculum and then assessing meaningful to students by placing the capacity within the faculty to deliver the principles in context with their current patient safety Curriculum and engaging and future practical roles, using relevant in capacity building work. examples of safety and giving students an opportunity to practise their patient Decisions regarding delivery of patient safety knowledge and skills. safety material will depend on the nature and content of existing curriculum, but Students learn better in a safe supportive may be matched to current educational learning environment, one which is formats. The curriculum addresses challenging but not intimidating and student knowledge and performance where experiential learning is facilitated. elements of patient safety, and there are Educators may adopt a variety of styles including roles as information provider,

1 role model, facilitator, assessor, planner groups, individual interviews, observation and resource provider. There is an and docements/records. Findings of important role for patients in delivering evaluation must be disseminated and patient safety education. action taken where appropriate.

Assessing patient safety Patient safety education activities Assessments may be formative or A number of different educational formats summative, and these may be in-course may be used in the delivery of the or end-of-course. Assessments strongly Curriculum, including lectures, ward influence study behaviour and learning round-based teaching, small group outcomes for students and therefore learning, case based discussions, should align with desired learning independent study, patient tracking, role outcomes. Blueprinting defines the play, simulation and undertaking competencies students are expected to improvement projects. Each of these has meet, and can be used to map patient benefits and challenges, and different safety topics across the curriculum as a methods are appropriate for different whole. The purpose of assessment learning goals. should drive the choice of format – for example, written (e.g. multiple choice Transnational Approach questions, modified essays, logbooks) or Health care is now globalized, and practical (e.g. direct observation, case- medical education should reflect this. based discussions, OSCE). The Curriculum Guide operates on universal principles that are applicable Evaluating patient safety globally, and though delivery should be Evaluation measures how and what is customized to local needs and culture. taught in the curriculum by collecting There is a need for international human data from students, patients, teachers and physical resource capacity building and/or other stakeholders. Choices must on an international level. be made about what is being evaluated, who the evaluation is for and what Introduction to topics questions the evaluation is trying to As future clinicians students need to answer. There are different types of learn about patient safety. There is a evaluation – proactive, clarificative, progression from knowing “what” to interactive, monitoring and impact – each knowing “how” and ultimately to “doing”. answering the different questions Best learning is through hands-on evaluation can ask. Data for evaluation experience with feedback from trainers, may be gathered in a number of ways – along with mentoring and coaching. self-reflection, questionnaires, focus There are a number of cultural barriers to

2 change which students can be helped to complex that the successful treatment explore and challenge. The Curriculum and outcome for each patient depends can be integrated with clinical care (eg on a range of factors, not just the infection control). Students need to learn competence of an individual health care to practise safe health care even if the provider. When so many people and prevailing medical culture is not different types of health-care providers supportive of this, and to learn to deal (doctors, nurses, pharmacists and allied with the conflicts this may create. health) are involved, it is very difficult to ensure safe care unless the system of Topic 1: What is patient safety? care is designed to facilitate timely and Health professionals are increasingly complete information and understanding being required to incorporate patient by all the health professionals. This topic safety principles and concepts into presents the case for patient safety. everyday practice. In 2002, WHO Member States agreed on a World Topic 2: What is human factors and Health Assembly resolution on patient why is it important to patient safety? safety because they saw the need to Human factors, engineering or reduce the harm and suffering of patients ergonomics is the science of the and their families as well as the interrelationship between humans, their compelling evidence of the economic tools and the environment in which they benefits of improving patient safety. live and work [3]. Human factors Studies show that additional engineering will help students hospitalization, litigation costs, infections understand how people perform under acquired in hospitals, lost income, different circumstances so that systems disability and medical expenses have and products can be built to enhance cost some countries between US$ 6 performance. It covers the human– billion and US$ 29 billion a year. A machine and human-to-human number of countries have published interactions such as communication, studies highlighting the overwhelming teamwork and organizational culture. evidence showing that significant Other industries such as aviation, numbers of patients are harmed due to manufacturing and the military have their health care, either resulting in successfully applied knowledge of permanent injury, increased length of human factors to improve systems and stay in hospitals or even death. We have services. Students need to understand learnt over the last decade that adverse how human factors can be used to events occur not because bad people reduce adverse events and errors by intentionally hurt patients but rather that identifying how and why systems break the system of health care today is so down and how and why human beings

3 miscommunicate. Using a human factors individual doctor or nurse working in a approach, the human– system interface hospital can do their very best in treating can be improved by providing better- and caring for their patients but alone designed systems and processes. This that will not be enough to provide a safe involves simplifying processes, and quality service. This is because standardizing procedures, providing patients depend on many people doing backup when humans fail, improving the right thing at the right time for them; communication, redesigning equipment in other words, they depend on a system and engendering a consciousness of of care. behavioural, organizational and technological limitations that lead to Topic 4: Being an effective team error. player Medical students’ understanding of Topic 3: Understanding systems teamwork involves more than and the impact of complexity on identification with the medical team. It patient care requires students to know the benefits of Students are introduced to the concept multidisciplinary teams and how effective that a health-care system is not one but multidisciplinary teams improve care and many systems made up of organizations, reduce errors. An effective team is one in departments, units, services and which the team members communicate practices. The huge number of with one another as well as combining relationships between patients, carers, their observations, expertise and health-care providers, support staff, decision-making responsibilities to administrators, bureaucrats, economists optimize patient care. The task of and community members as well as the communication and flow of information relationships between the various health- between health providers and patients and non-health-care services add to this can be complicated due to the spread of complexity. This topic gives medical clinical responsibility among members of students a basic understanding of the health-care team. This can result in complex organizations using a systems patients being required to repeat the approach. The lessons from other same information to multiple health industries are used to show students the providers. More importantly, benefits of a systems approach. When miscommunication has also been students think in systems they will be associated with delays in diagnosis, better able to understand why things treatment and discharge as well as break down and have a context for failures to follow up on test results. thinking about solutions. Medical Students need to know how effective students need to understand how an health-care teams work, as well as

4 techniques for including patients and underlying factors involved, is their families as part of the healthcare significantly better than a person team. There is some evidence that approach, which seeks to blame people multidisciplinary teams improve the for individual mistakes. Leape’s seminal quality of services and lower costs. article in 1994 showed a way to examine Good teamwork has also been shown to errors in health care, that focused on reduce errors and improve care for learning and fixing errors instead of patients, particularly those with chronic blaming those involved. Although his illnesses. This topic presents the message has had a profound impact on underlying knowledge required to many health-care practitioners, there are become an effective team member. still many embedded in a blame culture. However, knowledge alone will not make It is crucial that students begin their a student a good team player. They need vocation understanding the difference to understand the culture of their between blame and systems workplace, and how it impacts upon approaches. team functioning. Topic 6: Understanding and Topic 5: Understanding and learning managing clinical risk from errors Clinical risk management is primarily Understanding why health-care concerned with maintaining safe systems professionals make errors is necessary of care. It usually involves a number of for appreciating how poorly designed organizational systems or processes that systems and other factors contribute to are designed to identify, manage and errors in the health-care system. While prevent adverse outcomes. Clinical risk errors are a fact of life, the consequences management focuses on improving the of errors on patient welfare and staff can quality and safety of health-care services be devastating. Medical students and by identifying the circumstances and other healthcare professionals need to opportunities that put patients at risk of understand how and why systems break harm and acting to prevent or control down and why mistakes are made so those risks. Risk management involves they can act to prevent and learn from every level of the organization so it is them. An understanding of health-care essential that medical students errors understand the objectives and relevance also provides the basis for making of the clinical risk management strategies improvements and implementing in their workplace. Managing complaints effective reporting systems. Students will and making improvements, learn that a systems approach to errors, understanding the main types of which seeks to understand all the incidents in the hospital or clinic that are

5 known to lead to adverse events, Topic 8: Engaging with patients and knowing how to use information from carers complaints, incident reports, litigation, Students are introduced to the concept coroners’ reports and quality that the health-care team includes the improvement reports to control risks are patient and/or their carer, and that all examples of clinical risk management patients and carers play a key role in strategies. ensuring safe health care by: (i) helping with the diagnosis; (ii) deciding about Topic 7: Introduction to quality appropriate treatments; (iii) choosing an improvement methods experienced and safe provider; (iv) Over the last decade, health care has ensuring that treatments are successfully adopted a variety of quality appropriately administered; and (v) improvement methods used by other identifying adverse events and taking industries. These methods provide appropriate action. The health-care clinicians with the tools to: (i) identify a system underutilizes the expertise problem; (ii) measure the problem; (iii) patients can bring such as their develop a range of interventions knowledge about their symptoms, pain, designed to fix the problem; and (iv) test preferences and attitudes to risk. They whether the interventions worked. are a second pair of eyes if something Healthcare leaders such as Tom Nolan, unexpected happens. They can alert a Brent James, Don Berwick and others health-care worker if the medication they have applied quality improvement are about to receive is not what they principles to develop quality usually take, which acts as a warning to improvement methods for health the team that checks should be made. clinicians and managers. The Research has shown that there are fewer identification and examination of each errors and better treatment outcomes step in the process of health-care when there is good communication delivery is the bedrock for this between patients and their carers, and methodology. When students examine when patients are fully informed and each step in the process of care they educated about their medications. Poor begin to see how the pieces of care are communication between doctors, connected and measurable. patients and their carers has also Measurement is critical for safety emerged as a common reason for improvement. This topic introduces the patients taking legal action against student to improvement methods and health-care providers. the tools, activities and techniques that can be incorporated into their practice.

6 Topic 9: Minimizing infection through Topic 10: Patient safety and invasive improved infection control procedures WHO has a global campaign on infection WHO has a project on safe surgery. One control. We thought it important that this of the main causes of errors involving area be included in the Curriculum Guide wrong patients, sites and procedures is not only for consistency but also the failure of health-care providers to because along with surgical care and communicate effectively (inadequate medications these areas constitute a processes and checks) in preoperative significant percentage of adverse events procedures. Other examples of wrong suffered by patients. The problem of site/procedure/patient are: (i) the wrong infection control in health-care settings is patient in the operating room (OR); (ii) now well established, with health care- surgery performed on the wrong side or associated infections being a major site; (iii) wrong procedure performed; (iv) cause of death and disability worldwide. failure to communicate changes in the There are numerous guidelines available patient’s condition; (v) disagreements to help doctors and nurses minimize the about stopping procedures; and (vi) risks of cross-infection. Patients who failure to report errors. Minimizing errors have surgery or an invasive procedure caused by misidentification involves are known to be particularly prone to developing best-practice guidelines for infections and account for about 40% of ensuring the correct patient receives the all hospital-acquired infections. The topic right treatment. Students can learn to sets out the main causes and types of understand the value of all patients being infections to enable medical students to treated in accordance with the correct identify those activities that put patients site/procedure/patient policies and at risk of infection and to prepare protocols. Such learning would include students to take the appropriate action the benefit of protocols as well as to prevent transmission. knowledge of the underlying principles supporting a uniform approach to treating and caring for patients. One study of hand surgeons found that 21% of surgeons surveyed (n=1050) reported performing wrong site surgery at least once during their careers.

7 Topic 11: Improving medication safety An adverse drug reaction has been defined by WHO as any response to a medication that is noxious, unintended and occurs at doses used for prophylaxis, diagnosis or therapy. Patients are vulnerable to mistakes being made in any one of the many steps involved in ordering, dispensing and administering medications. Medication errors have been highlighted in studies undertaken in many countries, including Australia, which show that about 1% of all hospital admissions suffer an adverse event related to the administration of medications. The causes of medication errors include a wide range of factors including: (i) inadequate knowledge of patients and their clinical conditions; (ii) inadequate knowledge of the medications; (iii) calculation errors; (iv) illegible handwriting; (v) confusion regarding the name of the medication; and (vi) poor history taking.

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