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    Patient Safety WHO Document 272 pages Patient Safety WHO Document 272 pages Document Transcript

    • Patient Safety Curriculum GuideMulti-professional Edition
    • PatientSafetyCurriculumGuide:Multi-professionalEdition
    • WHO Library Cataloguing-in-Publication DataWHO patient safety curriculum guide: multi-professional edition.1.Patient care - education. 2.Curriculum. 3.Clinical competence.4.Health personnel - education. 5.Safety management. 6.Practiceguideline. I.World Health Organization. II.WHO Patient Safety.ISBN 978 92 4 150195 8 (NLM classification: WX 167)© World Health Organization 2011All rights reserved. Publications of the World Health Organizationare available on the WHO web site ( or can be purchasedfrom WHO Press, World Health Organization, 20 Avenue Appia,1211 Geneva 27, Switzerland (tel.: +41 22 791 3264;fax: +41 22 791 4857; e-mail: for permission to reproduce or translate WHO publications –whether for sale or for noncommercial distribution – should beaddressed to WHO Press through the WHO web site( designations employed and the presentation of the material inthis publication do not imply the expression of any opinion whatsoeveron the part of the World Health Organization concerning the legalstatus of any country, territory, city or area or of its authorities, orconcerning the delimitation of its frontiers or boundaries. Dotted lineson maps represent approximate border lines for which there may notyet be full agreement.The mention of specific companies or of certain manufacturers’products does not imply that they are endorsed or recommendedby the World Health Organization in preference to others of a similarnature that are not mentioned. Errors and omissions excepted,the names of proprietary products are distinguished by initial capitalletters.All reasonable precautions have been taken by the World HealthOrganization to verify the information contained in this publication.However, the published material is being distributed withoutwarranty of any kind, either expressed or implied. The responsibilityfor the interpretation and use of the material lies with the reader.In no event shall the World Health Organization be liable for damagesarising from its use.Printed in MaltaDesign: CommonSense, Greece
    • Contents Abbreviations 5 Forewords 8 Introduction 18 Part A: Teacher’s Guide 1. Background 22 2. How were the Curriculum Guide topics selected? 25 3. Aims of the Curriculum Guide 34 4. Structure of the Curriculum Guide 36 5. Implementing the Curriculum Guide 37 6. How to integrate patient safety learning into your curriculum 41 7. Educational principles essential for patient safety teaching and learning 51 8. Activities to assist patient safety understanding 56 9. How to assess patient safety 61 10. How to evaluate patient safety curricula 69 11. Web-based tools and resources 74 12. How to foster an international approach to patient safety education 753
    • Part B: Curriculum Guide TopicsDefinitions of key concepts 80Key to icons 82Introduction to the Curriculum Guide topics 83Topic 1: What is patient safety? 92Topic 2: Why applying human factors is important for patient safety 111Topic 3: Understanding systems and the effect of complexity on patient care 121Topic 4: Being an effective team player 133Topic 5: Learning from errors to prevent harm 151Topic 6: Understanding and managing clinical risk 162Topic 7: Using quality-improvement methods to improve care 176Topic 8: Engaging with patients and carers 192Introduction to Topics 9-11 209Topic 9: Infection prevention and control 210Topic 10: Patient safety and invasive procedures 227Topic 11: Improving medication safety 241AnnexesAnnex 1: Link to the Australian Patient Safety Education Framework 260Annex 2: Assessment method examples 261Acknowledgements 268 4
    • Abbreviations AHRQ Agency for Healthcare Research and Quality PBL problem-based learning AMR antimicrobial resistance PDSA plan-do-study-act APSEF Australian Patient Safety Education Framework PPE personal protective equipment ARCS accelerated recovery colectomy surgery RCA root cause analysis CBD case-based discussion RLS reporting and learning system CDC Centers for Disease Control and Prevention RPN risk priority number CPI clinical practice improvement SBA short best answer question paper CR-BSI catheter-related bloodstream infection SSI surgical site infection CRM crew resource management TB tuberculosis ECG electrocardiogram UK United Kingdom EMQ extended matching question USA United States of America FMEA failure mode effect analysis VA Veterans Affairs HCAI health care-associated infection VRE vancomycin-resistant Enterococcus HBV hepatitis B virus HIV human immunodeficiency virus HRO high reliability organization ICU intensive care unit IHI Institute for Healthcare Improvement IOM Institute of Medicine IPE interprofessional education IV intravenous MRI magnetic resonance imaging MCQ multiple choice question MEQ modified essay question Mini-CEX mini clinical evaluation exercise MRI magnetic resonance imaging MRSA methicillin-resistant Staphylococcus aureus MSF multisource feedback NASA National Aeronautics and Space Agency NCPS National Center for Patient Safety NPSEF National Patient Safety Education Framework NSAID non-steroidal anti-inflammatory drugs OR operating room OSCE objective structured clinical examination OTC over the counter5
    • PatientSafetyCurriculumGuide:Multi-professionalEdition
    • World Health OrganizationHealth care has evolved greatly over the past 20 years. Our knowledge of diseasesand technological innovations have all contributed to improving life expectancyduring the 20th Century. But one of the greatest challenges today is not aboutkeeping up with the latest clinical procedures or the latest high-tech equipment.Instead, it is about delivering safer care in complex, pressurized and fast-movingenvironments. In such environments, things can often go wrong. Adverse eventsoccur. Unintentional, but serious harm comes to patients during routine clinicalpractice, or as a result of a clinical decision.Many countries in the world have already recognized that patient safety is importantand are building ways and approaches to improve the quality and safety of care.They have also recognized the importance of educating health-care professionals onthe principles and concepts of patient safety. Strengthening such competencies isneeded in order to keep pace with the complexities of the system and the demandsof workforce requirements.The World Health Organization is currently leading a global drive to build on patientsafety education, its principles and approaches that lead to a future health-careworkforce educated to practise patient-centred care anywhere in the world. It hasembarked on developing a patient safety curriculum guide with a multi-professionalperspective, a health systems approach with a global reach. It has accelerated effortsin assisting universities and schools of health sciences to build and integrate patientsafety learning into their existing curricula.The World Health Organization, working with governments, universities and schoolsworldwide, international professional associations in the disciplines of dentistry,medicine, midwifery, nursing and pharmacy and their related student associations,have made patient safety education relevant to the needs and requirements ofcontemporary workforce environments. The combined energy, resources andexpertise have been essential in developing the Multi-professional edition of thePatient Safety Curriculum Guide. The fruits of applying its recommendations will beimmediate and measurable in terms of building the knowledge and skills of healthsciences students that will better prepare them for safer practice.Dr Margaret ChanDirector-GeneralWorld Health Organization WHO Patient Safety Curriculum Guide: Multi-professional Edition 8
    • World Health Organization Commitment to patient safety worldwide has grown since the late 1990s. This was prompted by two influential reports: To Err is Human, produced by the Institute of Medicine in the USA, in 1999 and An Organization with a Memory, produced by the United Kingdom Government’s Chief Medical Officer in 2000. Both reports recognized that error is routine during the delivery of health care and occurs in around 10% of hospital admissions. In a proportion of cases, the harm produced is serious, even fatal. Since the publication of these two influential reports, the quest to improve the safety of care for patients has become a global movement. This has led to a remarkable transformation in the way that patient safety is viewed. Having begun as a subject of minority academic interest, it is now a firm priority for most health- care systems. Yet, the current state of patient safety worldwide is still a source of deep concern. As data on the scale and nature of errors and adverse events have been more widely gathered, it has become apparent that unsafe care is a feature of virtually every aspect of health care. The education and training of dentists, doctors, midwives, nurses, pharmacists and other health-care professionals has long been the foundation of safe, high quality health care. Yet, it has been under-used and under-valued as a vital tool for addressing the challenges of achieving improved patient safety. It is clear that a new approach is needed if education and training are to play the full role that they should in improving patient safety. For the past three years, the World Health Organization has been exploring the links between education and health practice – between the education of the health- care workforce and the safety of the health system. As an outcome, it has developed this multi-professional Patient Safety Curriculum Guide, which addresses a variety of ideas and methods for teaching and assessing patient safety more effectively. The WHO Curriculum Guide is a comprehensive programme for effective student learning about patient safety. It highlights the key risks of health care and how to manage them, shows how to recognize adverse events and hazards, report and analyse them. It teaches about team-work and the importance of clear communication across all levels of health care, whilst emphasizing the importance of engaging with patients and carers to build and sustain a culture of patient safety. I hope this Curriculum Guide will inspire the future generation of health-care professionals to embark on a lifelong quest to provide their patients with the best quality and safest care they deserve. Sir Liam Donaldson Envoy for Patient Safety World Health Organization9 Forewords
    • FDI World Dental FederationToday there is a growing awareness and recognition of patient safety as a vital factorin health care. There is also a perceived need to look closely at procedures successfullyadopted in other professional environments, notably business safety, to see howthey can be adapted into the health-care situation. With this comes a pressing needfor students in all forms of health-care practice to learn and understand how tomanage and deal with adverse events, ensuring at the same time a high degree ofpatient safety.The World Health Organization’s (WHO) Patient Safety Curriculum Guide: Multi-professional Edition is an important resource: not only will it raise global awarenessof the need for patient safety education, but it will also help educators integrate theconcept of safety into existing health-care curricula.This will contribute towards building a foundation of knowledge and skills to betterprepare students for clinical practice and help develop a future workforce of health-care professionals educated in patient safety and capable of meeting the demandsof today’s complex environments.In the past year, FDI World Dental Federation has sought to review its global oralhealth strategies and identify key global issues and regional priorities. One of theissues raised was quality assurance and improvement with respect to patient safetyand patient communication/information. It is therefore heartening to see that issuesraised are so immediately translated into workable, usable educational materials,based on concepts derived from industry practice.The concept of patient safety as a ‘core’ attitude to be introduced early on in dentaltraining is one that FDI has long championed. The prominence this WHO syllabusgives to training future dentists in the techniques of practising patient safety in allaspects of their work augurs well for their future careers and the future of dentistryin the world.FDI is proud to have been involved in this collaborative project with WHO: it is verymuch a part of the process we have instigated to further the cause of oral healthand pursue goals in continuing education. It also usefully integrates dentistry intothe other health professions, highlighting the common principles that govern theirapproach to patient safety.Dr Roberto ViannaPresidentFDI World Dental Federation WHO Patient Safety Curriculum Guide: Multi-professional Edition 10
    • International Pharmaceutical Federation Patient safety is a high-priority issue for all professionals - like pharmacists - who care for the health and general well-being of people. For centuries, pharmacists have been the guardians /safeguards against “poisons” those substances which could cause harm to the public. Now more than ever pharmacists are charged with the responsibility of ensuring that when a patient receives a medicine, it will not cause harm. The recent shift of paradigm of pharmacy practice from a product-focused to a patient centered approach has lead to the further development of pharmaceutical care, which focuses on preventing or solving actual and potential drug therapy problems, through the provision of comprehensive services to patients. Pharmacists also contribute to collaborative practice in ambulatory and hospital settings, and there is strong evidence that patient safety can be increased through their active involvement in multi-disciplinary care teams. Believing that the strengthening of patient safety in pharmacists’ curricula could further enhance their capability to contribute to patient safety, FIP contributed to this document and welcomes this precious tool. Mr Ton Hoek General Secretary International Pharmaceutical Federation (FIP)11 Forewords
    • International Confederation of MidwivesMembers of the International Confederation of Midwives (ICM) have dedicatedconsiderable time and expertise to collaborating with the World Health Organizationand other health professions, to create a truly multi-disciplinary and multi-professional Patient Safety Curriculum Guide, to teach patient safety principles to awide range of health professionals. The case studies in this guide will help studentsnot only recognize the role of patient safety in different care settings but will alsohighlight the need for improved inter-professional collaboration and communicationto avoid health-related errors.As President of ICM, I congratulate the numerous health professionals and WHO,who together have created this Guide. I am of course especially proud of thecontributions from midwife members of ICM, who have worked tirelessly andcollaboratively to bring this Curriculum Guide to fruition. May it serve theinternational health community well as it strives to respond to the health needs ofthe world.Mrs Frances Day-StirkPresidentInternational Confederation of Midwives WHO Patient Safety Curriculum Guide: Multi-professional Edition 12
    • International Council of Nurses The International Council of Nurses is pleased to have contributed to the develop- ment of the WHO Patient Safety Curriculum Guide: Multi-professional Edition, which provides a common platform for health-care practitioners to address this im- portant issue. Nurses around the world have a major role to play in improving patient safety. Whilst individual professionals have a duty to ensure practice does no harm, increasingly care is being delivered by teams. Working from this comprehensive resource facili- tates team work and provides a common knowledge base that also offers flexibility for each discipline to make its unique contribution. In addition, this guide raises awareness of the need to integrate patient safety into the curriculum of all health professionals. Dr Rosemary Bryant President International Council of Nurses13 Forewords
    • World Medical AssociationSafety is a cornerstone of quality in health care and its success requires individualand team commitment. Individuals and processes are rarely single causes of errors.Rather, separate elements combine and together produce high-risk situations.Understanding risk in the complex processes of health and medical care requiresinformation about errors and so-called near misses. From them we can learn to closegaps of safety, reduce morbidity, mortality and to raise the quality of health care.Therefore, it is crucial to have a non-punitive safety culture to deal with errors, withreporting mechanisms that help prevent and correct system failures and humanerrors instead of seeking individual or organizational culpability. In most health-caresettings this blame-free culture still needs to be developed. One crucial step in thisprocess is to educate health professional students on the concept of safety in healthcare, collaborative practice and how to implement it in their future day-to-day work.Person-centred health care is becoming more complex and more specialised. Thisrequires that more attention is paid to seamless teamwork in health care. A trulycollaborative practice demands a high degree of communication, accurate passingon of task and results and clearly defined roles and responsibilities. A realisticunderstanding of the risks inherent in modern medicine makes it necessary that allhealth professionals are capable of cooperating with all relevant parties, of adoptinga proactive systems approach to safety and of performing with professionalresponsibility. This includes first and foremost the dialogue with our patients and topay respect to their needs, expectations, fears and hopes.The World Medical Association advocates health professionals to recognize safety asone of the core elements for improving quality in health care. Facilitating thedevelopment of collective knowledge about unsafe situations and practices andtaking preventive action to avoid unnecessary risks is key to success.The WHO Patient Safety Curriculum Guide offers an educational tool for students ofhealth professions to understand the concept of patient safety and collaborativepractice. It gives guidance to teachers on how to teach this topic with moderneducational methods.Dr Wonchat SubhachaturasPresidentWorld Medical Association WHO Patient Safety Curriculum Guide: Multi-professional Edition 14
    • International Association of Dental Students International Council of Nurses – Students’ Network International Federation of Medical Students’ Associations International Pharmaceutical Students’ Federation Given the importance of delivering safe care in today’s health-care settings, there is an ever growing need for students to learn about adverse events in health care and an urgent necessity for patient safety. The introduction of patient safety in health professionals education will contribute to building a foundation of knowledge and skills that will better prepare students for clinical practice. It will help generate a future workforce of health-care professionals educated in patient safety and capable of meeting the demands of todays complex environments. The International Association of Dental Students (IADS,) International Council of Nurses – Students’ Network (ICN-SN), International Federation of Medical Students’ Associations (IFMSA) and International Pharmaceutical Students’ Federation (IPSF) jointly welcomes the WHO Patient Safety Curriculum Guide: Multi-professional Edition as an important resource, not only to raise global awareness of the need for patient safety education, but also to support educators to introduce this discipline into existing health-care curricula and help prepare students for safer practice in their workplace environments. ICN-SN, IADS, IFMSA and IPSF endorse the WHO Patient Safety Curriculum Guide: Multi-professional Edition and welcomes WHO’s efforts in supporting dentistry, medical, nursing and pharmacy universities and faculties worldwide to introduce patient safety education in health-care curricula. The student associations appreciate WHO’s efforts in consulting with students as equal stakeholders, to ensure that their suggestions and views are incorporated into the Curriculum Guide. The associations strongly support the multi-professional edition of the WHO Patient Safety Curriculum Guide and congratulate WHO for making it possible for all stakeholders to move in this direction. Mr Ionut Luchian Ms Yasmin Yehia President Chairperson International Association International Council of Dental Students of Nurses – Students’ Network Mr Chijioke Chikere Kadure Mr Jan Roder President President International Federation International Pharmaceutical of Medical Students’ Associations Students’ Federation15 Forewords
    • The patient voice in professionaleducationHaving been involved in the development and piloting of the Patient SafetyCurriculum Guide for Medical Schools, it was a natural progression that Patients forPatient Safety would participate in the adaptation of the Curriculum Guide formulti-disciplinary use. We welcome this opportunity to collaborate with anotherWHO programme.In practice, our interaction with students of all disciplines and at all levels hasreinforced a very strong conviction that as part of their education students must beexposed to, and develop for themselves, an appreciation of the value of the patientexperience. When that is coupled with fostering an awareness of what constitutestruly patient-centred care they will then invariably combine heart, intellect and skillsto the benefit of patients and patient outcomes.Formally embedding the patient perspective into health-care education is key topatient safety, sustainable culture change and health-care improvement. Researchconducted at the University of British Columbia in Canada highlights that “Studentsremember what they learn from patients. The authentic and autonomous patient’svoice promotes the learning of patient-centred care”.The new WHO Curriculum Guide will bring long-awaited changes which will furtherensure safe care that is inclusive of patient and family. It is a very real fact that thestudents of today will be the health-care professionals of tomorrow – men andwomen who will hold our lives in their hands and whom we patients want to holdin high regard.Mrs Margaret MurphyExternal LeadPatients for Patient Safety Programme WHO Patient Safety Curriculum Guide: Multi-professional Edition 16
    • Meeting the needs of our future health-care professionals With a growing recognition of the unintended harm caused by health care itself comes the need for health-care students to learn how to deliver safer care. However, education of health-care professionals has not kept up with the fast pace of different health challenges and changing workforce requirements. Just 2% of the total world expenditure on health of US$ 5.5 trillion is spent on professional education. Innovative health professional education is urgently needed to prepare health-care professionals to deliver patient-centered health care. This calls for a competency-based curriculum with a multi-professional perspective, a systems approach, and a global reach. The Multi-professional Edition of the WHO Patient Safety Curriculum Guide is an updated edition of the Curriculum Guide for Medical Schools, published by WHO in 2009. This new edition covers the areas of dentistry, medicine, midwifery, nursing, pharmacy, and other related health-care professions. We hope that this Guide will promote and enhance the status of patient safety worldwide and ultimately prepare students for safe practice. As a comprehensive guide to implementing patient safety education in health-care schools and universities, it contains information for all levels of faculty staff and lays the foundation for capacity-building in the essential patient safety principles and concepts. The Curriculum Guide is a rich resource for senior decision-makers involved in the development of health-care curricula. Written with a global audience in mind and in language easily understood, the Curriculum Guide is composed of two parts: Part A: Teacher’s Guide and Part B: 11 patient safety topics. The Teacher’s Guide introduces patient safety concepts and principles and gives vital information on how best to teach patient safety. Part B includes 11 patient safety topics, each designed to feature a variety of ideas and methods for teaching and assessing, so that educators can tailor material according to their own needs, context, and resources. We, therefore, commend to you this publication. What could be more important than educating health-care professionals to become competent in patient-centered care? The Multi-professional Curriculum Guide helps build capacity to achieve this goal. We look forward to its widespread use. Professor Bruce Barraclough Professor Merrilyn Walton External Expert Lead Lead Author Patient Safety Curriculum Guide Patient Safety Curriculum Guide17 Forewords
    • IntroductionThe Multi-professional Edition of the Patient Sections of the Curriculum GuideSafety Curriculum Guide is a comprehensive The document comprises two parts: Part A:guide to assist effective capacity building in Teacher’s Guide; and Part B: 11 Patient Safetypatient safety education by health-care academic Topics. For convenience, the figures and tablesinstitutions. As patient safety teaching is relatively are numbered to correspond to the part andnew for most health-care educators, the the section in which they are presented.Curriculum Guide provides, in a single publication,educational frameworks and features a variety Part A is aimed at health-care educators.of concepts and methods for teaching and It supports them with knowledge and tools,assessing patient safety. and helps them develop the skills necessary for implementing patient safety educationThe present Curriculum Guide is designed to be in their institutions. Part A provides a systematiceasily integrated into existing health-care approach to building institutional curricula using a flexible approach It offers background information on how to selectto meet individual needs, and is applicable and teach each curriculum topic, makesto different cultures and contexts. While it offers suggestions on how to integrate patient safetyhealth-care schools and universities a teaching, and provides techniques for exploringrecommended framework and resource materials, how this subject could fit into the institution’sindividual adaptations to local requirements, existing curricula. Part A also highlights thesettings, student learning needs and resources educational principles that are essential to patientare encouraged. safety teaching and learning and proposes approaches for student assessment, as well asThe development of the Multi-professional evaluation of the current patient safety curricula.Curriculum Guide began in January 2010 and The importance of faculty engagement as anis based on the Curriculum Guide for Medical essential component for maintaining theSchools, published in 2009. A core working group sustainability of the programme is emphasizedcomprised of experts from international throughout the document. At the same time,professional associations in dentistry, medicine, clear examples on how patient safety might bemidwifery, nursing and pharmacy, as well as taught are provided throughout Part A.from the WHO regions, coordinated the workof reviewing the 2009 Curriculum Guide, Part B addresses health-care educatorsassessing available scientific evidence, and and students. It contains 11 ready-to-teach,rewriting sections as they would apply to dentists, topic-based, patient safety programmes that canmidwives, nurses and pharmacists. They also be used as a whole or on a per topic basis.provided multi-professional case studies to The topics cover a wide range of contextssupport interdisciplinary learning and actively in which patient safety can be taught and learned.fostered discussion among experts and authors.More than 50 international experts contributed The 11 topics are:to preparing this document. Authors, contributors, Topic 1: What is patient safety?experts, and other professionals who actively Topic 2: Why applying human factors is importantparticipated and facilitated the work process for patient safety.are listed in the acknowledgements section at Topic 3: Understanding systems and the effectthe end of the document. of complexity on patient care. WHO Patient Safety Curriculum Guide: Multi-professional Edition 18
    • Topic 4: Being an effective team player. Topic 5: Learning from errors to prevent harm. Topic 6: Understanding and managing clinical risk. Topic 7: Using quality improvement methods to improve care. Topic 8: Engaging with patients and carers. Topic 9: Infection prevention and control. Topic 10: Patient safety and invasive procedures. Topic 11: Improving medication safety. Educators can choose which of these topics to introduce into existing curricula as guided by institutional requirements, needs, resources, and capacity. For the actual teaching of the subject, a number of different educational approaches may be used, including lectures, ward round-based teaching, small group learning, case-based discussions, independent studies, patient tracking, role-playing, simulation, and undertaking improvement projects. There are benefits and challenges to each of these approaches and educators should bear in mind that different learning goals can be achieved by selecting different approaches. Annexes 1 and 2 give examples of the content and format of assessments /examinations. Teachers can choose the format based on the purpose of the assessment /examination and the learning outcome objectives. The CD-Rom on the inside cover of the document contains the electronic version of the Curriculum Guide, 11 sets of slides for teaching each topic, as well as information and tools for its promotion.19 Introduction
    • Part ATeacher’sGuidePatient SafetyCurriculum Guide:Multi-professionalEdition
    • 1. BackgroundWhy do health-care students need safety is everyone’s business and ranges frompatient safety education? patients to politicians. As health-care studentsHealth-care outcomes have significantly improved are among the future leaders in health care,with the scientific discoveries of modern medicine. it is vital that they are knowledgeable and skilfulHowever, studies from a multitude of countries in their application of patient safety principlesshow that with these benefits come significant and concepts. The multi-professional edition ofrisks to patient safety. We have learnt that the WHO Patient Safety Curriculum Guide setshospitalized patients are at risk of suffering an the stage for students, irrespective of their chosenadverse event, and patients on medication have profession, to begin to understand and practisethe risk of medication errors and adverse patient safety in all their professional activities.reactions. A major consequence of this knowledgehas been the development of patient safety as a Building students’ patient safety knowledge needsspecialized discipline to assist health-care to occur throughout the entire education andprofessionals, managers, health-care training of health-care students. Patient safetyorganizations, governments (worldwide) and skills and behaviours should begin as soon asconsumers who must become familiar with a student enters a hospital, clinic or health service.patient safety concepts and principles. Everyone By getting students to focus on each individualis affected. The tasks ahead of health care are patient, having them treat each patient as aimmense and require all those involved in care unique human being, and using their knowledgeto understand the extent of harm to patients and skills carefully, students themselves can beand why health care must move to adopt a safety role models for others in the health-care system.culture. Patient safety education and training Most health-care students have high aspirationsis only beginning to occur at all levels. Health-care when they enter into their chosen field, but thestudents, as future providers of health care and reality of health-care systems sometimes deflateshealth-care leaders, must prepare themselves their optimism. We want students to be ableto practise safe care. Though the curricula of to maintain their optimism and believe that theythe different health-care professions are can make a difference, both to the individual livescontinually changing to accommodate the latest of patients and the health-care system.discoveries and new knowledge, patient safetyknowledge is different because it applies to all How to use this Curriculumareas of practice and to all professions. The Curriculum has been designed for health-care educational institutions to implement patientHealth-care students will need to know how safety learning for students prior to becomingsystems impact on the quality and safety of health qualified health-care professionals. Faculties cancare, how poor communication can lead to introduce all the topics as a whole or they canadverse events and much more. Students need start more slowly by introducing one or moreto learn how to manage these challenges. at a time. Each topic has all the underpinningPatient safety is not a traditional stand-alone knowledge required to teach the subject includingdiscipline; rather, it is one that integrates into all suggestions for assessment. We have inserted caseareas of health care. The World Health studies to facilitate learning and encourageOrganization’s (WHO) Patient Safety programme, teachers and instructors to include them in theirand other projects such as this one, aims to teaching activities. We have also providedimplement patient safety worldwide. Patient different ideas about how to teach a particular WHO Patient Safety Curriculum Guide: Multi-professional Edition 22
    • topic. Many of the topics are best delivered once they are properly educated and trained in patient the student has experienced their professional safety concepts and principles they will struggle work environment as so much of patient safety to do this. learning requires a team approach and observation of the health service as a whole, not just the area Patient safety education for health-care where the student happens to be placed. professionals in the higher education sector has The topics have been designed so that students not kept up with workforce requirements [3-7]. For can be responsible for much of their own learning example, incident reporting systems for medication through reading online material that provides errors or surgical mistakes have been in use for them with the underpinning knowledge required, many years in several countries, but accounts followed by tasks that can be performed to put of specific curricula related to health-care errors or the acquired knowledge into practice. patient safety courses embedded in undergraduate education have started to be described only We encourage the different faculties and health recently in the published literature [5,8]. professions to add relevant professional literature and data to the topics that directly concern their A number of factors have impeded patient safety profession. For example, we would expect that education. First, the lack of recognition by relevant pharmacy articles and data collections be health-care educators that teaching and learning included for pharmacy students. Because this patient safety should be an essential part of the is a Multi-professional Curriculum Guide we were undergraduate curricula for health-care students, unable to provide examples for all professions, and that patient safety skills can be taught [9,10]. but we have included as many as possible where Many educators are unfamiliar with the literature available and relevant. and are unsure how to integrate patient safety learning into existing curricula [11,12]. Second, What is the Curriculum Guide? educators need to be open to new areas of The Curriculum Guide is a comprehensive knowledge [3]. One of the difficulties in programme for the implementation of patient introducing new curricula is a reluctance to address safety education in health-care educational knowledge that originates from outside one’s institutions worldwide. It comprises two parts. profession, such as systems thinking and quality- Part A is a teacher’s guide, which has been improvement methods [10]. It has also been designed to assist teachers to implement the suggested that the historical emphasis on Curriculum Guide. As we are aware that patient treatment of disease rather than prevention of safety is a new discipline and many health-care illness creates a culture that finds it difficult to give professionals and faculty staff will be unfamiliar merit to a “non-event”, i.e. a preventable adverse with many of the concepts and principles, this event [3]. A third factor relates to entrenched part lays the foundations for capacity-building attitudes regarding the traditional teacher-student in patient safety education. Part B provides relationship - one that may be hierarchical a comprehensive, ready-to-teach, topic-based and competitive [9] and where an “expert” patient safety programme that can be implemented disseminates information to the student [3,4]. either as a whole or on a per topic basis. This Curriculum Guide seeks to fill the gap Why was the Curriculum Guide in patient safety education by providing developed? a comprehensive curriculum designed to build Since the Harvard study [1] in 1991 first described foundation knowledge and skills for all health-care the extent of harm to patients, other countries students that will better prepare them for clinical have reported similar results, notwithstanding practice in a range of environments. the differences in their cultures and health systems. The realization that health care actually References harms patients has increased scrutiny of patient 1. Brennan TA et al. Incidence of adverse events care in the context of an increasingly complex and negligence in hospitalized patients: results health system. This complexity has been of the Harvard Medical Practice Study I. New intensified by rapidly changing medical technology England Journal of Medicine, 1991, 324:370–376. and service demands [2,3]. Doctors, nurses, 2. Runciman B, Merry A, Walton M. Safety and midwives, dentists, pharmacists, and other ethics in healthcare: a guide to getting it right, 1st ed. health-care professionals are expected to manage Aldershot, UK, Ashgate Publishing Ltd, 2007. this complexity in their daily work, provide evidence-based health-care services, and maintain 3. Stevens D. Finding safety in medical education. a safe environment for patients. However, unless Quality & Safety in Health Care, 2002,11:109–110.23 Part A 1. Background
    • 4. Johnstone MJ, Kanitsake O. Clinical risk management and patient safety education for nurses: a critique. Nurse Education Today, 2007, 27:185–191. 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, 80:600–606. 9. Sandars J et al. Educating undergraduate medical students about patient safety: priority areas for curriculum development. Medical Teacher, 2007, 29:60–61.10. Walton MM. Teaching patient safety to clinicians and medical students. The Clinical Teacher, 2007, 4:1–8.11. Walton MM, Elliott SL. Improving safety and quality: how can education help? Medical Journal of Australia, 2006,184 (Suppl. 10):S60-S64.12. Ladden MD et al. Educating interprofessional learners for quality, safety and systems improvement. Journal of Interprofessional Care, 2006, 20:497–505. WHO Patient Safety Curriculum Guide: Multi-professional Edition 24
    • 2. How were the Curriculum Guide topics selected? The Curriculum Guide covers 11 topics, including What is the Australian Patient Safety 16 of a total of 22 learning topics that were Education Framework? selected from the evidence-based Australian APSEF [1] was developed using a four-stage Patient Safety Education Framework (APSEF). approach: literature review; development of An additional topic not in APSEF was selected learning areas and learning topics; classification to support learning in infection control targeted into learning domains; and conversion into by the WHO programme to reduce infections a performance-based format. An extensive through better prevention and control. Figure consultation and validation process was A.2.1 illustrates the structure of APSEF. Table A.2.1 undertaken in Australia and internationally. lists the topics selected for inclusion from APSEF Published in 2005, the Framework is a simple, and and the topics in which learning occurs. flexible and accessible template describing Table A.2.2 sets out the levels of learning required the knowledge, skills and behaviours that all from the novice learner to the experienced health-care workers need to ensure safe patient health-care professional. care. It is divided into four levels of knowledge, skills and behaviours depending on a person’s position and clinical responsibility in a health service or organization. The Framework is designed to assist organizations and health-care professionals to develop educational curricula and training programmes. The Curriculum Guide was developed using the Framework.Figure A.2.1. Structure of the Australian Patient Safety Education Framework 7 Learning CategoriesCommunicate Using Adverse Working Being Learning & Specific effectively evidence events safely ethical teaching issues 2 2 L e a r n i n g To p i c s 3 Learning Domains in each Learning Topic Knowledge - Skills - Behaviours Underpinning/applied knowledge Performance elementsSource: National Patient Safety Education Framework, Commonwealth of Australia, 2005 [1]. 25 Part A 2. How were the Curriculum Guide topics selected?
    • Australian Patient Safety Education Framework learning areas and topicsThere are seven learning areas (categories) and 22 learning topics in APSEF.Table A.2.1 describes the Curriculum Guide topics and their relationship with APSEF.Table A.2.1. APSEF and the WHO Curriculum Guide topics APSEF topic Included in WHO topic curriculum Communicating effectively Involving patients and carers as partners in health care Yes Topic 8 Communicating risk Yes Topic 6 Communicating honestly with patients after an adverse event (open disclosure) Yes Topic 8 Obtaining consent Yes Topic 8 Being culturally respectful and knowledgeable Yes Topic 8 Identifying, preventing and managing adverse events and near misses Recognizing, reporting and managing adverse events and near misses Yes Topics 6 & 7 Managing risk Yes Topic 6 Understanding health-care errors Yes Topics 1 & 5 Managing complaints Yes Topics 6 & 8 Using evidence and information Employing best available evidence-based practice Yes Covered in Topics 9, 10 & 11 (Use of guidelines). Using information technology to enhance safety Yes Topic 2 Working safely Being a team player and showing leadership Yes Topic 4 Understanding human factors Yes Topic 2 Understanding complex organizations Yes Topic 3 Providing continuity of care Yes Topics 1 & 8 Managing fatigue and stress Yes Topics 2 & 6 Being ethical Maintaining fitness to work or practise Yes Topic 6 Ethical behaviour and practice Yes Topics 1 & 6 Continuing learning Being a workplace learner Yes Indirectly covered in Topics 4 & 8 Being a workplace teacher Yes Indirectly covered in Topic 4 Specific issues Preventing wrong site, wrong procedure, and wrong patient treatment Yes Topic 10 Medication safety Yes Topic11 Infection control (not part of APSEF) Yes Topic 9The three main stages in the development of 1. initial review of knowledge and developmentthe Framework content and structure were: of framework outline; WHO Patient Safety Curriculum Guide: Multi-professional Edition 26
    • 2. additional searching for content and Competencies- Enhancing patient safety across assignment of knowledge, skills, behaviours the health professions’ in 2009 [2]. Similar and attitudes; to the Australian approach, it provides an 3. development of performance-based format. interprofessional, practical and useful patient safety framework that identifies the knowledge, Since the publication of the Australian Patient skills, and attitudes required by all health-care Safety Education Framework in 2005, Canada professionals. released a framework entitled ‘The Safety Figure A.2.2. The Canadian Framework The Safety Competencies – Enhancing patient safety across the health professions Domain 2 Domain 1 Domain 3 Work in Contribute to a Culture Communicate Effectively Teams of Patient Safety for Patient Sqfety for Patient Safety Domain 6 Domain 5 Recognize, Domain 4 Optimize Human Respond to and Manage and Environmental Disclose Adverse Safety Risks Factors Events Source: The Safety Competencies, Canadian Patient Safety Institute, 2009 [2]. Stage 1–Review of knowledge and development Stage 2–Additional searching for content of the Australian Framework outline and assignment of knowledge, skills, behaviours and attitudes A search was conducted to identify the current body of knowledge relating to patient safety Each learning topic formed the basis for a more (as described in the next section). The literature, extensive search, including additional terms books, reports, curricula and web sites collected such as education, programmes, training, were then reviewed to identify the major activities adverse events, errors, mistakes, and organization associated with patient safety that had a positive /institution/health facility/health service. effect on quality and safety. These activities were All the activities (knowledge, skills, behaviours then grouped into categories termed “learning and attitudes) for each topic were listed until areas”. Each learning area was analysed and no more activities were forthcoming and further broken down into major subject areas, the sources exhausted. This list was then termed “learning topics”. See below for details culled for duplication, practicality and of the literature review process and the redundancy. The activities were then categorized Framework content structure. into the domains of knowledge, skills or behaviours. The rationale for the inclusion of each learning area and topic has been articulated in the body The final step in this stage was to allocate each of the Framework and is summarized below. activity to the appropriate level corresponding27 Part A 2. How were the Curriculum Guide topics selected?
    • to the degree of responsibility of health-care Level 4 (Organizational) identifies the knowledge,workers. skills, behaviours and attitudes required for clinical and administrative leaders with organizationalLevel 1 (Foundation) identifies the knowledge, responsibilities. Level 4 is not part of the progressiveskills, behaviours and attitudes that every learning that underpins the first three worker needs to have. The learning areas and topics were endorsed byLevel 2 is designed for health-care professionals the APSEF Project Reference Group and Steeringwho provide direct clinical care to patients and Committee. Extensive consultation with the widerwork under supervision, and for those with health system and community within Australia,managerial, supervisory and/or advanced clinical as well as internationally, completed the reviewresponsibilities. and endorsement process for the learning areas and topics and their content.Level 3 is for health-care professionals whohave managerial or supervisory responsibilities The outcome of this stage is shown in Table A.2.2.or are senior clinicians with advanced clinical This example is taken from Topic 8: Engaging withresponsibilities. patients and carers.Table A.2.2. APSEF content matrix Level 1 Level 2 Level 3 Level 4 (Foundation) (Organizational) For categories 1–4 For categories 2 and 3 For category 3 For category 4 health-care workers health-care workers health-care workers health-care leaders Learning objectives Provide patients Use good Maximize Develop strategies and carers with communication opportunities for staff to include the information and know its role for staff to involve patients and carers they need when in effective patients and carers in planning they need it health-care in their care and delivering relationships and treatment health-care services Knowledge Skills Behaviours and attitudesStage 3–Development of performance-based format The WHO Curriculum Guide topicsOnce the knowledge, skills and behaviours 1. What is patient safety?had been described for each level of health 2. Why applying human factors is importantprofessional, the activities were translated into for patient safetya performance-based format, which takes full 3. Understanding systems and the effectadvantage of the modular nature of the of complexity on patient careFramework. The most extensive consultation 4. Being an effective team playeroccurred at this stage of the Framework’s 5. Learning from errors to prevent harmdevelopment. Individual health-care workers 6. Understanding and managing clinical risk(nurses, doctors, pharmacists, physiotherapists, 7. Using quality-improvement methods tosocial workers, occupational therapists, dentists, improve careand others) were interviewed about aspects of 8. Engaging with patients and carersevery performance element in the Framework 9. Infection prevention and controland the entire document was distributed across 10. Patient safety and invasive proceduresthe Australian health-care sector for feedback. 11. Improving medication safety.International experts were also engaged inthe validation process. WHO Patient Safety Curriculum Guide: Multi-professional Edition 28
    • Rationale for each Curriculum and sanitation, all of which can be attributed Guide topic to limited financial resources, contribute to unsafe Health-care professionals who teach students patient care. may not immediately appreciate why certain topics are included in this Curriculum. They may Topic 2: Why applying human factors already be teaching a particular topic, but have is important for patient safety not categorized it as patient safety. Teachers Human factors is an area of expertise of engineers may also discover that many of the principles and cognitive psychologists. This topic may and concepts addressed in this Curriculum are provide some challenges for health professional similar to existing educational material, but with faculty as well as students. We recommend that a different emphasis. The significance of each you invite an appropriate person with human topic in the learning of health-care students factors expertise to give a lecture to the students. is clarified below. Human factors, engineering or ergonomics is the science of the interrelationship between humans, Topic 1: What is patient safety? their tools and the environment in which they Given that health-care professionals are live and work [4]. Human factors engineering will increasingly being required to incorporate patient help students understand how people perform safety principles and concepts into everyday under different circumstances so that systems practice, this topic presents the case for patient and products can be built to enhance performance. safety. In 2002, WHO Member States agreed It covers the human-machine and human-to- on a World Health Assembly resolution on patient human interactions such as communication, safety in recognition of the need to reduce the teamwork and organizational culture. harm and suffering of patients and their families, as well as the compelling evidence of the Other industries such as aviation, manufacturing economic benefits of improving patient safety. and the military have successfully applied Studies show that additional hospitalization, knowledge of human factors to improve systems litigation costs, health care-associated infections, and services. Students need to understand lost income, disability, and medical expenses how human factors can be used to reduce cost some countries between US$ 6 billion and adverse events and errors by identifying how US$ 29 billion a year [3, 4]. and why systems break down and how and why human beings miscommunicate. Using A number of countries have published studies a human factors approach, the human-system highlighting the overwhelming evidence showing interface can be improved by providing that significant numbers of patients are harmed better-designed systems and processes. due to their health care, either resulting in This often involves simplifying processes, permanent injury, increased length of stay (LOS) standardizing procedures, providing backup in health-care facilities, or even death. We have when humans fail, improving communication, learnt over the last decade that adverse events redesigning equipment and engendering occur not because people intentionally hurt a consciousness of behavioural, organizational patients. They are, rather, due to the complexity and technological limitations that lead to error. of today’s health-care systems, especially in developed countries, where the successful Topic 3: Understanding systems and treatment and outcome for each patient depend the effect of complexity on patient care on a range of factors and not just the competence Students are introduced to the concept of one individual health-care provider. When that a health-care system is not one, but many so many different types of health-care providers systems made up of organizations, departments, (doctors, nurses, pharmacists and allied health- units, services and practices. The huge number care workers) are involved, it is very difficult of relationships between patients, carers, to ensure safe care unless the system of care health-care providers, support staff, is designed to facilitate timely and complete administrators, economists and community information and understanding by all the health members, as well as the relationships between professionals. the various health-care and non-health-care services, add to this complexity. This topic Similarly, in developing countries, a combination gives students a basic understanding of of numerous unfavourable factors such as complex organizations using a systems approach. understaffing, inadequate structures and Lessons from other industries are used overcrowding, lack of health-care commodities to show students the benefits of a systems and shortage of basic equipment, poor hygiene approach.29 Part A 2. How were the Curriculum Guide topics selected?
    • When students think in terms of ‘systems’, they contribute to errors in the health-care system.will be better able to understand why things break While errors are a fact of life, the consequencesdown and so will have a context for thinking of errors on patient welfare and staff can beabout ‘solutions’. Health-care students need to devastating. Health-care professionals andappreciate how, as a provider of health care, students alike need to understand how and whyworking in a hospital or rural health clinic, they systems break down and why mistakes happen,will be doing their best to treat and care for their so they can act to prevent and learn from them.patients, but that alone they will not be able to An understanding of health-care errors alsoprovide a safe and quality service. This is because provides the basis for making improvementspatients depend on a number of people doing and implementing effective reporting systems [3].the right thing, at the right time for them. Students will learn that a systems approachIn other words, they depend on a system of care. to errors, which seeks to understand all the underlying factors involved, is significantly betterTopic 4: Being an effective team player than a person approach, which seeks to blameStudents’ understanding of teamwork involves people for individual mistakes. Lucian Leape’smore than identification with the team comprising seminal article in 1994 showed a way to examinetheir own profession. It requires students errors in health care that focused on learningknowing the benefits of multidisciplinary teams and fixing errors instead of blaming those involvedand how effective multidisciplinary teams improve [19]. Although his message has had a profoundcare and reduce errors. An effective team is one impact on many health-care practitioners, manywhere the team members, including the patient, are still stuck in a blame culture. It is crucial thatcommunicate with one another as well as students begin their vocation by understandingcombining their observations, expertise and the difference between blame and systemsdecision-making responsibilities to optimize approaches.patient care [5]. Topic 6: Understanding and managingThe task of communication and flow of clinical riskinformation between health providers and Clinical risk management is primarily concernedpatients can be complicated due to the spread with maintaining safe systems of care. It usuallyof clinical and professional responsibility among involves a number of organizational systems ordifferent members of the health-care team [6,7]. processes that are designed to identify, manageThis can result in patients being required to and prevent adverse outcomes. Clinical riskrepeat the same information to multiple health management focuses on improving the qualityproviders. More importantly, miscommunication and safety of health-care services, by identifyinghas also been associated with delays in diagnosis, the circumstances that put patients at risk of harmtreatment and discharge, as well as failures and acting to prevent or control those follow up on test results [8–12]. Risk management involves every level of the organization, so it is essential that studentsStudents need to know how effective health-care understand the objectives and relevance of clinicalteams work, as well as techniques for including risk management strategies in their workplace.patients and their families as part of the team. Managing complaints and making improvements,There is some evidence that multidisciplinary understanding the main types of incidents inteams improve the quality of services and lower the hospital or clinic that are known to leadcosts [13–15]. Good teamwork has also been to adverse events, knowing how to useshown to reduce errors and improve care for the information from complaints, incident reports,patients, particularly those with chronic illnesses litigation, coroners’ reports and quality-[16–18]. This topic presents the underlying improvement reports to control risks [20] are allknowledge required to become an effective team examples of clinical risk management strategies.member. However, knowledge alone will notmake a student a good team player. They need Topic 7: Using quality-improvement methodsto understand the culture of their workplace to improve careand how it impacts on team dynamics and Over the last decade, health care has successfullyfunctioning. adopted a variety of quality-improvement methods used by other industries. These methodsTopic 5: Learning from errors to prevent harm provide health-care professionals with the tools to:Understanding why health-care professionals (i) identify a problem; (ii) measure the problem;make errors is necessary to appreciate how (iii) develop a range of interventions designedpoorly-designed systems and other factors to fix the problem; and (iv) test whether the WHO Patient Safety Curriculum Guide: Multi-professional Edition 30
    • interventions worked. Health-care leaders, such as care-associated infections being a major cause Tom Nolan, Brent James, Don Berwick and others, of death and disability worldwide. There are have applied quality-improvement principles numerous guidelines available to help doctors, to develop quality-improvement methods for nurses, dentists and others minimize the risks health clinicians and managers. The identification of cross-infection. Patients who have surgery or and examination of each step in the process an invasive procedure are known to be particularly of health-care delivery is the bedrock of prone to infections and account for about 40% this methodology. When students examine each of all health care-associated infections. This topic step in the process of care, they begin to see how sets out the main causes and types of infections, the pieces of care are connected and measurable. to enable health-care students to identify Measurement is critical for safety improvement. the activities that put patients at risk of infection This topic introduces the student to the principles and to prepare students to take the appropriate of improvement theory and the tools, activities action to prevent transmission. and techniques that can be incorporated into their practice. Topic 10: Patient safety and invasive procedures Topic 8: Engaging with patients and carers By recognizing the unacceptable harm caused Students are introduced to the concept that by surgery, WHO has successfully campaigned the health-care team includes the patient and/or to reduce surgical adverse events. One of the main their carer, and that patients and carers play a key causes of errors involving wrong patients, sites role in ensuring safe health care by: (i) helping and procedures is the failure of health-care with the diagnosis; (ii) deciding about appropriate providers to communicate effectively (inadequate treatments; (iii) choosing an experienced and processes and checks) in preoperative procedures. safe provider; (iv) ensuring that treatments are Some examples of wrong site/procedure/patient appropriately administered; and (v) identifying are: (i) the wrong patient in the operating room adverse events and taking appropriate action (OR); (ii) surgery performed on the wrong side [21, 22]. The health-care system underutilizes or site; (iii) wrong procedure performed; (iv) failure the expertise patients can bring, such as their to communicate changes in the patient’s knowledge about their symptoms, pain, condition; (v) disagreements about stopping preferences and attitudes to risk. They are procedures; and (vi) failure to report errors. a second pair of eyes if something unexpected happens. They can alert a nurse, doctor, Minimizing errors caused by misidentification pharmacist or other health-care worker if the involves developing best practice guidelines medication they are about to receive is not for ensuring that the correct patient receives what they usually take, which acts as a warning the right treatment [7, 33]. Students can learn to the team that checks should be made. to understand the value of all patients being treated in accordance with the correct Research has shown that there are fewer errors site/procedure/patient policies and protocols. and better treatment outcomes when there is Such learning would include the benefits of using good communication between patients and their checklists or protocols, as well as knowledge of health-care providers, and when patients are fully the underlying principles supporting a uniform informed and educated about their medications approach to treating and caring for patients. [23–30]. Poor communication between health-care professionals, patients and their carers has also One study of hand surgeons found that 21% emerged as a common reason for patients taking of surgeons surveyed (n=1050) reported legal action against health-care providers [31, 32]. performing wrong site surgery at least once during their careers [34]. Topic 9: Infection prevention and control Because of the worldwide problem of infection Topic 11: Improving medication safety prevention and control and the efforts by WHO An adverse drug reaction has been defined to reduce health care-associated infections, it was by WHO [35] as any response to a medication considered important that this area be included that is noxious, unintended and occurs at doses in the Curriculum Guide, not only for consistency, used for prophylaxis, diagnosis or therapy. but also because together with surgical care Patients are vulnerable to mistakes being made and medication, it constitutes a significant in any one of the many steps involved in ordering, percentage of adverse events suffered by patients. dispensing and administering medication. The problem of infection control in health-care settings is now well established, with health Medication errors have been highlighted in studies31 Part A 2. How were the Curriculum Guide topics selected?
    • undertaken in many countries, which show emergency department. Emergency Medicinethat about 1% of all hospital admissions suffer Journal, 2001, 18:263– adverse event related to the administration 13. Baldwin D. Some historical notes onof medications [36]. The causes of medication interdisciplinary and interpersonal educationerrors include a wide range of factors including: and practice in health care in the US. Journal(i) inadequate knowledge of patients and their of Interprofessional Care, 1996, 10:173–187.clinical conditions; (ii) inadequate knowledge of 14. Burl JB et al. Geriatric nurse practitionersthe medications; (iii) calculation errors; (iv) illegible in long term care: demonstration ofhandwriting on the prescriptions; (v) confusion effectiveness in managed care. Journal of theregarding the name of the medication; and (vi) American Geriatrics Society, 1998,poor history taking [37]. 46(4):506–510.References 15. Wagner EH et al. Quality improvement in chronic illness care: a collaborative approach. 1. Walton MM et al. Developing a national patient Joint Commission Journal on Quality Improvement, safety education framework for Australia. 2001, 27:63–80. Quality & Safety in Health Care, 2006, 15:437–442. 16. Wagner EH. The role of patient care teams 2. The Safety Competencies, First Edition (revised in chronic disease management. British Medical August 2009). Toronto, Canadian Patient Journal, 2000, 320:569–572. Safety Institute, 2009 ( 17. Silver MP, Antonow JA. Reducing medication ucation/safetyCompetencies/Documents/Safety errors in hospitals: a peer review organisation %20Competencies.pdf; accessed 11 March collaboration. Joint Commission Journal on Quality 2011). Improvement, 2000, 26:332–340. 3. Chief Medical Officer. An organisation with 18. Weeks WB et al. Using an improvement model a memory. Report of an expert group on learning to reduce adverse drug events in VA facilities. from adverse events in the National Health Service. Joint Commission Journal on Quality Improvement, London, Department of Health, 1999. 2001, 27:243–254. 4. Kohn LT, Corrigan JM, Donaldson MS, eds. 19. Leape LL. Error in medicine. Journal of the To err is human: building a safer health system. American Medical Association, 1994, 272:1851- Washington, DC, Committee on Quality of 1857. Health Care in America, Institute of Medicine, 20. Walshe K. The development of clinical risk National Academies Press, 1999. management. In: Vincent C, ed. Clinical risk 5. Greiner AC, Knebel E, eds. Health professions management: enhancing patient safety, 2nd ed. education: a bridge to quality. Washington, DC, London, British Medical Journal Books, National Academy Press, 2003. 2001:45–61. 6. Gerteis M et al. Through the patient’s eyes: 21. Vincent C, Coulter A. Patient safety: what understanding and promoting patient centred care. about the patient? Quality & Safety in Health Care, San Francisco, Jossey-Bass Publishers, 1993. 2002, 11:76– 80. 7. Chassin MR, Becher EC. The wrong patient. 22. National Patient Safety Agency. Seven steps Annals of Internal Medicine, 2002, 136:826–833. to patient safety: your guide to safer patient care. London, NPSA, 2003 8. Baldwin PJ, Dodd M, Wrate RM. Junior doctors ( making mistakes. Lancet, 1998, 351:804–805. ns/seven-steps-to-patient-safety/; accessed 16 9. Baldwin PJ, Dodd M, Wrate RM. Young doctors: February 2011). work, health and welfare. A class cohort 1986–1996. 23. Coiera EW, Tombs V. Communication London, Department of Health Research and behaviours in a hospital setting: an Development Initiative on Mental Health of observational study. British Medical Journal, the National Health Service Workforce, 1998. 1998, 316:673–676.10. Anderson ID et al. Retrospective study of 1000 24. Clinical Systems Group, Centre for Health deaths from injury in England and Wales. Information Management Research. Improving British Medical Journal, 1988, 296:1305–1308. clinical communications. Sheffield, University of11. Sakr M et al. Care of minor injuries by Sheffield, 1998. emergency nurse practitioners or junior 25. Lingard L et al. I. Team communications in the doctors: a randomised controlled trial. Lancet, operating room: talk patterns, sites of tension 1999, 354:1321–1326. and implications for novices. Academic Medicine,12. Guly HR. Diagnostic errors in an accident and 2002, 77:232–237. WHO Patient Safety Curriculum Guide: Multi-professional Edition 32
    • 26. Gosbee J. Communication among health professionals. British Medical Journal, 1998, 317:316–642. 27. Parker J, Coeiro E. Improving clinical communication: a view from psychology. Journal of the American Medical Informatics Association, 2000, 7:453–461. 28. Smith AJ, Preston D. Communications between professional groups in a National Health Service Trust hospital. Journal of Management in Medicine, 1669, 10:31–39. 29. Britten N et al. Misunderstandings in prescribing decisions in general practice: qualitative study. British Medical Journal, 2000, 320:484–488. 30. Greenfield S, Kaplan SH, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Annals of Internal Medicine, 1985, 102:520–528. 31. Lefevre FV, Wayers TM, Budetti PP. A survey of physician training programs in risk management and communication skills for malpractice prevention. Journal of Law, Medicine and Ethics, 2000, 28:258-266. 32. Levinson W et al. Physician–patient communication: the relationship with malpractice claims among primary care physicians and surgeons. Journal of the American Medical Journal, 1997, 277:553–559. 33. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Guidelines for implementing the universal protocol for preventing wrong site, wrong procedure and wrong person surgery. Chicago, JCAHO, 2003. 34. Meinberg EG, Stern PJ. Incidence of wrong site surgery among hand surgeons. Journal of Bone & Joint Surgery, 2003;85:193–197. 35. World Health Organization. International drug monitoring–the role of the hospital. A WHO Report. Drug Intelligence and Clinical Pharmacy, 1970, 4:101–110. 36. Runciman WB et al. Adverse drug events and medication errors in Australia. International Journal for Quality in Health Care, 2003, 15 (Suppl. 1):S49–S59. 37. Smith J. Building a safer NHS for patients: improving medication safety. London, Department of Health, 2004.33 Part A 2. How were the Curriculum Guide topics selected?
    • 3. Aims of theCurriculum GuideThe speed with which new technology, including ñ introduce or strengthen patient safety educationdrugs, is introduced into health-care treatments in all health-care professional educationalwell demonstrates the constant change in health settings worldwide;care which, in turn, is changing the nature of ñ raise the international profile of patient safetythe work or tasks undertaken by the different teaching and learning;health professionals. In some countries, nurses ñ foster international collaboration on patientprescribe medication and non-medical personnel safety education research in the higherperform minor procedures. Regardless of education sector.the wealth of a country, patient safety principlesand concepts apply irrespective of the type Underpinning principlesof health-care worker, the place where thehealth care is delivered and the type of patients. Capacity-building is integral to curriculumSome developing countries may lack adequate changehealth-care resources and while staff shortages The main reason that WHO embarked on thismay make the environment more susceptible project was to assist the development of patientto poor quality and unsafe care, it does not safety education in health care. The requirementmean that health-care professionals cannot make of health professional education to develophealth care safer. While very important, more and integrate patient safety learning into thestaff and resources are not the main remedies curricula of the different professions is a challengefor minimizing harm to patients. This Curriculum for many institutions because of the limitedGuide is relevant to all health-care professional education and training of faculty staff in patientstudents irrespective of the resources available at safety concepts and principles. Health-caretheir facility. But the context of the environment faculties cannot be expected to develop newin which the health-care student will be placed curricula or review existing curricula if they areand working when qualified is important for unfamiliar with the requirements of the disciplineteaching. Taking account of the workplace of patient safety.context is necessary to bring authenticityto the learning experience and prepares students Health-care educators come from manyfor the work environment they will be entering. backgrounds (clinicians, clinician educators, non-clinician educators, managers, healthThe aims of the Curriculum Guide are to: professionals) and their collective experienceñ prepare health-care students for safe practice is necessary to deliver a rigorous programme in the workplace; in any particular profession. Many are expertsñ inform health-care educational institutions in their particular disciplines and usually of the key topics in patient safety; keep up-to-date using the accepted professionalñ enhance patient safety as a theme throughout pathways for their area. Patient safety knowledge all health-care professional curricula; requires additional learning that falls outsideñ provide a comprehensive curriculum to assist these traditional routes. To be an effective teaching and integrating patient safety learning; patient safety teacher, health professionals needñ further develop capacity for patient safety to be provided with the knowledge, tools and educators in health-care professional education; skills necessary for implementing patient safetyñ promote a safe and supportive environment education in their institutions. This is why for teaching students about patient safety; a Teacher’s Guide (Part A) has been developed WHO Patient Safety Curriculum Guide: Multi-professional Edition 34
    • to accompany the Curriculum Guide. It provides a more senior person, such as a doctor, about practical advice and information for each stage to make an error; this is universal and applies of curriculum development and renewal, to all cultures to varying degrees. Patient safety from assessing capacity to staff development principles require that everyone is responsible to programme design and implementation. for patient safety and should speak up, even when they are lower in the clinic or hospital A flexible curriculum to meet individual needs hierarchy. Teachers will need to make a judgement We recognize that the curriculum of most about the health-care environment and whether health-care programmes is already filled beyond it is ready and prepared for some of the challenges capacity. This is why we have designed each topic that will accompany the introduction of patient as a stand-alone unit, thus allowing for wide safety. variations in patient safety education implementation. The topics are also designed Teaching and assessment strategies are designed so they can be integrated into existing curricula, to take into account both diversity in available particularly in the doctor–patient stream. resources and environmental differences, The topics in the Curriculum Guide have each considerations that may be in terms of been designed with enough content for a 60–90 a developed versus developing country, minute educational session and feature a variety or a classroom versus a simulation centre. of ideas and methods for teaching and assessing so that educators can tailor material according A curriculum guide that is based on learning to their own unique needs, context and available in a safe and supportive environment resources. There is no requirement to absolutely We are mindful that students respond best when follow the outline provided. Teachers need to pay the learning environment is one that is safe, attention to the local environment, culture supportive, challenging and engaging. Patient and student learning experiences and then select safety learning occurs in many places–beside the most appropriate teaching method for the bed or chair, in the clinics and community, the content selected. in the pharmacy, in simulated environments, and in the classroom. It is essential that students Easily understood language for a targeted are supported in their learning and not made to yet global audience feel humiliated or inadequate. The activities in The Teacher’s Guide (Part A) of the Curriculum the Curriculum Guide are designed to be Guide is written for educators (those with the implemented in a supportive learning environment capacity to introduce or enhance patient safety where students feel comfortable asking questions, education at various levels), while the Curriculum volunteer what they do not understand, and share Guide (Part B: Topics) is written for teachers their understanding in an honest and open way. and students. The Curriculum Guide was written with a global audience in mind and in language easily understood by those with English as both a first and second language. A curriculum guide for all countries, cultures and contexts Every attempt has been made to ensure that the content in this curriculum takes into account the wide variety of contexts in which health-care educators and students teach and learn. An Expert Group, representing all WHO regions, has assessed the curriculum to ensure cultural appropriateness. Although some of the teaching activities and suggestions for students may not be culturally appropriate in every country, we are mindful that in all countries we need to change many of the aspects of clinical care. Much professional behaviour once thought appropriate is no longer acceptable today when taking patient safety considerations into account. For example, staff, such as nurses, pharmacists and junior doctors, are now envcouraged to speak up when they see35 Part A 3. Aims of the Curriculum Guide
    • 4. Structure of theCurriculum GuideTeacher’s Guide (Part A) Curriculum Guide topics (Part B)The Teacher’s Guide (Part A) relates to building The topics represent the actual patient safetycapacity for patient safety education, programme education curriculum.planning and design. Suggestions are providedregarding how patient safety educationmight be approached and implemented usingthe material presented in Part B. In Part A,we try to guide the reader through someimportant steps designed to support and achievethe implementation phase of curriculumdevelopment. WHO Patient Safety Curriculum Guide: Multi-professional Edition 36
    • 5. Implementing the Curriculum Guide How to use this Curriculum Guide the experiences of the health-care providers and This Curriculum Guide provides the resources locally available resources. This Curriculum Guide for teaching health-care students about patient is designed for all health professional students safety. It identifies the topics to be taught, and, therefore, teachers in specific professions how to teach them, and how you can assess should include relevant professional literature the different topics in the curriculum. Patient where possible to reinforce student learning. narratives and case studies are available at Part A of this Curriculum Guide aims to assist the beginning and end of each topic. These cases faculty staff to become familiar with patient safety can be used to demonstrate a particular aspect concepts and principles so they can begin to of the topic under discussion. We recognize that integrate patient safety learning in all educational the best learning occurs when the case study activities. Building capacity of faculty and teaching reflects local experiences; therefore, we encourage staff takes time and commitment. Figure A.5.1 teachers to modify the cases so that they reflect depicts the key stages.Figure A.5.1. Integrating patient safety education into health professional curricula Blueprint for integrating patient safety education into health professional curricula Continuous Review and improve quality improvement Evaluation Feedback from students/tutors /clinicians Faculty and Integration into existing curriculum workplace teachers Capacity building Patient Safety Leaders Patient safety curriculum development & consensus Consultation Commitment & FA C U LT Y priority A validated Patient Safety Patient Safety Curriculum Accreditation Curriculum requirements frameworksSource: supplied by Merrilyn Walton, Professor, Sydney School of Public Health, University of Sydney, Sydney,Australia, 2010. 37 Part A 5. Imlementing the Curriculum Guide
    • How to review your curriculum checking systems to ensure correct patientfor patient safety learning identification. Getting a picture of existing material in the relevant curriculum is necessaryIdentify the learning outcomes to identify the opportunities for enhancingTo start the process of curriculum development patient safety teaching.or renewal, it is important to first identifythe learning outcomes for patient safety. The patient safety curriculum is describedPart B contains the topics that have been chosen in Part B of this document. We have identifiedfor this Curriculum Guide, including the learning the topics, resources, teaching strategies andoutcomes; learning outcomes are further assessment methods that will make patientdiscussed in this section (Part A). safety teaching easier to introduce and integrate into the curriculum.Know what is already in the curriculumWe use the word “curriculum” to refer to Build on what is already in the curriculumthe broad spectrum of teaching and learning A good approach to patient safety educationpractices, including the strategies for developing is to enhance existing parts of a curriculum ratherskills and behaviours, as well as using appropriate than viewing patient safety as a new subjectassessment methods to test whether the learning to teach. There are elements of patient safetyoutcomes have been achieved. Students are that are new and will be additional to the existingguided in their learning by a curriculum that sets curriculum, but there are many aspects of patientout the requisite knowledge, skills and behaviours safety that can be added onto or achievedrequired to demonstrate competency upon with further development of a subject or topiccompletion of their chosen health professional that already We have found that mapping topics or learningBefore new material is introduced into areas in the existing curriculum will help identifya curriculum, it is important to know the content opportunities to include patient safety conceptsof the existing curriculum, as well as students’ and principles. Areas such as skills development,experiences in the hospitals and/or different professional and personal development, healthwork environments. It may be that students law, ethics and communication are all suitableare already experiencing some patient safety areas for including patient safety concepts andeducation in the hospitals and clinics that is not principles. Table A.5.1 is a template developedwritten down. The curriculum may already cover by the University of Sydney Medical Schoolsome aspects of this patient safety curriculum, (Australia) to review where patient safety learningsuch as the importance of protocols for hand could occur in the medical school curriculumhygiene to avoid infection transmission or and offer it as an example that can be followed.Table A.5.1. Mapping exercise: identification of patient safety content in the existing medicalprogramme Session/ Year Where is the Potential How is patient How is patient Comments area of the patient safety patient safety safety being safety being curriculum content? learning taught? assessed? Ethics 1 Respect for Honesty after Lecture Ethics essay, multiple Many patient patient an adverse choice questions (MCQ), safety principles autonomy event objective structured have an ethical clinical examination basis that can (OSCE) be used to make explicit the patient safety lessonMapping your curriculum will also help safety concepts in an integrated fashion.identify the opportunities for including patient WHO Patient Safety Curriculum Guide: Multi-professional Edition 38
    • How to assess the capacity of faculty the basis and urgency for patient safety education to integrate patient safety teaching into as well as to establish a relationship for later work. the existing curriculum One of the biggest challenges facing all health Convene a round table professions is the growing shortage of workplace Invite a select group of people from your teachers generally. There are few who know how profession who you think may be interested to integrate patient safety principles and concepts and might be possible role models or into structured teaching in a new area and many “champions” to participate to a round table will find the content unfamilar. Many health discussion about patient safety education for professionals intuitively adopt patient safety students. (The benefit of a round table format methods into their everyday practice, but may not is that there is no one expert obviously in charge know how to articulate what they do. This may and the group seeks to discuss and resolve be because they view any discussions about the issues together in a collegial fashion.) “systems” as the province of administrators and managers. Others may not think patient Conduct a seminar on patient safety safety teaching important or relevant to their area Seminars are typical venues for building new of practice but patient safety concerns everybody. knowledge. Seminars are useful for exposing Most health-care professionals today would be practitioners new to the area as, well as to experts conscious of the need for patient safety, but or respected practitioners who are knowledgeable because this area is so new to curriculum, about patient safety. Seminars can either be engaging health-care professionals will be a half-day or a full day. Topics could include: the first challenge for you. Building capacity (i) what is patient safety?; (ii) the evidence of the faculty can take time, but there are of why patient safety is important; (iii) how to a number of steps that can be taken to engage develop a curriculum for patient safety; (iv) how clinicians in patient safety teaching. to teach patient safety; and (v) how to assess patient safety. It is important to remember Survey to maintain the aim of the programme, which One way to find out who is interested in teaching is to build capacity for faculty staff and patient safety is to conduct a survey of those professionals to teach patient safety to students. who teach students. In some institutions there may be hundreds of teachers and in others not How to identify like-minded colleagues so many. Identify the persons who are in the best or associates position to incorporate patient safety teaching If you undertake the activities set out above in and ensure that they are included in the survey. relation to building capacity, this will help identify The mapping exercise described above will help like-minded people interested in teaching patient identify faculty staff who currently teach and are safety. Another way is to convene a meeting in a position to integrate patient safety concepts. and send an open invitation to faculty staff and The survey could include questions related to teachers. Make sure to schedule the meeting at an interest or knowledge of patient safety a time convenient for as many people as possible and practice in patient safety methods. This in order to attract maximum attendance (e.g. process could also identify persons interested some professions who see patients during the day in forming a group or committee to oversee may want to come, but cannot because of work the development of the patient safety curriculum demands). Another way is to put an article in the in your particular profession. faculty or university newsletter. This will let people know about patient safety, and even if they are Focus group not interested in getting involved, the article Run a focus group of health professionals from will raise awareness of the need to include patient your particular profession to find out what safety education in the curriculum. the current state of knowledge is about patient safety. This will also provide information about Patient safety teaching requires the person their attitudes towards patient safety learning responsible for implementing the programme in the curriculum. to engage interested and knowledgeable health professionals who have identified themselves Face-to-face meetings or have been appointed or nominated as a result Individual meetings with faculty staff and of previous contacts or meetings about patient workplace teachers from your profession will help safety. It is also a good idea to check the to convey a clear message about patient safety availability of experts from other faculties and education. This provides an opportunity to explain disciplines, such as engineering (human factors39 Part A 5. Imlementing the Curriculum Guide
    • knowledge), psychology (behavioural psychology, Guide has been designed for all health-careprocess and improvement theories), pharmacy students. Most health-care professions and(medication safety), and nursing and medicine disciplines have much to contribute, particularly(infection control). in teaching some of these topics. Engineers may be able to teach about human factors systemsTechniques to fit patient safety learning and safety cultures. Psychologists and behaviouralinto the curriculum scientists, nursing, medicine and pharmacyBrainstorming is a technique that requires and faculties can teach how their disciplines haveencourages everyone to suggest ideas for solving made safety improvements. Striving for diversitya problem. The problem being how to best gives the maximum chance to enable studentsintroduce patient safety learning into the to learn from other disciplines, particularly in thecurriculum. Each health-care faculty is different context of a team approach to patient safety.with varying resources, capacity and interestin patient safety. In some countries, patient safety Reaching agreementmay not yet be a community or government As in all discussions about curriculum content,concern and the urgency to include patient safety there will be different views about what should beeducation may not be perceived as a priority. included and what should be left out. The important point is to start and build up fromConvening introductory workshops on this the discussion. This means that compromise maymulti-professional edition of the WHO Patient be better in the long run–getting somethingSafety Curriculum Guide will provide an started rather than debating and discussingopportunity for members of the faculty to become the issues for lengthy periods of time. Anotherfamiliar with the core topics in patient safety. technique is to introduce new topics into theIt will also allow them to express any reservations, curriculum using a pilot, which could identifyask questions and clarify any concerns they have any problems and be used as a guide for futureabout the programme. topics. It also allows faculty staff members who are unsure of the value of patient safety learningPatient safety is best considered in the context to get used to the idea.of multidisciplinary learning. Staff should beencouraged to reflect on the feasibility of The next section gives more details aboutcombining some of the patient safety sessions developing and integrating the Curriculum Guidewith other health professionals. This Curriculum into existing curricula. WHO Patient Safety Curriculum Guide: Multi-professional Edition 40
    • 6. How to integrate patient safety learning into your curriculum General comments patient safety teaching and learning into an Patient safety is a relatively new discipline and existing curriculum. The benefits and challenges introducing any new material into an existing of different approaches will be covered to help curriculum is always challenging. What should be you determine the likely best fit for your school taught? Who should teach it? Where and how and to help you anticipate and plan what is will it fit in with the rest of the curriculum? required. What does it replace? The nature of patient safety education: If your professional school is in the process of ñ it is new; renewing an existing curriculum or if you belong ñ it spans a number of fields not traditionally to a new health professional facility, this is taught to health-care students, such as human an ideal time to make a case for allocating space factors, systems thinking, effective teamwork for patient safety education. However, most behaviours and managing error; health-care professional school curricula are well ñ it links with many existing and traditional established and already full. It is unusual to find subjects (applied sciences and clinical sciences) a block of free time waiting for a new area (see Box A.6.1 for some examples); of study. ñ it contains new knowledge and performance elements (see Box A.6.2 for examples); This section provides ideas on how to integrate ñ it is highly contextual.Box A.6.1. Linking patient safety education with traditional medical andnursing school subjectsAn example of how a patient safety topic, such as correct patient identification, has specific applicationsin 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? 41 Part A 6. How to integrate patient safety learning into your curriculum
    • Box A.6.2. Linking patient safety education with new knowledge and performance elementsPatient 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?”The field of patient safety is also very broad. Given ñ How is your curriculum delivered?this breadth and the need for contextualizing ñ Who is responsible for the delivery of thepatient safety principles, there are likely to be teaching?many opportunities in your curriculum toincorporate effective patient safety education into Once you have answered these questions, it willexisting sessions. However, some areas of patient become more apparent where and how patientsafety are relatively new to health-care professions safety can be included in your curriculum.and may not be so easy to graft onto an existingsession and hence are likely to need their own How is your overall curriculum structured?time slot in the curriculum. Topic 2, Why applying ñ Is it a traditional curriculum delivered by lectureshuman factors is important for patient safety, may be to large groups of students? Students first learndifficult to integrate or incorporate into an about the basic and behavioural sciences andexisting subject. One approach to this topic would once these are complete, they concentratebe to create a time and invite an expert from on particular areas relevant to the profession.either the faculty of engineering or psychology Education tends to be discipline-specific ratherto give a lecture followed by a small group than integrated.discussion. In this setting, the application and performanceHow to establish best fit using generic elements of patient safety may be best introducedcurriculum structures in the later years of the course. However, broadOnce you have reviewed your existing curriculum, knowledge of patient safety principles can still bedetermined what patient safety areas are already effectively introduced in the early years.taught and decided what patient safety topicsyou want to teach, it is time to think about how ñ Is it an integrated curriculum? Basic, behavioural,to incorporate the new content into your and clinical sciences and skills are coveredcurriculum. in parallel throughout the course and learning is integrated.When thinking about your curriculum considerthe following questions: In this setting, there are advantages to the verticalñ How is your overall curriculum structured? integration of knowledge, application andñ When and where in the curriculum are particular performance elements of patient safety education subjects and topics taught that might lend throughout the course. themselves to inclusion of patient safety content? Knowledge and performance requirementsñ How are individual topics structured in terms of patient safety of learning objectives, delivery methods and ñ Student learning is ideally experienced in the assessment methods? workplace setting; relevance is more apparent WHO Patient Safety Curriculum Guide: Multi-professional Edition 42
    • once students understand how health care public health, epidemiology, ethics, or other is delivered and they are more familiar with behavioural science-based subjects. Suitable topics the workplace environment. for early introduction include: (i) what is patient ñ Students will be more likely to change practices safety?; and (ii) systems and complexity in health if they have the opportunity to use what they care. If your curriculum is integrated and students have learnt shortly after it is covered in the are taught clinical skills from the first year, then curriculum. patient safety topics are best introduced early and vertically integrated throughout the entire course. When teaching a patient safety topic, there are This makes patient safety a constant theme and advantages if the knowledge and performance provides opportunities to reinforce and build requirements are covered together. A clear upon earlier learning. Ideally, students should be understanding of the scope of a problem in exposed to patient safety education prior to and patient safety will provide motivation and insight upon entering the workplace. when learning about performance requirements. When and where in the curriculum are Students are also less likely to feel demoralized particular subjects and topics taught about the risks facing patients from the health- that might lend themselves to inclusion care system they will soon be a part of. If they of patient safety teaching? explore solutions (applications) and learn practical Any area of learning relevant to a particular strategies (performance elements) to make them profession can potentially house a patient safety safer providers of health care at the same time, topic if a sample case is part of the session and they will be more positive. For logistical reasons, is relevant to that discipline. For example, a case it may not be possible to cover the knowledge involving a medication error in a child could be and performance requirements of a patient safety used as the starting point for teaching nurses topic at the same time. about understanding and learning from errors while studying paediatrics. Similarly, during If your curriculum is traditional, then knowledge learning about managing patients after hip and performance requirements of patient safety or knee replacements, a physiotherapy student are best taught in later years when students have could learn about the topic “patient safety more knowledge of professional practice and and invasive procedures”. Many areas could house exposure to patients and workplace skills’ training. the topic of “understanding and learning from The context for the knowledge and performance errors” if the case was relevant to that particular requirements should match the students’ ability discipline. The learning, however, is generic to put into practice their new knowledge. and relevant for all disciplines and all students. Introductory patient safety knowledge can still be Box A.6.3 sets out opportunities for examining included in the early years in subjects such as the integration of patient safety topics. Box A.6.3. Integration of patient safety topics Patient safety topic Subjects that could house patient safety topics Minimizing infection through Microbiology improved infection control Procedural skills’ training Infectious diseases Clinical placements Improving medication safety Pharmacology Therapeutics Being an effective team player Orientation programmes Communication skills’ training (interprofessional) Emergency disaster training What is patient safety? Ethics Introduction to the clinical environment Clinical and procedural skills’ training43 Part A 6. How to integrate patient safety learning into your curriculum
    • How are individual curriculum topics ñ simulation/skills laboratories;structured in the following areas? ñ traditional tutorials.ñ learning objectives;ñ delivery methods; It will probably be easier to incorporate patientñ assessment methods. safety topics into pre-existing educational delivery methods familiar to students and staff.Implementation of new patient safety content Examples of models for implementationinto your curriculum will be more efficientif the associated learning objectives and delivery Example 1: Patient safety as a stand-alone subject inand assessment methods are consistent with a traditional curriculum occurring in the final years.the structure of objectives, and delivery See chart A.6.1.and assessment methods of existing subjects. ñ educational methods could consist ofHow is your curriculum delivered? a combination of lectures, small groupñ lectures; discussions, project work, practical workshops,ñ work placements, online activities on or simulation based exercises; the wards, in pharmacies, in delivery suites; ñ adding a layer of patient safety to priorñ small group tutorial teaching; knowledge before entering the workforce.ñ problem-based learning (PBL);Chart A.6.1. Patient safety as a stand-alone subject in a traditional curriculumoccurring in the final yearYears 1 and 2:basic, appliedand behaviouralsciences Patient safety topicsYears 3 and 4:disciplines andclinical skillsExample 2: Patient safety as a stand-alone subject in with links to other subjects, e.g. lectures at thean integrated curriculum. See chart A.6.2. start of term that relate to topics that will come up in tutorials or on placement over the coursePatient safety could be a stand-alone subject of the year.Chart A.6.2. Patient safety as a stand-alone subject in an integrated curriculum Year 1 Topic 1: what is patient safety? PBL/other delivery format Year 2 Topics 2, 3 and 5: why applying human factors is important for patient safety; understanding systems Clinical skills workshops and the effect of complexity on patient care; and clinical placements learning from errors to prevent harm Year 3 Topics 4, 7, 9 and 10: being an effective team player; using quality-improvement methods to improve care; infection prevention and control; patient safety and invasive procedures Year 4 Topics 6, 8 and 11: understanding and managing clinical risk; engaging with patients and carers; improving medication safety WHO Patient Safety Curriculum Guide: Multi-professional Edition 44
    • Example 3: Integrating patient safety into pre-existing In the fourth year there could be a lecture on subjects–example A. See chart A.6.3. medication safety as part of therapeutics, a workshop on safe drug administration, and a PBL A number of subjects could set aside some or small group learning format where a case is sessions where the main objective of the tutorial discussed that demonstrates the multifactorial or lecture is to cover a patient safety topic. nature of error using a case or medication error.Chart A.6.3. Implementation of patient safety as a stand-alone subject into pre-existingsubjects (A) Year 1 PBL Patient safety case Clinical skills Patient safety activity Lecture Patient safety topic Year 2 PBL Patient safety case Clinical skills Patient safety activity Lecture Patient safety topic Year 3 PBL Patient safety case Clinical skills Patient safety activity Lecture Patient safety topic Year 4 PBL Patient safety case Clinical skills Patient safety activity Lecture Patient safety topic Example 4: Integrating patient safety into pre-existing objectives should include an element subjects–example B. See Chart A.6.4. of patient safety. See Box A.6.4 for examples. Work together with subject leaders to incorporate The more patient safety topics are integrated elements of patient safety into selected into the established curriculum, the easier educational sessions. Although the main focus it will be to incorporate the performance of the session is not a patient safety topic, requirements in a meaningful way, elements of patient safety education are weaved and provide context for patient safety into the session. For this to occur, session concepts. 45 Part A 6. How to integrate patient safety learning into your curriculum
    • Chart A.6.4. Implementation of patient safety as a stand-alone subject in pre-existingsubjects (B) Year 1 PBL Patient Patient safety case safety case Clinical skills Patient Patient Patient Patient Patient Patient safety safety safety safety safety safety activity activity activity activity activity activity Lecture Patient safety topic Year 2 PBL Patient Patient safety case safety case Clinical skills Patient Patient Patient Patient Patient Patient safety safety safety safety safety safety activity activity activity activity activity activity Lecture Patient safety topic Year 3 PBL Patient Patient safety case safety case Clinical skills Patient Patient Patient Patient Patient Patient safety safety safety safety safety safety activity activity activity activity activity activity Lecture Patient safety topic Year 4 PBL Patient Patient safety case safety case Clinical skills Patient Patient Patient Patient Patient Patient safety safety safety safety safety safety activity activity activity activity activity activity Lecture Patient safety topicBox A.6.4. 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 Patients are always provided with an explanation and consent to being part of bedside/chairside or clinic 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 Sterile technique and sharps’ disposal are included. Involve patient in risk intravenous cannulation 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. Include consent training. PBL on pulmonary embolism Students are encouraged to discuss the importance of patient education when where the index case is prescribing potentially dangerous medication. commenced on an oral anticoagulant WHO Patient Safety Curriculum Guide: Multi-professional Edition 46
    • A cautionary note topic; tasks are allocated and the students solve The more that patient safety is integrated into problems together and reflect on their effort. the existing curriculum, the more it is dispersed, The following suggestions show how patient dependent on a greater number of teachers, safety topics can be integrated into PBL cases. and the more it becomes harder to coordinate ñ Include information in the case that relates effective delivery. You will need to find the balance to a patient safety issue. To achieve this, between integration of the new material and include aspects of the realities of the the ability to coordinate its delivery. It is a good health-care delivery system, which will provide idea to keep a detailed record of what patient opportunities to explore issues relating safety element is integrated into the existing to patient safety. curriculum, how it is being taught and how it is ñ Make the case relevant to your local health-care being assessed. From an educational perspective, environment. integration of patient safety is ideal; however, ñ The case may include a near miss or adverse this aim needs to be balanced by the practicalities event. of implementation. ñ The case may include a threat to patient safety, thus helping students to recognize where the When asked by a university or accrediting body hazards in the system lie. where and how patient safety is taught to students, the relevant faculty needs to have A case may include a nurse, pharmacist, information that is sufficiently detailed to allow midwife, dentist or doctor. The case can include an observer to attend such a session and see a professional being assertive (speaking up) patient safety education being delivered. It may with the more senior persons being receptive be that a combination of the above approaches to the intervention by the junior staff member, is more appropriate for your setting. thus resulting in improved patient care. The patient safety issue may be a major or minor Once you have an overall plan of what, where component of the PBL case. and how you want to incorporate patient safety into your curriculum, it will be easier to add to the curriculum in a piecemeal fashion, topic by topic over time, rather than trying to add Example of a PBL case every aspect of your plan at once. In this way Jeremy So is a 15-year-old boy who arrives you can learn as you go, and start achieving small at the local medical clinic with noisy goals early. breathing and itch. His father says he was fine 30 minutes ago and that he just be- Suggestions for including patient safety came unwell quite suddenly. On examina- learning in problem-based learning sessions. tion, Jeremy looks distressed and nervous. Some health-care programmes use PBL as the He has a puffy face, his lips are huge, and preferred educational delivery method. PBL he can hardly open his eyes as they are so programmes, originally pioneered at McMaster swollen. He has red blotches on his skin University in Canada, requires students to and he is scratching his body. Every time collaboratively work together on a particular he breathes in he makes a noise. Case example: the same case written to elicit discussion of medical error as well as answers to the above questions Jeremy is a 15-year-old boy who arrives at the local medical clinic with noisy breathing and itch. His father says he was fine 30 minutes ago and that he just became unwell quite suddenly. On 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 swollen. He has red blotches on his skin and he is scratching his body. Every time he breathes in he makes a noise. Jeremy’s father says his son was like this once before after taking a medicine called penicillin and he was told never to have penicillin again because it could kill him. Jeremy saw a doctor this morning because of a runny nose, sore throat and fever. The doctor prescribed amoxicillin, which Jeremy started earlier today. Jeremy’s father wonders if his son might also be allergic to this new medicine amoxicillin.47 Part A 6. How to integrate patient safety learning into your curriculum
    • professional needs to acquire about a procedure before undertaking that procedureCase example: the case may (Topics 6 and 10);include examples of how ñ sterile precautions (Topic 11);to enhance patient safety. ñ communicating risk (Topics 6 and 9);A nurse, pharmacist or medical student ñ correct patient identification, correct site,noticing some important information that correct patient (Topic 10);the doctor has overlooked. The case can ñ follow-up (Topics 2, 6, 9 and 10).describe the nurse (or other health profes-sional) being assertive (speaking up), the Patient safety learning and application to thedoctor being receptive to the nurse, and performance of specific procedures:the patient’s care being improved as a ñ common problems, hazards/traps,result. troubleshooting (Topics 2 and 5); ñ common and serious complications and how to minimize them (Topics 1 and 5);Integration of patient safety into ñ advice for patients regarding follow-upa procedural skills training programme (Topics 6 and 9);Many procedures and treatments have the ñ equipment familiarity (Topic 2);potential to harm patients. This is especially so ñ specific applications of broad patient safetywhen learners who are still lacking in experience topics (all topics).are involved. Procedures can cause harm throughcomplications, pain and emotional distress, Example. Correct patient identification whenand by not being effective or necessary in the taking a blood sample.first place. The knowledge, skill and behaviour of How to label sample tubes to minimize chancethe person performing the procedure can help of misidentification:to minimize some of the potential risks for ñ label at the bedside;patients. Integrating patient safety education ñ check the patient’s name with an open-endedwith procedural skills training at an undergraduate question;level will help students to be mindful of their ñ ensure that the patient’s name matches theresponsibilities to patients when embarking label on the sample tube and the label on theon procedures. This section provides some request form, i.e. perform a “three-way check”.suggestions on how to integrate patient safetyeducation with procedural skills training in your A variety of educational methods can be usedschool. As a starting point, consider the following to introduce the broad patient safety topics asquestions: they apply to performing procedures, e.g. lectures,1. When, where and how are procedural skills reading material, group discussion, tutorials and taught in your programme? online activities.2.What are the skills taught?3.When do students start to perform procedures The best time to learn the knowledge and on patients? Ideally, the patient safety messages performance requirements of a patient safety should precede or coincide with this. topic is when learning the steps of the procedure. This may occur in a practical tutorial at thePatient safety topics to consider including bedside, using simulation in a skills laboratory,in a procedural skills training programme or as a tutorial without a “hands-on” component.Broad patient safety topics that are relevant Students could be asked to read a particularfor all procedures: article or guidelines prior to attendingñ the learning curve. Understand that an the teaching session. inexperienced learner is more likely to cause harm and/or fail a procedure compared to an Tutorials on particular procedures provide experienced practitioner. What strategies can an excellent opportunity to reinforce generic be used to help minimize harm while still principles, to detail patient safety applications allowing for learning to take place? For example, for a particular procedure, and for students to the role of careful preparation, planning, practise performance elements of patient safety. background knowledge, observation of others performing the procedure, simulation, For example, if your school utilizes immersive supervision, feedback and follow-up of patients scenario-based simulation training to learn (Topics 2, 5 and 6); disaster management or a particular procedureñ the required background knowledge a health or treatment, there is an opportunity to WHO Patient Safety Curriculum Guide: Multi-professional Edition 48
    • incorporate team training into that programme. Skills training may provide opportunities The advantages of this type of training for students to learn about and practise for incorporating patient safety messages are the following patient safety performance the realistic situations that mirror many real life elements: challenges that can emerge from the scenario. ñ communicating risk; As an example, knowing what to do in an ñ asking permission; emergency situation is different from actually ñ accepting refusal; doing it, especially when working as part of ñ being honest with patients; a team. The real elements introduced are time ñ empowering patients–helping patients be pressure, stress, teamwork, communication, active participants in their own care; equipment familiarity, decision making in action ñ keeping patients and relatives informed; and knowing the environment. Similar to other ñ hand hygiene; forms of experiential learning, there are ñ patient-centred focus during history taking opportunities to practise the performance and appropriate examinations; requirements demonstrating safe practice. ñ clinical reasoning–diagnostic error, consideration of risk benefit ratio of procedures, investigations Note: Immersive scenario-based teaching using and management plans. simulation can be a highly effective way for students to learn, but can also be quite How to collaborate with ward/clinic/ confronting for students and not always community-based teachers and teachers a comfortable way to learn. Attention of professional skills to creating a safe and supportive learning For patient safety principles to be integrated environment is very important if this broadly throughout the curriculum, the educational method is used. See the section cooperation of many individual teachers will need on underpinning educational principles for to occur, particularly if patient safety education more details on creating a safe and supportive is to be delivered in small group settings and skills learning environment. tutorials. Skills training programme We mentioned in the beginning of this section Skills training includes learning how to take that many teachers will not be familiar with a patient history, how to perform an appropriate patient safety concepts and specific knowledge examination, clinical reasoning, interpretation and performance requirements will be new. of test results, preparation of medications, For example, students may see health-care and procedural and communication skills, professionals in the workplace asking patients such as providing information, counselling their name in a hurried and disrespectful manner, and obtaining informed consent. taking shortcuts that may compromise patient safety, or displaying a “blame and shame” A range of methods are used to teach health attitude when things go wrong. Tutors will need professionals the relevant skills, such as bedside to reflect on their own practice if they are to be or chairside tutorials, medication preparation in effective patient safety teachers and role models. pharmacies, practising with simulated patients, practising with peers, observing videos of expert The following strategies may assist to engage performance, participation in the clinical teachers in patient safety teaching: environment and presenting cases. ñ conduct a patient safety workshop or lecture series for teachers; Consider when and how your school delivers ñ invite guest speakers to promote patient safety; its skills programme. ñ engage/excite teachers about the inclusion of patient safety in the curriculum; A number of patient safety topics will be ñ parallel patient safety education in the appropriate for inclusion in any skills programme. postgraduate setting; And since the programme may offer opportunities ñ clearly state patient safety learning objectives to practise performance elements of patient in tutor notes; safety, it is important that good habits be ñ provide tutors’ notes on patient safety topics; developed early. Note that bedside/chairside/ ñ assess patient safety content in examinations. benchside tutorials offer rich opportunities for tutors to role model safe practice–for example, Using case studies patient-centred communication, hand hygiene, We provide a number of case studies for each the use of checklists and protocols. topic that can be used to demonstrate why the49 Part A 6. How to integrate patient safety learning into your curriculum
    • topic is relevant to patient safety. The best way Different types of cases have been used, rangingto use case studies is to have the students/ from health services that rely heavily oninstructor read the case and then either discuss technology to ones with limited small groups a range of discussion points This means that many of the case studies willor answer a number of questions relating to apply to most health-care programmes; if not,the case. Alternatively, an interactive session with the case studies can be modified by changinga large group can also work. We have included the environment in which the case takes place.suggested questions or discussion points after The case can also have another type of healtheach case study. The focus of the questions is provider involved when the one identified into get the students to focus on the underlying the case study does not exist. For example,factors rather than just focus on the people patients can be changed from male to femalewho were involved. or female to male (if culturally appropriate), can have family members present or absent,Build local case studies or come from a rural area or a city. After a caseCase studies can either demonstrate how not study has been modified to take into accountto do something (learning from negative local elements, give the case study to a colleagueexperience) or how to do something right to see if it makes sense and is relevant(learning from positive experience). For example, to the topic, local environment and context.if a case study is being developed for the topic“being an effective team player”, then the localcase study would have elements of teamsthat are familiar to the local institutions, clinicsor hospitals.The following steps will assist in building localcases relevant to the topic being taught.Review the sections of each topic in thisCurriculum Guide outlining: ñ the relevance of the topic to the workplace; ñ the learning objectives for the topic.Write down the activities that are capturedin the objectives.Obtain case studies from: ñ the Curriculum Guide; or ñ ask nurses, midwives, dentists, pharmacists, doctors and other health professionals in the hospital or clinic to provide identified cases.Develop a realistic story that containsthe elements set out in the objectives.The context of the case study should be familiarto the students and health-care professionals.For example, if there are no pharmacy serviceslocally available, then the case studies shouldtake this into account.How to modify the case studies inthe Curriculum GuideMost of the case studies are written to illustratea behaviour or process. Many of the cases wehave selected and those supplied by membersand affiliates of the WHO Expert Group relateto more than one topic, such as understandingerrors, communication, teamwork and engagingwith patients. We have listed all of the casesunder each topic that we think could be usedto demonstrate an appropriate learning objective. WHO Patient Safety Curriculum Guide: Multi-professional Edition 50
    • 7. Educational principles essential for patient safety teaching and learning For patient safety education to result in safe in the workplace as they arise. For example, practice and improved patient outcomes it needs correct patient identification is important in: to be meaningful to students. As with any ñ sending off blood samples; teaching, one of the major challenges is to ensure ñ administering medication; transfer of the learning to the workplace. What ñ putting labels on imaging request forms; can educators do to encourage students to apply ñ writing in patients’ files; their learning in a practical way in the real life ñ writing on patients’ medication charts; work setting? ñ performing procedures; ñ working with patients who have difficulty The following strategies can help. with communication; ñ communicating with family and relatives Context is highly relevant in teaching of the patient; patient safety ñ referral to other health-care professionals. Contextualize patient safety principles Use examples that are of interest or soon Patient safety principles need to be made will be relevant to students relevant to the daily activities of health-care Draw on situations that the students may find workers. Aim to show students when and how themselves in when they are novice health-care patient safety knowledge can be applied in professionals and/or as students on placement. practice. This means using examples that For example, if the educational session is about students can relate to. being a patient advocate, it is far better to use an example of a student being assertive with Use examples that are realistic for your a senior practitioner, rather than the senior setting practitioner needing to be assertive with hospital Think about the sort of work most of your management. In this way, the relevance of students will be doing after they graduate the material will be more apparent to students, and have this in mind when choosing clinical thus resulting in better motivation for learning. contexts in which to incorporate patient safety See the following example education. Including a case about malnutrition, morbid obesity or malaria is not particularly useful if these conditions are extremely uncommon in your practice setting. Use situations and settings that are common and Case example relevant for the majority of your graduates. While observing a surgical operation, a nursing student notices that the surgeon is Identify practical applications closing the wound and there is still a pack Help students identify the situations in which inside the patient. The student is not sure if they can apply their patient safety knowledge the surgeon is aware of the pack and is and skills. In this way they are more likely wondering whether to speak up. to recognize opportunities for safe practice51 Part A 7. Educational principles essential for patient safety teaching and learning
    • Give students the opportunity to apply ñ Introduce yourself to students and ask thetheir patient safety knowledge and skills students to introduce themselves. Show anBy giving students the opportunity to practise interest in them as individuals as well as showing“safe practice”, such behaviours will hopefully an interest in their learning.become habitual and students will be more ñ At the start of your teaching session, explaininclined to approach clinical situations with how the session will run. This will let thea patient safety mindset. students know what to expect, and also what is expected of them.Practising safely can occur as soon as students ñ Orient learners to the environment you arecommence their training–for example, in: teaching in. This is especially important if youñ tutorials or private study, e.g. brainstorming are in the workplace, clinical environment, solutions for hazardous situations; or a simulation environment. Students needñ a simulation setting, e.g. skills laboratory, to know what is expected of them if they are simulation laboratory, role play; in a new setting.ñ the clinical environment, e.g. hand hygiene when seeing patients, correct patient identification when drawing blood from a patient; Simulationñ patient interactions–when advising, students Simulation environments can be confusing can practise encouraging patients to be as some aspects are real, some aspects are informed, ask questions, and be proactive not, and the learner is asked to pretend in ensuring care progresses as planned. that some aspects are real. Make sure that the learners know the level of immersionCreate an effective learning environment required for the role play and how reali-Aspects of the learning environment can also have stically you expect them to treat thea bearing on the effectiveness of teaching and situation. It may be embarrassing for alearning. An ideal learning environment is one nursing student to talk to an intravenousthat is safe, supportive, challenging and engaging. (IV) cannulation insertion practice arm as if it were a real patient when the teacher’sSafe and supportive learning environments intention was just to use the IV insertionA safe and supportive learning environment practice arm for practising the manualis one in which: aspects of the task.ñ students feel comfortable to ask “stupid” questions;ñ volunteer what they do not understand;ñ share what they do understand in an honest ñ Invite students to ask questions and speak up and open way. if there is anything they do not understand. This sends the message that not knowingStudents who feel safe and supported tend to be is okay.more open to learning, enjoy being challenged, ñ Never criticize or humiliate a student for lackand are more prepared to actively participate in of knowledge or poor performance. Rather,learning activities. this should be viewed as a learning opportunity. ñ If active participation is required, ask forIf students feel unsafe and not supported, they volunteers rather than singling people outwill tend to be reluctant to disclose knowledge yourself.deficits and less likely to engage actively for fear ñ Consider demonstrating how to do somethingof feeling embarrassed or being humiliated in yourself before asking students to have a turn.front of their teachers and peers. The student’s For example, when teaching about howprimary aim becomes self-preservation rather to create a sterile field before administeringthan learning. Attention to creating a safe and an injection, it is much more efficient tosupportive learning environment not only makes demonstrate how to do it correctly at thelearning more enjoyable, but also, importantly, outset, rather than have a student do it in frontmakes learning more effective. The teacher has of their peers before having been taught howa significant role in making the learning and making mistakes that need to be corrected.environment a comfortable place for students. ñ When asking questions of a group of students, it is best to ask the question first, give studentsSuggestions for helping to create a safe and time to think about the question, and then looksupportive learning environment: for someone to provide a response. Avoid WHO Patient Safety Curriculum Guide: Multi-professional Edition 52
    • choosing a student before asking the question. It can be challenging to deliver lectures that are Some students will find this unnerving and may engaging. The following strategies may help: have trouble thinking clearly if a whole class is ñ try to be interactive; waiting for their response. ñ pose questions to the students; ñ If, as the teacher, you are asked a question you ñ have students discuss an issue or share their do not know the answer to, do not try to hide experience in pairs; this fact or apologize for not knowing. ñ tell a story to illustrate a point; To respond in such a way would send a message ñ use case examples or problems that students to the students that not knowing is can easily relate to as the starting point for unacceptable. A useful quote to remember is, the lecture; “the three most important words in health ñ relate theoretical concepts to concrete examples; professional education are “I don’t know”” [1]. ñ have students critique a video, case, statement, ñ When providing feedback on performances in solution or problem. the practice (or simulation) setting, make it a two-way conversation. Ask students for their Activities such as observing a hospital or clinic opinion before giving your own and include activity, reading an article or observing a aspects of performance that were done well procedure can be made more engaging if students and areas that need more work. Help students have a task to complete as part of the process. develop a plan for addressing the areas that Ideally, the task would help develop critical need more attention. reflection skills. For example, if students are required to attend peer review meetings, they Challenging and engaging learning could have some preset questions to address environments based on their observations. Students who are challenged by the teacher are likely to progress their learning more rapidly. Teaching styles A challenging learning environment is one where Individual educators tend to adopt a preferred students are encouraged to think about and do style of teaching if the option exists [2]. The things in new ways. Assumptions are challenged preferred style is likely to be determined by a and new skills are developed. Students value combination of the teacher’s beliefs about what these kinds of learning activities. It is important works best, their aptitudes, and what they feel to emphasize the difference between most comfortable with. a challenging learning environment and an intimidating learning environment. A safe and Styles can range from teacher-led where the supportive learning environment is a prerequisite teacher adopts the expert role and presents for challenging students. When students feel safe information to the learners via a lecture or and supported they are open to being challenged, demonstrates how to do something via role when they are challenged they will be more modelling, to student-centred where the teacher inclined to engage in the process. may simply facilitate students to learn for themselves and from peers–for example, small Another important facet to effective teaching group project work. Teachers who adopt the is to engage students by using learning activities, student-centred approach may see their role as which require them to exercise their brain, a motivator and guide for students as they work mouth or hands, not just their ears. Try to avoid through a learning activity. The teacher’s skills activities where students are simply passive may be in formulating engaging learning activities, recipients of information. The more active facilitating group discussion, asking thought- the activity, the more likely it is to impact on provoking questions, and/or providing effective the students’ learning. feedback. Experiential learning activities such as Each teaching style has advantages and interviewing a patient, practising a procedural disadvantages, which will vary with the content skill in a workshop and role play are usually very to be taught, the number of students, the engaging simply by virtue of the fact that students’ preferred learning styles (if known), they require students to do things. Small group the teacher’s abilities, and the time and resources work also tends to be engaging because of available for the teaching session. Advantages of the collaborative nature of the activity, student-centred styles include the encouragement the tendency of the case to generate questions of collaboration, communication and proactive in the minds of the learners, and the need group problem-solving skills among students–all to solve problems. useful experiences for being an effective team53 Part A 7. Educational principles essential for patient safety teaching and learning
    • member in the workplace. It is helpful to be aware The following half questions may give you ideasnot only of your preferred teaching style, but also about how to create a patient safety learningto be aware of other ways of teaching that may moment:be equally or more effective in particular ñ what are the hazards for the patient here...circumstances. The ability to be flexible is ñ what do we need to be mindful of in thisencouraged. It may be that you will need to adjust situation...your usual methods to fit in with the overall ñ how can we minimize the risks...curriculum delivery design of your programme. ñ what would make this situation more risky for the patient...Harden identifies six important roles of the ñ what should we do if X should occur...teacher [3] : ñ what will be our plan B...ñ information provider; ñ what would we say to the patient if X occurred...ñ role model; ñ what are our responsibilities...ñ facilitator; ñ who else can help with this situation... otherñ assessor; health-care staff? Patient?ñ planner; ñ what happened? How can we prevent thisñ resource producer. in the future… ñ what can we learn from this situation...As an information provider in the field of patient ñ let’s look at the risk–benefit ratio of yoursafety, it is important to be well informed about it. suggested plan...This requires knowledge of basic patient safetyprinciples, why it is important in the workplace or Some of the best teaching students willclinical setting, and what staff can do to promote experience comes from patients themselves.patient safety in the workplace. Spending time Their role in health-care education has a longreflecting on one’s own practice and approaches history, usually in relation to describing theirto hazards in the workplace will help identify experience of a disease or illness. However,relevant teaching points for your students. they can also teach students aboutThere are many ways a teacher can demonstrate communication, risk communication, ethics,safe practice. When you are in the practice setting responses to adverse events, and more.with patients, students will notice how you:ñ interact with patients and families; A cautionary noteñ respect the wishes of patients and families; Remember that students may becomeñ inform patients and families of risks; demoralized if there is undue emphasis on risk,ñ consider risk–benefit ratios in determining errors, and patient harm. An effective patient management plans; safety teacher will be able to balance thisñ respond to and invite questions from patients by addressing the positive aspects of the area, and families; such as solutions to problems, progress in patientñ cleanse your hands between patients; safety, and equipping students with concreteñ adopt a team approach; strategies to improve their practice. It is alsoñ welcome advice from colleagues; important to remind students of the successñ adhere to workplace protocols; of the majority of patient care episodes. Patientñ acknowledge uncertainty; safety is about making care even better.ñ acknowledge and learn from your own and others’ errors [4]; Tools and resource materialñ problem-solve system issues; The Teaching on the run series was developedñ look after yourself and your colleagues. by Australian clinicians and is relevant to health professional education in the workplaceYou can be a very effective patient safety teacher where there are many demands on teacherssimply by being a safe practitioner yourself in who are also service providersthe presence of students who are eager to learn. ( the-run/tips; accessed 4 January 2011).Considering the patient in patient safetylearning National Center for Patient Safety of the USPatient safety education can be incorporated Department of Veterans Affairsinto many different educational settings from (; accessed 17 Februarythe practice environment to the lecture theatre 2011).and tutorial room simply by being mindfulof where the learning opportunities occur. Cantillon P, Hutchinson L, Wood D, eds. ABC WHO Patient Safety Curriculum Guide: Multi-professional Edition 54
    • of learning and teaching in medicine, 2nd ed.London, British Medical Journal Publishing Group, 2010. Sandars J, Cook G, eds. ABC of patient safety. Malden, MA, Blackwell Publishing Ltd, 2007. Runciman B, Merry A, Walton M. Safety and ethics in health care: a guide to getting it right, 1st ed. Aldershot, Ashgate Publishing Ltd, 2007. References 1. “I don’t know”: the three most important words in education. British Medical Journal, 1999, 318:A. 2. Vaughn L, Baker R. Teaching in the medical setting: balancing teaching styles, learning styles and teaching methods. Medical Teacher, 2001, 23:610–612. 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, 22:334–347. 4. Pilpel D, Schor R, Benbasset J. Barriers to acceptance of medical error: the case for a teaching programme. Medical education, 1998, 32:3–7.55 Part A 7. Educational principles essential for patient safety teaching and learning
    • 8. Activities to assist patientsafety understandingIntroduction ñ tie themes together with as many topics asHealth-care students are accustomed to learning possible;new information by studying and then working ñ activate prior knowledge using pre-tests andhard to apply their new knowledge and skills concept maps and gathering backgroundin patient care. In the case of patient safety, information;just “trying harder” will not work [1]. Hence, ñ challenge learners by presenting topics thata great deal of thought needs to be given to are more difficult from time to time;the timing and format of educational delivery. ñ demonstrate the behaviours you are seeking to promote.The purpose of this chapter is to outline thevarious strategies that can be used to assist Lecturespatient safety understanding. These are the same In a lecture [4], the teacher presents a topic toas the variety of teaching strategies that are used a large group of students. This traditionally occursfor teaching other aspects of health care. The in a face-to-face setting; however, recently, somechallenge for the educator is to see if patient universities give students the option of viewingsafety elements can be incorporated into existing the lecture online via podcasting.teaching and learning activities. If so, it avoidspatient safety topics being seen as an “add Lectures should have both:on”–and hence extra work–rather than simply ñ aims–indicating the general theme of thebeing part of a holistic approach to health-care lecture, e.g. the aim of this lecture is toeducation. introduce you to the topic of patient safety; ñ objectives–relating directly to the learning andA fundamental principle, in keeping with that should be achievable by the end of thethe principles of effective teaching, is that lecture, e.g. by the end of this lecture you willopportunities for “active learning” should be be able to list three major studies that highlightmaximized, during which the learners engage the extent of harm caused by health-carewith the learning process in a meaningful, rather than being passive recipientsof information. Lectures should last about 45 minutes as concentration falls after this time. Therefore,Active learning can be summarized with it is important that they do not contain toothe following statement [2]: much material–aim for four or five key points at the most.Don’t tell students when you can show them,and don’t show them when they can do it Lectures are often structured as follows withthemselves three principal elements (set, body, close):Lowman has outlined some teaching strategies ñ the set, or introduction, is the initial periodfor increasing the effectiveness of active learning, of the lecture when the lecturer explainsincluding [3]: why the topic is important and outlinesñ use information that is of interest to learners the objectives of the session; and involves real life events; ñ the body is the main content part of the lecture;ñ present dramatic or provocative material; ñ the conclusion should revisit the objectivesñ reward learners; and the key points of the presentation. WHO Patient Safety Curriculum Guide: Multi-professional Edition 56
    • Benefits: Tools and resource material ñ able to convey information to large numbers The Teaching on the run series was developed of students at one time; by clinicians and is relevant to health professional ñ useful for providing an overview of broad topics, education in the workplace where there are many to impart factual information and introduce demands on teachers who are also service theoretical concepts; providers ñ provide up-to-date information and ideas that ( are not easily accessible in texts or papers; the-run/tips; accessed 4 January 2011). ñ can explain or elaborate on difficult concepts and ideas and how these should be addressed. Small group activities–learning with others This occurs when students learn in the setting Challenges: of a small group, usually with a tutor, but also ñ keeping large numbers of students actively with a patient. The main feature is student engaged; participation and interactivity used in relation ñ senior students and junior staff generally prefer to a particular problem, but with more onus on more experiential techniques; students to be responsible for their own learning, ñ presentation skills; e.g. project work. ñ usually there is some dependence on technology; Benefits: ñ content (health-care harm) can be discouraging. ñ sharing own stories; ñ listening to patient stories; Examples: ñ learning from peers; ñ Topic 1: What is patient safety? ñ multiple perspectives; ñ Topic 2: Why applying human factors is ñ learning teamwork and communication skills. important for patient safety. Challenges: Learning on the run during work and clinical ñ group dynamics; placements ñ resource implications in terms of tutor time; Teaching that occurs in the context of ward ñ expertise of the tutor. rounds, clinics or in bedside/chairside teaching sessions. Examples: ñ Topic 2: Why applying human factors is Benefits: important for patient safety (human factors ñ ward-based, clinics, benchside and chairside considerations of commonly used equipment). teaching provides ideal opportunities to teach ñ Topic 4: Being an effective team player and observe history taking and examination (teamwork in the work setting or clinical skills, as well as communication and environment). interpersonal skills–the teacher can also role model safe, ethical, professional practice; Tools and resource material ñ patient safety issues are everywhere in the work Learning to use patient stories. NHS Evidence - environment; innovation and improvement ñ contextualized; ( ñ real–hence highly relevant; urce.aspx?resID=384118; ñ interesting and often challenging. accessed 4 January 2011). Challenges: Beyea SC, Killen A, Knox GE. Learning from ñ lack of time due to work pressure; stories–a pathway to patient safety. Association ñ lack of knowledge of how to incorporate of periOperative Registered Nurses Journal, 2004, 79, patient safety topics into bedside teaching; 224-226. ñ opportunistic—not possible to prepare and difficult to deliver a uniform curriculum. This Curriculum Guide: ñ enables health-care organizations and their Examples: teams to successfully implement a series ñ Topic 9: Infection prevention and control of interventions to improve the safety and (hand hygiene issues in the workplace). quality of care that their patients receive; ñ Topic 10: Patient safety and invasive ñ is based around the collection and use of procedures (including patient identification patient stories; processes). ñ shows a method for collecting effective stories57 Part A 8. Activities to assist patient safety understanding
    • from all members of society–patients, carers, Benefits: guardians and members of staff; ñ student can proceed at own pace;ñ shows that everyone has a different, equally valu- ñ student can focus on own knowledge gaps; able perception of their health-care experience. ñ opportunity for reflection; ñ cheap, easy to schedule;Case discussion ñ flexible for learner.This occurs when a group of students–oftenwith a tutor–discuss a clinical case. Challenges: ñ motivation;Benefits: ñ lack of exposure to multiple inputs;ñ can use an actual or invented case to illustrate ñ may be less engaging; patient safety principles; ñ marking the work and providing the feedbackñ contextualized–makes concepts real and is time-consuming for the teacher. relevant;ñ learn to solve problems as they arise in Buddying a patient who uses a health the workplace; service (hospital, clinic, private consultingñ enables linking of abstract concepts to the real rooms, formulary): patient tracking life situation. A student follows an individual patient throughout their journey through the healthChallenges: service or hospital. The exercise includesñ choosing/developing realistic cases that the student accompanying the patient for all encourages students to become actively investigations, tests, and procedures. engaged in the discussion;ñ using the case effectively to challenge thinking Benefits: and generate thoughtful learning; ñ includes the opportunity to learn aboutñ encouraging students to generate problem- the health-care system; solving themselves. ñ see things from the patient perspective; ñ see how different health-care areasTools and resource material interact together.Incident analyses from parent hospital, clinicsor workplace. Challenges: ñ timetabling;Agency for Healthcare Research and Quality ñ shaping the experience into a learningweekly morbidity and mortality cases exercise;(; accessed 4 January ñ limited opportunity for students to share2011). their learning, obtain feedback from peers, and get assessed.GamesGames are fun and encompass a spectrum from Role plays (docudrama)computer games to situational role play. A well-known educational method that allow students to act out roles of health-careBenefits: professionals in particular situations. Theseñ fun, enjoyable; fall into two types:ñ challenging; ñ students improvise the dialogue andñ can illustrate teamwork, communication. actions to fit a predetermined scenario; ñ students “act out” the roles and dialogueChallenges: of a case study situation.ñ relating the game to the workplace;ñ clearly defining the purpose of the game Benefits: upfront. ñ cheap; ñ requires little training;Tools and resource material ñ always available; ñ interactive–enables learners to try “what if”htm; accessed 4 January 2011. scenarios; ñ experiential–introduces and sensitizes learnersIndependent study to the roles that patients, their families, andStudy undertaken by the student, e.g. assignment health-care practitioners and administrators playwork, essays. in patient safety situations; WHO Patient Safety Curriculum Guide: Multi-professional Edition 58
    • ñ allows the learner to adopt a more senior role ñ full recreations of actual clinical environments or the role of a patient; allow to explore complete interpersonal ñ can demonstrate different perspectives; interactions with other clinical staff and provide ñ ideal for exploring factors in association with training on teamwork, leadership and interprofessional teamwork and communication communication; in the prevention of patient safety errors. ñ intensive and intrusive recording of the simulation session is feasible, including audio Challenges: taping and videotaping; there are no issues ñ writing the scenarios or scripts; of patient confidentiality–the recordings can ñ developing sufficiently meaningful situations be preserved for research, performance that allow for choices, decisions, conflicts; assessment or accreditation. [7] ñ time-consuming; ñ not all students are involved (some are only Challenges: passive spectators); ñ some modalities are very expensive; ñ students can get off the topic and the role ñ specialized expertise required for teaching play fizzles out. and for upkeep of some of the training devices. Tools and resource material Kirkegaard M, Fish J. Doc-U-drama: using drama Improvement projects to teach about patient safety. Family Medicine, Quality improvement is a continuous cycle 2004, 36:628–630. of planning, implementing strategies, evaluating the effectiveness of these strategies, and reflection Simulation to see what further improvements can be made. In the context of health care, simulation is defined Quality-improvement projects are typically as “an educational technique that allows interactive, described in terms of the plan-do-study-act (PDSA) and at times immersive activity by recreating all or part cycle [8] as follows: of a clinical experience without exposing patients to ñ plan–the change, based on perceived ability the associated risks” [5]. It is likely that in the future to improve a current process; increased access to various forms of simulation ñ do–implement the change; training will emerge because of the increasing ñ study–analyse the results of the change; ethical imperative to avoid patient harm [6]. ñ act–what needs to happen next to continue the improvement process. A number of different simulation modalities are available, including: The PDSA cycle approach encourages health ñ screen-based computer simulators; professionals to develop and be actively engaged ñ low-tech models or mannequins used to practise in strategies they hope will lead to improvements. simple physical manoeuvres; It also promotes evaluation of these changes once ñ standardized patients (patient actors); the strategies have been implemented. Therefore, ñ sophisticated computerized (“realistic”) full-body this can be a very useful approach to have patient mannequin simulators; students involved at a ward or clinic level, ideally ñ virtual reality devices. as part of a multidisciplinary team approach to patient safety. Most quality-improvement projects Benefits: by their very nature have an inherent patient ñ no risk to patients; safety element. ñ many scenarios can be presented, including uncommon but critical situations in which Benefits: a rapid response is needed; ñ motivating; ñ participants can see the results of their decisions ñ empowering; and actions; errors can be allowed to occur ñ learn about change management; and reach their conclusion (in real life a more ñ learn to be proactive; capable clinician would have to intervene); ñ learn to problem solve. ñ identical scenarios can be presented to different clinicians or teams; Challenges: ñ the underlying causes of the situation are ñ sustaining momentum and motivation; known; ñ time commitment. ñ with mannequin-based simulators clinicians can use actual equipment, exposing limitations Example: in the human–machine interface; Hand hygiene issues in a clinical environment.59 Part A 8. Activities to assist patient safety understanding
    • Tools and resource materialBingham JW. Using a healthcare matrix to assesspatient care in terms of aims for improvement andcore competencies. Joint Commission Journal onQuality and Patient Safety, 2005, 31:98–105.US Agency for Healthcare Research and Qualitymortality and morbidity web site(; accessed 17February 2011).References1. Kirkegaard M, Fish J. Doc-U-Drama: using drama to teach about patient safety. Family Medicine, 2004, 36:628–630.2. Davis BG. Tools for teaching. San Francisco, Jossey-Bass Publishers, 1993.3. Lowman J. Mastering the techniques of teaching. San Francisco, Jossey-Bass Publishers, 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):S22–S28.6. Ziv A, Small SD, Glick S. Simulation based medical education: an ethical imperative. Academic Medicine, 2003, 78:783–788.7. 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, 22:206–212. WHO Patient Safety Curriculum Guide: Multi-professional Edition 60
    • 9. How to assess patient safety The purposes of assessment right team, practising in a health service that is Assessment is an integral part of any curriculum. designed to minimize failures, and active support The content and format of assessment procedures for patient safety initiatives from the organization strongly influence the study behaviour and and management. Students as novices are learning outcomes of the students. It is essential expected to have rudimentary knowledge and that assessments support the exit learning skills and with time and exposure to the outcome objectives, as well as providing appropriate role models and mentors, as well as appropriate motivation and direction for the experience of working in well-functioning teams, students. Assessments should be meaningful and they will become more astute and responsive to give confidence to teachers, course planners and the many environmental factors that make patient external stakeholders, such as accreditation care unsafe. Given this context for student bodies, standards boards and the future employers learning about patient safety, the purpose of of students. Newble and Cannon [1] emphasise assessment in patient safety should be to provide that clarity about the purpose of assessment is feedback and motivate the students to engage extremely important. They list a range of with patient safety. Any assessment process assessment purposes. The two in bold are key should reflect this. for patient safety learning: ñ judging mastery of essential skills and Engaging students in the assessment process knowledge; One of the biggest challenges facing educational ñ rank ordering students; institutions is finding appropriate instructors ñ measuring improvement over time; or health professionals to teach patient safety ñ diagnosing student difficulties; in the workplace. One way to address this ñ providing feedback to students; difficulty is to implement a student-driven ñ evaluating the effectiveness of a course; curriculum. But the main reason for getting ñ motivating students to study; students to perform patient safety tasks is that ñ setting standards; learning by doing is a most effective teaching ñ quality control for the public. method. At the University of Sydney Medical School (Australia), students are required to In patient safety, getting the students to actually undertake patient safety activities in their final perform the tasks and practise doing them is two years and while on their placements in often more difficult than designing an assessment the hospitals. They are provided with web-based, instrument to demonstrate how well they underpinning knowledge designed to give them performed the activity. Bearing in mind that many just-in-time learning. The WHO topics can be health professionals are not yet competent in appropriately edited and made available on patient safety, the focus on assessment should be the web for just-in-time reading before students supportive of the continued development of the practise the activities associated with the learning students’ knowledge and skills in patient safety. topic. Students record their experiences and No student should be prevented from continuing answer the questions posed for a particular their course by a failure in a patient safety area activity on a one-page template. At the end unless it is egregious and intentionally dangerous. of the block/term, students meet in small groups Patient safety is not an area that lends itself to with their tutor to discuss their experiences students studying alone. Patient safety depends and observations. Tutors or supervisors on a complex set of factors–working with the are required to verify by way of signature61 Part A 9. How to assess patient safety
    • the students’ accounts completing the mandatory curriculum and the required activitiesformative assessment for the particular topic. the students are to perform, as well asBelow is an example of a Topic (3) from this the assessment requirement.Figure A.9.1. Content of topic 3: The University of Sydney, Australia Topic 3 Activities Assessment Understanding Read Learning topic on line Tutor sign-off of satisfactory student systems and participation and performance in face-to-face the impact Follow a patient from the time session (or clinician sign-off of activity of complexity they enter hospital until completion in the event of no face-to-face on patient care discharge or a clear outcome session). Use the template to make notes on the above activityFigure A.9.2 is the template the students the patient on their journey through the hospitaluse to make notes while they observe or clinic.Figure A.9.2. Example of student report form for topic 3:The University of Sydney, Australia Stage 3 (Year 3 of postgraduate medical programme): Topic 3: Understanding systems ............................................................................................ Student name ......................................................................................... Student number ..................................................................................... Date of activity ....................................................................................... Summary of the patient journey: 3 main observations: 3 most important things you learned: Position of person signing-off on completion of activity Name (print) ........................................................................................... Signature ................................................................................................ Position ................................................................................................... Date signed .............................................................................................For other activities such as medication safety There are more examples of student assessmentor invasive procedures, students are required in Part B, Annex have a health professional observe themparticipating in an activity (e.g. medication One of the benefits of student-led activities isreconciliation, preparation of medications the potential to change the workplace the pharmacy, ward round with a pharmacist, When students request staff if they can observeobservation of the time-out process prior or participate in a particular activity andto a procedure). The person who observed them the reasons why, they open up discussion aboutmust sign a form confirming the student’s the patient safety programme. Many of the topicscompletion of the task. can be delivered using a student-led delivery. WHO Patient Safety Curriculum Guide: Multi-professional Edition 62
    • The role of measurement in assessment The above example from the University of Sydney There are four components to reliable assessment is an example of mandatory summative measures: validity (is the assessment method assessment. The students are required to perform valid?); reliability (does the assessment always the activities and are assessed through face-to- produce consistent results?); practical (what time face discussion or observation. Students have and resources does it require?); and positive impact a semester to complete the assignments of course on learning (does it work from the perspective summative assessments. Such assessments can of the learner?) [1]. typically be at the end of an eight-week block, end of term, end of year, or end of programme. For further reading about measurement The bulk of this chapter covers the requirements in assessment, the following resources may be of end-of-course assessments. useful. In-course summative assessments Brown S, Glasner A, eds. Assessment matters There is a range of course assessments that in higher education: choosing and using diverse can easily be introduced in the patient safety approaches. Buckingham, Society for Research curriculum. Many health educational programmes into Higher Education and Open University Press, could incorporate these elements into existing 1999. portfolios or the “record of achievement”. Miller A, Imrie B, Cox K. Student assessment in Some features of “best assessment” higher education: a handbook for assessing practices in patient safety performance. London, Kogan Page Ltd, 1998. The following assessment principles will apply to achieving the aims of a patient safety Formative assessments curriculum. The assessments should: Formative assessments are a vital and inherent ñ drive learning in the intended direction part of the learning process for students. of meeting the exit learning outcomes Patient safety learning lends itself to formative of a newly-graduated health professional assessment. A wide range of such activities is capable of safe patient care; possible within all components of any health-care ñ have a strong formative element, with regular programme. Self-assessment is the ability of opportunities for remediation and counselling students to assess their own learning needs throughout the course; and choose educational activities that meet these ñ be integrated with, for example, clinical needs. (The preponderance of evidence suggests competence and not be discipline-based; that students have a limited ability to accurately ñ be included in examinations of clinical self-assess and may need to focus more on competence and professional behaviours in external assessment.) all stages of the course; ñ be included in examinations of basic sciences, Formative assessments should be continuous e.g. integrated in population health sciences and provide feedback to students about their at all stages of the course; performance. The aim of this type of assessment ñ be progressive and ensure that proportions of is to get the students to open up about their material from previous stages will be included observations and experience working in health in all subsequent exams; care. We want them to feel free to reveal their ñ be developed with the expectation that they vulnerabilities and weaknesses. A punitive will meet quality assurance standards; approach will do the opposite and force students ñ claim fairness by engaging students and staff to hide their true level of knowledge and skills. in the process of development; They may also be reluctant to talk about their ñ be motivating and provide direction for what observations, particularly when they relate students need to learn to practise safely; to unsafe care or practices. ñ be feasible and acceptable to both faculty and students. Summative assessment All components of assessment that the students Defining what is to be tested have to pass, or have to complete before progression from one part of the course to Defining the range of competencies to be another may occur, are regarded as summative. tested (a blueprint) In general terms, they fall into two types Students internationally are concerned about of assessment: end-of-course examinations the amount of material in the curriculum that and in-course assessments. they have to learn, and are made anxious by not63 Part A 9. How to assess patient safety
    • knowing what might be assessed. Faculty should Some competencies need to be systematicallydescribe the range of competencies (or knowledge) assessed to ensure that students build onto be tested, which would normally be drawn their knowledge and integrate these intodirectly from the learning outcomes of their area of practice. Table A.9.1 showsthe curriculum. It is important to ensure that different components of patient safety thatthe planned assessment adequately samples could be used for end-of-course assessmentsthe range of competencies by the end throughout a four-year health professionalof the health-care professional degree. degree course.Table A.9.1. A blueprint showing end-of-course assessments for componentsof the patient safety curriculum Assessable learning outcomes Year that curriculum modules are first assessed in a typical programme Year 1 Year 2 Year 3 Year 4 What is patient safety? X Health-care systems X Communication X Safe patient care X Engaging with patients X Team work X Quality Improvement X Health-care errors X Medication safety XSelect appropriate test methods Quality-improvement methods may be bestIt is important to emphasize that assessment in assessed via a student project. There are a numberpatient safety is aligned with the agreed learning of basic concepts in assessment to help decideoutcomes. It is unlikely that any particular the most appropriate type of assessment format.assessment format is suitable to assess everything One of the most well known is Miller’s triangle,required. It is best to be aware of the range of which suggests that a student’s performanceassessment methods and make a decision based is made up of four levels (see Figure A.9.3):on an understanding of their strengths and ñ knows;limitations. Let the purpose of the assessment, for ñ knows how;example, “to assess knowledge of adverse event ñ shows how;reporting”, drive the choice of format, in this case ñ does.a modified essay question (MEQ) or a multiplechoice question (MCQ).Figure A.9.3. Miller’s triangle Direct observation in real life contexts (emerging technology) Does Direct observation in simulated Shows how contexts (e.g. OSCE) Source: Miller GE. The assessment of clinical Knows how Various (written or computer-based) skills/competence/ selected and constructed response performance. questions (item writing technology) Knows Academic Medicine,1990 [2]. WHO Patient Safety Curriculum Guide: Multi-professional Edition 64
    • For example, “showing how” is related to specific but unless the faculty has the resources available competencies that are appropriate for the level to provide quality feedback, this method should of expertise of the student. These can be be avoided. examined by, for example, an objective structured clinical examination (OSCE) station. Multiple choice question/extended matching question MCQ and EMQ are very attractive formats Again, looking at Figure 3, one can see that in that they can test a wide sample of the knowledge (knows) can be tested by MCQs, curriculum, can be machine-marked, and give for example. reliable scores of a student’s ability. However, their main drawback in testing patient safety Typical assessment formats within a health is that they tend to test knowledge only. professional school might include: For example, this method could be used to test whether a student knows the characteristics Written: of successful teams, but this assessment cannot ñ essay; test whether the student applies any of this ñ multiple choice items (1 from 4/5); knowledge in practice. The EMQ has been ñ extended matching questions (EMQ); designed to address the issue of guessing ñ structured short answer questions; in multiple-choice examinations. See Part B, ñ modified essay question (MEQ); Annex 2, for an example of an MCQ. ñ extended written work (e.g. project reports, posters); Modified essay questions/key feature ñ portfolio or log books. MEQs or key feature formats are designed to be answered in 5–10 minutes, and encourage Workplace performance (practical): short note responses to appropriate scenarios. ñ multiple station exams; Providing a model answer and marking scheme ñ direct observation of performance (e.g. observed helps examiners maintain some standardization. long cases, mini clinical evaluation exercise Several MEQs on a range of different subjects can [mini CEX]); be asked in the time it takes to write one essay ñ 360 degree or multisource feedback (MSF); sampling just one area of the curriculum. ñ structured reports (e.g. attachment assessments); See Part B, Annex 2, for a nursing example. ñ oral presentations (e.g. projects, case-based discussion); Portfolio/logbook ñ self-assessment; A spectrum of assessment methods that can be ñ structured oral exams. easily linked to key learning outcomes range from a log of professional activities through to There are some strengths and weaknesses with a record of achievements throughout a segment all of these formats and these need to be of the programme, to documentation supporting considered when choosing the right assessment an annual appraisal complete with learning plans. for a particular learning outcome within a patient A particularly useful component of the portfolio safety curriculum. is the critical incident. Students can be asked to reflect in a structured way on situations they Written have observed where patient safety was an issue. The students hand in their portfolios or logbooks Essay for marking by an appropriate tutor. The traditional essay is used in some places. There is great advantage in allowing students Clinical/practical to demonstrate their critical thinking, reasoning There is a wealth of research evidence to suggest and problem-solving skills. While it is tempting that having more than one observer improves to set essays, which allow learners to express their the accuracy of competency assessments. thoughts, as an assessment method they are very It is very important that considerations of patient time-consuming to mark and subject to much safety are incorporated within the marking rubrics variability in judges’ marks. The key to successful and examiner training and feedback sessions marking of essays is the quality of the feedback of each of the assessments used in the health to students. Just being given a mark without professional school context. If the topic any comments is discouraging to students who is assessed separately, it will drive students wish to know what the marker thought of their to learn patient safety as something extra to be responses to the set questions. Some of the topics added on, rather than as an integral part of safe do lend themselves to essay-type assessments, patient care.65 Part A 9. How to assess patient safety
    • Objective structured clinical examination to ensure that elements of patient safety areOSCE comprises of a circuit of short simulated included on the rating form. It is particularlyclinical cases assessed either by a standardized important in a mini-CEX to have a goodpatient or the instructor/clinical teacher. Patient preparation of raters and ensure that trainerssafety can be incorporated as at least one item of instructors/supervisors include referenceswithin the checklist for each simulated scenario. to patient safety in the training sessions.Alternatively, a single case can be entirelydedicated to a patient safety case, for example, End of clinical placement assessments/communicating an adverse event to a simulated global rating scalespatient who has been given the wrong This assessment aims to give a credible viewmedication. Cases in which the student is required of a student’s progress and is usually completedto look at treatment charts, test results, X-rays by the instructor or supervisor, based on personalor investigations are sometimes called static knowledge or after consultation with colleagues.stations as they do not require the student to be Patient safety criteria need to be included.observed. This allows, for example, prescribingerrors to be simulated and the students’ actions Case-based discussion (CBD)recorded. See Part B, Annex 2, for an example The CBD is a structured discussion of casesof an OSCE. by the instructor/supervisor focusing on professional/clinical reasoning and decisionMultisource feedback making. It takes real cases in which the studentMSF are collated views from a range of health- has been involved. This is a relativelycare workers or peers about the student in underexplored technique for examiningthe learning environment. Ideally, checklist items the understanding of patient safety issues asabout safe patient care and good communication related to real cases.would be included in the rating form. Matching assessment to expected learningMini clinical evaluation exercise outcomesA mini-CEX is where the supervisor or instructor It is always important to match assessmentsobserves a student performing history taking, to intended learning outcomes. Mostan examination, or communication exercise on curricula will have learning outcomes, somea real patient and rates the student on several more detailed than others. In Table A.9.2,domains. Aggregated scores of several encounters the complete list of learning outcomesare used to determine the competency of for patient safety can be easily matched withthe student. Once again, it is important appropriate assessments.Table A.9.2. Sample of typical end of a professional educational programme learningoutcomes for patient safety showing typical assessment formatsCompetencies Assessment formatsSafe patient care: systemsUnderstand the complex interaction between Essay, Formative assessment sign-off that studentthe health-care environment, health professional accompanied a patient on their journey throughand patient the service, followed by small group discussion.Aware of mechanisms that minimize error, e.g. Formative assessment sign-off by instructor orchecklists, clinical pathways supervisor that student participated in a time out or other activity.Safe patient care: risk and prevention MCQ/MEQKnow the main sources of error and riskin the workplace Essay/MEQUnderstand how personal limitationscontribute to risk Viva/Portfolio WHO Patient Safety Curriculum Guide: Multi-professional Edition 66
    • Promote risk awareness in the workplace by identifying and reporting potentialrisks to patients and staff PortfolioSafe patient care: adverse events and near missesUnderstand the harm caused by errors and system failures Essay/MEQAware of principles of reporting adverse eventsin accordance with local incident reporting systems MEQUnderstand principles of the management of adverse events and near misses MEQUnderstand the key health issues of your community MCQAware of procedures for informing authorities of “notifiable diseases” MCQUnderstand the principles of disease outbreak management MEQSafe patient care: infection controlUnderstand prudent antibiotic/antiviral selection MCQPractise correct hand hygiene and aseptic techniques OSCEAlways use methods to minimize transmission of infection between patients OSCEKnow the risks associated with exposure to radiological investigations and procedures MCQ/MEQKnow how to order radiological investigations and procedures appropriately MEQSafe patient care: medication safetyKnow the medications most commonly involved in prescribing and administration errors MCQKnow how to prescribe and administer medications safely OSCEKnow the procedures for reporting medication errors/near misses in accordance with local requirements PortfolioCommunicationPatient interaction: contextUnderstand the impact of the environment on communication, e.g. privacy, location MEQUse good communication and know its role in effective health-care relationships OSCEDevelop strategies to deal with the difficult or vulnerable patient OSCEPatient interaction: respectTreat patients courteously and respectfully, showingawareness and sensitivity to different cultures and backgrounds OSCE/mini-CEXMaintain privacy and confidentialityProvide clear and honest information to patients and respect their treatment choices OSCE/mini-CEXPatient interaction: providing informationUnderstand the principles of good communication OSCE/mini-CEX/MSFCommunicate with patients and carers in ways they understand OSCEInvolve patients in discussions about their care PortfolioPatient interaction: meetings with families or carersUnderstand the impact of family dynamics on effective communication PortfolioEnsure relevant family/carers are included appropriately in meetings and decision making PortfolioRespect the role of families in patient health care MEQ/portfolioPatient interaction: breaking bad newsUnderstand loss and bereavement MEQParticipate in breaking bad news to patients and carers OSCEShow empathy and compassion OSCEPatient interaction: open disclosureUnderstand the principles of open disclosure MEQEnsure patients are supported and cared for after an adverse event OSCEShow understanding to patients following adverse events OSCEPatient interaction: complaintsUnderstand the factors likely to lead to complaints MEQ/portfolioRespond appropriately to complaints using the local procedures OSCEAdopt behaviours to prevent complaints OSCE 67 Part A 9. How to assess patient safety
    • Tools and resource material PortfoliosNewble M et al. Guidelines for assessing clinical Wilkinson T et al. The use of portfolios forcompetence. Teaching and Learning in Medicine, assessment of the competence and performance1994, 6:213–220. of doctors in practice. Medical Education, 2002, 36:918–924.Roberts C et al. Assuring the quality of high stakesundergraduate assessments of clinical Referencescompetence. Medical Teacher, 2006, 28:535–543. 1. Newble D, Cannon R. A handbook for medical teachers, 4th ed. Dordrecht, Kluwer AcademicWalton M et al. Developing a national patient Publishers, education framework for Australia. Quality 2. Miller GE. The assessment of clinicaland Safety in Health Care 2006 15:437-42. skills/competence/performance. Academic Medicine,1990, 65 (Suppl.):S63-S67.Van Der Vleuten CP. The assessment ofprofessional competence: developments, researchand practical implications. Advances in HealthScience Education, 1996, 1:41–67.Case-based discussionSouthgate L et al. The General Medical Council’sperformance procedures: peer review ofperformance in the workplace. Medical Education,2001, 35 (Suppl. 1):S9–S19.Miller GE. The assessment of clinicalskills/competence/performance. Academic Medicine,1990, 65 (Suppl.):S63–S67.Mini clinical evaluation exerciseNorcini J. The mini clinical evaluation exercise(mini-CEX). The Clinical Teacher, 2005, 2:25–30.Norcini J. The mini-CEX: a method for assessingclinical skills. Annals of Internal Medicine, 2003,138:476–481.Multisource feedbackArcher J, Norcini J, Davies H. Use of SPRAT for peerreview of paediatricians in training. British MedicalJournal, 2005, 330:1251–1253.Violato C, Lockyer J, Fidler H. Multisourcefeedback: a method of assessing surgical practice.British Medical Journal, 2003, 326:546–548.Multiple choice questionsCase SM, Swanson DB. Constructing written testquestions for the basic and clinical sciences.Philadelphia, National Board of Medical Examiners,2001.Objective structured clinical examinationNewble DI. Techniques for measuring clinicalcompetence: objective structured clinicalexaminations. Medical Education, 2004,35:199–203. WHO Patient Safety Curriculum Guide: Multi-professional Edition 68
    • 10. How to evaluate patient safety curricula Introduction In this section we have summarised some general Assessment = student performance principles of evaluation. Following the publication Evaluation = quality of courses/ of this document, WHO plans to make available programmes, quality of teaching standard evaluation tools for this curriculum. As individuals, we engage in evaluation every day: Step 1: Developing an evaluation plan what to eat, what clothes to wear, how good that movie was. Evaluation is an important component What is being evaluated? of any curriculum and should be included in your A fundamental first step in developing an strategy for implementing patient safety curricula evaluation plan is identifying the evaluation at your institution or in your hospital/classroom. object: is it a single patient safety session? It can be as simple as having students complete Is it the entire curriculum? Are we evaluating a questionnaire after exposure to a patient safety the faculty’s capacity for implementation? Are we session to see what they thought, or as complex evaluating teacher performance/effectiveness? as a faculty-wide review of the entire curriculum, Objects for evaluation can be classified either as which may involve surveys and focus groups with policy, programme, product or individual [1]–and students and staff, observation of teaching all can be applied in the educational setting. sessions, and other evaluation methods. Who are the stakeholders? Evaluation involves three main steps: There are often many stakeholders involved in ñ developing an evaluation plan; the evaluation of patient safety education. ñ collecting and analysing information; However, it is important to identify a primary ñ disseminating the findings to appropriate audience as this will impact on the question(s) stakeholders for action. you want your evaluation to answer. The primary audience may be the university, the relevant How evaluation differs from assessment professional faculty, hospital administration, Information on assessment and evaluation can be teachers, students or patients/the public. For confusing due to the fact that some countries example, you may be the primary stakeholder use the two terms interchangeably. The easiest if you are a teacher wanting to know how your way to remember the difference between students are responding to the introduction assessment and evaluation is that assessment of patient safety education in your course. is about measuring student performance, while evaluation is about examining how and what What is the purpose of the evaluation? we teach. In assessment, data are collected from After identifying the primary audience/ a single source (the student), whereas in stakeholder(s), the next step is to decide what evaluation, data may be collected from a number you are trying to achieve from the evaluation. of sources (students, patients, teachers, and/or What question(s) are you trying to answer? other stakeholders). These may differ depending on your role in patient safety education. Table A.10.1 gives examples of the kinds of questions that might be asked depending on the primary stakeholder.69 Part A 10. How to evaluate patient safety curricula
    • Table A.10.1. Examples of stakeholder questions Stakeholder Possible questions for evaluation Hospital administrators/clinical staff Does teaching patient safety to health professionals 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 engaged in learning about patient safety? Are they applying patient safety principles in their placements?What form(s) of evaluation is/are most appropriate? the stages of programme/curriculumEvaluation types or forms can be categorized implementation you are at, the kinds of questionsas follows: proactive, clarificative, interactive, you are asking, and the key approaches required.monitoring and impact [2]. The forms differ in Table A.10.2 provides a summary of each formterms of the primary purpose of the evaluation, of evaluation.Table A.10.2. Forms of evaluation Purpose Proactive Clarificative Interactive Monitoring Impact Orientation Synthesis Clarification Improvement Justification Justification Fine tuning Accountability Major focus Context for All elements Delivery Delivery Delivery curriculum Outcomes Outcomes State of None (not yet Development Development Settled Settled programme/ implemented) phase phase Implemented Implemented curriculum Timing Before During During During After relative to implementation Key approaches Needs Evaluation Responsiveness Component Objectives-based assessment assessment Action research analysis Needs-based Review of Logic Developmental Devolved Goal-free the literature development performance Empowerment Process-outcome Accreditation assessment Quality review Realistic Systems analysis Performance audit Gathering Review of Combination On-site A systems Pre-ordinate evidence documents, data- of document observation approach research designs bases analysis, Questionnaires requires Treatment and Site visits interview and availability control groups observation Interviews of management Focus groups, where possible nominal group Findings include Focus groups information Observation technique programme plan Degree of data systems Tests and other Delphi technique and implications structure the use of quantitative data for needs assess- for organization. depends on indicators, and Can lead approach. Determining all ment the meaningful to improved the outcomes May involve use of morale requires use of providers performance more exploratory (teachers) and information methods programme and qualitative participants evidence (students) WHO Patient Safety Curriculum Guide: Multi-professional Edition 70
    • Types of Is there a need What are What is the Is the programme Has the programmequestions for the the intended programme reaching the target been implemented programme? outcomes and trying to population? as planned? how is the achieve? What do we Is implementation Have the stated goals programme know about How is it meeting stated been achieved? designed to the problem going? objectives and achieve them? Have the needs that the benchmarks? Is the delivery of students, teachers programme What is the working? How is and others served will address? underlying implementation by the programme been rationale Is delivery What is going between sites? achieved? for the consistent recognized as programme? with the How is What are best practice? programme implementation the unintended What elements plan? now compared to outcomes? need to be a month / 6 months/ modified to How could How do differences 1 year ago? maximize delivery be in implementation intended changed Are our costs affect programme outcomes? to make it rising or falling? outcomes? more effective? Is the How can we fine Is the programme programme How could tune the programme more effective for some plausible? this organization to make it more participants than for be changed efficient? More others? Which aspects to make it effective? of the Has the programme more effective? programme Are there any been cost-effective? are amenable programme sites to subsequent that need attention monitoring to ensure more for impact effective delivery? evaluation?Source: Adapted from Owen J. Program evaluation: forms and approaches, 2006 [1]. Step 2: Collecting and analysing information Self-reflection Self-reflection is an important activity for all Collection educators and has an important role in evaluation. There are a number of data sources and collection An effective method for reflection involves: methods to consider in an evaluation of patient ñ writing down your experience of teaching (in safety curricula or any other evaluation object. this case, patient safety education) or feedback How many and which ones you use depends on received from others; your evaluation’s purpose, form, scope and scale. ñ describing how you felt and whether you were Potential data sources include: surprised by those feelings; ñ students (prospective, current, past, withdrawn); ñ re-evaluating your experience in the context ñ self (engaging in self-reflection); of assumptions made [3]: ñ colleagues (teaching partners, tutors, teachers – Were they good assumptions? Why, or why external to the course); not? ñ discipline/instructional design experts; ñ professional development staff; Engaging in self-reflection will allow for the ñ graduates and employers (e.g. hospitals); development of new perspectives and a greater ñ documents and records (e.g. teaching materials, commitment to action in terms of improving or assessment records). enhancing curriculum and/or teaching. Data may be collected from the above-listed Questionnaires sources in a variety of ways, including self- Questionnaires are easily the most common reflection, questionnaires, focus groups, individual method of data collection, providing information interviews, observation, and documents/records. on people’s knowledge, beliefs, attitudes, and 71 Part A 10. How to evaluate patient safety curricula
    • behaviour [4]. If you are interested in research Observationand publishing the evaluation results, it may be For some forms of evaluation it may be usefulimportant to use a previously validated and to conduct observations of patient safetypublished questionnaire. This will save you both educational sessions to obtain an in-depthtime and resources and will allow you to compare understanding of how material is being deliveredyour results with those from other studies using and/or received. Observations should involvethe same instrument. It is always useful as a first the use of a schedule to provide a frameworkstep to search the literature for any such tools for observations. The schedule can be relativelythat may already be in existence. unstructured (e.g. a simple notes sheet) or highly structured (e.g. the observer rates the objectMore often than not, however, teachers/faculties/ of evaluation on a variety of predetermineduniversities choose to develop questionnaires dimensions and makes comments on each).for their own individual use. Questionnairesmay be comprised of open- and/or closed-ended Documents/recordsquestions and can take a variety of formats, As part of your evaluation, you may also wishsuch as tick-box categories, rating scales, to examine documental or statistical information,or free text. Good questionnaire design is integral such as teaching materials used or studentto the collection of quality data and much has performance data gathered. Other informationbeen written about the importance of layout such as hospital data on adverse events mayand how to construct appropriate items [5]. also be useful, depending on your evaluationYou may wish to consult one of the references question(s).or resources provided prior to developing yourquestionnaire for evaluation of patient safety Analysisteaching or curricula. Your data collection may involve just one of the above or other methods, or it may involve several.Focus groups In either case, there are three interconnectedFocus groups are useful as an exploratory method elements to consider in terms of data analysis [1]:and means of eliciting student or tutor ñ data display–organizing and assemblingperspectives [6]. They often provide more in-depth information collected in a meaningful way;information than questionnaires and allow for ñ data reduction–simplifying and transformingmore flexible, interactive exploration of attitudes the raw information into a more workabletowards and experiences of curriculum change. or usable form;They can be used in conjunction with ñ conclusion drawing–constructing meaningquestionnaires or other data collection methods from the data with respect to your evaluationas a means of checking or triangulating data, question(s).and can vary in terms of structure and deliveryfrom the conversational and flexible to the strictly Step 3: Disseminating findings and takingregimented and formal. Depending on resources actionavailable and the level of analysis sought, you All too often the conclusions andmay wish to audio or video record focus groups recommendations of evaluations are not actedin addition to, or in place of, taking notes. upon–the first step in avoiding this is by ensuring that this valuable information isIndividual interviews fed back in a meaningful way to all relevantIndividual interviews provide the opportunity stakeholders. If the evaluation is on the qualityfor more in-depth exploration of attitudes of patient safety teaching, then resultstowards potential curriculum change and (e.g. from student questionnaires, peer-observedexperiences with the curriculum once it has been teaching sessions) must be relayed to andimplemented. As with focus groups, they can be discussed not only with the administration,unstructured, semi-structured, or structured but also with the teachers. Brinko [7] providedin format. Although individual interviews an excellent review of best practice onprovide information on a narrower range the process of giving feedback both for studentsof experience than focus groups, they also allow or colleagues. It is important that any feedbackthe interviewer to explore more deeply the is received in a way that encourages growthviews and experiences of a particular individual. or improvement. If the evaluation focuses onOne-to-one interviews may be a useful method the effectiveness of the patient safety curriculum,for obtaining evaluation data from colleagues, any conclusions and recommendations forinstructors or supervisors, or faculty improvement must be communicated to allleaders/administrators. who participated in implementing the curriculum WHO Patient Safety Curriculum Guide: Multi-professional Edition 72
    • (e.g. at the institution, faculty, teacher and student levels). The format for dissemination must be meaningful and relevant. Effective communication of evaluation outcomes, findings and recommendations is a key catalyst for improvements in patient safety teaching and curriculum design. Tools and resource material You may find the following resources useful for various stages of your evaluation planning and implementation: DiCicco-Bloom B, Crabtree BF. The qualitative research interview. Medical Education, 2006, 40:314–321. Neuman WL. Social research methods: qualitative and quantitative approaches, 6th ed. Boston, Pearson Educational Inc, Allyn and Bacon, 2006. Payne DA. Designing educational project and program evaluations: a practical overview based on research and experience. Boston, Kluwer Academic Publishers, 1994. University of Wisconsin-Extension. Program development and evaluation, 2008 (; accessed 17 February 2010). Wilkes M, Bligh J. Evaluating educational interventions. British Medical Journal, 1999, 318:1269–1272. References 1. Owen J. Program evaluation: forms and approaches, 3rd ed. Sydney, Allen & Unwin, 2006. 2. Boud D, Keogh R, Walker D. Reflection, turning experience into learning. London, Kogan Page Ltd, 1985. 3. Boynton PM, Greenhalgh T. Selecting, designing and developing your questionnaire. British Medical Journal, 2004, 328:1312–1315. 4. Leung WC. How to design a questionnaire. Student British Medical Journal, 2001, 9:187–189. 5. Taylor-Powell E. Questionnaire design: asking questions with a purpose. University of Wisconsin- Extension, 1998 (; accessed 17 February 2011). 6. Barbour RS. Making sense of focus groups. Medical Education, 2005, 39:742–750. 7. Brinko K. The practice of giving feedback to improve teaching: what is effective? Journal of Higher Education, 1993, 64:574–593.73 Part A 10. How to evaluate patient safety curricula
    • 11. Web-based toolsand resourcesEach topic has a set of tools that have beenselected from the World Wide Web and designedto assist health professionals and students toimprove the care they deliver to patients.We have only included tools that are freelyavailable on the Internet. All of the sites wereaccessible as of January 2011.Included in the list are examples of guidelines,checklists, web sites, databases, reports and factsheets. Very few of the tools have been througha rigorous validation process. Most measures inquality tend to be about processes of care andquality that apply to small groups of patientsin highly contextualized environments [1], suchas a ward, a rehabilitation unit or a clinic.Most patient safety initiatives require healthprofessionals to measure the steps they takein the delivery care process. By doing this, you willbe able to tell if the planned changes have madeany difference to patient care or the outcome.Focusing on measurement has been a necessaryand important step in teaching patient safety;if you do not measure, how do you know thatan improvement has been made? Even thoughstudents will not be expected to measure theiroutcomes by the time they graduate, they shouldbe familiar with the PDSA cycle that formsthe basis of measurement. Many of the tools onthe Internet incorporate the PDSA cycle.Reference1. Pronovost PJ, Miller MR, Wacher RM. Tracking progress in patient safety: an elusive target. Journal of the American Medical Association, 2006, 6:696–699. WHO Patient Safety Curriculum Guide: Multi-professional Edition 74
    • 12. How to foster an international approach to patient safety education Patient safety impacts on all countries care workers deepens the crisis in developing In 2002, WHO Member States agreed on a World countries. There is evidence that developing Health Assembly Resolution on patient safety in countries which have invested in the education recognition of the compelling evidence of the of future generations of health-care workers need to reduce the harm and suffering of patients have seen their assets stripped by the predations and their families, and the economic benefits from health-care systems of countries with of improving patient safety. The extent of patient transitional or advanced economies, during harm from their health care had been exposed times of workforce shortages there [2]. by the publication of international studies from a number of countries including Australia, The globalization of health-care delivery has Canada, Denmark, New Zealand, the United forced health-care educators to recognize the Kingdom (UK) and the United States of America challenges of preparing all health-care students (USA). The concerns of patient safety are not only to work in their country of training, international and it is widely recognized that but also to work in other health-care systems. adverse events are considerably underreported. Harden [3] described a three-dimensional model While most patient safety research has been of medical education, relevant to all health-care conducted in Australia, the UK and the USA professional education, based on the: and a number of other European countries, ñ student (local or international); patient safety advocates wish to see patient ñ teacher (local or international); safety adopted in all countries around the world, ñ curriculum (local, imported or international). not just in those that have had the resources to study and publish their patient safety initiatives. In the traditional approach to teaching and This internationalization of patient safety requires learning patient safety, local students and local novel approaches to the education of future teachers use a local curriculum. In the doctors and health-care practitioners. international graduate or overseas student model, students from one country pursue Globalization a curriculum taught in another country and The global movements of nurses, doctors developed by teachers in a third. In the and other health professionals have produced branch-campus model, students, usually local, many opportunities for enhancing postgraduate have an imported curriculum taught jointly by health-care education and training. The mobility international and local teachers. of students and teachers, and the interconne- ctedness of international experts in curriculum A second important consideration in the design, instructional methods and assessment, internationalization of health-care education married with local campus and clinical environ- is the affordability of e-learning technologies ments, have led to a concordance in what that allow a global interconnectivity where constitutes good health-care education [1]. the provider of a teaching resource, the teacher of that resource, and the student do not WHO has noted a global shortage of 4.3 million all have to be on campus, in a hospital or out health-care workers. The ‘brain drain’ of health- in a community at the same time.75 Part A 12. How to foster an international approach to patient safety education
    • The old style of curriculum emphasizes the Content experts in patient safety and educationalmobility of students, teachers and the curriculum developers are few and far between, and oftenacross the boundaries of two countries by mutual work in isolation. This impedes the sharing ofagreement, with a high expectation that information, innovation and development andthe country of practice will provide much of often results in unnecessary duplication ofthe training when the student graduates. resources and learning activities. An international approach to patient safety education wouldThe new way involving the internationalization ensure that there is true capacity-building inof patient safety education is integrated and patient safety education and training worldwide.embedded within a curriculum and involves This is one way that developed countries can sharecollaboration between a number of schools in their curriculum resources with developingdifferent countries. In this approach, the principles countries.of patient safety are taught in a global contextrather than the context of a single country. References 1. Schwarz MR, Wojtczak A. Global minimumThis model offers a considerable range of essential requirements: a road towardschallenges and opportunities for international competency oriented medical education. Medicalcollaboration in patient safety education. This Teacher, 2002, 24:125–129.Curriculum Guide serves as an excellent base 2. World Health Organization, Working togetherin this regard. It is important that the standards for Health, The World Health Report 2006of international health-care education institutions (;are reviewed to ensure that the principles of accessed 15 June 2011).patient safety are included. At a more local level,it is important for countries to customize and 3. Harden RM. International medical educationadapt materials. A good example of an and future directions: a global approach to health-care education Academic Medicine, 2006, 81 (Suppl.):S22– the experience with virtual medical schools [4]. 4. Harden RM, Hart IR. An international virtualHere, a number of international universities have medical school (IVIMEDS): the future for medicalcollaborated to form a virtual medical school education? Medical Teacher.dedicated to enhanced learning and teaching.This model could be adaptable to patient safety.People’s Open Access Education Initiative:Peoples-uni (;accessed 17 February 2011) has establisheda web-based curriculum on patient safety forhealth professionals who are unable to accessmore expensive postgraduate courses.Common components of a virtual patient safetycurriculum could be:ñ a virtual library that would provide access to up-to-date resources, tools and learning activities, and access to international patient safety literature (for example, the topics);ñ an “ask-the-expert” facility with online access to patient safety experts from different countries;ñ a bank of virtual patient safety cases with emphasis on ethical hazards, disclosure and apology;ñ an approach to patient safety which is culturally aware and respects competences;ñ an assessment bank of patient safety items for sharing (for example, the Hong Kong International Consortium for Sharing Student Assessment Banks is a group of international medical schools that maintains a formative and summative bank of assessment items across all aspects of medical courses). WHO Patient Safety Curriculum Guide: Multi-professional Edition 76
    • Part BCurriculumGuideTopicsPatient SafetyCurriculum Guide:Multi-professionalEdition
    • Definitions of Key ConceptsThe WHO Conceptual Framework for the and/or restriction of participation in society,International Classification for Patient Safety associated with past or present harm.(v.1.1). Final Technical Report 2009 12. Disease: a physiological or psychological 1. Adverse reaction: unexpected harm resulting dysfunction. from a justified action where the correct process was followed for the context in which 13. Error: failure to carry out a planned action as the event occurred. intended or application of an incorrect plan. 2. Agent: a substance, object or system which 14. Event: something that happens to or involves acts to produce change. a patient. 3. Attributes: qualities, properties or features 15. Harm: impairment of structure or function of of someone or something. the body and/or any deleterious effect arising there from. Harm includes disease, injury, 4. Circumstance: a situation or factor that may suffering, disability and death. influence an event, agent or person(s). 16. Harmful incident (adverse event): an 5. Class: a group or set of like things. incident that resulted in harm to a patient. 6. Classification: an arrangement of concepts 17. Hazard: a circumstance, agent or action into classes and their subdivisions, linked with the potential to cause harm. so as to express the semantic relationships between them. 18. Health: a state of complete physical, mental and social well-being and not merely the 7. Concept: a bearer or embodiment of absence of disease or infirmity. meaning. 19. Health care: services received by individuals 8. Contributing factor: a circumstance, or communities to promote, maintain, action or influence that is thought to have monitor or restore health. played a part in the origin or development of an incident or to increase the risk of an 20. Health care-associated harm: harm arising incident. from or associated with plans or actions taken during the provision of health care, rather 9. Degree of harm: the severity and duration than an underlying disease or injury. of harm, and any treatment implications, that result from an incident. 21. Incident characteristics: selected attributes of an incident.10. Detection: an action or circumstance that results in the discovery of an incident. 22. Incident type: a descriptive term for a category made up of incidents of a common11. Disability: any type of impairment of body nature, grouped because of shared, agreed structure or function, activity limitation features. WHO Patient Safety Curriculum Guide: Multi-professional Edition 80
    • 23. Injury: damage to tissues caused by an agent 39. Violation: deliberate deviation from or event. an operating procedure, standard or rule. 24. Mitigating factor: an action or Source: WHO conceptual framework for the international circumstance that prevents or moderates classification for patient safety. Geneva, World Health the progression of an incident towards Organization, 2009 harming a patient. (; accessed 11 March 2011). 25. Near miss: an incident that did not reach the patient. Definitions from other sources 26. No harm incident: an incident that reached 1. Health care-associated infection: an a patient, but no discernable harm resulted. infection that was neither present nor incubating at the time of patient’s admission, 27. Patient: a person who is a recipient of health which normally manifests itself more than care. three nights after the patient’s admission to hospital [1]. 28. Patient characteristics: selected attributes of a patient. 2. Patient safety culture: a culture that exhibits the following five high-level attributes that 29. Patient outcome: the impact upon a patient health-care professionals strive to operationalize that is wholly or partially attributable to an through the implementation of strong safety incident. management systems; (1) a culture where all health-care workers (including front-line staff, 30. Patient safety: the reduction of risk physicians, and administrators) accept of unnecessary harm associated with health responsibility for the safety of themselves, care to an acceptable minimum. their coworkers, patients, and visitors; (2) a culture that prioritizes safety above financial 31. Patient safety incident: an event or and operational goals; (3) a culture that circumstance that could have resulted, or encourages and rewards the identification, did result, in unnecessary harm to a patient. communication, and resolution of safety issues; (4) a culture that provides for organizational 32. Preventable: accepted by the community learning from accidents; (5) a culture that as avoidable in the particular set of provides appropriate resources, structure, circumstances. and accountability to maintain effective safety systems [2]. 33. Reportable circumstance: a situation in which there was significant potential for References harm, but no incident occurred. 1. National Audit Office. Department of Health. A Safer Place for Patients: Learning to improve patient 34. Risk: the probability that an incident will safety. London: Comptroller and Auditor General occur. (HC 456 Session 2005-2006). 3 November 2005. 2. Forum and End Stage Renal Disease Networks, 35. Safety: the reduction of risk of unnecessary National Patient Safety Foundation, Renal harm to an acceptable minimum. Physicians Association. National ESRD Patient Safety Initiative: Phase II Report. Chicago: 36. Semantic relationship: the way in which National Patient Safety Foundation, 2001. things (such as classes or concepts) are associated with each other on the basis of their meaning. 37. Side-effect: a known effect, other than that primarily intended, related to the pharmacological properties of a medication. 38. Suffering: the experience of anything subjectively unpleasant.81 Part B Definitions of Key Concepts
    • Key to IconsSlide number 1Topic number T1GroupsLectureSimulation exercisesDVDBook WHO Patient Safety Curriculum Guide: Multi-professional Edition 82
    • Introduction to the Curriculum Guide topics Being patient-centred entire lifecycle and are associated with staying This patient-centred Curriculum is designed healthy, getting better, living with illness or specifically for the health professional student disability, and coping with the end of life. The and places patients, clients and carers at the changing health-care environment (new models centre of health-care learning and service delivery. of care for treating chronic and acute conditions, The underpinning and applied knowledge and the continuously expanding evidence base and the required demonstration of performance technological innovations, complex care delivered set out in these topics calls for students by teams of health-care professionals, and engaged and health-care workers to think about how relationships with patients and carers) has created to incorporate patient safety concepts and new demands for the health-care workforce. principles into everyday practice. This Curriculum recognizes this changing environment and aims to cover a wide variety of Patients and the wider community in all countries patients in multiple situations and locations being are predominantly passive observers to the treated by multiple health-care workers. significant changes occurring in health care. Many patients still do not fully participate in decisions Why do students in the health about their health care, nor are they involved in professions need to learn about patient discussions about the best way to deliver health safety? services. Most health services today continue to The scientific discoveries of modern health care place the health professionals at the centre of care. have led to markedly improved patient outcomes. The disease-focused models of care emphasize However, studies conducted in many different the role of the health professional and management countries have shown that significant risks to by organizations without appropriate consideration patient safety have accompanied these benefits. of the patients who are at the receiving end A major consequence of this knowledge has been of health care. Patients need to be at the centre the development of patient safety as a specialized of care and not at the receiving end of care. discipline. Patient safety is not a traditional stand- alone discipline; rather, it is one that can and There is strong evidence that patients effectively should be integrated into all areas of health care. self-manage their conditions with appropriate support. Decreased attention to the acute setting As future clinicians and leaders in health care, and increased attention to treating patients in students need to know about patient safety, multiple sites requires health-care workers to put including how systems impact on the quality patient interests first–to seek and provide full and safety of health care and how poor information, to be respectful of their cultural communication can lead to adverse events. and religious differences, to seek permission Students need to learn how to manage these to treat and work with them, to be honest when challenges and how to develop strategies to things go wrong or the care is suboptimal, prevent and respond to errors and complications, and to focus health-care services on prevention as well as how to evaluate results to improve and minimization of risk or harm. performance in the long term. The community perspective The WHO Patient Safety programme aims to Community perspectives on health care reflect improve patient safety worldwide. Patient safety the changing needs for care over an individual’s is everyone’s business–health professionals,83 Part B Introduction to the Curriculum Guide topics
    • managers, cleaners and catering staff, information about medications and to askadministrators, consumers and politicians. questions. The best ways for students to learnAs students are the health-care leaders of the about patient safety are through hands-onfuture, it is vital that they be knowledgeable experience or practise in a simulated environment.and skilful in their application of patient safety Students need expert clinical coaching even moreprinciples and concepts. This Curriculum Guide than lectures on underpinning theories. Whenequips students with essential knowledge of instructors observe students’ performance andpatient safety, as well as describing the necessary provide feedback, students will continuouslyskills and behaviours to help them perform improve and eventually master many skillsall their professional activities safely. important to patient safety.The time to build students’ knowledge of patient Mentoring and coaching are also particularlysafety is right at the beginning of their training relevant to patient safety education. Studentsprogrammes. Students need to be ready to naturally try to copy and model the behaviourpractise patient safety skills and behaviours as of their instructors and senior practitioners.soon as they enter a hospital, clinic or patient’s The ways in which role models behave will havehome. Students also need the opportunity, a great influence on how students behave andwhenever possible, to consider safety issues in how they will eventually practice when they finisha simulated environment prior to actual practice their training. Most students come to health carein the real world. with high ideals–wanting to be a healer, to show compassion, and to be a competentBy getting students to focus on each individual and ethical health professional. However, whatpatient, having them treat each patient as a they frequently see is rushed care, rudeness tounique human being, and practising applying their colleagues, and professional self-interest. Slowly,knowledge and skills to benefit patients, students their high ideals are compromised as they try to fitthemselves can be role models for others in in with the surrounding work culture.the health-care system. Most health-care studentsenter their training programmes with high Patient safety education and this Curriculumaspirations. Nevertheless, the reality of the system Guide recognize these strong influences andof health care sometimes deflates their optimism. factors exist in some settings. We believe thatWe want students to be able to maintain their these negative influences can be moderated andoptimism and believe that they can make their impact minimized by talking with studentsa difference in both the individual lives of patients about the prevailing work culture and the impactand to the health-care system. of such a culture on the quality and safety of patients. Recognizing the barriers to patient safetyHow to teach patient safety: managing and talking about them will give students a sensethe barriers of the system as a problem (as opposed toEffective student learning depends on instructors the people in the system being the problem)using a range of educational methods, such as and allow them to see that changing the systemexplaining technical concepts, demonstrating skills for the better is possible and a goal worth strivingand instilling attitudes–all of which are essential for. The barriers are not the same in every countryfor patient safety education. Teachers of patient and culture or even across different clinicalsafety use problem-based teaching (facilitated settings within one region. Country-specificgroup learning), simulation-based learning (role barriers might include laws and regulationsplay and games) and lecture-based teaching governing the health system. These laws may(interactive/didactic), as well as mentoring and prevent the implementation of certaincoaching (role models). practices. Different cultures have their own approaches to hierarchies, errors andPatients judge their health-care providers not by the resolution of conflicts. The extent to whichhow much they know, but by how they perform. students are encouraged to be assertive in theAs students progress in the clinical and work presence of instructors and/or senior clinicians,environment, the challenge is to apply their particularly in circumstances in which a patientgeneral scientific knowledge to specific patients. might be at risk of harm, will depend on theIn doing so, students go beyond “what” they situation and the readiness of the localhave learned in class to knowing “how” to apply professional culture for change. In some societies,their knowledge. The best way for students to patient safety concepts might not easily fit inlearn is by doing. Patient safety practices require with cultural norms. These barriers are exploredstudents to act safely–to check names, to seek in more depth later in this topic (see the section WHO Patient Safety Curriculum Guide: Multi-professional Edition 84
    • Confronting the real world: helping students to become How the topics in this Curriculum Guide patient safety leaders). relate to health-care practice Table B.I.1 shows how the topics in this The barriers most evident to students are those Curriculum Guide are integrated into health care, that surface during their professional placements using hand hygiene as an example. Many patient and treatment settings and relate mainly to senior safety principles apply across health care, such as instructors/ supervisors or health professionals teamwork, medication safety, and engaging who are unable to adapt to the new health-care with patients. We use this example because challenges or who actively discourage any change minimizing the transmission of infection can be in response to them. Their behaviour can achieved by health-care workers cleansing their transform a student from an advocate for patient hands in the right way at the right time. Using safety into a passive textbook learner. The way correct hand hygiene practices seems to be such that different health professionals (nurses, an obvious and easy thing to achieve. But, pharmacists, dentists, doctors, etc.) maintain their despite hundreds of campaigns to educate own professional cultures, which results in a silo health professionals, faculty, students and approach to health care, is also another significant other staff about standard and universal barrier. Failure to communicate across disciplines precautions, we do not appear to have fixed can lead to health-care errors. An interdisciplinary this problem and rates of health care-associated team approach is much more effective in reducing infections (HCAI) are climbing worldwide. errors, improving staff communication, and Each curriculum topic contains important promoting a healthier work environment. learning for health-care students in a particular area. Taken together, the topics provide As instructors and supervisors become familiar the underpinning knowledge and prepare with this Curriculum, they will quickly realize that health-care students to maintain correct student learning may not be practised in the real hand hygiene techniques, as well as to identify life setting. Some health professionals may feel how to make system-wide improvements. that teaching patient safety to health-care students is an unachievable goal because of The Curriculum Guide topics and their the many barriers involved. Yet, once barriers are relation to patient safety named and discussed, they are not so daunting. While the topics are stand alone, Table B.I.1 Even discussions among groups of students about demonstrates how all the topics are necessary for the realities and the barriers can inform and teach. the development of appropriate behaviour by health At the very least, they can allow a constructive professionals. Using hand hygiene as an example, critique of the system and time for reflection on we show how the learning from each of the topics how things are done. is necessary to achieve and sustain safe health care.Table B. I. 1. How the topics are interrelated: the example of hand hygieneProblem area: minimizing Curriculum Guide topic and relevance to practicethe spread of infectionProblem caused by poor Topic 1 “What is patient safety?” describes the evidence of the harm and sufferinginfection control. caused by adverse events. As students learn about the discipline of patient safety and their own role in minimizing the incidence and impact of adverse events, they will be able to appreciate the importance of their own behaviours, such as using appropriate hand hygiene techniques, for the prevention and control of infection.Health-care workers know Topic 2 “Why applying human factors is important for patient safety” explainsthat infection is a problem. how and why humans work the way they do, and why they make errors. AnHowever, just knowing this understanding of human factors will assist the identification of opportunities for errorsdoes not seem to change and help students to learn how they can be avoided or minimized. Understandingpractice. People tend to use the factors involved in errors and their root causes will help students to understandcorrect hand hygiene the context of their actions. Telling people to try harder (cleanse their hands correctly)techniques for a while, will not change anything. They need to see their own actions in the context of thebut then they forget. 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 the way they work and use standard precautions. 85 Part B Introduction to the Curriculum Guide topics
    • Health-care workers want to maintain Topic 3 “Understanding systems and the effect of complexity onproper infection prevention and patient care” shows how patient care includes multiple steps and multiplecontrol procedures, but there are relationships. Patients depend on health-care professionals treating them intoo many patients to care for the right way; they depend on a system of health care. Students need toand time constraints appear to know that good health care requires a team effort. They need to understandpreclude adequate hand hygiene. that cleansing hands is not an optional extra, but an important step in caring for patients. Understanding how each person’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-based hand Topic 4: “Being an effective team player” explains the importancerubs or cleaning agents on of teamwork among health-care professionals. If no alcohol-based handthe wards because the clerk forgot rubs are available, it is up to every member of the team to notify theto order them. appropriate person to ensure availability. Just complaining that someone forgot to order hand 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 a professional and a team player. Adverse events are often caused by a cascade of many seemingly trivial things–not cleansing hands, no medication chart available, or the delayed attendance of a clinician. Reminding someone to order the hand rubs is not trivial, it can prevent an infection.A surgeon left the theatre Topic 5: “Learning from errors to prevent harm” shows how blamingmomentarily to answer a mobile people does not work, and that if people fear being accused of negligencephone. He returned to theatre or blamed, no one will report or learn from adverse events. A systemsand continued the operation wearing approach to errors seeks to identify the underlying causes of errors andthe same gloves. The patient to ensure that they are not repeated. An examination of the causes of theexperienced a postoperative wound infection may show that the surgeon left the theatre and did not useinfection. appropriate sterile techniques upon his return. Blaming a person alone 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 was Topic 6: “Understanding and managing clinical risk” shows studentsinfected, made a written complaint the importance of having systems in place to identify problems and fixto the hospital about his care. potential problems before they occur. Complaints can tell a clinician or manager if there are particular problems. This patient’s letter of complaint about his infection may be the 10th letter in a month, which could tell the hospital that there may be a problem with infection control. 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 Topic 7: “Using quality-improvement methods to improve care”a problem with infection in a particular provides examples of methods for measuring and making improvements intheatre and wants to know more clinical care. Students need to know how to measure care processes in orderabout the problem. to determine whether changes have led to improvements.The hospital now knows that one Topic 8: “Engaging with patients and carers” shows students theof its theatres has a higher infection importance of honest communication with patients after an adverse eventrate than the others. Patients are and the importanceof giving complete information to patients about theircomplaining and the hospital’s care and treatment. Engaging with patients is necessary to maintaininfection problem has received media the trust of the community.coverage. WHO Patient Safety Curriculum Guide: Multi-professional Edition 86
    • The hospital decides that infection is a particular Topic 9: “Infection prevention and control” describesproblem and that everyone needs to be reminded the main types and causes of infections. It also coversof the mportance of complying with standard relevant steps and protocols for minimizing infections.precautions.The hospital decides to review infection control Topic 10: “Patient safety and invasive procedures”in theatres because surgical-site infections comprise demonstrates to students that patients having surgerya significant percentage of the adverse events being or other invasive procedures are at a higher risk of infectionreported by staff. 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 overwork will help students appreciate the multiple factors that are at play in surgery.Records from the surgical ward were reviewed using Topic 11: “Improving medication safety” is importanta quality-improvement method (one that asks “what because medication errors cause a significant proportionhappened?” instead of “who did it?”), as the team of adverse events. The scale of medication error issearched for an intervention that might help lower immense and students need to identify factors that leadthe infection rate. The team learned that the appropriate to errors and know the steps to take to minimize these.administration of prophylactic antibiotics can help Medication safety ensures that students know aboutprevent infections. But this practice would also require the potential for adverse drug reactions and thatthat a complete medication history be available they consider all relevant factors when prescribing,for each patient to avoid interactions with other dispensing, administering, and monitoring the effectsmedications they might be prescribed. of medications. Confronting the real world: helping students formal feedback and subjective and objective to become patient safety leaders assessments of their competence and One of the main challenges to patient safety commitment. Patient safety requires that reform is the receptiveness of the workplace to health-care professionals talk about their new ways of delivering care. Change can be very mistakes and learn from them, but students difficult for organizations and health professionals may fear that disclosing their own mistakes or who are used to treating patients in particular the mistakes of a senior professional, instructor ways. They do not necessarily see anything wrong or supervisor may have repercussions for with how they deliver care and are not convinced them or the people involved. Over-reliance that they need to change. They may feel on workplace-based instructors or supervisors threatened or challenged when someone, for teaching and assessment may encourage particularly a junior staff member, sees and even students to conceal their mistakes and perform does things differently. In these circumstances, requested tasks, even when they know that they unless students are supported with positive are not yet competent to perform those tasks. coaching and given an opportunity to discuss their Students may be reluctant to talk about patient experiences, much of the teaching and learning safety or express their concerns about ethical about patient safety in training programmes will issues with senior staff. They may be fearful of be undermined. receiving an unfavourable report or of being seen as “lacking in commitment” or “having a bad Students very quickly learn how members of their attitude”. Students may hold founded or chosen health-care profession behave and what unfounded fears that speaking up for a patient or is expected of them and, because they are novices, disclosing errors may lead to unfavourable reports, they wish to fit in as soon as possible. Students decreased employment opportunities and/or in the health professions are often very dependent reduced chances for gaining access to advanced upon instructors and supervisors for information training programmes. and professional support. Discussions about health-care errors are difficult For students, maintaining the confidence of for all health-care professionals in all cultures. an instructor or supervisor is paramount. Their Openness to learning from errors will often progression depends on favourable reports depend on the personalities of the senior from their teachers based on informal and professionals involved. In some cultures and 87 Part B Introduction to the Curriculum Guide topics
    • organizations, openness about errors may be new and bad) were attributed to the professional’sand, therefore, very difficult for faculty. In these skills, not those of the team. They were notcases, it may be appropriate for the students to professionally accountable to anyone other thantalk about errors in student teaching sessions. themselves and, in some places, non-payingIn some places, these discussions are held in patients were predominantly viewed as learningclosed meetings and, in more advanced material. Although much has changed, someeducational settings, teams may talk about errors remnants of the old culture have persisted andopenly and have many policies in place to assist shaped the attitudes of health-care professionalshealth-care workers navigate their way through who trained in that cultural error. But, eventually, every culture will haveto confront the human suffering caused by errors. Modern societies want safe, quality health careOnce the suffering is openly acknowledged by the delivered by health professionals working inhealth professionals who work in the hospitals, a safety culture. This safety culture has startedclinics, and community, it will be difficult to to permeate health-care workplaces around themaintain the status quo. Many will adopt different world and students will encounter both traditionalapproaches to hierarchies and patient-care attitudes and those that reflect a safety Some of these newer approaches view The challenge for all students, irrespective of theirthe team as the main instrument of health-care culture, country or discipline is to practise safedelivery, envisaging a flatter hierarchy in which health care, even when those around them do not.everyone caring for the patient can appropriatelycontribute. It is helpful to be able to differentiate between certain old approaches that may negatively affectIt may help students if they can understand why patient care and certain new practices that fosterthe expectations and attitudes of some senior patient-centred care. It is also important toprofessionals and faculty seem to be at odds with acknowledge that this cultural shift may createwhat they have learned about patient safety. some tension for the student or trainee whoHealth care has not been designed with patient is keen to practise with safety in mind, but whosesafety in mind. It has evolved over time, with direct senior is not aware of, or in favour of,many aspects of care being a consequence of these new approaches. It is important thattradition rather than explicit concerns for safety, students talk to their supervisors before they startefficiency and efficacy within the context of implementing the suggested new techniques.contemporary health care. Many attitudes withinhealth care are deeply rooted in a professional We do not expect students to put themselvesculture that originated at a time when hierarchical or their careers at risk in the interest of changingstructures were commonplace in society–health the system. But we do encourage studentscare was seen as a life vocation and clinicians, to think about how they might approach theirparticularly doctors, were considered infallible. training and maintain a patient safety perspectiveWithin that conceptual framework, good health- at the same time. Table B.I.2 below providescare professionals were thought to be incapable a framework to give students some ideas forof making mistakes, training was through managing the conflicts they may experience whileapprenticeship, and patient outcomes (good they are assigned to a workplace for training.Table B.I.2. Managing conflicts: the old way and the new way Area or attribute Example Old way New way Hierarchies in A senior health Student says nothing (1) Seek clarification on the health care: practitioner does not and conforms to inadequate "when and how" of hand Hand hygiene cleanse his/her hands practices, imitating hygiene with the clinician between patients. the senior clinician. or other senior person. (2) Say nothing, but use safe hand hygiene techniques. (3) Say something in a respectful manner to the clinician and continue to use safe hand hygiene techniques. WHO Patient Safety Curriculum Guide: Multi-professional Edition 88
    • Hierarchies Surgeon does not Adopt the approach (1) Actively help the restin heath care: participate in checking of the senior surgeon of the team to completeSurgical site the correct site for and do not participate the checking protocol. surgery or verifying in checking–decide the patient’s identity. that checking is too menial a task. The surgeon is resentful of the preoperative checking protocol, believing it to be a waste of time, and puts pressure on the rest of the team to hurry up.Hierarchies in Student is aware that Say nothing for fear (1) Immediately share concernhealth care: a patient has a known of being seen to disagree about allergy with the nurse.Medication serious allergy to with a senior persons Student views this as being penicillin and observes decision. Presume that a helpful part of the team and a senior nurse about the nurse must know also his/her responsibility as to administer penicillin. what he/she is doing. a patient advocate.Paternalism: Student asked Accept task. Do not let (1) Decline the task and suggestConsent to obtain consent senior staff know your level that a clinician with some from a patient for of ignorance about the familiarity with the treatment a treatment the treatment. Talk to the would be more appropriate for student has never patient about the treatment this task. heard of before. in a vague and superficial (2) Accept the task, but explain way so as to obtain you know little about the the patient’s signature on treatment and will need some the consent form. teaching about it first, and request that one of the supervisors comes along to help/supervise.Paternalism: The patients are Accept the situation and (1) Take the lead in greetingRole of ignored during the do nothing. Assume that each patient: “Hello Mr Ruiz,patients in ward round and not this is the way things are we are reviewing all of our patientstheir care engaged in discussions done. Conform to behaviours this morning. How are you feeling about their care. that do not include or today?”. engage patients and their Family members are (2) If there is time pressure to keep families. asked to leave moving, explain to the patient the bedside when and his/her family, “I will come the doctors are doing back to talk to you after the ward their ward rounds. round”. (3) Find out your patient’s concerns before the round and raise them with the senior clinicians on the round at the bedside, e.g. “Mr Carlton is hoping to avoid surgery, is this an option for him?”. (4) Invite and encourage patients to speak up during the ward round. (5) Ask your supervisor whether he/she thinks patients and their relatives can add value to the ward round discussions and so improve the efficiency of the unit. 89 Part B Introduction to the Curriculum Guide topics
    • Infallibility A junior staff Admire the staff member (1) Ask the staff member how he feelsof health-care member on the ward for his stamina and and whether it is wise or even responsibleprofessionals: announces with commitment to his work. to still be working.Hours of work pride that he has been (2) Ask when he is due to finish and how at work for the last he plans to get home. Is he safe to drive 36 hours. a car? (3) Make some helpful suggestions: “Is there someone who can carry your pager so you can go home and get some rest?” Or, “I didn’t think staff were allowed to work such long hours, you should complain about your roster”.Infallibility Mistakes are only Accept the culture that says (1) Understand that everyone willof health-care made by people health professionals who make mistakes at some time and thatprofessionals: who are incompetent make mistakes are “bad” or the causes of errors are multifactorialAttitude or unethical. “incompetent”. Try harder and involve latent factors nottoward Good health-care to avoid making mistakes. immediately obvious at the timemistakes professionals do not Remain silent, or find the error was made. Look after your make mistakes. someone or something else patients, yourself and your colleagues to blame when you have in the event of an error and actively made a mistake. promote learning from errors. Look at the mistakes others make and tell yourself that you would not be as stupid.Infallibility of A senior health Accept that the way (1) Talk to a supervisor about openhealth-care practitioner makes to handle a mistake disclosure to patients and whetherprofessionals: a mistake and tells is to rationalize it as the hospital or clinic has a policy aboutMaking the patient it was a problem associated with providing information to patients aftermistakes a complication. the patient, rather than adverse events. Staff do not talk the care provided. Quickly (2) Ask the patient if he/she would like about their mistakes learn that senior staff do more information about their care and, in peer-review not disclose errors to if so, advise the doctor that the patient meetings. patients or their colleagues would like more information. and model your behaviour on them. (3) Tell your supervisor or team leader when you make a mistake and ask how a similar mistake can be avoided in the future. (4) Fill out an incident form, if appropriate.Infallibility A health practitioner Aspire to be like this (1) Recognize the arrogance in suchof health-care who acts “god-like” person and admire attitudes and model behaviour on staffprofessionals: and looks down on how everyone bows who work in teams and share theirOmniscience junior health profes- down to him. knowledge and responsibilities. sionals and patients.Blame/shame A health practitioner Say nothing and model (1) Offer support and understanding who makes a mistake behaviour on other staff to a colleague who is involved in an is ridiculed or who talk negatively about incident. humiliated by their a health professional (2) Talk to colleagues and your supervisor supervisor. involved in an incident. about better ways to understand mistakes than just blaming the person involved. A hospital disciplines a staff member for (3) Focus on the mistake. Ask “what an error. happened?” rather than “who was involved?”. Try to generate discussion within the team/tutorial group about the multiple factors that might have been involved. WHO Patient Safety Curriculum Guide: Multi-professional Edition 90
    • Teamwork: Students and junior Change behaviour (1) Be mindful that the team fromMy team is clinicians identify to reflect that of a patient’s perspective is everyonethe nursing only other clinicians the rest of the clinicians who cares and treats the patient–nurses,team of the same discipline and identify only ward staff and allied health-care workers,(or the as being part of their with the members as well as the patient and his/her familymidwifery/ team. of your own profession. The clinicians in the (2) Always suggest including otherdental/ ward do their rounds members of the health-care team inmedical without a member conversations about a patient’s careteam) of other professions and treatment. present. (3) Acknowledge and maximize the benefit of an interprofessional team. Patient narratives The use of narratives in health care as a learning tool has been effective for generations of health professionals. Stories about both gifted and difficult work colleagues, about good and bad teachers, instructors and supervisors, about tips for surviving a particular shift or rotation are just a few examples. These stories focus largely on the health-care student perspective. Missing from the usual narrative toolbox are the patients’ stories. Their experiences are reminders that they too are part of the health-care team and that they too have something to offer. Patient narratives included in each learning topic, are designed to highlight the importance of the topic from a patient perspective and to bring the Curriculum to life by giving some real examples of what can go wrong in the delivery of health-care services in the absence of a patient-centred approach. Fictitious names have been used for most of the patient narratives, except where permission has been given by the family, such as in the case of Caroline Anderson. These real patient stories are taken from the Australian Patient Safety Education Framework (APSEF) 2005. 91 Part B Introduction to the Curriculum Guide topics
    • Topic 1What is patient safety?Caroline’s storyOn 10 April 2001, Caroline, aged 37, was Caroline’s pain was helped by the medicationsadmitted to a city hospital and gave birth to until 2 May when her condition deteriorated.her third child in an uncomplicated caesarean Her husband then took her to the local countrydelivery. Dr A was the obstetrician and Dr B hospital in a delirious state. Shortly afterwas the anaesthetist who placed the epidural arriving at the hospital on 3 May, she startedcatheter. On 11 April, Caroline reported that convulsing and mumbling incoherently. Dr C,she felt a sharp pain in her spine and had recorded in the medical records “? Excessiveaccidentally bumped the epidural site the opiate usage, sacroiliitis”. Her condition wasnight before the epidural was removed. During critical by this stage and she was rushedthis time, Caroline repeatedly complained by ambulance to the district hospital.of pain and tenderness in the lumbar region.Dr B examined her and diagnosed “muscular” By the time she arrived at the district hospital,pain. Still in pain and limping, Caroline was Caroline was unresponsive and needingdischarged from the city hospital on 17 April. intubation. Her pupils were noted to be dilated and fixed. Her condition did not improve andFor the next seven days, Caroline remained on 4 May she was transferred by ambulanceat her home in the country. She telephoned to a second city hospital. At 1.30pm onDr A about her fever, shaking, intense low back Saturday 5 May, she was determined to havepain and headaches. On 24 April, the local no brain function and life support wasmedical officer, Dr C, examined Caroline and withdrawn.her baby and recommended that they both beadmitted to the district hospital for back pain A postmortem examination revealed anand jaundice, respectively. epidural abscess and meningitis involving the spinal cord from the lumbar region toThe admitting doctor at the district hospital, the base of the brain, with cultures revealingDr D, recorded that Caroline’s back pain a methicillin-resistant Staphylococcus aureusappeared to be situated at the S1 joint rather (MRSA) infection. Changes to the liver, heartthan at the epidural site. On 26 April, the and spleen were consistent with a diagnosisbaby’s jaundice had improved, but Caroline of septicemia.had not yet been seen by the generalpractitioner, Dr E, who acknowledged that The coronial investigation concluded thathe had forgotten about her. The medical Caroline’s abscess could and should have beenregistrar, Dr F, examined Caroline and diagnosed earlier. The following discussiondiagnosed sacroiliitis. He discharged her with of the coroner’s report into the death ofprescriptions for oxycodone hydrochloride, Caroline Anderson highlights many ofparacetamol, and diclofenac sodium. He also the issues addressed in this multi-professionalinformed Caroline’s obstetrician, Dr A, of his edition of the WHO Patient Safety Curriculumdiagnosis. Guide. WHO Patient Safety Curriculum Guide: Multi-professional Edition 92
    • Discussion In a major departure from accepted medical The observation that surfaced repeatedly in practice, Dr E agreed to see Caroline and this story was the inadequacy in recording simply forgot about her. detailed and contemporaneous clinical notes and the regular incidence of notes being lost. The last doctor to examine Caroline at the The anaesthetist, Dr B, was so concerned district hospital was the medical registrar, about Caroline’s unusual pain that he Dr F, who discharged her with prescriptions consulted the medical library, but he did not for strong analgesics without fully investigating record this in her clinical notes. He also failed his provisional diagnosis of sacroiliitis, which to communicate to Caroline the risk of what he thought could have been postoperative he now thought to be “neuropathic” pain or of infectious origin. With regards to or to ensure that she was fully investigated medication safely, Dr F’s handwritten notes before discharge. There were also concerns to Caroline were considered vague and that evidence-based guidelines were not ambiguous in instructing her to increase followed with respect to Dr B scrubbing prior the dose of oxycodone hydrochloride if the to the epidural insertion as it was the view pain increased, while monitoring specific of an independent expert that the bacteria changes at the same time. The notes that that caused the abscess was most likely Dr F made on a piece of paper detailing his to have originated from the staff or examination and the possible need for environment at the city hospital. magnetic resonance imaging (MRI) have never been found. It was clear that Caroline would be managed by others after her discharge. However, she The one doctor who the coroner believed was not involved as a partner in her health could have taken global responsibility care by being given instructions about for Caroline’s care was her obstetrician, the need to seek medical attention if her back Dr A. He was phoned at least three times pain worsened. Similarly, no referral letter after her discharge from the city hospital or phone call was made to her local medical with reports of her continuing pain and officer, Dr C. problems, but failed to realize the seriousness of her condition. It was the coroner’s opinion that each of the doctors who examined Caroline after From the birth of her child to her death 25 she returned to the country was hasty in days later, Caroline was admitted to four reaching a diagnosis, mistakenly believing different hospitals. There was an obvious that any major problem would be picked up need for proper continuity of care in by someone else down the track. Dr C made the handover of responsibilities from each only a very cursory examination of Caroline set of medical and nursing staff to another. as he knew she was being admitted to The failure to keep adequate notes with the district hospital. The admitting doctor, provisional/differential diagnoses and Dr D, thought that there was a 30% chance investigations and provide discharge of Caroline having an epidural abscess, but summaries and referrals led to a delay in did not record it in the notes because he the diagnosis of a life-threatening abscess believed that it would be obvious to colleagues. and, ultimately, Caroline’s death. Source: Inquest into the death of Caroline Barbara Anderson, Coroner’s Court, Westmead, Sydney, Australia, 9 March 2004. (Professor Merrilyn Walton was given written permission by Caroline’s family to use her story in teaching health-care students to help them learn about patient safety from the perspective of patients and families).93 Part B Topic 1. What is patient safety?
    • Introduction–Why is patient relating to poor hygiene and sanitation. 1safety relevant to health care? In addition, an unfavourable socio-economicThere is now overwhelming evidence that background and patients affected by malnutritionsignificant numbers of patients are harmed and other types of infection and/or diseasesfrom health care, resulting in permanent injury, contribute to increasing the risk of healthhospital admissions, increased lengths of stay care-associated hospital and even death. Over the last decade,we have learned that adverse events occur not Several studies have shown that the risk ofbecause people intentionally hurt patients, developing surgical site infections in developingbut rather due to the complexity of health-care countries is significantly higher than in developedsystems today, where the successful treatment countries, with rates ranging between 19% toand outcome for each patient depend on 31% across different hospitals and countries [1].a range of factors, in addition to the competence WHO figures for unsafe medications demonstrateof each individual health-care provider. that an estimated 25% of all medicines consumed in developing countries are probably counterfeit,When so many and varied types of health-care thus contributing to unsafe health care.providers (physicians, midwives, dentists, surgeons, A WHO survey of medication safety andnurses, pharmacists, social workers, dieticians, counterfeit medicines reports from 20 countriesand others) are involved, it can be very difficult found that 60% of counterfeit medicine casesto ensure safe care, unless the system of care is occurred in developing countries and 40%designed to facilitate the timely and complete in the developed world [2]. Another WHO studyexchange of information among all the health showed that at least half of all hospital medicalprofessionals involved in caring for the patient. equipment in developing countries is unusable or only partly usable at any given time [3].Patient safety is an issue in all countries that In some countries, about 40% of hospital bedsdeliver health services, whether these services are located in structures originally built for otherare privately commissioned or funded by purposes. This makes facilities for radiationthe government. Failing to adequately check protection and infection control extremelythe identity of a patient or prescribing antibiotics difficult to incorporate, with the result that suchwithout regard for the patient’s underlying facilities are often either substandard or absentcondition or administering multiple drugs without [4]. Even on the basis of limited and estimatedpaying attention to the potential for adverse drug evidence from developing countries, it is likelyreactions can lead to patient injury. Patients are that a combination of efforts specifically relatednot only harmed by the misuse of technology. to the education and training of health careThey can also be harmed by poor communication professionals is urgently needed.between different health-care providers, ordelays in receiving treatment. Patient safety in both developed and developing countries is a broad subject that could incorporateThe situation of health care in developing the latest technology, such as electroniccountries merits particular attention. The poor prescribing and redesigning clinics and out-patientstate of infrastructure and equipment, unreliable settings, but also washing hands correctly andsupply and quality of drugs, shortcomings in knowing how to be an effective team member.infection control and waste management, Many of the features of patient safetypoor performance of personnel because of low programmes do not involve financial resources,motivation or insufficient skills and severe but rather the commitment of individuals tounder-financing of the health services makes practise safely. Individual health-care providersthe probability of adverse events much higher can improve patient safety by engaging withthan in the developed world. Important patient patients and their families in a manner thatsafety issues include: health care-associated shows respect, checking procedures, learninginfection, injuries due to surgical and anaesthesia from errors and communicating effectivelyerrors, medication safety, injuries due to medical with other members of the health-care team.devices, unsafe injection practices and blood Such activities can also help minimize costsproducts, unsafe practices for pregnant women as they minimize the harm caused to patients.and newborns. In many hospital settings, The reporting and analysis of errors can helpthe challenge of health-care associated infection identify the main contributing widespread, with infection control measures Understanding the factors that leadvirtually non-existent. This is the result of to errors is essential for thinking abouta combination of numerous unfavourable factors the changes that will prevent errors. WHO Patient Safety Curriculum Guide: Multi-professional Edition 94
    • Keywords explain why it has taken so long for patient Patient safety, systems theory, blame, blame safety to be seen as a priority. In addition, culture, system failures, person approach, mistakes affect one patient at a time, and staff violations, patient safety models, interdisciplinary working in one area may only infrequently and patient-centred. experience or observe an adverse event. Errors and system failures do not all happen at the 2 Learning objectives same time or place, which can mask the extent Students should understand the discipline of errors in the system. of patient safety and its role in minimizing the incidence and impact of adverse events, as The collection and publication of patient well as maximizing recovery from these events. outcome data is not yet routine for all hospitals and clinics. However, a significant number of Learning outcomes: knowledge studies that have examined patient outcome data and performance [11,13,14] have shown that many adverse events Patient safety knowledge and skills cover many are preventable. In a landmark study, Leape et al. areas, including effective teamwork, accurate [14] found that more than two-thirds of the and timely communication, medication safety, adverse events in their sample were preventable, hand hygiene and procedural and surgical skills. 28% were due to the negligence of a health The topics in this Curriculum Guide have been professional and 42% were caused by factors selected based on evidence of their relevance other than negligence. They concluded that and effectiveness. In this topic, we present many patients were injured as a result of poor an overview of patient safety and set the scene medical management and substandard care. for deeper learning in some of these above areas. For example, we introduce the term sentinel event Bates et al. [15] found that adverse drug events in this topic, but we present a more thorough were common and that serious adverse drug discussion of its meaning and relevance events were often preventable. They further to patient safety in Topic 5 (Learning from found that medications harmed patients at errors to prevent harm to patients) and Topic 6 an overall rate of about 6.5 per 100 admissions (Understanding and managing clinical risk). in large United States teaching hospitals. Although most of these events resulted from Knowledge requirements 3 errors at the prescribing and dispensing stages, Students should know: many also occurred at the administration stage. ñ the harm caused by health-care errors The authors of this study suggested that and system failures; prevention strategies should target both stages ñ lessons about error and system failure of the drug delivery process. Their research, from other industries; based on self-reports by nurses and pharmacists ñ the history of patient safety and the origins and daily chart review, is a conservative figure of the blame culture; because many doctors do not routinely self-report ñ the difference between system failures, medication errors. violations and errors; ñ a model of patient safety. Many studies confirm that health-care errors are prevalent in our health systems and that the 4 Performance requirements associated costs are substantial. In Australia [16], Students need to apply patient safety thinking errors result in as many as 18 000 unnecessary in all professional activities. They need to deaths and more than 50 000 disabled patients. demonstrate the ability to recognize the role of In the United States [17], health-care errors result patient safety in the delivery of safe health care. in at least 44 000 (and perhaps as many as 98 000) unnecessary deaths each year, as well The harm caused by health-care 5 as one million excess injuries. errors and system failures Even though the extent of adverse events In 2002, WHO Member States agreed on a World in the health system has long been recognized Health Assembly resolution on patient safety [5-12], the degree to which these events are in recognition of the need to reduce the harm acknowledged and managed varies greatly and suffering of patients and their families and across health systems and health professions. in acknowledgement of the compelling evidence of Poor information and poor understanding of the economic benefits of improving patient safety. the extent of the harm caused and the fact that Studies show that additional hospitalization, most errors do not cause any harm at all may litigation costs, infections acquired in hospitals,95 Part B Topic 1. What is patient safety?
    • lost income, disability and medical expenses has been exposed by the publication of thehave cost some countries between US$ 6 billion international studies listed in Table B.1.1.and US$ 29 billion a year [17, 18]. These studies confirm the large numbers of patients involved and show the adverse eventThe extent of patient harm from health care rate in four countries.Table B.1.1. Data on adverse events in acute-care hospitals in Australia, Denmark,the United Kingdom and the United States of America Study Year in which Number of Number of Adverse data was collected hospital admissions adverse events event rate (%) 1 USA 1984 30 195 1 133 3.8 (Harvard Medical Practice Study) 2 USA (Utah–Colorado study) 1992 14 565 475 3.2 3 USA 1992 14 565 787 5.4 (Utah–Colorado study) a 4 Australia (Quality 1992 14 179 2 353 16.6 in Australian Health Care Study) 5 Australia (Quality 1992 14 179 1 499 10.6 in Australian Health Care Study)b 6 UK 1999–2000 1 014 119 11.7 7 Denmark 1998 1 097 176 9.0Source: World Health Organization, Executive Board 109th session, provisional agenda item 3.4, 5. 2001, EB 109/9 [19].a Revised using the same methodology as the Quality in Australian Health Care Study (harmonizing the four methodological discrepancies between the two studies).b Revised using the same methodology as the Utah–Colorado Study (harmonizing 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 Carestudies.The studies listed in Table B.1.1 used retrospective many health systems categorize adverse eventsmedical record reviews to calculate the extent by level of seriousness. The most serious adverseof patient injury as a result of health care [20-23]. events, which cause serious injury or death,Since then, Canada, England and New Zealand are called sentinel events. In some countries, thesehave published similar adverse event data [24]. are named the “should never be allowed to happen”While the rates of injury differ among the events. Many countries now have, or are puttingcountries that publish data, there is unanimous in place, systems to report and analyse adverseagreement that the harm incurred is of significant events. To further improve care over the longconcern. The catastrophic deaths that are term, some countries have even mandated thereported in the media, while horrific for reporting of sentinel events accompanied by rootthe families and health professionals involved, cause analyses (RCA) to determine the originare not representative of the majority of adverse of each error. The reason for categorizing adversehealth-care events. Patients are more likely to events is to ensure that the most serious onessuffer less serious, but nevertheless debilitating with the potential to be repeated are analysedevents, such as wound infections, decubitus using quality-improvement methods, andulcers and unsuccessful back operations [24]. to make certain that the causes of the problemSurgical patients are more at risk than others [25]. are uncovered and steps taken to prevent similar incidents. These methods are coveredTo assist the management of adverse events, in Topic 7. WHO Patient Safety Curriculum Guide: Multi-professional Edition 96
    • Table B.1.2. Some adverse events reported in Australia and the USA [19] Type of adverse event USA Australia (% of 1 579 total events) (% of 175 total events) Suicide of inpatient or within 72 hours of discharge 29 13 Surgery on wrong patient or body site 29 47 Medication error leading to death 3 7 Rape/assault/homicide in an inpatient 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 -Source: Runciman B, Merry A, Walton M. Safety and ethics in health care: a guide to getting it right, 2007 [24].N/A indicates that this category is not on the official list of reportable sentinel events for that country. Human and economic costs Lessons about error and system 6 There are significant economic and human failure from other industries costs associated with adverse events. Large-scale technological disasters involving The Australian Patient Safety Foundation spacecraft, ferries, offshore oil platforms, estimated the costs of claims and premiums railway networks, nuclear power plants a on insurance for large medical negligence suits nd chemical installations in the 1980s led to in the state of South Australia to be about $18 the development of organizational frameworks million (Australian) for 1997–1998 [26]. for safer workplaces and safer work cultures. The National Health Service in the UK pays The central principle underpinning efforts to around í400 million every year to settle clinical improve the safety of these industries was negligence claims every year [14]. In December that accidents are caused by multiple factors, 1999, the United States Agency for Healthcare not single, isolated factors. Individual situational Research and Quality (AHRQ) reported that factors, workplace conditions and latent preventing medical errors has the potential organizational factors and anagement decisions to save approximately US$ 8.8 billion per year. are commonly involved. Analyses of these Also in 1999, the Institute of Medicine (IOM) disasters also showed that the more complex in its seminal report To err is human estimated the organization, the greater potential for that between 44 000 and 98 000 people die a larger number of system errors. each year from medical errors in hospitals alone, thus making medical errors the eighth leading Turner, a sociologist who examined organizational cause of death in the USA. The IOM report also failures in the 1970s, was the first to appreciate estimated that preventable errors cost USA that tracing the “chain of events” was critical about US$17 billion annually in direct and to understanding the underlying causes of indirect costs. an accident [32,33]. Reason’s work on the cognitive theory of latent and active errors The human costs in pain and suffering include and risks associated with organizational accidents loss of independence and productivity for both built on this research [34, 35]. Reason analysed patients and their families and carers have not the features of many of the large-scale disasters been calculated. While debates [27-31] within occurring in the 1980s and noted that latent the medical profession about the methods used human errors were more significant than to determine the rates of injury and their costs technical failures. Even when faulty equipment to the health system continue, many countries or components were present, he observed that have accepted that the safety of the health-care human action could have averted or mitigated system is a priority area for review and reform. the bad outcomes. 97 Part B Topic 1. What is patient safety?
    • An analysis of the Chernobyl catastrophe [36] Reason [39] used these lessons from industry toshowed that organizational errors and violations make sense of the high number of adverse eventsof operating procedures that were typically viewed in health-care environments. He stated that onlyas evidence of a “poor safety culture” [37] at a systems approach (as opposed to the morethe Chernobyl plant were really organizational common person approach based on blamingcharacteristics that contributed to the incident. individuals) will create a safer health-care culture,The lesson learnt from the Chernobyl investigation because it is easier to change the conditionswas the critical importance of the extent to which people work under than it is to change humana prevailing organizational culture tolerates behaviour. To demonstrate a systems approach,violations of rules and procedures. This was also he used industrial examples that show the benefitsa feature of the events preceding the ‘Challenger’ of built-in defences, safeguards and barriers.shuttle crash [38]. The investigation of that crash When a system fails, the immediate questionshowed how violations had become the rule should be why it failed rather than who causedrather than the exception. (The investigating it to fail. For example, which safeguards failed?commission found flaws in the shuttle design Reason created the Swiss cheese model [40]and poor communication may have also to explain how faults in the different layers ofcontributed to the crash.) Vaughan analysed a system can lead to accidents/mistakes/incidents.the ‘Challenger’ crash findings and describedhow violations were the product of continued Reason’s Swiss cheese model below (Figure B.1.1)negotiations between experts searching depicts the different kinds of factors (latentfor solutions in an imperfect environment factors, error-producing factors, active failureswith incomplete knowledge. Vaughan suggested and defences) associated with adverse events.that the process of identifying and negotiatingrisk factors leads to the normalization of risky The diagram shows that a fault in one layer ofassessments. the organization is usually not enough to cause an accident. Bad outcomes in the real world usuallyTable B.1.1. ‘Challenger’s’ crash occur when a number of faults occur in a number of different layers (e.g. rule violations, inadequate resources, inadequate supervision and inexperience) and momentarily line up to permitViolations that could have led a trajectory of accident opportunity. For example,to the ‘Challenger’s’ crash if a junior doctor was properly supervised in aFor nearly a year before the Challenger’s timely way, then a medication error might belast mission, engineers were discussing a avoided. To combat errors at the sharp end ofdesign flaw in the field joints. Efforts were the model, Reason invoked the “defence in-depth”made to redesign a solution to the problem principle [41], according to which successive layersbut, before each mission, officials from of protection (understanding, awareness, alarmsboth NASA and Thiokol (the company that and warnings, restoration of systems, safetydesigned and built the boosters) certified barriers, containment, elimination, evacuation,that the solid rocket boosters were safe to escape and rescue) are designed to guard againstfly. (See: McConnell M. Challenger: a major the failure of the underlying layer. The organizationmalfunction. London, Simon & Schuster, is designed to anticipate failure, thereby1987:7). The Challenger completed nine minimizing the hidden latent conditions that allowprevious missions before its fatal crash. actual or “active” failures to cause harm. WHO Patient Safety Curriculum Guide: Multi-professional Edition 98
    • Figure B.1.1. Swiss cheese model: steps and factors associated with adverse events 7 Latent factors Organizational processes – workload, handwritten prescriptions Management decisions – staffing levels, culture of lack of support for interns Active failures Error – slip, lapse Violation Defences Inadequate – AMH confusing Error-producing factors Missing – no pharmacist Environmental – busy ward, interruptions Team – lack of supervision Individual – limited knowledge Task – repetitious, poor medication chart design Patient – complex, communication difficulties AMH=Australian Medicines HandbookSource: Coombes ID et al. Why do interns make prescribing errors? A qualitative study. Medical Journal of Australia, 2008(Adapted from Reason’s model of accident causation) [41]. History of patient safety responsible may receive remedial training, 8 9 and the origins of the blame a disciplinary interview or be told never to do it culture again. We know that simply insisting that health- The way we have traditionally managed failures care workers try harder does not work. Policy and mistakes in health care has been based on and procedures may also be changed to help the person approach–we single out the individuals health-care workers avoid allergic reactions directly involved in the patient care at the time in patient. However, the focus is still on the of the incident and hold them accountable. individual staff member rather than on how the This act of “blaming” in health care has been system failed to protect the patient and prevent a common way for resolving problems. We refer the administration of the wrong medication. to this as the “blame culture.” Since 2000, there has been a dramatic increase in the number Why do we blame? of references to the blame culture in the health A demand for answers as to why the adverse literature [42]. This may be due to the realization event occurred is not an uncommon response. that systemic improvements cannot be made It is human nature to want to blame someone as long as we focus on blaming individuals. and it is far more emotionally satisfying for This willingness to assign blame is thought to be everyone involved in investigating an incident one of the main constraints on the health system’s if there is someone to blame. Social psychologists ability to manage risk [40, 43-46] and improve have studied how people make decisions about care. For example, if a patient is found to have what caused a particular event, explaining it as received the wrong medication and suffered attribution theory. The premise of this theory is a subsequent allergic reaction, we look for that people naturally want to make sense of the the individual student, pharmacist, nurse or doctor world. So, when unexpected events happen, we who ordered, dispensed or administered the automatically start trying to figure out their cause. wrong drug and blame that person for the patient’s condition. Individuals who are identified Pivotal to our need to blame is the belief that as responsible are also shamed. The person punitive action sends a strong message to others 99 Part B Topic 1. What is patient safety?
    • that errors are unacceptable and that those Errors have multiple causes: personal, task-related,who make them will be punished. The problem situational and organizational. For example,with this assumption is that it is based on a belief if a dental, medical or nursing student enteredthat the offender somehow chose to make the a sterile area without correctly scrubbing, it mayerror rather than adopt the correct procedure: be because the student was never shownthat the person intended to do the wrong thing. the correct way or had seen others not complyBecause individuals are trained and/or have with scrubbing guidelines. It is also possibleprofessional/organizational status, we think that the cleaning agent may have run out orthat they “should have known better” [47]. that the student was hurrying to respond toOur notions of personal responsibility play a role an emergency. Within a skilled, experiencedin the search for the guilty party. Professionals and largely well-intentioned workforce, situationsaccept responsibility for their actions as part are more amenable to improvement than people.of their training and code of practice. It is easier For example, if staff were prevented fromto attribute legal responsibility for an accident entering theatres until appropriate cleansingto the mistakes or misconduct of those in direct techniques were followed, then the riskcontrol of the treatment than to those at the of infection would be diminished.managerial level [47]. Reason warned against being wise afterIn 1984, Perrow [48] was one of the first to write the event–so-called “hindsight bias”–becauseabout the need to stop “pointing the finger” most people involved in serious accidents do notat individuals when he observed that between intend for anything to go wrong and generally60% and 80% of system failures were attributed do what seems like the right thing at the time,to “operator error” [5]. At that time, the though they “may be blind to the consequencesprevailing cultural response to mistakes was of their actions” [35].to punish individuals rather than address anysystem-related problems that may have Today, most complex industrial/high-technologicalcontributed to the error(s). Underpinning this managers realize that a blame culture will notpractice was the belief that, since individuals bring safety issues to the surface [50]. While manyare trained to perform tasks, a failure of a task health-care systems are beginning to recognizemust relate to a failure of individual performance this, we have not yet moved away fromdeserving punishment. Perrow believed that the person approach–in which finger-pointingthese socio-technical breakdowns are a natural or cover-ups are common–toward an open cultureconsequence of complex technological systems in which processes are in place to identify failures[31]. Others [49] have added to this theory by or breaks in the “defences”. Organizations thatemphasizing the role of human factors at both place a premium on safety routinely examinethe individual and institutional levels. all aspects of their system in the event of an accident, including equipment design, procedures,Reason [40], building on the earlier work training and other organizational features [51].of Perrow [48] and Turner [33], provided thefollowing two-fold rationale for human error. ViolationsFirstly, human actions are almost always The use of a systems approach for analysing errorsconstrained and governed by factors beyond and failures does not imply a blame-free culture.the immediate control of the individual. In all cultures, individual health professionalsFor example, nursing students must follow are required to be accountable for their actions,policies and procedures developed by the nursing maintain competence and practise ethically.staff. Second, people cannot easily avoid actions In learning about systems thinking, studentsthat they did not intend to perform. For example, should appreciate that, as trusted healtha dental student who may have intended to professionals, they are required to act responsiblyobtain consent from a patient for an operation and are accountable for their actions [44].might have been unaware of the rules for Part of the difficulty is that many healthinformed consent. A nursing student may not professionals break professional rules daily,have understood the relevance of checking such as using incorrect hand hygiene techniquesto make sure the signed consent form is on or letting junior and inexperienced providers workrecord before a procedure. Or, the patient without proper supervision. Students may seemay have indicated to a student that he/she health-care professionals on the wards or in clinicsdid not understand what was signed and who cut corners and think that this is the waythe student may not have mentioned this that things are done. Such behaviours are notto the doctor. acceptable. Reason studied the role of violations WHO Patient Safety Curriculum Guide: Multi-professional Edition 100
    • 10 in systems and argued that, in addition A model of patient safety to a systems approach to error management, The urgency of patient safety was raised over we need effective regulators with the appropriate a decade ago, when the United States IOM legislation, resources and tools to sanction convened the National Roundtable on Health unsafe clinician behaviour [40]. Care Quality. Since then, debate and discussion about patient safety worldwide have been Reason defined a violation as a deviation from informed by lessons learned from other safe operating procedures, standards or rules [40]. industries, the application of quality-improvement He linked the categories of routine and optimizing methods to measure and improve patient care, violations to personal characteristics and necessary and the development of tools and strategies violations to organizational failures. to minimize errors and failures. All of this knowledge has strengthened the position of Routine violations the safety sciences in the context of health-care Professionals who fail to practise hand hygiene services. The need to improve health care between patients because they feel they are by redesigning processes of care has been too busy are an example of a routine violation. acknowledged by WHO and its representative Reason stated that these violations are common countries, as well as by most health professions. and often tolerated. Other examples in health care would be inadequate information exchange The emergence of patient safety as a discipline between staff at the change of a shift (hand-offs in its own right has been made possible or hand-overs), not following a protocol, and thanks to other disciplines, such as cognitive not attending on-call requests. psychology, organizational psychology, engineering and sociology. The application Optimizing violations of theoretical knowledge from these disciplines Senior professionals who let students perform has led to the development of postgraduate a procedure without proper supervision because courses in quality and safety and patient safety they are busy with their private patients are an education in prevocational and vocational example of an optimizing violation. This category programmes for health-care professions. involves violations in which a person is motivated by personal goals, such as greed or thrills from The application of patient safety principles risk-taking, the performance of experimental and concepts in the workplace does not require treatments, and the performance of unnecessary health providers to have formal qualifications procedures. in quality and safety. Rather, it requires them to apply a range of skills and be aware of patient Necessary violations safety considerations in every situation, Time-poor nurses and doctors who knowingly recognizing that things can go wrong. Health skip important steps in administering (or professionals should make a habit of sharing their prescribing) medication, or a midwife who fails experiences of adverse events. Today, increased to record a woman’s progress because of time emphasis is being put on being an effective team constraints, are examples of necessary violations. member, as we learn more about the role of A person who deliberately does something accurate and timely communication in patient they know to be dangerous or harmful does not safety. Training to become an excellent team necessarily intend a bad outcome, but poor member starts in professional school. Learning understanding of professional obligations and how to substitute roles and appreciate the other’s a weak infrastructure for managing unprofessional perspective is central to effective teamwork. behaviour provide fertile ground for aberrant behaviour to flourish. Leaders in patient safety have defined patient safety as follows: By applying systems thinking to errors and failures, “A discipline in the health-care sector that we can ensure that when such an event occurs, applies safety science methods towards we do not automatically rush to blame the people the goal of achieving a trustworthy system closest to the error. Using a systems approach, of health-care delivery. Patient safety is also we can examine the entire system of care to find an attribute of health-care systems; it minimizes out what happened rather than who did it. the incidence and impact of, and maximizes Only after careful attention to the multiple factors recovery from adverse events” [52]. associated with an incident can there be an assessment as to whether any one person was This definition provides the scope for the conceptual responsible. model of patient safety. Emanuel et al. [47]101 Part B Topic 1. What is patient safety?
    • designed a simple model of patient safety. Sometimes instructors introduce students inIt divides health-care systems into the following a way that is designed to instil confidence infour main domains: the student and the patient, without realizing1. those who work in health care; that they may be stretching the truth in doing2. those who receive health care or have a stake so. As it can be awkward to correct what the in its availability; instructor has said at that point, it is a good idea3. the infrastructure of systems for therapeutic to check with the instructor as to how he/she interventions (health-care delivery processes); usually introduces students to patients4. methods for feedback and continuous beforehand, especially the first time you are improvement. working together. Students must clearly explain to patients and their families that they areThis model shares features with other in fact students. 11quality-design models [53], includingunderstanding the system of health care, Understand the multiple factors 13recognizing that performance varies across involved in failuresservices and facilities, understanding methods Students should look beyond a health-carefor improvement, including how to implement mistake or failure in care and understand thatand measure change, and understanding there may be many factors associated withthe people who work in the system and an adverse event. This will involve the studentstheir relationships with one another and asking questions about the underlying factorswith the organization. and encouraging others to consider an error from a systems perspective. For example, they couldHow to apply patient safety thinking be the first in a team meeting or discussion groupin all health-care activities to ask questions about possible causes of errorsThere are many opportunities for students by using the phrase “what happened?”, ratherto incorporate patient safety knowledge into than “who was involved?”. The five “whys”their clinical and professional work. (keep on asking why something happened when given an answer) is a method used 12Develop relationships with patients to keep discussions about causes focused onEveryone, including health professional students, the system rather than the people involved.should relate and communicate with individualpatients as unique human beings with theirown experience of their disease or illness. Theapplication of learned knowledge and skills alone Table B.1.2. The five “whys”will not necessarily result in the best outcomesfor patients. Students also need to speakwith patients about how they view their illnessor condition and its impact on them and their The five “whys”families. Safe and effective care depends on Statement: The nurse gave the wrong drug.patients disclosing their experiences of their Why?illnesses, their social circumstances, their attitudes Statement: because she misheard the nameto the risks involved, and their values and of the drug ordered by the doctor.preferences for how they wish to be treated. Why?Students and their instructors must ensure Statement: because the doctor was tiredthat patients understand that students are not and it was the middle of the night and thequalified health-care professionals. When they nurse did not want to ask him to repeatare introduced to patients or their families, the name.students should always be described as Why?“students”. It is important not to describe Statement: because she knew that he hasstudents as “junior dentists” or “junior nurses”, a temper and would shout at her.“student doctors”, “young pharmacists”, Why?“assistants” or “colleagues” as this can leadthe patient to think that the student is qualified. Statement: because he was very tired andHonesty is very important for patient safety. had been operating for the last 16 hours.It is important that students advise patients of Why?their correct status, even if that means correcting Because...what their supervisor or instructor has said. WHO Patient Safety Curriculum Guide: Multi-professional Edition 102
    • Avoid blaming when an error occurs Act ethically every day It is important that students support each other Learning to be a good health-care professional and their colleagues in the other health requires observation of respected senior professions when they are involved in an adverse health professionals, as well as practical clinical event. Unless students are open about errors, experience involving patients. One of the there will be little opportunity to learn from privileges students have is the opportunity them. However, students are often excluded from to learn by treating real patients. Most patients meetings where discussions about adverse events understand that students have to learn and that are held. Also, some schools, hospitals and clinics the future of health care depends on training. may not hold such meetings. This does not Yet, it is also important that students remember necessarily mean that clinicians want to hide that their opportunity to interview, examine, their errors; it may mean they are unfamiliar with and treat patients is a privilege that is granted patient safety strategies for learning from them. by each individual. In most situations, patients They may also have medico-legal fears and worry cannot be examined by a student unless they about possible interference from administrators. have given their consent. Students should Fortunately, as patient safety concepts become always ask permission from each patient more widely known and discussed in health care, before they physically touch or seek personal more opportunities are arising for reviewing care information from them. They should also be and making the improvements necessary to aware that patients may withdraw this privilege minimize errors. Students can ask their supervisors at any time and request that the student stop if their organization conducts meetings or other what he/she is doing. peer-review forums, such as morbidity and mortality meetings in which adverse events Even in a teaching clinic, it is important that are reviewed. Students, irrespective of their level clinical instructors advise patients that their of training and education, must appreciate cooperation in educational activities is entirely the importance of reporting their own errors voluntary. Clinical instructors and students to their supervisors. must obtain verbal consent from patients before students’ interview or examine them. When Practise evidence-based care patients are asked to allow a student to examine Students should learn how to apply evidence- them, they should be told that the examination based practices. They should be aware of the role is primarily for educational purposes. An example of guidelines and appreciate how important it is of appropriate wording of such a request to follow them. When a student is placed in a is “would you mind if these students ask you clinical setting, he/she should seek out information about your illness and/or examine you so that about the common guidelines and protocols they can learn more about your condition?” that are used. These guidelines and protocols should be evidence-based whenever possible. It is important that all patients understand that their participation is voluntary and that Maintain continuity of care for patients a decision not to participate will not The health system is made up of many parts compromise their care. Verbal consent is that interrelate to produce a continuum of care sufficient for most educational activities, for patients and families. Understanding the but there will be times when written consent journey that patients make through the health- is required. Students should make inquiries care system is necessary to understanding if they are in doubt about the type of consent how the system can fail. Important information required. can be missed, outdated or incorrect. This can lead to inadequate care or errors. The continuity- Particular care should be taken when involving of-care chain is then broken, leaving the patient patients in teaching activities because the vulnerable to a poor outcome. benefit to the patient is secondary to the educational needs of the students. Patient Be aware of the importance of self-care care and treatment are usually not dependent Students should be responsible for their own on student engagement. well-being and that of their peers and colleagues. Students should be encouraged to have their own Explicit guidelines for health professional doctors and be aware of their own health status. teachers and students provide protection If a student is in difficulty (mental illness or drug for everyone. If no guidelines exist, it is a good or alcohol impairment), he/she should be idea to request that the faculty develop a policy encouraged to seek professional help. on the relationship between students and103 Part B Topic 1. What is patient safety?
    • the patients they are allowed to treat. Properly in patient care, they should discuss the matterdesigned guidelines will protect patients, with a senior faculty member of choice.promote high ethical standards and help everyoneto avoid misunderstandings. All students who feel that they have been subjected to unfair treatment because of theirMost schools for the health-care professions are refusal to do something that seems to be wrongaware of the problem of the “hidden curriculum” should seek advice from senior health-care education. Studies show thatstudents on clinical placements have felt Recognize the role of patient 14pressured to act unethically [54] and they report safety in the delivery of safethat these situations are difficult to resolve. health careAll students and trainees potentially face similar The timing of a student’s entry into a clinicalethical dilemmas. On the rare occasion where environment or the workplace varies acrossa clinical supervisor directs students to participate training programmes. Prior to enteringin patient management that is perceived to be a clinical environment, students should askunethical or misleading to the patient, faculty questions about other parts of the healthstaff should deal with the matter. Many students system that are available to the patientmay not be confident enough to raise such and ask for information about the processesmatters with their supervisors and are often that are in place to identify adverse events.unsure of how to act. Raising this issue in teachingabout patient safety is very important. This role Ask questions about other parts of the health systemconfusion can lead to student stress and can that are available to the patient.have a negative impact on morale and the The success of a patient’s care and treatmentdevelopment of the students’ professionalism. depends on understanding the total health systemIt can also place patients at risk. Learning how available to the particular patient. If a patientto report concerns about unsafe or unethical comes from an area in which there is nocare is fundamental to patient safety and relates refrigeration, then sending that patient hometo the capacity of the system to support reporting. with insulin that needs refrigeration will not assist the patient. An understanding of systems (Topic 3)Students should be aware of their legal and will help the student appreciate how differentethical obligations to put the interests of patients parts of the health system are connectedfirst [12]. This may include refusal to comply and how continuity of care for the patientwith an inappropriate instruction or direction. is dependent on all parts of the systemThe best way to resolve such a conflict (or at least communicating in an effective and timelygain a different perspective) is for the student manner. Τ3to speak privately with the health professional orresponsible staff person concerned. The patient Ask for information about the processes that are in placeshould not be part of this discussion. The student to identify adverse events.should explain the problem(s) and why he/she Most hospitals or clinics will have a reportingis unable to comply with the instruction or system to identify adverse events. It is importantdirection. If the clinician or responsible staff that students be aware of these events andperson ignores the issues raised and continues understand how they are managed by the instruct the student to proceed, then discretion If there are no reporting requirements in place,should be used as to whether to proceed the student can ask the appropriate peopleor withdraw from the situation. If it is decided how such events are managed. At the very least,to continue, patient consent must be confirmed. this may generate some interest in the topic.If the patient does not consent, the student (Reporting and incident management are coveredmust not proceed. in Topics 3, 4 and 6). Τ3 Τ4 Τ6If a patient is unconscious or anaesthetized anda supervisor asks a medical or nursing student Teaching strategies and formatsto examine the patient, the student should explain The prevalence data used in this topic have beenwhy he/she cannot proceed unless the patient published in the literature and cover a numberhad given prior consent. It may be appropriate of different countries. Some instructors mayin such circumstances to discuss the situation wish to make the case for patient safety usingwith another person in the faculty or clinic. prevalence data from their own country. If suchIf students are uncertain about the propriety data is not available in the professional literature,of the behaviour of any other person involved some relevant data may be available through WHO Patient Safety Curriculum Guide: Multi-professional Edition 104
    • databases maintained by the local health service. Ways to teach the differences between system For example, there are many trigger tools failures, violations and errors: freely available on the World Wide Web for ñ use a case study to analyse the different the measurement of adverse events that are avenues for managing an adverse event; designed to help health-care professionals ñ have students participate in or observe a root measure their adverse event rates. If there are cause analysis; no general measures available for a particular ñ have students describe the effect of not using country or institution, teachers may want to look an interdisciplinary team approach. for data for one area of care, such as infection rates. Infection rates in a particular country An interactive/didactic session may be available and this could be used Invite a respected senior health professional to demonstrate the extent of transmission from within your institution or country to talk of potentially preventable infections. There may about health-care errors in the workplace. also be literature about adverse events associated If no one is available, then use a video of an with your specific profession. influential and respected practitioner talking about It is appropriate to use these data in teaching. errors and how the system of health care exposes everyone to them. Video clips of speeches This topic can be broken up into sections to be that have been made by patient safety leaders included in existing curricula. It can be taught are available on the Internet. Listening to someone in small groups or as a stand-alone lecture. talk about errors and how they affect patients If the topic is being delivered as a lecture, then and staff is a powerful introduction to patient the slides at the end of the topic may be helpful safety. Students can be encouraged to respond for presenting the information. to the presentation. The instructor can then go through the information in this topic to Part A of the Curriculum Guide sets out demonstrate to students how and why attention a range of teaching methods for patient to patient safety is essential for safe clinical safety, since lectures are not always the best practice. approach. PowerPoint slides or overhead projector slides can Small group discussion be used. Start the session with a case study and Instructors may wish to use any of the activities ask the students to identify some of the issues listed below to stimulate discussion about patient presented in that scenario. Use the accompanying safety. Another approach is to have one or more slides at the end of this topic as a guide. students prepare a seminar on the topic of patient safety using the information in this topic. Other ways to present different sections of this They could then lead a discussion about the areas topic are listed below. covered in the topic. The students could follow the headings outlined below and use any of Lessons about error and system failure from other the activities listed below to present the material. industries The tutor facilitating this session should also be ñ Invite a professional from another discipline, familiar with the content, so that information such as engineering or psychology, to talk can be added about the local health system about system failures, safety cultures and and clinical environment. the role of error reporting. ñ Invite someone from the aviation industry to talk Ways to teach about harm caused by adverse about that industry’s response to human errors. health-care events and system failures: ñ use examples from the media (newspapers History of patient safety and origins of the blame culture and television); ñ Invite a senior respected clinician to talk about ñ use de-identified case examples from your own the damage caused by blaming. hospitals and clinics; ñ Invite a quality and safety officer to discuss ñ use a case study to construct a flowchart systems in place to minimize errors and manage of a patient’s journey; adverse events. ñ use a case study to brainstorm all of the things that went wrong and the times when Simulation a particular action might have prevented Different scenarios could be developed concerning the adverse outcome; adverse events and the need to report and analyse ñ invite a patient who has experienced an adverse errors. For each scenario, have students identify event to talk to students. where the system broke down, how the problem105 Part B Topic 1. What is patient safety?
    • could have been prevented and steps that Dental student under pressureshould to be taken if such an error occurs This case illustrates how a chain of events can lead toin the future. unintended harm. In this case, the number of fillings, the closeness of the caries to the pulp, and multiple missedOther teaching and learning activities opportunities by health-care staff to check the patient’sThere are many other opportunities for students blood pressure all contributed to the adverse learn about patient safety. The followingare examples of activities that students could Peter, a 63-year-old man with a history ofperform, either alone or in pairs: hypertension and heart attack, was scheduledñ follow a patient on his/her journey through to have several tooth fillings. On the morning the health-care service; of his appointment at the dental clinic he tookñ spend a day with a health professional from his usual antihypertensive and anticoagulant a different discipline and identify the main role medicines. and functions of that profession;ñ routinely seek information about the illness At the clinic, the dental student greeted Peter or condition from the patients’ perspective and proceeded to do the fillings. The dental as you interact with them; student sought his supervisor’s permissionñ inquire whether your school or health service to give dental anaesthesia to Peter, but he failed has processes or teams to investigate to check his vital signs prior to administering and report on adverse events. If practical, ask the anaesthetic. He administered two capsules students to seek permission from the relevant of 2% lidocaine with 1:100 000 epinephrine supervisor to observe or take part in these and proceeded to remove caries in two upper activities; teeth. In one of these teeth, the caries turnedñ find out whether your school conducts out to be very close to the pulp. A third capsule mortality and morbidity meetings or other was administered before a lunch break. peer-review forums in which adverse events are reviewed and/or quality-improvement Peter returned in the afternoon to have more meetings; fillings done. The student sought permissionñ discuss clinical errors they have observed from his supervisor to carry out mandibular using a no-blame approach; anaesthesia, but again failed to check theñ inquire about a main protocol used by patient’s vital signs. In all, the patient received the staff in a clinical setting in which they five capsule-syringe cartridges of anesthetic have been placed. Students should ask how (1.8 mL each) for a total of 180 mg lidocaine the guideline was written, how staff know and 0.09 mg epinephrine over six hours. At 3pm, about it, how to use it, and when to deviate Peter began to feel uncomfortable and was from it. flushed and diaphoretic (perspiring). His blood pressure was 240/140 and his pulse was 88.Case studies The student contacted his supervisor and theyCaroline’s story is described at the beginning called for an ambulance. Paramedics arrivedof this topic. This case illustrates the importance and Peter was taken to the emergencyof continuity of care and how a system of care department of the nearest hospital for treatmentcan go badly wrong. of his hypertensive emergency.From the birth of her child to her death 25 days Questionslater, Caroline was admitted to four different – What factors may have contributed to thehospitals and, therefore, there was a need dental student not checking Peter’s vital signsfor proper continuity of care in the hand-over at any point during the day?of responsibilities from each set of medical andnursing staff to another. The failure to keep – Did the student tell the supervisor about Peter’sadequate notes with provisional/differential medical history? Had it become routine to skipdiagnoses and investigations and provide checking vital signs in that clinic?discharge summaries and referrals led to a delayin the diagnosis of a life-threatening abscess – What systems could be put in place to preventand, ultimately, to Caroline’s death. this type of incident in the future?Ask students to read the case and to identify Source: Case supplied by Shan Ellahi, Patient Safetysome of the underlying factors that may have Consultant, Ealing and Harrow Community Services,been present during her care and treatment. National Health Service, London, UK. WHO Patient Safety Curriculum Guide: Multi-professional Edition 106
    • Patient safety in a midwifery context Source: Case supplied by Teja Zaksek, Senior This case deals with practice realities and the Lecturer and Head of Teaching and Learning, consequences of overlooking important results. Midwifery Department, University of Ljubljana Health Faculty, Ljubljana, Slovenia. Mary was a woman in her 26th week of pregnancy and had just started antenatal classes. Tools and resource material She was taking iron supplements for her mild Finkelman A, Kenner C. Teaching IOM: anaemia which caused her occasional constipation. implementing Institute of Medicine reports in nursing This was treated by Mary changing her diet. education, 2nd ed. Silver Spring, MD, American She also had several vaginal infections during her Nurses Association, 2009. pregnancy, but nothing severe. Reason JT. Human error. New York, Cambridge At the beginning of her 27th week, Mary’s University Press, 1999. abdominal cramps were worsening, so she called her midwife. The midwife performed a vaginal Reason JT. Managing the risks of organizational examination and determined that the cervix was accidents, 1st ed. Aldershot, UK, Ashgate of moderate consistency, mid-position, closed Publishing Ltd, 1997. and 1 cm long, but the midwife did not ask any questions beyond how long she had the cramping. Runciman B, Merry A, Walton M. Safety and ethics She made a diagnosis and told Mary that in health care: A guide to getting it right, 1st ed. she was experiencing Braxton-Hicks contractions. Aldershot, UK, Ashgate Publishing Ltd, 2007. The midwife gave her another appointment to be seen in two days. Vincent C. Patient safety. Edinburgh, Elsevier Churchill Livingstone, 2006. At the visit two days later, Mary said the abdominal cramping had stopped, but that Emanuel L et al. What exactly is patient safety? she had some bleeding and was feeling very tired. In: Henriksen K, Battles JB, Keyes M A, Grady ML, The midwife told Mary that a small amount eds. Advances in patient safety: new directions and of bleeding is normal after a vaginal examination alternative approaches. Rockville, MD, Agency and that she should be resting more. for Healthcare Research and Quality, 2008:19-35. Four days following her last visit, Mary noticed Kohn LT, Corrigan JM, Donaldson MS, eds. that she had increased vaginal secretions. To err is human: building a safer health system. She had sporadic cramps and so she contacted Washington, DC, Committee on Quality of Health her midwife again by telephone. The midwife care in America, Institute of Medicine, National again reassured Mary that the cramps were due Academies Press, 1999 to constipation and explained that increased ( vaginal secretions are normal during pregnancy. 579; accessed 21 February 2011). A few hours later, Mary developed stronger, more regular uterine contractions and was taken Crossing the quality chasm: A new health system to the maternity hospital for preterm labour for the 21st century. Washington, DC, Committee and gave birth to a premature baby girl. on Quality of Health Care in America, Institute of Medicine, National Academies Press, 2001. Twelve hours after birth, the baby girl was diagnosed with pneumonia. This infection Assessing this topic was caused by Streptococcus agalactiae (Group B A range of assessment methods are suitable Streptococcus), diagnosed from the vaginal swabs for this topic, including essay questions, taken just prior to birth at the time of admission multiple-choice questions (MCQ), short best to hospital. answer questions (BAQ), case-based discussion (CBD), and self-assessment. Logs and journals Questions can also be used. Encourage students to develop – What factors may have been present that a portfolio approach to learning about patient led the midwife to maintain her original safety. The benefit of a portfolio approach diagnosis? is that each student will have a collection of their patient safety activities at the end – What were the underlying system factors that of the patient training programme that they may have been associated with Mary having may be able to use in job applications and a premature baby with pneumonia? in their future careers.107 Part B Topic 1. What is patient safety?
    • The assessment of knowledge of the potential 7. United States Congress House Sub-Committeeharm to patients, the lessons from other |on Oversight and Investigation. Cost and qualityindustries, violations and the blame-free approach of health care: unnecessary surgery. Washington, DC,and models for thinking about patient safety United States Government Printing Office, 1976.can all be assessed using any of the following 8. Barr D. Hazards of modern diagnosis andmethods: therapy – the price we pay. Journal of Americanñ portfolio Medical Association, 1956, 159:1452–1456.ñ CBD 9. Couch NP et al. The high cost of low-frequencyñ objective structured clinical examination (OSCE) events: the anatomy and economics of surgical station mishaps. New England Journalñ written observations about the health system of Medicine, 1981, 304:634–637. and the potential for error (in general). 10. Friedman M. Iatrogenic disease: AddressingStudents can also be asked to write reflective a growing epidemic. Postgraduate Medicine,statements about the topics, for example: 1982, 71:123–129.ñ effects of adverse events on patients’ trust 11. Dubois R, Brook R. Preventable deaths: in health care; who, how often, and why? Annals of Internalñ the community response to media stories Medicine, 1988, 109:582–589. about patient harm and negligence; 12. McLamb J, Huntley R. The hazards ofñ the role of health professionals in mentoring hospitalization. Southern Medical Association students and the role of patients in the health- Journal, 1967, 60:469–472. care system. 13. Bedell S et al. Incidence and characteristics of preventable iatrogenic cardiac arrests.The assessment can be either formative Journal of the American Medical Association, 1991,or summative; rankings can range from 265:2815–2820.satisfactory/unsatisfactory to giving a mark. 14. Leape L et al. Preventing medical injury. QualityPlease refer to the section in the Teacher’s Guide Review Bulletin, 1993, 8:144–149.(Part A) on the type of assessment suitable forpatient safety topics. Examples of some of these 15. Bates DW et al. Incidence of adverse drugassessment methods are also provided in Part B, events and potential adverse drug events:Annex 2. implications for prevention. Journal of the American Medical Association, 1995, 274:29–34.Evaluating the teaching of this topic 16. Weingart SN et al. Epidemiology of medical error.Evaluation is important in reviewing how a British Medical Journal, 2000, 320:774–777.teaching session went and how improvements 17. Kohn LT, Corrigan JM, Donaldson MS. To err iscan be made. See the Teacher’s Guide (Part A) human: Building a safer health system.for a summary of important evaluation principles. Washington, DC, Committee on Quality of Health Care in America, Institute of Medicine,References National Academies Press, 1999. 1. WHO Guidelines on Hand Hygiene in Health 18. Expert group on learning from adverse events in Care, The burden of Health care-associated the NHS. An organisation with a memory. London, infection, 2009; 6-7. Department of Health, London, United 2. World Health Organization Fact sheet NÆ275: Kingdom, 2000. Substandard and counterfeit medicines, 2003. 19. World Health Organization, Executive Board 3. Issakov A, Health care equipment: a WHO 109th session, provisional agenda item 3.4, perspective. In van Grutting CWG ed. Medical 5 December 2001, EB 109/9. devices: International perspectives on health 20. Davis P et al. Adverse events in New Zealand public and safety. Elsevier, 1994. hospitals: principal findings from a national survey. 4. Schultz DS, Rafferty MP, Soviet health care and Occasional Paper 3. Wellington, New Zealand Perestroika, American journal of Public Health, Ministry of Health, 2001. 1990, Feb; 80(2):193-197. 21. Brennan TA et al. Incidence of adverse events 5. Steel K, Gertman PM, Crescenzi C, Anderson J. and negligence in hospitalized patients: results Iatrogenic illness on a general medical practice of the Harvard Medical Practice Study I. New service at a university hospital. New England England Journal of Medicine, 1991, 324:270–276. Journal of Medicine, 1981, 304:638–642. 22. Wilson RM et al. The Quality in Australian 6. Schimmel E. The hazards of hospitalization. Health Care Study. Medical Journal of Australia, Annals of Internal Medicine, 1964, 60:10–110. 1995, 163:458–471. WHO Patient Safety Curriculum Guide: Multi-professional Edition 108
    • 23. Baker GR et al. The Canadian Adverse Events 38. Vaughan D. The Challenger launch decision: risky Study: the incidence of adverse events among technology, culture and deviance at NASA. Chicago, hospital patients in Canada. Canadian Medical University of Chicago Press, 1996. Association Journal 2004, 170:1678–1686. 39. Reason JT. Human error: models and 24. Runciman B, Merry A, Walton M. Safety and management. British Medical Journal, 2000, ethics in health care: a guide to getting it right, 320:768–770. 1st ed. London, Ashgate Publishers Ltd, 2007. 40. Reason JT. Managing the risks of organisational 25. Andrews LB et al. An alternative strategy for accidents. Aldershot, UK, Ashgate Publishing studying adverse events in medical care. Lancet, Ltd, 1997. 1997, 349:309–313. 41. Coombes ID et al. Why do interns make 26. Runciman W. Iatrogenic injury in Australia: a report prescribing errors? A qualitative study. Medical prepared by the Australian Patient Safety Foundation. Journal of Australia, 2008, 188:89–94. Adelaide, Australian Patient Safety Foundation, 42. Gault WG. Experimental exploration of implicit 2001 (; accessed 23 blame attribution in the NHS. Edinburgh, February 2011). Grampian University Hospitals NHS Trust, 2004. 27. Eisenberg JM. Statement on medical errors. Before 43. Millenson ML. Breaking bad news Quality and the Senate Appropriations Subcommittee Safety in Health Care, 2002, 11:206–207. on Labor, Health and Human Services and 44. Gault W. Blame to aim, risk management in the Education. Washington, DC, 13 December,1999. NHS. Risk Management Bulletin, 2002, 7:6–11. 28. Thomas E, Brennan T. Errors and adverse events 45. Berwick D M. Improvement, trust and in medicine: an overview. In: Vincent C, ed. the health care workforce. Quality and Safety Clinical risk management: enhancing patient safety. in Health Care, 2003, 12 (Suppl. 1):i2i6. London, BMJ Books, 2002. 46. Walton M. Creating a ‘no blame’ culture: Have 29. Haywood R, Hofer T. Estimating hospital deaths we got the balance right? Quality and Safety due to medical errors: preventability is in in Health Care, 2004, 13:163–164. the eye of the reviewer. Journal of the American Medical Association, 2001, 286:415–420. 47. Maurino DE, Reason J, Johnson N, Lee RB. Beyond aviation human factors Aldershot, UK, 30. Thomas E, Studdert D, Brennan T. The reliability Ashgate Publishing Ltd, 1995. of medical record review for estimating adverse event rates. Annals of Internal Medicine, 2002, 48. Perrow C. Normal accidents: living with high- 136:812–816. technologies, 2nd ed. Princeton, NJ, Princeton University Press, 1999. 31. McDonald C, Weiner M, Sui H. Deaths due to medical errors are exaggerated in Institute 49. Douglas M. Risk and blame: essays in cultural of Medicine report. Journal of the American theory. London, Routledge, 1992. Medical Association, 2000, 248:93–95. 50. Helmreich RL, Merritt AC. Culture at work in 32. Turner BA. The organizational and inter organi- aviation and medicine. Aldershot, UK, Ashgate sational development of disasters. Administrative Publishing, 1998. Science Quarterly, 1976, 21:378–397. 51. Strauch B. Normal accidents–yesterday and 33. Turner BA. Man-made disasters London, today. In: Hohnson CW, ed. Investigating and Wykeham Science Press, 1978. reporting of accidents. Washington, DC, National Transportation Safety Board, 2002. 34. Reason J. The contribution of latent human failures to the breakdown of complex systems. 52. Emanuel L et al. What exactly is patient safety? Philosophical Transactions of the Royal Society In: Henriksen K, Battles J B, Keyes M A, Grady of London. Series B Biological Sciences, 1990, ML, eds. Advances in patient safety: new directions 327:475–484. and alternative approaches. Rockville, MD, Agency for Healthcare Research and Quality, 35. Reason JT. Human error. New York, Cambridge 2008:19-35. University Press, 1999. 53. Vincent C. Patient safety, 2nd ed. London, 36. Pidgen N. Safety culture: transferring theory and Blackwell, 2010. evidence from major hazards industries. Department of Transport Behavioural Research 54. Hicks LK et al. Understanding the clinical in Road Safety, 10th Seminar, London, 2001. dilemmas that shape medical students’ ethical development: Questionnaire survey and focus 37. International Atomic Energy Agency. The Cherno- group study. British Medical Journal, 2001, byl accident: updating of INSAG1. INSAG7: Interna- 322:709–710. tional Nuclear Safety Group (INSAG), 1992:24.109 Part B Topic 1. What is patient safety?
    • Slides for Topic 1: What is patient safety?Didactic lectures are not usually the best wayto teach students about patient safety. If a lectureis being considered, it is a good idea to planfor student interaction and discussion duringthe lecture. Using a case study is one wayto generate group discussion. Another way isto ask the students questions about differentaspects of health care that will bring outthe issues contained in this topic, such asthe blame culture, the nature of error, and howerrors are managed in other industries.The slides for Topic 1 are designed to helpthe teacher deliver the content of this topic.The slides can be changed to fit the localenvironment and culture. Instructors do nothave to use all of the slides and it is bestto tailor the slides to the content being coveredin the teaching session.All drug names used are according to the WHOInternational Nonproprietary Names for PharmaceuticalSubstances(;accessed 24 March 2011). WHO Patient Safety Curriculum Guide: Multi-professional Edition 110
    • Topic 2 Why applying human factors is important for patient safety Introduction–Why applying 1 An unaccounted retractor human factors is important The study of human factors examines Suzanne’s medical history included four the relationship between human beings caesarean sections in a 10-year period. The and the systems with which they interact [1] second and third operations were performed by focusing on improving efficiency, creativity, at hospital B, and the fourth at hospital C. productivity and job satisfaction, with the goal Two months after her fourth caesarean, of minimizing errors. A failure to apply Suzanne presented to hospital C suffering human-factors principles is a key aspect of most severe anal pain. adverse events (harm to patients) in health care. Therefore, all health-care workers need to have A doctor performed an anal dilation under a basic understanding of human-factors general anaesthesia and retrieved a surgical principles. Health-care workers who do not retractor from the rectum that was 15 cm understand the basics of human factors are long by two cm wide, with curved ends. It like infection control professionals who do not was of a type commonly used by hospitals in understand microbiology. the area and the engraved initials indicated it came from hospital B. The doctor thought Keywords that the retractor had been left inside Su- Human factors, ergonomics, systems, human zanne after one of her caesareans and it had performance. worked its way gradually through the 2 peritoneum into the rectum. Learning objectives Students should understand the relationship During her fourth caesarean, the surgeon between human factors and patient safety noted the presence of gross adhesions, or and apply this knowledge in the clinical/ scarring, to the peritoneum, whereas no professional setting. scarring had been observed by the doctor who had performed the third caesarean Learning outcomes: two years earlier. While it is not known for knowledge and performance certain what had occurred, the instrument was most likely to have been left inside Knowledge requirements 3 Suzanne during her third caesarean and Students need to know the meaning remained there for more than two years. of the term human factors and understand the relationship between human factors Source: Health Care Complaints Commission and patient safety. Annual Report 1999–2000, New South Wales Government (Australia), 2001:58. Performance requirement 4 Students need to apply their knowledge of human factors in their work environment.111 Part B Topic 2. Why applying human factors is important for patient safety
    • Box B.2.1 below, published by the Australian Commission on Safety and Quality in Health Care, answerssome basic questions about human factors and its relationship to health care.Box B.2.1. Basic questions about human factors in health careHuman factors in health careQ. What does the term “human factors” However, the health-care system can bemean? made safer by recognising the potentialA. Human factors apply wherever humans work. for error, and by developing systems andHuman factors acknowledges the universal strategies to learn from mistakes so asnature of human fallibility. The traditional to minimize their occurrence and effects.approach to human error might be calledthe “perfectibility” model that assumes that Q. Is it possible to manage humanif workers care enough, work hard enough, factors?and are sufficiently well trained, errors will be A. Yes, management of human factors involvesavoided. Our experience, and that of the application of proactive techniques aimedinternational experts, tells us that this attitude at minimizing and learning from errors or nearis counter-productive and does not work. misses. A work culture that encourages the reporting of adverse events and near missesQ. What does the study of human in health care allows the health-care systemfactors involve? and patient safety to improve.Human factors is a discipline that seeksto optimize the relationship between Aviation is a good example of an industrytechnology and humans, applying information that has embraced the study of human factorsabout human behaviour, abilities, limitations, as an approach to improving safety. Sinceand other characteristics to the design the mid-1980’s, aviation has accepted humanof tools, machines, systems, tasks, jobs and fallibility as inevitable and, rather than demandenvironments for effective, productive, safe constant perfection that is not sustainableand comfortable human use. and publicly punishing error, this industry has designed systems to minimize the impactQ. Why is the issue of human factors of human error. The aviation safety recordin health care important? is now a testament to this approach–despiteA. Human factors issues are major contributors an average of 10 million take-offs and landingsto adverse events in health care. In health care annually, there have been fewer than 10 fataland other high-risk industries, such as the crashes a year worldwide in commercialaviation industry, human factors can have aviation since 1965, and many of these haveserious and sometimes fatal consequences. occurred in developing nations.Source: Human factors in health care. Australian Commission on Safety and Quality in Health Care, 2006($File/humanfact.pdf; accessed 21 February 2011). 5Human factors and ergonomics to understand how people perform underThe terms human factors and ergonomics are used different circumstances. We define humanto describe interactions between individuals at factors as: the study of all the factors that make itwork, the task at hand, and the workplace itself. easier to do the work in the right way.These terms may be used interchangeably. Another definition of human factors is the studyThe study of human factors is an established of the interrelationship between humans, thescience that uses many disciplines (such as tools and equipment they use in the workplace,anatomy, physiology, physics and biomechanics) and the environment in which they work [1]. WHO Patient Safety Curriculum Guide: Multi-professional Edition 112
    • 9 Application of human factors knowledge providers to perform at their best while One can apply human factors knowledge caring for patients. This is important because wherever humans work. In health care, knowledge the goal of good human-factors design is to of the effects of human factors can help us accommodate all the individuals who use and to design processes that make it easier for interact with the system. This means thinking health-care providers to do their jobs correctly. about system-design issues not only in terms The application of human-factors principles of the vulnerability of patients, anxious family is highly relevant to patient safety because, members and calm, rested, experienced clinicians, embedded in the discipline of human factors but also inexperienced health-care workers engineering, are the basic sciences of safety. who might be stressed, fatigued and rushing. Human factors principles can help us to make sure we use safe prescribing and dispensing practices, Human factors experts use evidence-based communicate well in teams, and effectively share guidelines and principles to design ways 10 information with other health-care professionals to make it easier to safely and efficiently 11 and patients. These tasks, once thought to be complete tasks such as: (i) prescribing basic, have become quite complicated as a result and dispensing medications; (ii) handing- 12 of the increasing complexity of health-care off (handing-over) information; (iii) moving systems. Much of health care is dependent on patients, (iv) charting medications and 13 the professionals providing the care. Human other orders electronically; and (v) preparing factors experts believe that mistakes can be medications. If these tasks were made easier reduced by focusing on health-care providers for health-care practitioners, then those and studying how they interact with and practitioners would be able to provide safer health as part of their environments. The application care. These tasks require design solutions that of human factors principles can make it easier include software (computer order entry systems for health-care providers to care for patients. and programmes to support dispensing), hardware (IV pumps), tools (scalpels, syringes, Human factors principles can be applied patient beds) and the appropriate physical 6 in any environment and industries such layout of work areas, including proper lighting. as aviation, manufacturing, and the military The technological revolution in health care have been applying knowledge of human has increased the relevance of human factors factors to improve systems and services for in errors because the potential for harm is great many years [2]. when technology and health-care devices are mishandled [3]. Knowledge of human factors also Lessons and examples from other industries allows better understanding of the impact of show that, by applying human-factors fatigue on humans. Tired health-care professionals 7 principles, we can improve work are more prone to memory lapses and mistakes processes in health care. For example, the because fatigue can impair performance and underlying causes of many adverse events relate produce mood swings, anxiety, depression to miscommunication between people in the and anger [4, 5]. If a nurse has to work an extra system and their actions. Many people think shift because of staff shortages, then one might that communication difficulties among members predict that the nurse will be sleep-deprived of health-care teams are related to the fact that and more prone to errors. each person has a number of tasks that need to be performed at one time. Human-factors In its broadest sense, the study of human 14 engineering research shows that what factors incorporates human–machine is important is not the number of tasks that need interactions (including equipment design) 15 to be completed, but the nature of those tasks. as well as human–human interactions, such A professional may be able to explain the steps as communication, teamwork and organizational in a simple procedure to a student while he/she culture. Human-factors engineering seeks is performing that procedure but, in a complicated to identify and promote the best fit between case, he/she may not be able to do so while people and the environment within which concentrating on the task at hand. An they live and work, especially in relation understanding of human factors and adherence to the technology and physical design features to human factors principles is fundamental present in their work environment. to the discipline of patient safety [3]. This field recognizes that the workplace needs Human factors experts help make it to be designed and organized to minimize 8 easier for the widest range of health-care the likelihood of errors and the impact of errors113 Part B Topic 2. Why applying human factors is important for patient safety
    • when they do occur. While we cannot eliminate the medication or dosage as a result ofhuman fallibility, we can act to moderate and the distraction.limit risks. Our brain can also play “tricks” on 18 19Note that the study of human factors is not as us by misperceiving the situation, thereby 20directly about humans as the name might suggest. contributing to the occurrence of errors.However, it is about understanding humanlimitations and designing the workplace and The fact that we can misperceive 21the equipment we use to allow for variability situations, despite the best of intentions,among humans and their activities. is one of the main reasons that our 22 decisions and actions can be flawed, thus 23Knowing how fatigue, stress, poor 16 resulting in “silly” mistakes– regardlesscommunication, disruption and inadequate of experience level, intelligence, motivationknowledge and skill affect health 17 or vigilance. In health-care settings, we describeprofessionals is important because it helps us these situations as errors and these errors mayto understand predisposing characteristics that have consequences for patients.may be associated with adverse events and errors.The fundamental basis of the study of human These are important considerations 24factors relates to the issue of how human to recognize because they are remindersbeings process information. We acquire that making errors is not so much bad as 25information from the world around us, interpret inevitable. In simple terms, error is theand make sense of it and then respond to it. downside of having a brain. Reason [6] describedErrors can occur at each step in this process error as the failure of a planned action to achieve(see Topic 5). Τ5 its intended outcome or the difference between what was actually done and what should haveHuman beings are not machines; machines, been done.when maintained properly, are on the wholevery predictable and reliable. In fact, compared The relationship between human 26to machines, humans are unpredictable and factors and patient safetyunreliable, and our ability to process information is It is important for all health-care workers to belimited due to the capacity of our working mindful of situations that increase the likelihoodmemory. However, human beings are very of error for human beings [7]. This is especiallycreative, self-aware, imaginative and flexible in important for students and other inexperiencedtheir thinking [6]. junior staff. 27Human beings are also distractible, which A number of individual factors affectis both a strength and a weakness. Distractibility human performance, thereby predisposing 28helps us notice when something unusual is a person to error. Two factors withhappening. We are very good at recognizing the greatest impact are fatigue and stress.and responding to situations rapidly and There is strong scientific evidence linking fatigueadapting to new situations and new information. and impaired performance making it a knownHowever, our ability to be distracted also risk factor in patient safety [8]. Prolongedpredisposes us to error because, when work has been shown to produce the samewe are distracted, we may not pay attention deterioration in performance as a blood alcoholto the most important aspects of a task level of 0.05 mmol/l, which would make it illegalor situation. Consider a medical or nursing to drive a car in many countries [9].student taking a blood sample from a patient.As the student is in the process of cleaning up The relationship between stress and 29after taking the blood sample, a patient in performance has also been confirmeda neighbouring bed calls out for assistance. through research. While high stress levels 30The student stops what he/she is doing, goes are something that everyone can relate to,to help that patient, and forgets that the tubes it is important to recognize that low levelsof blood are not labelled. Or consider of stress are also counterproductive, as they cana pharmacist who is taking a medication order lead to boredom and failure to attend to a taskover the telephone and is interrupted by with appropriate vigilance.a colleague asking a question. In such a situation,the pharmacist may mishear the person on The aviation industry requires individual pilotsthe other end of the line or fail to check to use a number of personal checklists to monitor WHO Patient Safety Curriculum Guide: Multi-professional Edition 114
    • their performance–an approach that health-care Make things visible workers could easily adopt. All health-care Students will observe that many wards and clinics workers should consider using a series of personal have equipment that is necessary for diagnosing, error-reduction strategies to ensure that they treating and following-up with patients perform optimally at work. (e.g. X-ray units, infusion pumps, electric scalpels, oxygen tubes). Many students will be required The acronym IM SAFE (illness, medication, 31 to use such equipment. Again, the use of pictures stress, alcohol, fatigue, emotion) that was and notices about the steps involved in switching developed in the aviation industry is useful these devices on and off and reading the displays as a self-assessment technique to determine will help the student master the skills involved. whether a person is safe for work when Another good example of the use of visual they enter the workplace each day. (This tool reminders is the use of pictorial reminders is discussed further in Topic 5). for staff and patients concerning hand hygiene. Τ5 Putting knowledge of human Review and simplify processes 32 factors into practice Simple is better. This statement applies to all walks There are a number of ways that students of life, including health care. Some can put their knowledge of human factors into health-care tasks have become so complicated practice as they care for patients. that they are a recipe for error–examples include hand-off (or hand-over) and discharge processes. Apply human factors thinking to the work Making hand-offs simpler by implementing environment [10] communication strategies that are purposeful, Students can apply human factors thinking fewer in number and involve the patient will as soon as they enter a clinical teaching reduce errors. Students can help simplify environment. In addition, the following tips communication processes by repeating back are known to limit the potential for human instructions and ensuring that they understand error. any protocols being instituted. If there is no protocol for hand-offs, for example, the student Avoid relying on memory could ask how the different health-care To do well in examinations, students must professionals ensure that the information they remember lots of facts and information. are attempting to communicate is received and This is fine for examinations but, when it comes understood correctly and how they are confident to treating patients, relying solely on memory the patient has been treated correctly, as well as is dangerous, particularly when the result being sure that the patient or their carer may be a patient receiving a wrong drug has received accurate and timely information. or dosage. Students should look for pictures and diagrams of the steps involved in Other examples of simplifying processes could a treatment process or procedure. Checking include: (i) limiting the range of drugs available one’s actions against a picture or diagram can for prescribing; (ii) restricting the number reduce the load on the working memory, of different dosage preparations of the drugs freeing the student to focus on the task that are available; and (iii) maintaining at hand, such as taking a medical history inventories of frequently administered drugs. or administering an appropriate drug. Standardize common processes This is a major reason that protocols are and procedures so important in health care–they reduce reliance Even students who work in only one facility on memory. On the other hand, having too may observe each department or clinic many protocols is unhelpful, especially if they doing certain things differently. This means are not updated in a timely manner or are not that they have to relearn how things are done evidence-based. Students should ask about when moving to each new area. Health-care the main protocols used in the setting in which facilities that have standardized the way they are working, so that they can become they do things (where appropriate) help staff familiar with them. It is important to check by reducing their reliance on memory–this when the protocols were last reviewed. Finding also improves efficiency and saves time. out more about the process by which protocols Discharge forms, prescribing conventions are updated reinforces the important point and types of equipment can all be standardized that to be effective, a protocol must be a living within a hospital, region or even a whole document. country.115 Part B Topic 2. Why applying human factors is important for patient safety
    • Routinely use checklists disciplines have incorporated health careThe use of checklists has been successfully into their field. There may also be a clinicianapplied in many areas of human endeavour, who has studied human factors and appliedsuch as studying for examinations, travelling that knowledge to their practice. Invite a suitableand shopping. Following the recent publication person to give a lecture to cover the basicof results of research commissioned by WHO knowledge, using health-care case studies inin the New England Journal of Medicine regarding their presentations.the use of a safe surgery checklist [11], the useof checklists is now common in many health-care Individual and small group activitiesactivities. Students should get into the habit Instructors may choose to use practical exercisesof using checklists in their practice, particularly that explore the human-factors considerationswhen there is an evidence-based way of selecting of common clinical equipment. Good and pooror implementing treatment. examples illustrating human-factors principles can be found in any and every clinical environment.Decrease reliance on vigilance Additionally, instructors might ask studentsHumans quickly become distracted and bored to consider the impact of human factorsif there is not much going on. Students should be in nonclinical areas, such as their personal lives,alert to the potential for error when they are relationships at school and past employment.involved in lengthy repetitive activities. In suchsituations, most of us will pay decreased attention Examples:to the task at hand, particularly if we become 1. Request students to examine equipment intired. Our efforts to stay focused will fail at some various parts of the facility in which they arepoint. working (e.g. rehabilitation unit, emergency department, clinic, intensive care unit (ICU),Summary 33 34 radiology department, pharmacy, dentalIn summary, the lessons from the study of human surgery).factors in other industries are relevant to patientsafety in all health-care environments. This ñ Which area has the most equipment? Whatincludes understanding the interactions and are the hazards associated with using a singleinterrelationships between humans and the tools piece of equipment to treat multiple patients?and machines they use. Understanding the Is the equipment well-maintained? Howinevitability of error and the range of human do human factors affect the effective, safecapabilities and responses in any given situation functioning of the equipment?is essential to knowing how the application ofhuman-factors principles can improve health care. ñ For the various pieces of equipment they discover, consider the following:Teaching strategies and formats – How easy is it to find the on/off switch?This topic is likely to be very new for most – How easy is it to work out how thepeople, so it is probably a good idea to first equipment works?present it as a stand-alone topic. This topic – Are senior students, faculty andprovides an opportunity for imaginative and technicians struggling to work out howcreative teaching in the clinical environment to use the equipment?and is ideally taught using practical exercisesrather than didactic lectures. Many faculty 2. Consider the practical use of alarms.staff will not be familiar with this area and may – How often do the alarms on differentwish to involve teachers from other faculties sorts of equipment go off?such as engineering or psychology. These – How often are alarms ignored?faculties may have experts in human factors – What happens when the alarm isengineering who will be able to give suspended and is it clear how longan introductory lecture of the principles. it is suspended for? – Is silencing the alarm an “automatic”Lecture for general introduction response or is there a systematicBecause this topic will be new knowledge approach to finding its cause?for the students it may be appropriate to invitean expert in human factors to give a lecture 3. Consider how the design of a piece ofon the underlying principles. Experts in human equipment is related to safety. For example,factors are usually found in the disciplines how easy is it to programme a particularof engineering or psychology. Some of these infusion pump correctly? WHO Patient Safety Curriculum Guide: Multi-professional Edition 116
    • – What hazards are associated with having review human-factors issues (see Topic 5: Learning more than one type of infusion pump from errors to prevent harm). in the same work area/facility? Case studies 4. Design a checklist for performing an urgent The following cases illustrate how fatigue can clinical procedure. compromise the safety of care provided by health-care Use the investigation of an adverse event to workers. Nurses: Too Tired To Be Safe? Tuesday, July 20, 2004 wrong method of administration, wrong time or failure to give it altogether. The News. What’s true of doctors is true of registered nurses: Those who routinely work Errors and near-errors increased when nurses’ long, often unpredictable hours, such as shifts shifts exceeded 12 hours per day, when that exceed 12 hours, make more mistakes their work weeks exceeded 40 hours or than those who work fewer hours. when they worked unplanned overtime at the end of a regular shift. “Nurses are no That’s the conclusion of a federally funded different than other occupational groups” study in the July/August issue of the journal Rogers said. “When they work longer hours, Health Affairs. The study is one of the first the risk of errors goes up.” to examine the relationship between medical errors and fatigue among registered nurses, The Impact on Patients. Like previous who provide most of the direct care to hospital studies of medical residents, this one did not patients. attempt to link errors directly to patient harm. An earlier study conducted in Pennsylvania The Study. Ann Rogers, an associate professor found that adding an extra surgical patient at the University of Pennsylvania School of to a nurse’s workload increased her patients’ Nursing, and her colleagues studied 393 nurses chances of dying or suffering a serious who worked full time in hospitals around complication. the country. Nearly all were female and most were white, middle-aged, employed by large And More Broadly. Concern about the urban hospitals and had more than a decade prevalence of medical errors and the effects of experience. of fatigue on doctors-in-training have led to new rules in some specialties that limit For two weeks, each nurse kept a detailed log their work weeks to 80 hours and shifts to of her hours, breaks and mistakes. Overall, a maximum of 24 hours. Some states are 199 errors and 213 near-errors were detected, considering imposing limits on nurses’ shifts, usually by the nurses themselves. Most errors which have lengthened in the past decade or near-errors involved medication, including because of staff cutbacks by hospitals as well the wrong drug, wrong dose, wrong patient, as a nationwide nursing shortage. Source: Goodman SG. Nurses: too tired to be safe? Washington Post. Tuesday, 20 July 2004. © 2004 The Washington Post Company. Activity Sleep-deprived health-care worker – Ask students to read the article published After completing her 36-hour work shift at in the Washington Post and reflect on possible a large academic medical centre, a first-year factors that might be associated with tired internal medicine resident got into her automobile nurses. to drive home. En route, the resident fell asleep117 Part B Topic 2. Why applying human factors is important for patient safety
    • behind the wheel of her car and struck a car As the symptoms persisted, Sandra decideddriven by a 23-year-old woman who sustained to seek a second opinion and went to seea head injury that left her permanently disabled. a different obstetrician. The second obstetrician admitted her for an examination underThe injured woman (plaintiff) filed a medical anaesthesia and dilation and curettage.malpractice lawsuit against the medical centre, The second obstetrician telephoned the firstalleging that the centre “knew, or should have obstetrician after finding a swab left behindknown, that the resident had worked 34 of the 36 hours during the packing of the episiotomy wound.she had been on duty and that it knew, or shouldhave known, that the resident therefore was tired Activityfrom the excessive hours she worked and left the – If teaching nursing students, ask about the rolehospital with impaired judgment because she was of the nurse in the operating theatre, particularlydeprived of sleep.” in relation to the swab left behind during the original procedure. Ask about the processQuestions for establishing the underlying factors that may– Have you encountered a similar situation be associated with the adverse event. with any of your peers or co-health workers? Source: WHO Patient Safety Curriculum Guide– If you encounter a similar situation, how would for Medical Schools expert consensus group. Case you advise this resident after completing supplied by Ranjit De Alwis, Senior Lecturer, a 36-hour work shift? International Medical University, Kuala Lumpur, Malaysia.– Do you agree that the medical centre is liable for the injuries sustained by the woman? Change in routine practice without notifying the health-care team– What measures would you suggest to prevent This case illustrates the effect of human factors similar incidents from occurring? on patient safety. This incident reflects lack of communication within the clinical team and failureSource: Case supplied by Professor Armando C. to follow the agreed-upon treatment protocols,Crisostomo, Division of Colorectal Surgery, leading to compromised patient care.Department of Surgery, University of the PhilippinesMedical College/ Philippines General Hospital, Mary is a dentist specializing in root canalManila, The Philippines. treatments. She usually performs the entire treatment procedure in one session, whichA swab left behind after an episiotomy is a fact well-known by her dental team.This case illustrates a failure in checking protocolsin operating theatres. One day, she felt ill while performing a root canal treatment procedure on an upper molar ofSandra, a 28-year-old woman, consulted her a patient. Because she was not feeling well,obstetrician complaining of a three-day history she decided not to fill the root canals of the toothof foul-smelling vaginal discharge. Sandra and to leave this task for another appointment.had given birth to a baby boy 10 days earlier. Mary did not explain the situation to the dentalShe required an episiotomy during the delivery assistant. At the same time, the dental assistantprocess. The obstetrician suspected a urinary did not annotate the need for a new root canaltract infection and prescribed a five-day course treatment session.of antibiotics. Mary forgot about the case. The patient followedSandra returned to see the obstetrician a week up his dental treatment with other dentists and,later with the same symptoms. She had since the case history was not adequatelycompleted the course of antibiotics. Vaginal documented, no other dentist particularly worriedexamination revealed tenderness at the about the unfinished root canal treatment.episiotomy site and some swelling. The Another dentist subsequently filled the toothobstetrician went through Sandra’s case notes in cavity without noticing that the root canals weredetail, looking particularly at the notes relating to unfilled.the delivery and the swab count. The count wasdocumented in the case notes and had been Three months later, the patient came backverified by a second nurse. An additional course with a significant lesion near the tooth rootof antibiotics was prescribed. with inflammation. At that time, it was necessary WHO Patient Safety Curriculum Guide: Multi-professional Edition 118
    • to prescribe an antibiotic treatment before 01E5610/$File/humanfact.pdf; accessed extracting the diseased molar. 21 February 2011). Questions Gosbee J. Human factors engineering and patient – Nominate some factors that may have safety. Quality and Safety in Health Care, 2002, contributed to incomplete documentation 11:352-354. of the incomplete treatment. This article is available free of charge on the – What factors may have been present that led World Wide Web and provides a basic explanation to other dentists on subsequent follow-up of human factors and their relevance to patient appointments failing to assess the unfilled safety. root canals of the teeth? Mistake-proofing design – Discuss the responsibilities of different team Grout J. Mistake-proofing the design of health care members (in your area of practice) as they processes (prepared under an IPA with Berry relate to record-keeping and documentation. College). AHRQ publication no. 070020. Rockville, MD, Agency for Healthcare Research and Quality, Source: Case supplied by Shan Ellahi, Patient Safety May 2007 Consultant, Ealing and Harrow Community Services, ( National Health Service, London, UK. oofing.pdf; accessed 18 January 2011). Assessing knowledge of this topic Health-care workers fatigue A range of assessment strategies are suitable Berlin L. Liability of the sleep deprived resident. for use with this topic, including MCQs, essays, American Journal of Roentgenology, 2008; short BAQ, CBD, and self-assessment. Having 190:845-851. a student or group of students lead a small group discussion on a human-factors issue in the clinical References area is a useful way to elicit understanding. 1. Kohn LT, Corrigan JM, Donaldson MS, eds. If students are in the workplace, request that To err is human: building a safer health system. they observe how technology is used and what Washington, DC, Committee on Quality of preparatory steps are taken to train health-care Health Care in America, Institute of Medicine, workers in using it. National Academies Press, 1999. 2. Cooper N, Forrest K, Cramp P. Essential guide to Evaluating the teaching of this topic generic skills. Malden, MA, Blackwell, 2006. Evaluation is important in reviewing how a teaching session went and how improvements 3. National Patient Safety Education Framework, can be made. See the Teacher’s Guide (Part A) sections 4.2 and 4.5 for a summary of important evaluation principles. ( hing.nsf/Content/C06811AD746228E9CA2571 Tools and resource material C600835DBB/$File/framework0705.pdf; accessed 21 February 2011). Patient safety 4. Pilcher JJ, Huffcutt AI. Effects of sleep National Patient Safety Education Framework, sections deprivation on performance: A meta-analysis. 4.2 and 4.5 Sleep, 1996, 19:318-26. ( 5. Weinger MB, Ancoli-Israel S. Sleep deprivation ng.nsf/Content/C06811AD746228E9CA2571C600 and clinical performance . Journal of the American 835DBB/$File/framework0705.pdf: accessed Medical Association, 287:955-7 2002. 21 February 2011). 6. Runciman W, Merry A, Walton M. Safety and ethics in healthcare: a guide to getting it right, 1st Clinical human-factors group ed. Aldershot, UK, Ashgate Publishing, 2007.; accessed 18 January 2011. This site has a PowerPoint presentation clearly 7. Vincent C. Clinical risk management–enhancing explaining human factors. patient safety. London, British Medical Journal Books, 2001. Human factors in health care. Australian Commission 8. Flin R, O’Connor P, Crichton M. Safety at the on Safety and Quality in Health Care, 2006 sharp end: a guide to nontechnical skills. Aldershot, ( UK, Ashgate Publishing Ltd, 2008. ng.nsf/Content/6A2AB719D72945A4CA2571C50 9. Dawson D, Reid K. Fatigue, alcohol and119 Part B Topic 2. Why applying human factors is important for patient safety
    • performance impairment. Nature, 1997, 388:235–237.10. Carayon P. Handbook of human factors and ergonomics in health care and patient safety. Mahwah, NJ, Lawrence Erlbaum, 2007.11. Haynes AB et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 2009, 360:491-499.Slides for Topic 2: Why applying humanfactors is important for patient safetyDidactic lectures are not usually the best wayto teach students about patient safety, butthis particular topic has some theoretical principlesthat students must become familiar with. Invite an engineer or psychologist who is an expert inhuman factors to provide an overview of humanfactors. If a lecture is being considered, it isa good idea to plan for student interactionand discussion during the lecture. Using a casestudy is one way to generate group discussion.Engineers may give examples from otherindustries, such as aviation and transport. If theseexamples are used, provide also an example thatis relevant to health care so the students can seehow the theory applies. Another way is to askthe students questions about different aspectsof health care that will bring out the issuescontained in this topic. The slides for Topic 2are designed to assist the instructor in deliveringthe content of this topic. The slides can bechanged to fit the local environment and culture.Instructors do not have to use all of the slidesand it is best to tailor the slides to the areas beingcovered in the teaching session. WHO Patient Safety Curriculum Guide: Multi-professional Edition 120
    • Topic 3 Understanding systems and the effect of complexity on patient care Patients injected with wrong normally ordered 20 ml vials of Conray 280. solution However, for a period of approximately five months they incorrectly ordered and supplied Jacqui had an exploratory procedure called to theatre 5 ml vials of 60% Conray 280 an endoscopic retrograde cholangio with 10% phenol with the label clearly stating pancreatography (ERCP) at a large teaching “use under strict supervision–caustic substance” hospital for a suspected disorder of her gall and “single dose vial”. A nurse finally picked up bladder. Under general anaesthetic, the mistake, which had been missed by an endoscope was inserted into her mouth the pharmacy department and many teams of and guided through the oesophagus to the theatre staff. duodenum. Cannulas were inserted through the endoscope into the common bile duct The way in which medications are ordered, and a contrast medium injected so an X-ray stored, delivered to operating theatres and could be taken. the method for ensuring that correct medications are given to patients involve Two months later, Jacqui was told that she multiple steps with many opportunities was one of 28 patients who had been injected for errors. Understanding the complexity of with contrast medium containing a corrosive the system is necessary to understand where substance, phenol. The pharmacy department and how the components fit together. Source: Report on an investigation of incidents in the operating theatre at Canterbury Hospital 8 February – 7 June 1999, Health Care Complaints Commission, Sydney, New South Wales, Australia. September 1999:1–37 (; accessed 18 January 2011). Introduction–Why systems thinking time. That is, they depend on a system of care [1]. 1 is important for patient safety Being a safe health-care professional requires Health care is rarely carried out by single an understanding of the complex interactions individuals. Safe and effective care is dependent and relationships that occur in health care. Such not only on the knowledge, skills and behaviours awareness, for example, can help practitioners of front-line workers, but also on how those identify the opportunities for mistakes that workers cooperate and communicate in the work can harm patients and clients and take steps environment, which itself is usually part of a larger to prevent them. This topic is about the system organization. In other words, patients depend of health; how to reduce errors is discussed in on many people doing the right thing at the right detail in Topic 5.121 Part B Topic 3. Understanding systems and the effect of complexity on patient care
    • Keywords they become familiar with the workings of theirSystem, complex system, high reliability particular area or discipline. They can then easilyorganization (HRO). forget about the rest of the system.Learning objective 2 A complex system is one in which there 6Understand how systems thinking can improve are so many interacting parts that it ishealth care and minimize adverse events. difficult, if not impossible to predict 7 the behaviour of the system based on 8Learning outcomes: knowledge knowledge of its component parts [3].and performance The delivery of health care fits this definition of a complex system, especially in a larger facility.Knowledge requirements 3 Large facilities are usually made up of manyStudents should be able to explain the terms interacting parts, including humans (patients andsystem and complex system as they relate staff), infrastructure, technology and therapeuticto health care and why a systems approach agents. The various ways that the parts of theto patient safety is superior to the traditional system interact with each other and the wayapproach. in which they act collectively are highly complex and variable [3].Performance requirement 4Students should be able to describe the elements All health-care professionals need to have anof a safe health-care delivery system. understanding of the nature of complexity in health care, as it is important for preventingWhat students need to know about adverse events and helpful in terms of analysingsystems in health care: explain what is situations in which things have gone wrong.meant by the terms system and complex (This is covered in more detail in Topic 5.)system as they relate to health care Otherwise, there can be a tendency to blame only the individuals directly involved in a situation, 5What is a system? without realizing that there are usually manyThe word system is a broad term that is used other contributory factors. Health care is complexto describe any collection of two or more due to [3]:interacting parts or “an interdependent group ñ the diversity of tasks involved in the deliveryof items forming a unified whole” [2]. of patient care; ñ the dependency of health-care providers on oneHealth professional students will be familiar with another;the concept of systems in the context of biological ñ the diversity of patients, clinicians and otherand organic systems. Organic systems include staff;something as small as a single cell to more complex ñ the huge number of relationships betweenorganisms or whole populations. These systems patients, carers, health-care providers, supportare in a continuous state of information exchange staff, administrators, family and communityboth internally and externally. The continuous members;process of input, internal transformation, output ñ the vulnerability of patients;and feedback is characteristic of these systems. ñ variations in the physical layout of clinicalThese same characteristics apply to the multiple environments;systems that make up health care, as well as ñ variability or lack of regulations;the health-care system as a whole. ñ implementation of new technology; ñ the diversity of care pathways and organisationsComplex systems involved;When students first enter a large clinical facility, ñ increased specialization of health-carethey are often overwhelmed by its complexity– professionals–while specialization allows a widerthe large number of health-care providers, allied range of patient treatments and services, it alsoprofessionals and clinical specialties, the diversity provides more opportunity for things to goof patients the different departments, the wrong and errors to be made.different smells, etc. These students are seeingand reacting to the health-care facility as a Students working with patients quicklysystem. It appears chaotic and unpredictable, understand that each individual patient requiresand they wonder how they will ever adapt care and treatment tailored to his/her ownto the environment. Eventually, they are assigned specific condition and circumstances. A studentto different wards, departments and clinics and can quickly see that when all of the individualized WHO Patient Safety Curriculum Guide: Multi-professional Edition 122
    • health services are combined, they form organizational processes, such as simplification a system of care. and standardization, that are recognized safety principles were rarely applied in the health-care Many health services present as a delivery systems they examined [4]. system–buildings, people, processes, desks, equipment, telephones–yet unless the people A systems approach requires us to look at health involved understand the common purpose care as a whole system, with all its complexity and aim, the system will not operate in a unified and interdependence, shifting the focus from fashion. People are the glue that binds and the individual to the organization. It forces us maintains the system. to move away from a blame culture toward a systems approach. Using a systems approach, An understanding of the health-care system an allied professional will be able to tell a primary requires students to think beyond their own future provider that there may be a problem with profession. For the system to work effectively, fulfilling an order immediately because of other doctors, nurses, pharmacists, midwives, and other competing demands. The primary provider health professionals need to understand each and the allied professional can then work out other’s roles and responsibilities. The functioning a solution to the problem together, thus of the system also requires their understanding foreseeing and avoiding a problem later on. the effect of complexity on patient care and that complex organizations, such as health-care In summary, a systems approach enables us services, are prone to errors. For example, until to examine organizational factors that underpin relatively recently, we viewed the hundreds dysfunctional health care and accidents/errors of services provided to patients in a hospital as (poor processes, poor designs, poor teamwork, separate distinct services. The work of doctors financial restraints and institutional factors) was separate from that of nurses, pharmacists rather than focus on the people who are and physiotherapists. Units and departments associated with or blamed for these events. were also seen as distinct entities. This type of approach also helps us to move away from blaming toward understanding If the emergency department was not able and improve the transparency of the processes to see patients quickly enough, we thought of care rather than focusing solely on the single that by fixing the broken bit–the emergency act of care. department–without any attention to other services that relate to it, we could solve the The traditional approach when things problem. But, perhaps the emergency department go wrong–blame and shame was not able to transfer patients to the wards In such a complex environment, it is no 9 in a timely manner because there were no surprise that many things go wrong on 10 available beds. The staff may have had too many a regular basis. When something does go conflicting priorities that impeded their abilities wrong, the traditional approach is to blame to be responsive to patient needs. the health-care worker most directly involved in caring for the patient at the time–often Even though health professionals confront many a student or other junior staff member. While challenges in their workplaces daily and may even the tendency to blame an individual (the person understand the multiple components and approach) [5] is strong–and very natural–it is relationships that are prone to dysfunction, they unhelpful and actually counterproductive often have difficulty thinking in terms of systems for a number of reasons. Whatever role that because, typically, they have not been trained the blamed health-care worker may have had to think in the concepts or language of systems in the evolution of the incident, it is very unlikely theory, nor do they use its tools to make sense that his/her course of action was deliberate of the systems in which they work. in terms of patient harm. (A deliberate action is called a violation.) See Topic 5: Learning from errors Knowledge about the complexity of health care to prevent harm and Topic 6: Understanding and will enable health-care professionals to understand managing clinical risk. Τ5 Τ6 how organizational structure and work processes can contribute to the overall quality of patient Most health-care workers involved in 11 care. Much of the knowledge about complex an adverse event are very upset by the organizations comes from other disciplines, such prospect that their action (or inaction) 12 as organizational psychology. In a study published may have been in some way contributory. in 2000, the United States IOM reported that The last thing they need is punishment.123 Part B Topic 3. Understanding systems and the effect of complexity on patient care
    • Wu described the health-care worker as responsible or accountable for their actions.the “second victim” in such circumstances [6]. A systems approach requires that we understandThe natural tendency in such situations is to limit all the underlying factors that contributed toreporting. Workers will be hesitant to report the incident; just focusing on the person will notincidents if they believe that they will then be identify the main causes and, therefore, the sameblamed for anything untoward that may have incident is likely to reoccur.happened. If such a culture of blame is allowedto persist, a health-care organization will have Accountabilitygreat difficulty in decreasing the chance of adverse All health professionals have ethical and legalincidents of a similar nature occurring in the future responsibilities for which they are accountable.(see Topic 5: Learning from errors to prevent harm). While these requirements may vary from Τ5 profession to profession and country to country,Unfortunately, many health-care professionals, they generally aim to give confidence to theincluding senior providers, allied professionals community that the health professional can beand managers share, with many in the wider trusted to have the knowledge, skills andcommunity, a different view, which supports behaviours set by the relevant professionalthe idea that an individual should be blamed. body. These ethical and legal responsibilitiesThis represents a major challenge, especially for are often misunderstood by health professionalsjunior staff (see the Introduction to Part B–Topics). and many remain unsure about the difference between negligent actions, unethical actionsBut using a systems approach does not mean and mistakes. The following table sets outthat health professionals do not have to be the basic differences.Table B.3.1. Definitions of medico-legal terms Type of medico- Definitions Comments legal behaviour Negligence 1. Failure to exercise the skill, care and learning expected The components of a reasonably prudent health-care provider [7]. of negligence 2. Care provided failed to meet the standard of care reasonably are determined expected of an average practitioner qualified to care for the patient in question, (SP-SQS 2005) or that fell below by the country the standard expected of physicians in their community [8]. in which the action 3. Failure to use such care as a reasonably prudent and careful takes place. person would use under similar circumstances [9]. 4. The failure (usually on the part of a physician or other health-care professional) to exercise ordinary, reasonable, usual or expected care, prudence or skill (that would usually or customarily be exercised by other reputable physicians treating similar patients) in the performance of a legally recognized duty, resulting in foreseeable harm, injury or loss to another; negligence may be an act of omission (i.e. unintentional) or commission (i.e. intentional), characterized by inattention, recklessness, inadvertence, thoughtlessness or wantonness; in health care, negligence implies a substandard deviation from the “standard of medical practice” that would be exercised by a similarly trained professional under similar circumstances [10]. Professional (In the definition for malpractice.) Each country will have misconduct Professional misconduct or unreasonable lack of skill in the its own system for performance of a professional act, a term that may be applied registering the different to physicians, lawyers and accountants [10]. health professions Professional misconduct is separate from malpractice and relates and for managing to all health professionals. It is defined differently in many countries. complaints about Professional misconduct usually refers to a significant departure professional competence from the standard of care expected of a health professional. and conduct. WHO Patient Safety Curriculum Guide: Multi-professional Edition 124
    • Mistakes 1. An action that may conform exactly to the plan, but the plan Failure to be honest is inadequate to achieve its intended outcome [11]. about errors may 2. A rule-based or knowledge-based error that is an error constitute professional of conscious thought. Rule-based errors usually occur during misconduct in some problem-solving when a wrong rule is chosen-either because of a misperception of the situation and thus the application countries. In some of the wrong rule, or because of misapplication of a rule, countries mistakes usually one that is strong (frequently used), that seems to fit may be punishable. adequately. Knowledge-based errors arise because of a lack It is important to know of knowledge or misinterpretation of the problem [12]. how the country 3. A deficiency or failure in the judgement and/or inferential you are studying processes involved in the selection of an objective or in the specification of the means to achieve it, irrespective whether in manages health-care or not the actions directed by this decision-scheme run mistakes. according to plan; errors of conscious... including rule-based errors that occur during problem solving when a wrong rule is chosen, and knowledge-based errors that arise because of lack of knowledge or misinterpretation of the problem [13]. A systems approach also means that students this blame-free culture does not apply only and health professionals are required to be to students, but also to other staff, even those professionally responsible for their actions. who have been in practise for a long time and If a dental student administers the wrong have many years of experience. medication to a patient because he/she failed to follow the protocol for checking medications, Accountability is a professional obligation and should that student be held accountable? An no one thinks that individuals should not be held analysis of such a case using a systems approach accountable. However, in addition to personal would examine the factors that contributed to accountability, there is also system accountability. the student not checking the medication: what System accountability requires that the system if the student was new to the dental clinic and examine itself. For too long, health-care systems was not being supervised?; or if he/she did not have passed the responsibility for mistakes and know the steps involved?; or was unaware that errors in the system onto individual health-care a policy existed to help make sure the correct workers. medication is given to the correct patient?; or if he/she was unsure, but there was no one The best health-care organizations understand around with whom to check and the student the difference between violations and mistakes feared getting into trouble for delaying the and have implemented accountability mechanisms administration of the drug? Systems thinking that are fair, transparent and predictable, in that would suggest that this student was not prepared staff are aware of the types of matters for which for such duties. But if the student was prepared, they will be held personally responsible. was being supervised by a dentist and was aware of the protocols, but did not check the medication Patients are also part of the system and when because he/she was lazy or sloppy or wanted little attention is paid to their literacy level or their to finish work early, then that student would be cultural backgrounds, they are at risk of receiving responsible for the error. Inexperienced health-care suboptimal care and treatment. These patients workers may not always be supervised; in such are unlikely to complain or raise issues with circumstances, they should seek advice from health-care professionals. Patients as a group a senior colleague, notwithstanding the pressure usually have the least say in how a health service to move patients through the service. should operate; they are often required to accommodate inconvenience, inadequate care Most circumstances surrounding adverse events and treatment and inadequate information. are complicated, so it is best to use a systems Patients put up with unsatisfactory care because approach to understand what happened and they often understand the pressures on the why before making any decisions about personal health-care workers and do not want to offend accountability. It is important to remember that them. Quite often, patients do not understand 125 Part B Topic 3. Understanding systems and the effect of complexity on patient care
    • their condition or appreciate the importance Team factorsof adhering to a treatment protocol–for example, Much of health care is provided byfollowing a medication course as prescribed. multidisciplinary teams. Factors such as teamIt is often the case that when patients feel better, communication, role clarity and teamthey discontinue taking their medication without management have been shown to be importantreferring to a health-care professional. It is in other industries and their importancetherefore important that health-care workers in health care is now increasingly beingspend time explaining treatment protocols and recognized [15].the impact of non-compliance to patients. Environmental factorsThe new approach 13 These are the features of the environmentSafety experts believe that although it is hard in which health-care professionals change aspects of complex systems, it is harder These features include lighting, noise andto change the behaviour and thinking processes physical space and layout.of human beings, in terms of their contributionsto errors [5]. Therefore, the main response to an Organizational factorserror should be to try to change the system using These are the structural, cultural and policy-a systems approach [5]. A systems approach to related characteristics of the organization.errors in health care requires an understanding Examples include leadership characteristics,of the multiple factors involved in each of culture, regulations and policies, levels ofthe areas that make up the health-care system. hierarchy and supervisors’ span of control.Health-care workers are part of the system. 14Analyses of accidents in other industries indicate The Swiss cheese modelthat there is rarely ever one cause of an accident. Looking at health care from this broad seriesRather, system failures stem from a wide range of perspectives highlights the multifactorialof factors. The intention of a systems approach nature of any single patient safety incident orfor incident investigation is to improve the design event. This is why students in the healthof the system, to prevent errors from occurring in professions must carefully guard against jumpingthe future and/or to minimize their consequences. to blame an individual for an adverse event and instead consider the associated systemicReason outlined the many elements of the issues. Most adverse events involve both systemicsystem that should be considered as part of and human factors. Reason used the term activea “systems-thinking” approach to accident failures to describe errors made by workersinvestigation in the following categories [14]. that have immediate adverse effects. But he also described a second essential preconditionPatient and provider factors for the occurrence of an adverse event, namely,These are the characteristics of the individuals the presence of one or more latent conditions.involved, including the patient. It is important Latent conditions are usually the result of poorto remember that health-care providers, students decision making, poor design and poor protocolsand patients are all part of the system. developed by people other than those working on the front line. These conditions are oftenTask factors set in place long before the event in question.These are characteristics of the tasks health-care Examples of latent conditions for health-careproviders perform, including the tasks themselves, staff include fatigue, inadequate staffing levels,as well as factors such as workflow, time pressure, faulty equipment and inadequate training andjob control and workload. supervision [16].Technology and tool factors Reason created the Swiss cheese model to explainTechnology factors refer to quantities and how faults in different layers of a system leadqualities of technologies in the organization. to incidents [5]. This model shows how a faultSuch factors include the number and types in one layer of a system of care is usually notof technologies and their availability, usability, enough to cause an accident (see Figure B.3.1).accessibility and location. The design of tools Adverse events usually occur when a numberand technologies, including their integration of faults occur in a number of layers (for example,with other technologies, user training, propensity fatigued workers plus inadequate procedures plusto breakdown or crash, responsiveness and other faulty equipment) and momentarily line updesign characteristics would also be included to permit a “trajectory” of accident opportunityin this category. (indicated by the arrow in the Figure B.3.1). WHO Patient Safety Curriculum Guide: Multi-professional Edition 126
    • Figure B.3.1. Defences, barriers and safeguards Reason‘s “Swiss cheese” model of accident causation Somes holes due to active failures Hazards Other holes due to latent conditions Losses Successive layers of defences, barriers & safeguardsSource: Reason JT. Managing the risks of organisational accidents, 1997 [14]. To prevent these adverse events from occurring, and rescue), designed to guard against the Reason proposed the use of multiple defences failure of the underlying layer (see Figure B.3.2). in the form of successive layers of protection The advantage of the systems approach (understanding, awareness, alarms and warnings, to investigating situations is that it considers restoration of systems, safety barriers, all of the layers, to see if there are ways that containment, elimination, evacuation, escape any of them can be improved.Figure B.3.2. Layers of defences 15 Potential adverse events Patient Policy writing, Standardizing, Automation Improvements training simplifying to devices, architectureSource: Veteran Affairs (US) National Center for Patient Safety [17]. 127 Part B Topic 3. Understanding systems and the effect of complexity on patient care
    • How students can 16 17 18 because the admission and the resulting actions toapply this knowledge prevent future similar errors save the organization time and money. Imagine a health system inUnderstand the term high reliability organization which staff could freely admit their mistakes and(HRO) we had the capacity to adopt/install featuresThe term HRO [18] refers to organizations that and resources, so that similar mistakes could beoperate under hazardous conditions, but manage prevented or minimized. The adverse event rateto function in a way that is almost completely would significantly decrease, saving many lives,“failure-free”. That is, they have very few adverse reducing suffering and improving staff These organizations include air trafficcontrol systems, nuclear power plants and naval Know the characteristics of high reliabilityaircraft carriers. While there are many differences organizations [18]between these industries and health care, HROs share the following characteristics:the message for health care is that it is possible ñ preoccupation with failure: acknowledge and planto achieve consistently safe and effective for the possibility of failure due to the high-risk,performance despite high levels of complexity error-prone nature of their activities;and unpredictability in the work environment. ñ commitment to resilience: proactively seek outThese HROs demonstrate to health-care unexpected threats and contain them beforeorganizations that they too can improve safety they cause harm;by focusing on the systems involved. ñ sensitivity to operations: pay close attention to the issues facing the workers on the frontline; andThe differences between the HROs described ñ a culture of safety in which individuals feelabove and health-care organizations are comfortable drawing attention to potentialsignificant and go to the very heart of the existing hazards or actual failures without fear ofproblems. As health-care providers, we do not criticism from their seniors.routinely think that health care will fail. Failureis not part of the professional mindset, unless Apply the lessons learned 19it has to do with specific treatments. As we from HROs to health careprovide care, we are generally not mindful Health-care organizations can learn from otherof the possibility that health professionals might HROs. We can examine their successes andmiscommunicate or that a surgeon may be study what factors made them work. We can alsoextremely tired after having worked all night learn from their failures, specifically how disastersor that a doctor’s handwriting might be illegible, occur and what factors are typically that a pharmacist might dispense the incorrectdose and a nurse might then administer that The role of regulationmedicine. Any one of these may be a factor in Due to the nature of their work with the public,an adverse event. Health-care professionals are health-care professionals are regulated in mostused to talking to individual patients about risks countries. Professional regulation protectsin relation to known side-effects and the public by requiring practitioners to achievecomplications, but they do not apply the same the competencies needed to practice thereasoning to the treatment being provided by profession and establishing and enforcingthe system as a whole. Systems thinking requires standards of practice. Regulation establishesthat health professionals think about both types criteria to be entered on the register and maintainof potential risk: treatment risks and system risks. a license to practice. The role of regulators includes receiving and investigating complaintsHROs are also known for their resilience–they against individual health practitioners and takingtry to pre-empt failures and take steps to prevent the appropriate action if required such asthem. Patients are the most resilient component suspension, deregistration or conditions placedof our health system and many adverse events on their practice.are avoided because of the resilience of thepatients themselves. They get better despite Summary 20being given the wrong medication or treatment. A systems approach helps us to understand and analyse the multiple factors underpinning adverseWe do not yet have a culture of safety in health events. Therefore, using a systems approach tocare. HROs put a lot of effort into establishing evaluate the situation–as distinct from a personand maintaining cultures of safety and provide approach–will have a greater chance of resultingincentives and rewards for workers. In an HRO, in the establishment of strategies to decreasepeople are rewarded if they admit a mistake the likelihood of recurrence. WHO Patient Safety Curriculum Guide: Multi-professional Edition 128
    • Case studies The anaesthetist and the surgeon discussed the preoperative antibiotics required for the The importance of cross-disciplinary patient who was about to have a laparoscopic communication cholecystectomy. The anaesthetist informed In many cases of avoidable maternal death identified the surgeon of the patient’s allergy to penicillin in the UK Confidential Enquiry, care was hampered by and the surgeon suggested clindamycin as a lack of cross-disciplinary or cross-agency cooperation an alternative preoperative antibiotic. and communication problems, including poor or The anaesthetist went into the sterile corridor nonexistent cooperation between team members, to retrieve the antibiotic, but returned and inappropriate or inadequate telephone consultations, explained to the circulating nurse that he could failure to share relevant information between health not find any suitable antibiotic in the sterile professionals, including between general practitioners corridor. The circulating nurse got on the phone and the maternity team, and poor interpersonal skills. to request the preoperative antibiotics. This study also identified another issue concerning The anaesthetist explained that he could not midwifery care that revolved around a failure to order them because there were no order forms recognize deviations from normal, which resulted (he looked through a folder of forms). The in women not being referred for appropriate medical circulating nurse confirmed that the requested evaluation. The following case study highlights antibiotics “are coming”. the importance of these issues. The surgical incision was performed. Six minutes An underweight, young, non-English-speaking later, the antibiotics were delivered to the OR refugee who also had a low haemoglobin count and immediately injected into the patient. was booked for midwifery-led care. Her husband, This injection happened after the time of incision, who had very poor English himself, acted as which was counter to the protocol requiring that interpreter. She was admitted to the hospital late antibiotics be administered prior to the surgical in pregnancy with bleeding and abdominal pain. incision, in order to avoid surgical site infections. Constipation was diagnosed, despite abnormal liver function tests, and she was sent home under Questions midwifery-led care. She was readmitted some – What could be done to ensure that this weeks later, late in pregnancy with abdominal incident does not happen again? pain and, despite a further abnormal blood assay, no senior medical opinion was sought and she – How does this case illustrate the need was again discharged. Some days later, she was for interdisciplinary communication? admitted in extremis, with liver and multi-organ failure, her unborn baby having died in the – Who can stop a procedure if a problem occurs? meantime. Despite the severity of her condition, her care was still uncoordinated and, although she Source: WHO Patient Safety Curriculum Guide was visited by a critical care senior house officer, for Medical Schools expert group. Case supplied she remained in the delivery suite. The woman by Lorelei Lingard, Associate Professor, University died two days later of disseminated intravascular of Toronto, Toronto, Canada. coagulation related to fatty liver of pregnancy. A system failure resulting in death Question This example highlights how pressurized environments – Using a systems approach, describe the factors may fail to provide basic standards of care. that may be associated with this catastrophic outcome and how similar adverse events might Mrs Brown was a 50-year-old administrative be prevented in the future. assistant working in the supply department of a hospital. She was overweight. She slipped in her Source: The confidential enquiry into maternal garden while getting the newspaper and struck and child health (CEMACH). Saving Mother’s Lives her leg on a garden tap. She suffered a fracture 2005-2008, London, 2007 (; of her fibula and was admitted to hospital accessed 21 February 2011). because it was swollen and painful and required reduction. The procedure was delayed because A failure to administer preoperative antibiotic the operating theatre was busy and her injury prophylaxis in a timely manner according was a relatively minor one. The orthopaedic ward to protocol was full and so she was placed in a medical ward. This example highlights how health services may have Two days later, the fracture was reduced and her difficulty accommodating last-minute changes. leg was put in plaster. When she got up to go129 Part B Topic 3. Understanding systems and the effect of complexity on patient care
    • home she collapsed and died. At autopsy it was – What could have prevented this error?found that she had suffered a massive pulmonaryembolus. At no stage was heparin prescribed Source: Case supplied by Shan Ellahi, Patient Safetyfor the prevention of deep vein thrombosis Consultant, Ealing and Harrow Community Services,or any other preventive measures. Her husband National Health Service, London, UK.was told that she had died from a clot onthe lung which had formed in her leg as a result Tools and resource materialof swelling and trauma. The lack of preventivemeasures was not mentioned. Clinical micro system assessment tool Batalden PB et al. Microsystems in health care:Activities part 9. Developing small clinical units to attain– Construct a flowchart of Mrs Brown’s admission peak performance. Joint Commission Journal from her accident to her death. on Quality and Safety, 2003, 29:575–585 (– Identify all the health professionals who may ns/JQIPart9.pdf; accessed 20 February 2011). have been involved in her care and treatment. Learning to improve complex systems of care– What are the possible factors that may have Headrick LA. Learning to improve complex contributed to her death? systems of care. In: Collaborative education to ensure patient safety. Washington, DC, Health ResourcesSource: Case study taken from Runciman B, and Services Administration/Bureau of HealthMerry A, Walton M Safety and ethics in health care: Professions, 2000: 75–88.a guide to getting it right. Aldershot, UK, AshgatePublishing Ltd, 2008:78. Organizational strategy Kohn LT, Corrigan JM, Donaldson MS, eds.Chain of errors leading to wrong-site dental To err is human: building a safer health Washington, DC, Committee on QualityThis case illustrates how latent problems in the system of Health Care in America, Institute of Medicine,can lead to errors at the point of care (the sharp end). National Academies Press, 1999.An oral surgeon was performing a surgical Runciman B, Merry A, Walton M. Safety and ethicsremoval of lower third molar, which was in health care: a guide to getting it right, 1st ed.completely impacted. None of the third molars Aldershot, UK, Ashgate Publishing Ltd, 2007.(on either side) were visible. Teaching strategies and formatsAccording to the clinical record, the right thirdmolar was to be extracted. However, the X-ray Interactive DVDon the view box appeared to show that it was The WHO Learning from Error workshop includesthe right third lower molar that was impacted a DVD or downloadable fileand that the left third lower molar was absent. ( about intrathecal vincristine, which depicts a case ofThe oral surgeon made the incision, raised the intrathecal vincristine administration and theflap and started the osteotomy. The impacted systems issues that contributed to the evolutionmolar did not appear, so the surgeon enlarged of this incident. The aims of the workshop are:the osteotomy. The surgeon finally realized that to enhance awareness of the risks of vincristinethe right third molar was not there and that administration; to develop an understandinghe had made a mistake when he had reviewed of the need for a new emphasis on patient safetythe clinical notes earlier and planned the in hospitals; to equip participants with the skillsoperation. Furthermore, the dental assistant to contribute to patient safety and to identifyhad displayed the X-ray in the wrong position, local policies and procedures to make thereversing the left and right sides of the mouth. workplace safer. (This workshop could apply to most of the topics in this Curriculum Guide).Questions– What factors may have existed that caused Lecture on systems and complexity the surgeon to select the wrong tooth? Small group discussion– What may have caused the assistant to put Small group discussions could be held about the X-ray in the wrong position? the various levels of the system in your workplace. WHO Patient Safety Curriculum Guide: Multi-professional Edition 130
    • The group could discuss a relevant professional 5. Reason JT. Human error. New York, Cambridge article, such as The wrong patient [19], with University Press, 1990. a tutor. Alternatively, the group could select one 6. Wu AW. Medical error: the second victim. of the cases above to discuss using a systems British Medical Journal, 2000, 320:726–727. perspective. As part of this exercise, the group 7. Medical Event Reporting System for Transfusion could discuss the roles of different team members. Medicine (MERS-TM). Patient Safety and the “Just Culture”: A Primer for Health Care Other student activities Executives. Prepared by David Marx. New York: – Follow a patient from the time he/she enters Columbia University, 2001. a health-care facility to the time he/she is dis- charged and identify all the steps and types 8. Brennan TA, Leape LL, Laird NM, et al. Incidence of health-care workers involved in treating of adverse events and negligence in hospitalized that patient. patients: Results of the Harvard Medical Practice – Arrange for the students to meet in small Study I. N Engl J Med 1991; 324:370-376. groups with a tutor and discuss their findings 9. Joint Commission on Accreditation of and observations. Healthcare organizations, editor. Lexicon: – Discuss the roles and functions of people from Dictionary of Health Care Terms, Organizations, different parts of the health-care system. and Acronyms. 2nd ed. Oakbrook Terrace: Joint – Visit unfamiliar parts of the organization. Commission on Accreditation of Health – Participate in or observe a root cause analysis. Organizations; 1998. 10. Segen JC. Current Med Talk: A Dictionary Assessing knowledge of this topic of Medical Terms, Slang & Jargon. Stanford, CT: Each student could be asked to write an account Appleton and Lange, 1995. of a patient’s experience, in which the student 11. Reason JT. Managing the Risks of Organizational follows that patient throughout the course Accidents. Aldershof, UK: Ashgate, 1997. of his/her treatment. 12. Leape LL. Error in medicine. In: Rosenthal MM. A range of assessment strategies are suitable Mulcahy L, Lloyd-Bostock S, eds. Medical for this topic, including MCQs, essays, short Mishaps: Pieces of the Puzzle. Buckingham, UK: BAQ, CBD, and self-assessment. Having a student Open University Press, 1999, pp. 20-38. or group of students lead a small group discussion 13. Committee of Experts on management of Safety on the various levels of the system in their own and Quality in Health care, Glossary of terms workplace is a useful way to elicit understanding. related to patient and medication safety - approved terms. Council of Europe. 2005. Evaluating the teaching of this topic 14. Reason JT. Managing the risks of organisational Evaluation is important in reviewing how accidents. Aldershot, UK, Ashgate Publishing a teaching session went and how improvements Ltd, 1997. can be made. See the Teacher’s Guide (Part A) 15. Flin R, O’Connor P. Safety at the sharp end: for a summary of important evaluation principles. a guide to nontechnical skills. Aldershot, UK, Ashgate Publishing Ltd, 2008. References 16. Cooper N, Forrest K, Cramp P. Essential guide to 1. University of Washington Center for Health generic skills. Oxford, Blackwell Publishing, 2006. Sciences. Best practices in patient safety education 17. Veteran Affairs (US) National Center for Patient module handbook. Seattle, Center for Health Safety (; accessed Sciences, 2005. 24 May 2011). 2. Australian Council for Safety and Quality 18. Agency for Healthcare Research and Quality in Health Care. National Patient Safety Education (AHRQ). High reliability organization strategy. Framework. Canberra, Commonwealth of Rockville, MD, AHRQ, 2005. Australia, 2005. 19. Chassin MR. The wrong patient. Annals 3. Runciman B, Merry A, Walton M. Safety and of Internal Medicine, 2002, 136:826–833. ethics in health-care: a guide to getting it right, 1st ed. Aldershot, UK, Ashgate Publishing Ltd, 2007. 4. Kohn LT, Corrigan JM, Donaldson MS, eds. Slides for Topic 3: Understanding To err is human: building a safer health system. systems and the effect of complexity Washington, DC, Committee on Quality on patient care of Health Care in America, Institute of Medicine, Didactic lectures are not usually the best way National Academies Press, 1999. to teach students about patient safety. If a lecture131 Part B Topic 3. Understanding systems and the effect of complexity on patient care
    • is being considered, it is a good idea to planfor student interaction and discussion duringthe lecture session. Using a case study is one wayto generate group discussion. Another wayis to ask the students questions about differentaspects of health care that will bring out theissues contained in this topic, such as the blameculture, the nature of error and how errorsare managed in other industries.The slides for Topic 3 are designed to helpthe instructor deliver the content of this topic.The slides can be changed to fit the localenvironment and culture. Instructors do nothave to use all of the slides and it is bestto tailor the slides to the areas being coveredin the teaching session. WHO Patient Safety Curriculum Guide: Multi-professional Edition 132
    • Topic 4 Being an effective team player A treating team did not Simon had been drinking and the intern communicate with each other decided that he was simply drunk; a diagnosis supported by Simon’s rowdy and aggressive Simon, an 18-year-old man, was brought by behaviour. However, such behaviour can also ambulance to hospital. He had been involved indicate serious head injury. Simon was in a fight and suffered a serious head injury prescribed medication for nausea and placed when his head hit the pavement. The under observation. On a number of occasions, ambulance officers were very busy and did not the nurses and intern separately tested have time to brief the health professionals in his verbal and motor responses. the emergency department. Simon wasn’t able to say his name or speak clear words when As time passed, the nurses documented his he was first examined by a triage nurse then deteriorating condition in the clinical notes a doctor. The doctor in attendance, an intern, but did not communicate this directly was only weeks out of medical school. to the intern. Unfortunately, the intern relied He didn’t have a supervisor on that night on verbal communications and didn’t take and he and the nursing staff failed to recognise sufficient notice of the notes. Simon died four the seriousness of Simon’s head injury. and half hours after entering the hospital. Source: National Patient Safety Education Framework, Commonwealth of Australia, 2005. Introduction–Why teamwork the health-care professionals looking after her 1 is an essential element of patient during the day are not the same as those who safety care for her at night and on the weekend. Effective teamwork in health-care delivery can In a large teaching hospital, there will be teams have an immediate and positive impact on patient of doctors for each specialty area and professions, safety [1]. The importance of effective teams in all of whom need to coordinate care with each health care is increasing due to factors such as: other–the nursing staff, pharmacists, other allied (i) the increased incidence of complexity and health providers and the patient’s primary care specialization of care; (ii) increasing co-morbidities; team. In a place where there are limited resources, (iii) the increasing incidence chronic disease; the team may only be a nurse, midwife, a doctor (iv) global workforce shortages; and (v) initiatives and the pregnant woman, but it is just as for safe working hours. important that they act in a coordinated way with good communication at all times. A typical example of complex care involving multiple teams is the treatment of a pregnant Many students will be familiar with the medical woman with diabetes who develops a pulmonary team commonly associated with large hospitals. embolus. Her health-care team might include The medical team is hierarchical and includes nurses, a midwife, an obstetrician, an the most senior doctors to the most junior. endocrinologist and a respiratory physician, as well From a patient perspective, the team is broader as the pregnant woman herself. In addition, than just the medical team. It also includes nurses,133 Part B Topic 4. Being an effective team player
    • allied health professionals and ward staff Introduction to health-care teamswho are caring for and treating the patient. What is a team? 6This topic acknowledges that students in the The nature of teams is varied and complex.early parts of their training programmes are In health care the most effective team fromunlikely to have personally worked as members the patient’s perspective is the multidisciplinaryof a health-care team and often have little team, but teams may draw from a singleunderstanding of how health-care teams are professional group. Team members may workconstructed and operate effectively. In this topic, closely together in one place or be located acrosswe aim to draw on students’ past experiences a geographic area. Some teams have a constantof teamwork and look toward the teams they set of members whereas the membershipswill increasingly participate in as advanced of other teams may change frequently. Examplesstudents and practising clinicians. of teams include choirs, sporting teams, military units, aircraft crews and emergency responseKeywords teams. In health care, patients are treated in aTeam, values, assumptions, roles and responsibilities, variety of environments–the home, clinics, smalllearning styles, listening skills, conflict resolution, hospitals and large teaching hospitals. In eachleadership, effective communication. of these places how well the team communicates with one another and with the patient willLearning objectives 2 determine how effective the care and treatmentStudents should understand the importance is, as well as how the team members feel aboutof teamwork in health care and know how their be effective team players. Recognize that,as a student, you will be a member of a number Regardless of their nature, health-care teams canof health-care teams. be said to share certain characteristics. These include the team members:Learning outcomes: knowledge ñ knowing their role and the roles of othersand performance in the teams and interact with one another to achieve a common goal [2]; 3 4Knowledge requirements ñ making decisions [3];Knowledge requirements for this topic include ñ possessing specialized knowledge and skills anda general understanding of the different types often function under high-workload conditionsof teams in health care, how teams improve [4,5];patient care, how teams form and develop ñ acting as a collective unit, as a result ofthe characteristics of effective teams and the interdependency of the tasks performedeffective leadership, communication techniques by team members [6]. A team is not the same asfor health-care teams, techniques for resolving some other small groups, such as a committeedisagreement and conflict, the barriers who come together from a variety ofto effective teamwork and how to assess team backgrounds for a particular purpose and notperformance. usually associated with hands-on patient care. 5 7Performance requirements Salas defined a team as:Application of the following teamwork principles ñ a distinguishable set of two or more peoplewill promote effective health care. who interact dynamically, interdependentlyñ Be mindful of how one’s values and assumptions and adaptively towards a common and valued affect interactions with others. This is particularly goal/objective/mission, who have been important when patients and staff are from each assigned specific roles or functions different cultural backgrounds. to perform and who have a limited lifespanñ Be mindful of the other members of the team of membership [7]. and how psychosocial factors affect team interactions. Health-care professionals are required to sit onñ Be aware of the impact of change on teams. many committees, which are established to assistñ Include the patient in the team, as well as management with problems or planning exercises; his/her family when appropriate. these are not teams.ñ Use appropriate communication techniques.ñ Use mutual support techniques.ñ Resolve conflicts.ñ Be open to changing and observing behaviours. WHO Patient Safety Curriculum Guide: Multi-professional Edition 134
    • The different types of teams of health care, could also include the 8 found in health care physiotherapist, dentist and/or pharmacist. There are many types of teams in health care. These include rural health-care clinics, women Coordinating teams and baby clinics, birthing units, ICUs, medical The coordinating team is the group responsible wards, primary-care teams working in the for day-to-day operational management, community, teams assembled for a specific task, coordination functions and resource management such as emergency response teams, and for core teams. Nurses often fill such coordinating multi-professional teams, such as multidisciplinary roles in hospitals. In rural settings and clinics, cancer care teams, that come together to plan the coordinating team may comprise managers and coordinate a patient’s care. of health services, nurses, doctors or other health professionals. Teams can have a common geographic location, as in a rural clinic or hospital, or team members Contingency teams may be spread across multiple locations, as Contingency teams are formed for emergent in a multidisciplinary cancer team or primary or specific events (e.g. cardiac arrest teams, health-care team. Teams can include a single disaster response teams, obstetric emergency discipline or involve the input of professionals teams, rapid response teams). The members from multiple disciplines, including administrative of a contingency team are drawn from a variety staff; the patient should always be considered of core teams. as part of the team. The roles these professionals play will vary between and within teams at Ancillary services different times. Roles of individuals on the team Ancillary service teams consist of individuals are often flexible and opportunistic. For example, such as cleaners or domestic staff who provide the leadership might change depending on the direct, task-specific, time-limited care to patients expertise required. or support services that facilitate patient care. The members of these teams are often not In support of patient-centred care and patient located where patients receive routine care. safety, patients and their carers are increasingly being considered as active members of the Ancillary service teams are primarily service health-care team. As well as being important delivery teams whose mission is to support for shared decision-making and informed consent, the core team. This does not mean that they engaging the patient as a team member can should not share the same goals. The successful improve the safety and quality of care, as the outcome of a patient undergoing surgery patient is a valuable source of information, requires accurate information on catering being the only member of the team who is and instructions in relation to “nil by mouth” present at all times during care. They are also orders, so that he/she does not inadvertently the ones with expertise in the experience of their receive a meal that may present a choking risk. illness or condition. In general, ancillary service teams function independently. However, there may be times The TeamSTEPPSì [8] programme when they should be considered as part of 9 developed in the United States identifies the core team. a number of different, but interrelated team types that support and deliver health care. Support services Support services teams consist of individuals Core teams who provide indirect, task-specific services Core teams consist of team leaders and members in a health-care facility. The members of these who are directly involved in caring for the patient. service-focused teams help to facilitate the Core team members include direct care providers optimal health-care experience for patients such as nurses, pharmacists, doctors, dentists, and their families. Their roles are integrated assistants and, of course, the patient or their carer. in that they manage the environment, assets These members operate from the health-care and logistics within a facility. Support services facility clinic or ward. Core members also include consist primarily of a service-focused team continuity providers-those who manage the whose mission is to create an efficient, safe, patient from assessment to discharge, for comfortable and clean health-care environment, example, case managers. The core team may which affects the patient care team, market change often, but usually would consist of a perception, operational efficiency and patient physician and nurse and, depending on the area safety.135 Part B Topic 4. Being an effective team player
    • Administration must be part of the communication pathways;Administration includes the executive leadership their involvement has been shown to alsoof a unit or facility and has 24-hour accountability minimise errors and potential adverse events.for the overall function and management ofthe organization. Administration shapes the The link between nontechnical skills, such asclimate and culture for a teamwork system to teamwork, and adverse events is now wellflourish by establishing and communicating vision, established [9,10], as is the increasing burdendeveloping and enforcing policies and providing of chronic disease, co-morbidities and agingnecessary resources for their successful populations. These challenges requireimplementation, setting expectations for staff a coordinated and multidisciplinary approach(roles and responsibilities), holding teams to care [11].accountable for their performance and definingthe culture of the organization. In a major review of team training, Baker et al. [1] said that the training of health professionals asHow the use of teams improves 10 teams “constitutes a pragmatic, effective strategy forpatient care enhancing patient safety and reducing medical errors.”Health care has traditionally viewed the individualclinician as being solely responsible for a patient’s Teamwork has been associated with improvedcare and treatment. However, patients today are outcomes in areas such as primary care [12]rarely looked after by just one health professional. and cancer care [13]. Teamwork has also beenPatient safety, in the context of a complex associated with reduced medical errors [14, 15].health-care system, recognizes that effective As summarized in Table B.4.1, improvingteamwork is essential for minimizing adverse teamwork can have benefits beyond improvedevents caused by miscommunication with others patient outcomes and safety, including benefitscaring for the patient and misunderstandings for the individual practitioners in the team andof roles and responsibilities. Patients have a vested the team as a whole, as well as the organizationinterested in their own care and they too in which the team resides [11].Table B.4.1. Measures of effective teamworkMeasurable outcomes of effective teamwork Individual benefits Organizational benefits Team benefits Patients Team members Reduced hospitalization Improved coordination Enhanced satisfaction Enhanced job time and costs of care with care satisfaction Reduced unanticipated Efficient use Acceptance Greater role clarity admissions of health-care services of treatment Better accessibility Enhanced communication Improved health Enhanced well-being for patients and professional diversity outcomes and quality of care Reduced medical errorsSource: Adapted from Mickan SM, Rodger SA. Effective health care teams: a model of six characteristics developed from sharedperceptions. Journal of Interprofessional Care, 2005 [16].How teams form and develop 11Considerable research into how teams form anddevelop has been conducted in other high-stakesindustries. As detailed in Table B.4.2 there are fourstages of team development: forming; storming;norming; and performing [17]. WHO Patient Safety Curriculum Guide: Multi-professional Edition 136
    • Table B.4.2. Stages of team development Stage Definition Forming Typically characterized by ambiguity and confusion. Team members may not have chosen to work together and may communicate in a guarded, superficial and impersonal manner. They may be 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 there may be 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.Source: Modified from Flin RH, O’Connoer P, Crichton M. Safety at the sharp end: a guide to nontechnical skills, 2008 [18]. Similar to other industries, many health-care Health-care teams come in many guises; some teams, such as emergency or surgical teams, are very stable, but others can be very unstable are required to work together and need to be with frequent changes in membership. fully functional without any time to establish Each member of the team will have different interpersonal relationships and go through levels of knowledge and skills, which have the forming or norming phases described above to be accommodated. Mickan and Roger [16] [18]. For this reason, it is important that have described the following list of simple health-care professionals know how to be characteristics that underpin effective health-care an effective team member prior to their joining teams irrespective of how stable or unstable the team. The following section describes they are. the characteristics of effective teams. Common purpose 12 Characteristics of successful teams Team members generate a common and There are many models to describe effective clearly defined purpose that includes teamwork. Historically, these have come from collective interests and demonstrates shared other industries, such as aviation’s crew resource ownership. management (CRM). Box B.4.1 sets out the main characteristics of CRM developed Measurable goals in the aviation industry. Teams set goals that are measurable and focused on the team’s task. Box B.4.1. Summary of crew resource management Effective leadership Teams require effective leadership that set and maintain structures, manage conflict, The application of CRM in health listen to members and trust and support members. The authors also highlighted care the importance of team members agreeing CRM was developed by the aviation indus- on and sharing leadership functions. try to improve communications in the cock- pit and implement team-centred decision Effective communication making systems. CRM is defined as “using Good health-care teams share ideas and all available sources –information, equip- information quickly and regularly, keep ment, and people– to achieve safe and written records and allow time for team efficient flight operations.” (The National reflection. Some of the most in-depth Transportation Safety Board, USA). CRM analysis of interprofessional team has been used in health care to improve communication (across disciplines and not team work and communications and initi- just among medical specialties) has focused ate other safe processes. on high-stakes teams, such as are found in surgery [19, 20]. 137 Part B Topic 4. Being an effective team player
    • Good cohesion context of a ward round or clinic consultation.Cohesive teams have a unique and identifiable Include the patient in a safety check to ensureteam spirit and commitment and have greater that the correct information and completelongevity as team members want to continue information is available to everyone on the team.working together. Communication techniques 15Mutual respect for health-care teamsEffective teams have members who respect The Irish-English writer, George Bernard Shaw,each others talents and beliefs, in addition famously said, “The greatest problem withto their professional contributions. Effective communication is the illusion that it has beenteams also accept and encourage a diversity accomplished”. Good communication skills lie atof opinion among members. the core of patient safety and effective teamwork. The following strategies can assist team membersAdditional requirements in accurately sharing information and ensuringAdditional requirements for effective teams that the focus is on the information beinginclude [8, 18, 21]: communicated. Use of a tool called ISBARñ individual task proficiency (both in terms of (Introduction, Situation, Background, Assessment, personal technical skills and teamwork skills); Recommendation) has recently been demonstratedñ task motivation; to improve telephone referrals by medical studentsñ flexibility; in an immersive simulated environment [22].ñ the ability to monitor their own performance;ñ effective resolution of and learning from conflict; The following description and case examplesñ engagement in situation monitoring. have been taken from the TeamSTEPPSì programme [8].Leadership 13 14Effective leadership is a key characteristic of an ISBAReffective team. Effective team leaders facilitate, ISBAR is a technique for communicating criticalcoach and coordinate the activities of other team information about a patient’s concern thatmembers by: requires immediate attention and action. Theñ accepting the leadership role; technique is intended to ensure that the correctñ asking for help as appropriate; information and level of concern is communicatedñ constantly monitoring the situation; in an exchange between health professionals.ñ setting priorities and making decisions;ñ utilizing resources to maximize performance; Introductionñ resolving team conflicts; “My name is Mary Smith and I am a nurse lookingñ balancing the workload within the team; after Mrs Joseph, who is in ward 4 in bed 5.”ñ delegating tasks or assignments;ñ conducting briefings, huddles and debriefings; Situationñ empowering team members to speak freely What is going on with the patient? and ask questions; “I am calling about Mrs Joseph in room 251. Chiefñ organizing improvement and training activities complaint is shortness of breath of new onset.” for the team;ñ inspiring other members of the team and Background maintaining a positive group culture; What is the clinical background or context?ñ ensuring that the team stays on track and meets “Patient is a 62-year-old female post-op day expected outcomes. one from abdominal surgery. No prior history of cardiac or lung disease.”Including the patient as a member of thehealth-care team is a new concept. Traditionally Assessmentthe role of the patient has been more passive What do I think the problem is?as the recipient of health care. But we know that “Breath sounds are decreased on the right sidepatients bring their own skills and knowledge with acknowledgement of pain. Would likeabout their condition and illness. Students can to rule out pneumothorax.“begin showing leadership in this area by tryingto include patients and their families as much Recommendationas possible. Establishing eye contact with patients, What would I do to correct it?checking and confirming information and seeking “I feel strongly that the patient should be assessedadditional information can all be done in the now. Can you come immediately?” WHO Patient Safety Curriculum Guide: Multi-professional Edition 138
    • If the health-care team member is dissatisfied information conveyed by the sender is understood with the response to their request for immediate by the recipient as intended [23]: attendance, they should seek assistance Step one: Sender initiates message. and advice from another more senior person. Step two: Recipient accepts message and provides feedback. Call-out Step three: Sender double-checks to ensure Call-out is a strategy to communicate important that the message has been understood. or critical information to inform all team members simultaneously during emergent situations. Doctor: Give 25 mg Benadryl IV push. This technique helps team members anticipate Nurse: 25 mg Benadryl IV push? the next steps and directs responsibility to a Doctor: That’s correct. specific individual responsible for carrying out the task. An example of a call-out exchange Hand-over or hand-off between a team leader and a resident is shown Hand-over or hand-off is a crucial time below. for the accurate exchange of information. Errors in communication can result in Leader: Airway status? patients not being treated correctly and they Resident: Airway clear. may suffer an adverse outcome. Clinical hand- Leader: Breath sounds? over refers to the transfer of professional Resident: Breath sounds decreased on right. responsibility and accountability for some Leader: Blood pressure? or all aspects of care for a patient or group Resident: BP is 96/92. of patients, to another person or professional group on a temporary or permanent basis. Check-back “I pass the baton” is a strategy to assist timely This is a simple technique for ensuring that and accurate hand-offs.I Introduction Introduce yourself, your role and job and the name of the patientP Patient Name, identifiers, age, sex, locationA Assessment Present chief complaint, vital signs, symptoms and diagnosisS Situation Current status/circumstances, including code status, level of (un)certainty, recent changes and response to treatmentS Safety concerns Critical lab values/reports, socioeconomic factors, allergies and alerts (falls, isolation, etc.)TheB Background Co-morbidities, previous episodes, current medications and family historyA Actions What actions have been taken or are required? Provide a brief rationaleT Timing Level of urgency and explicit timing and prioritization of actionsO Ownership Identify who is responsible (person/team), including patient/familyN Next What will happen next? Anticipated changes? What is the plan? Are there contingency plans? Resolving disagreement 16 However, it is important for all members and conflict of the team to feel they can comment The ability to resolve conflict or disagreement when they see something that they feel will in the team is crucial to successful teamwork. impact on the safety of a patient. This can be especially challenging for junior members of the team, such as students, The following protocols have been developed or in teams that are highly hierarchical to help members of a team express their in nature. concern in a graded manner. 139 Part B Topic 4. Being an effective team player
    • Psychological safety Describe the specific situation or behaviourThis is the degree to which people perceive and provide concrete evidence or data.their work environment as conducive to taking Express how the situation makes you feelthese interpersonal risks [24]. and what your concerns are. Suggest other alternatives and seek agreement.Two-challenge rule Consequences should be stated in termsThe two-challenge rule is designed to empower of their effect on established team goalsall team members to stop an activity if they sense or patient safety.or discover an essential safety breach. There maybe times when an approach is made to a team Challenges to effective 17member, but is ignored or dismissed without teamworkconsideration. This will require a person to voice A number of specific barriers exist to establishinghis/her concerns by restating their concerns and maintaining effective teamwork in healthat least twice if the initial assertion is ignored care. Some of these are described below.(thus the name “two-challenge rule”). Thesetwo attempts may come from the same person Changing rolesor two different team members: In many health-care environments there is considerable change and overlap in the rolesThe first challenge should be in the form played by different health-care professionals.of a question. Examples include changes in the role of midwives,Nurse: I am worried about Mrs Jones in bed 23. She radiographers reading plain film X-rays, nurseslooks unwell and her symptoms are different to those performing colonoscopies, dental therapistsshe normally presents with. Can you have a look at her? performing extractions and simple dental restorative procedures, and nurse practitioners,The second challenge should provide some nurse-midwives and pharmacists prescribing for the team member’s concern. These changing roles can present challengesNurse: I am really worried about Mrs Jones. to teams in terms of role allocation andHer symptoms are worrying me. I think she needs to be acknowledgement. In addition, there may beseen now. members of the team who do not have any particular qualifications such as a dental assistantRemember, this is about advocating for the or a nurse aid or assistant. These people arepatient. The two-challenge tactic ensures that important members of the team and should bean expressed concern has been heard, understood, coached and supported as equal team members.and acknowledged. In some instances they may be required to carry out duties they are not trained for. If this occursThe team member being challenged must they should be properly prepared and supported.acknowledge the concerns.Doctor: From what you have said, you seem pretty Changing settingsworried about Mrs Jones. I will see her now. The nature of health care is changing in many ways, including increased delivery of careIf this does not result in a change or is still for chronic conditions in community careunacceptable, then the person with the concern settings and the transfer of many surgicalshould take stronger action by talking to procedures to outpatient centres. Thesea supervisor or the next person up the chain changes require the development of new teamsof command. and the modification of existing teams.CUS Health-care hierarchiesCUS is shorthand for a three-step process Health care is strongly hierarchical in nature,for assisting people in stopping a problematic which can be counterproductive to well-activity. functioning and effective teams where all members’ views should be considered;I am Concerned the team leader is not necessarily a doctor.I am Uncomfortable While there has been growing acknowledgementThis is a Safety issue that teamwork is important in health care, this has not been translated into changedDESC script practices, especially in countries whereDESC describes a constructive process for resolving the cultural norms of communication may notconflicts. The goal is to reach consensus. take naturally to teamwork. WHO Patient Safety Curriculum Guide: Multi-professional Edition 140
    • Individualistic nature of health care that have been developed to promote team Many health-care professions, such as nursing, communication and performance, including ISBAR, dentistry and medicine, are based on call-out, check-back and “I pass the baton”. the autonomous one-to-one relationship between the provider and patient. While this relationship What students need 21 22 23 remains a core value, it is challenged by many to do to apply teamwork concepts of teamwork and shared care. This can principles be observed at many levels, from clinicians Students can apply teamwork principles as soon being unwilling to share the care of their patients as they start their training. Many health-care through to the medico-legal implications degree programmes are based on problem-based of team-based care. learning (PBL) or involve small group discussions which require students to work together in teams Instability of teams to build knowledge and solve problems. Through As discussed previously, health-care teams are these activities, students can begin to understand often transitory in nature, coming together for how teams function and what makes an effective a specific task or event (e.g. cardiac arrest teams). learning group. Learning to share information, The transitory nature of these teams places great textbooks and lecture notes is a forerunner emphasis on the quality of training for team to sharing information about patients or clients. members, which raises particular challenges in health care, where education and training Be mindful of how one’s values and are often paid insufficient attention as workers assumptions affect interactions with other focus on service delivery. team members Students learn by observing how different health Accidents in other industries 18 professionals interact with each other. They will Reviews of high-profile incidents, such as aviation realize that even though a team may be made up disasters, have identified three main types of of many personalities and practice styles, this will teamwork failings as contributing to accidents, not necessarily make the team less effective. namely, unclear definition of roles, lack of explicit Rather, the complimentary strengths and coordination and other miscommunication weaknesses of different members of the team can [18,25]. facilitate the delivery of high-quality, safe care. 19 Assessing team performance Be mindful of the roles of team members Assessing the performance of a team is an and how psychosocial factors affect team important step in improving team performance. interactions and recognize the effect of change A number of teamwork assessment measures on team members are available [18, 26, 27]. Teams can be assessed It can often be difficult for students (and indeed in a simulated environment, by direct observation practising clinicians) to appreciate the different of their actual practice or through the use of roles that health-care professionals play in teams, teamwork exercises, such as those described in or how teams respond to change or psychosocial the sections below on teaching teamwork. factors. Students can be encouraged to make structured observations of teams, to observe Teams can be assessed either at the level the roles that different individuals play and how of individual performance within the team the allocation of these roles relates to both or at the level of the team itself. Assessments the personal characteristics and professions of may be performed by an expert or through the individual team members. Students can be peer-ratings of performance. encouraged to talk to different team members about their experiences of working in a team. An analysis of the learning styles or problem- Faculty can themselves ensure that students solving skills individuals bring to teamwork are included in teams and assigned roles, so that can be useful following the assessment of team they can observe these processes from the inside. performance [28]. It is crucial that all team members understand the role and functions of the different professions 20 Summary of knowledge requirements so that appropriate referrals and treatment are Effective teamwork does not just happen. instituted for patients. It requires an understanding of the characteristics of successful teams, as well as knowledge of how Include the patient as a member of the team teams function and ways to maintain effective When students are interviewing patients, taking team functioning. There are a variety of tools a history, performing a procedure or providing141 Part B Topic 4. Being an effective team player
    • care interventions for patients, they should Ask for clarification if something does not maketake time to communicate and engage with sense. Ask questions and continually clarify. Clarifythe patient. This can include talking with patients your role in different situations.about what they are doing or talking about anyanxieties or concerns the patient or their carers Nurse: Mr Brown is going to have an X-ray.might have. Students can actively include patients Student: So, we are taking Mr Brown to have an X-rayin clinics and ward rounds by either inviting them participate at the time or by discussing with Nurse: Yes.the team how patients might be included in such Student: Who is taking Mr Brown for his X-ray?discussions. Be assertive when necessary. This is universallyUse mutual support techniques, resolve difficult, yet if a patient is at risk of serious injury,conflicts, use appropriate communication then health professionals, including students,techniques and change and observe must speak up. Senior clinicians will be gratefulbehaviours in the longer term if one of their patients avoidsStudents can practise all of these competencies a serious adverse event. When conflict occurs,either in their work with their peers in study concentrate on “what” is right for the patient,groups or within health-care teams as they move not on establishing “who” is right or wrong.through their programme and are increasinglyinvolved in patient care. As detailed below, Brief the team before undertaking a teammany teamwork exercises can be used with activity and perform a debriefing afterwards.groups of students and practitioners to explore This encourages every member of the teamleadership styles, conflict-resolution techniques to contribute to discussions about how thingsand communication skills. The degree to which went and what can be done differently orstudents can experience or observe these activities better next time.will be dependent on how safe the health-careprofessionals feel in raising issues or problems Case studieswith the team or the team leader. Faulty communication by the teamA number of practical tips exist to help students This case study highlights how poor teamwork canimprove their communication skills. Students contribute to patient harm.can start practising good teamwork at the verybeginning of their training. Clear and respectful A doctor was coming to the end of his first weekcommunication is the basis for good teamwork. in the emergency department. His shift had endedAlways introduce yourself to the patient and the an hour before, but the department was busy andteam or those you are working with, even if you his registrar asked if he would see one last patient.will only be working together for a few minutes. The patient was an 18-year-old man. He wasLearn the names of team members and use them. with his parents who were sure he had taken anSome people do not bother to learn the names overdose. His mother had found an empty bottleof the team members who are less present, such of paracetamol that had been full the day allied health-care workers, believing that they He had taken overdoses before and was underare not as important. However, team members the care of a psychiatrist. He was adamant that hewill have better relationships with other team had only taken a couple of tablets for a headache.members if they use people’s names rather than He said he had dropped the remaining tabletsreferring to them by their profession, such as on the floor, and so had then thrown them away.“nurse” or “assistant.” When delegating tasks The parents said they had found the empty bottleto people, look at them and check that they have six hours earlier and felt sure that he could notthe information to enable them to do the task. have taken the paracetamol more than four hoursTalking into the air is an unsafe practice because before they found the bottle (i.e. 10 hours earlier).it may not be clear who you are addressing. Useobjective language, not subjective language. The doctor explained that a gastric lavage would be of no benefit. He took a blood test insteadRead back instructions and close the to establish paracetamol and salicylate levels.communication loop in relation to patient-care He asked the lab to phone the emergencyinformation. State the obvious to avoid confusion. department with the results as soon as possible.Nurse: Mr Brown is going to have an X-ray. A student nurse was at the desk when the labStudent: So, we are taking Mr Brown to have an X-ray technician phoned. She wrote the results in the now. message book. The salicylate level was negative. WHO Patient Safety Curriculum Guide: Multi-professional Edition 142
    • When it came to the paracetamol result, – Discuss how the doctor and student nurse the technician said, “two,” paused, and then might have felt and how to assist them through said, “one three.” “Two point one three,” debriefing without placing blame. repeated the nurse, and put down the phone. She wrote “2.13” in the book. The technician Source: National Patient Safety Agency. London, did not say whether this level was toxic and Department of Health, 2005. Copyright and he did not check whether the nurse had other intellectual property rights in this material understood. When the doctor appeared belong to the NPSA and all rights are reserved. at the desk, the nurse read out the results. The NPSA authorises health-care organizations The doctor checked a graph he had spotted to reproduce this material for educational and earlier on the notice board, which showed non-commercial use. how to treat overdoses. A failure to relay information between staff There was also a protocol for managing and confirm assumptions, resulting in an paracetamol overdoses on the notice board, adverse patient outcome but it was covered by a memo. The graph showed This example highlights how the dynamics between that 2.13 was far below the treatment level. surgical trainees and staff and the movement of staff The doctor thought briefly about checking in and out of the operating room can allow adverse with the registrar, but she looked busy. Instead, events to happen. he told the student nurse that the patient would need to be admitted overnight, so that Before a routine gastric bypass patient was the psychiatrist could review him the next day. brought into the operating room, one nurse The doctor went off duty before the printout reported to a second nurse that the patient came back from the lab. It read “paracetamol was allergic to “morphine and surgical staples”. level: 213”. The mistake was not discovered This information was repeated again to the staff for two days, by which time the patient surgeon and the anaesthetist before the start was starting to experience the symptoms of the procedure. of irreversible liver failure. It was not possible to find a donor liver for transplant and the patient As the surgery was coming to an end, the staff died a week later. If he had been treated when surgeon left the operating room, leaving a surgical he arrived at the emergency department, he might fellow and two surgical residents to complete not have died. the procedure. The surgical fellow then also left the operating room, leaving the two residents The doctor was told what had happened by his to close the incision. The two surgical residents consultant on Monday when he started his next stapled a long incision closed along the length shift and, while still in a state of shock, explained of the patient’s abdomen. They stapled the three that he had acted on what he thought was the laparoscopic incisions closed as well. When correct result. He had not realized, he admitted, the residents began the stapling, a medical that paracetamol levels are never reported student removed a sheet of paper from the with a decimal point. Because he had not seen patient’s chart and took it over to the residents. the protocol, he had also not appreciated that it The medical student tapped one of the residents might have been appropriate to start treatment on the shoulder, held the paper up for her before the paracetamol level had come back to read and told her that the patient was allergic anyway, bearing in mind that the history, although to staples. The resident looked at it and said, contradictory, suggested the patient might well “You cannot be allergic to staples”. have taken a considerable number of tablets. It would be unfair to blame the doctor, The staff surgeon returned to the operating room the student nurse or the technician individually. as the residents were completing the stapling. The real weakness is the lack of safety checks in He saw that the residents had stapled the incisions the system of communicating test results. and informed them that the patient did not want At least three people made a series of small staples. He told them that they would have mistakes and the system failed to pick them up. to take all the staples out and suture the incision. He apologized for neglecting to inform them Activities of this allergy. One of the residents asked whether – Draw a diagram of the flow of information you could be allergic to staples and the staff among the health professionals in this story surgeon said, “It does not matter. The patient and highlight the points of communication is convinced that she is.” The staff surgeon told breakdown. the residents they would have to remove all143 Part B Topic 4. Being an effective team player
    • the staples and sew the incisions. This took an Source: WHO Patient Safety Curriculum Guideadditional 30 minutes. for Medical Schools. Case supplied by Ranjit De Alwis, Senior Lecturer, International MedicalDiscussion University, Kuala Lumpur, Malaysia.– Discuss how this case demonstrates the importance of clear communication between all Everyone on the team counts team members, as well as the issue of patient This is an example of how an initiative such as a needs and preferences. preoperative team briefing can provide an opportunity for individual members of the operative team to provideSource: WHO Patient Safety Curriculum Guide for information that affects a patient’s outcome.Medical Schools. Case supplied by Lorelei Lingard, A preoperative team briefing is a short gatheringAssociate Professor, University of Toronto, Toronto, including nurses, surgeons and anaesthetists heldCanada. before a surgery with the goal of discussing important patient and procedure-relevant issues.Emergency resuscitation requires teamworkThis case illustrates the importance of the team In preparation for a low anterior resection andbeing prepared to carry out an effective code blue ileostomy, the interprofessional team met foror emergency resuscitation. a briefing. The surgeon asked a nurse whether she had anything to contribute. The nurseSimon, a medical officer, was in the cafeteria reported that the patient was worried abouteating a late lunch. Halfway through his meal, her hernia. In response to this, the surgeona cardiac arrest announcement was made over questioned the patient (who was still awake)the public address system. He ran to get the lift about the hernia. The surgeon then explained toup to the fifth floor ward where the emergency the operating room team how he would proceedwas. It was peak hour and the lifts were busy. around the hernia and that he might use mesh.By the time he reached the patient, a nurse hadwheeled in the cardiac arrest trolley and another Questionsnurse had an oxygen mask on the patient. – Is this the place for discussion with a patient who most likely had preoperative medication?“Blood pressure, pulse, heart rate?” yelledthe doctor. – What type of informed consent was the patient able to provide? What is meant by “patient wasA nurse grabbed a blood pressure cuff and began worried about her hernia”?to inflate it. The nurse holding the oxygen masktried to find a pulse on the patient’s wrist. The – Should the nurse have brought this up priormedical officer shouted for an electrocardiogram to the patient arriving in the operating theatre?monitor to be placed on the patient and forthe head of the bed to be lowered. The nurses – Should this have been documented in the med-tried to follow his orders; one stopped trying ical record with follow-up?to get the blood pressure and lowered the bed.This made the oxygen mask fall off as the tubing Source: WHO Patient Safety Curriculum Guide forgot caught in the side panels of the bed. Medical Schools. Case supplied by Lorelei Lingard, Associate Professor, University of Toronto, Ontario,Simon became agitated. He had no idea of the Canada.heart rate or rhythm. The patient did not seemto be breathing. The heart monitor came on Emergency in a dental officeand showed ventricular fibrillation. This case study illustrates the importance of all members of the team being adequately prepared to work together“Pads and 50 joules”, called Simon. in an emergency.The nurses look at him and say, “What?”“Pads and 50 joules, stat!” Simon replied. During a molar extraction, the patient started“Call a doctor, any doctor, to come and assist me sweating and became pale. The patient askednow!” he yelled. the dentist to stop the treatment as he wasThey could not revive the patient. feeling sick.Activity The dentist stopped the treatment and laid the– Describe this confusing case in a clear manner. patient flat and raised his legs. He then took her Identify the key factors and outcomes. pulse and asked for the emergency equipment. WHO Patient Safety Curriculum Guide: Multi-professional Edition 144
    • The dental assistant had only been working in A recent systematic review of teamwork training the centre for a short time. No one had told developed for medical students and junior doctors her where the emergency equipment was kept. found that teaching teamwork skills to students She left the dental office, leaving the dentist and young doctors was moderately effective over alone with the patient while she looked for the short term and appeared to be more effective the emergency equipment. when more teamwork principles were addressed within the training programme [29]. The patient’s clinical situation continued to deteriorate rapidly. The dentist, who was alone Any team education and training programme in the office without any emergency equipment, must consider local culturally acceptable went out to ask for help. behaviour, in regard to speaking up in a team and the nature of hierarchies in a given country. Two minutes later, the dentist came back with the dental assistant (who had now located the We conclude this section with a discussion emergency equipment) and two other colleagues. of interprofessional education that may or may not be an option for consideration within your The patient did not seem to be breathing at curriculum. that time. The dentists began cardiopulmonary resuscitation (CPR). The dental assistant phoned Teamwork education over the course for an ambulance. of a programme Over the course of a year training programme, The team were unable save the patient. there are opportunities to stratify teaching and learning around teamwork. For instance, Questions a programme could be structured in the following – What factors are associated with this incident? way: – In what ways could improved communication Early year(s) between team members have prevented this death? Didactic presentations on: ñ the basics of teamwork and learning styles; Source: Case supplied by Shan Ellahi, Patient Safety ñ different types of teams in health care; Consultant, Ealing and Harrow Community Services, ñ different learning styles. National Health Service, London, UK. Small group activities that focus on: Teaching strategies and formats ñ building fundamental team-based skills; This topic includes a number of strategies ñ appreciating different learning and problem- for learning and practising teamwork. Effective solving styles; teams do not just happen and there is a ñ reflecting on experiences in teams outside substantial body of underpinning theory that of health care; can be appropriately delivered in a didactic ñ the roles of various health-care teams. manner. The knowledge requirements listed above can form the basis for didactic presentations. Middle and later year(s) Given that one of the most effective ways Didactic presentations on: of learning about teamwork is to participate in ñ the roles and responsibilities of different health a team, we include a number of team-based professionals in teams; activities that can easily be run with small groups ñ characteristics of effective teams; of students with limited resources. Given that ñ strategies for overcoming barriers to effective students will often have had little experience teamwork. participating in health-care teams, we include activities in which students can reflect on their Small group activities that include: experiences of teamwork unrelated to health care. ñ interprofessional participation; ñ refection on the experience of participating To familiarize students with actual health-care in health-care teams as a student; teams, we have also included activities that ñ teamwork simulation in a health-care context anticipate the types of teams that students will (high or low fidelity). increasingly encounter as they move forward in their training and careers.145 Part B Topic 4. Being an effective team player
    • Teaching activities at the end of the exercise. The purpose of the debriefing is to reflect on what worked wellEngaging role models for the team, so that effective behaviours areGiven that teamwork is not always recognized reinforced. The team should also reflect on theor valued in the health-care environments difficulties and challenges they faced. Strategiesencountered by students, it is important to manage the challenges should be exploredto engage clinical role models in the delivery and then practised in subsequent sessions.of teamwork education. If possible, identifyclinicians with good reputations for working Building newspaper towers: an example ofin multidisciplinary teams to serve as role models. a team-building exerciseIdeally, these role models should present different This is an example of an interactive exerciseaspects of the theory behind teamwork and that requires no physical contact and thatgive examples from their own experiences. can be varied depending on group size, dynamicsWhenever possible, role models should be drawn and the time available.from multiple health-care professions. To begin, divide the students groups of 2–6Reflective activities around experiences people. Issue each group an equal numberof teamwork of sheets of newspaper (the fewer the moreA simple way to introduce teamwork concepts difficult, 20–30 sheets is fine for a 10–15 minuteto students is to get them to reflect on teams exercise), and a roll of sticky tape. The task isthey may have participated in during school to construct the tallest freestanding tower madeor university. These may include sporting teams, only of newspaper and sticky tape in the allottedwork teams, choirs, etc. Reflective exercises can time. The point of the exercise is to demonstrateinclude the creation of simple surveys that can be the importance of planning (time, methodused to draw out questions concerning teamwork. of construction, creativity) and the motivational effect of a team task. Instructions need to beReflective exercises can also be built around very clear. For instance, does the tower haveexamples of teamwork failures or successes that to be free-standing or can it be braced? It doesmay be topical and/or current within the local not matter which; it matters only that any issuescommunity. This may include the development affecting a clear result are clarified.of quizzes or group discussions about newspaperarticles describing failures of sporting teams You can allocate as many sheets as you wish,associated with teamwork failures or high-profile depending on the main purpose of the exerciseexamples of clinical errors due to failures in and, to an extent, the amount of time availableteamwork. The case studies provided for this and the number of individuals on each team.topic could also be used to reflect on failures in As a general rule, fewer sheets should be usedteamwork. when teams are smaller and less time is available for the exercise. Short periods of time,High-profile examples of teamwork failures large teams, and lots of sheets lead to lotsand successes outside of health care, such as of chaos. This may be ideal for demonstratingplane crashes or nuclear power station failures, the need for leadership and management.are often used in the teaching of teamwork Unless your focus is leadership and managingprinciples. A number of these are described the planning stage, avoid the combinationin detail by Flin et al. [18]. of small numbers of sheets and large teams. Small teams do not need lots of sheets, unlessTeam-building exercises you make a rule that all of the material must beThere are a wide range of activities that can help used, in order to put pressure on the planningpromote an understanding of team dynamics and design stage.and different learning styles. A simple searchof the Internet will provide many examples. Simulated health-care environmentsThese can be useful for any team participant Simulation is increasingly used to learn andand require no prior knowledge of health care or practise teamwork in health care. Simulatedteamwork. These exercises can be fun and often environments are ideal for learning as theyhave a positive side-effect of bonding student combine safety–there is no real patient–withgroups together. the ability to increase or decrease the speed of evolution of the scenarios, especially ifRemember, one of the most important parts mannequin-based simulation techniques are used.of any team-building exercise is the debriefing This is ideal for teamwork exercises, as the WHO Patient Safety Curriculum Guide: Multi-professional Edition 146
    • importance of sound teamwork behaviours The faculty should identify teams to which is particularly manifest in emergency, time-critical students will be welcomed and ideally given some situations. In addition, students get a chance form of participatory role. These teams may include to experience what it is like to manage a situation well-established multidisciplinary care planning in real time. teams, such as those found in mental health or oncology, or more fluid teams, such as those found Ideally, simulated environments may be used in emergency departments. They may also include to explore teamwork using mixed groups primary health-care teams in the community. of health-care professionals. When exploring teamwork, the focus should not be on the It is important for students to reflect on their technical skills of the students, but rather their team-based experiences in health care and share interaction and communication with one another. these experiences with their peers and faculty. The best way to ensure that this remains the focus This will allow discussion of both the positive of the exercise is to allow the students to learn and negative aspects of their experiences. and practise the technical aspects of the scenario Students should be asked to identify model teams together prior to the actual scenario, usually and explain why they believe these teams can be through an initial procedural workshop. If the identified as such. They should be encouraged team struggle with basic knowledge and skills, to ask questions such as: then the opportunity to discuss teamwork may be ñ what were the strengths of the team? lost, as there may be so many important clinical ñ what professions were represented on the team and technical issues to discuss. However, if the and what were their roles? students are well-drilled on the technical aspects ñ did the team have clear goals? of the scenario beforehand, the challenge is ñ was there a clear leader? for them to put what they know into action as ñ were all team members permitted to a team. The simulation then becomes a powerful participate? opportunity to explore the nontechnical aspects ñ how did members of the team communicate of the scenario, namely the teamwork, leadership with one another? and communication issues that emerge ñ how could the student see the team improving? as the scenario unfolds [18]. ñ was the patient part of the team? ñ what were the outcomes and were they As with the other team-building exercises effective? discussed above, it is vital that a structured debriefing be conducted to explore the way Students should be asked to explore and reflect the teams performed in the exercise: what worked on areas of teamwork in which errors are know well and why, what was difficult and why, and to occur, such as communication between what could be done to improve performance on primary- and secondary-care providers or during subsequent occasions. If different health-care hand-over/hand-off. students are working together in the simulation, the different roles, perspectives and challenges It may also be possible for students to take of each profession can be discussed during part in a panel discussion with an effective the debriefing as well. multidisciplinary team to discuss how the team functions and works together. The major constraint associated with simulation exercises is that they can be resource intensive, Interprofessional education especially if a computerized mannequin is used Teamwork in health care cannot be discussed and/or attempts are made to make a teaching without mentioning the important role of setting look like a clinical environment. interprofessional education (IPE) in undergraduate health education. Participating in health-care teams Students, particularly in the later parts of their At the heart of IPE is the preparation of future training programmes, should be encouraged practitioners for effective team-based practice, to participate in different types of health-care by bringing students from different disciplines teams at every opportunity. If clinicians from together during their undergraduate education a particular department or clinic maintain the to learn from and with each other. This helps traditional silo (not multidisciplinary) approach students learn to appreciate and respect to health care, this should not prevent students the different roles of health professionals before from working with other health professionals they have joined specific professional groups as part of a team. themselves.147 Part B Topic 4. Being an effective team player
    • While there is a compelling argument that many principles of effective teamworkundergraduate IPE should improve subsequent as possible.teamwork, the research to support this argumentis not yet conclusive. Tools and resource materialUniversities have taken different approaches TeamSTEPPSì: Strategies and tools toto introducing IPE into their curricula depending enhance performance and patient safety.on available resources, the available undergraduate United States Department of Defence, inprogrammes and the degree of support for the collaboration with the Agency for Healthcareconcept at senior levels. Approaches have ranged Research and Quality (AHRQ)from a full re-engineering and alignment of all ( curricula through the addition of IPE tm; accessed 20 February 2011). TeamSTEPPSìmodules and activities to supplementing existing also includes free access to a number of videos.curricula on a relatively opportunistic basis. The SBAR Toolkit is available on the above-The resources and activities included in this mentioned TeamSTEPPS web siteguide are intended to be useful for teaching ( in a particular professional field, as well undamentals/module6/igcommunication.htm#sbaras multi-professional student groups. sl9; accessed 14 November 2010).A list of further reading on IPE and links Assessing knowledge of this topicto universities that have introduced IPE into their Many different modalities can be used to assesscurricula is provided below. teamwork. MCQ can be used to explore knowledge components. A portfolio can be used to recordTools and resource material (IPE) and reflect on team activities encountered overGreiner AC, Knebel E, eds. Health professions the course of the training a bridge to quality. Washington, DC,National Academies Press, 2003. Assignments can be specifically designed to require teamwork among students. This mayAlmgren G et al. Best practices in patient safety include students self-selecting a health- or non-education: module handbook. Seattle, University health-related project to complete or facultyof Washington Center for Health Sciences suggesting a project such as planning theInterprofessional Education, 2004. development of an apartment for a person who uses a wheelchair or planning the developmentUniversities that have introduced major initiatives of a rural outreach programme for oral IPE include: In developing the assignment, the emphasis is notñ Faculty of Health Sciences, Linkoping University, so much on the outcome of the project, Sweden. (; accessed but rather how students work together. 20 February 2011).ñ College of Health Disciplines, University of British Later assessments can be more complex. Students Columbia, Canada. (; could review a team with which they have accessed 20 February 2011). worked and development recommendations for how that team could be improved.Free team-building games can be found at thefollowing web site: A writing assignment could include tracking team functions by following either a patient’shtm; accessed 20 February 2011. hospital stay for a defined period of time or tracking a health-care provider and reviewingSummary how many teams he/she intersects with and whatIn summary, team training for students in his/her roles are on each team.the health-care professions can be based ona variety of techniques, many of which can be Teams could be asked to identify a safety issue,delivered in the classroom or in low-fidelity collect data on it, analyse the data and describesimulated environments. interventions to prevent or mitigate the safety issue.Ideally, students should take part in real teamsand learn through experience and guided Depending on available resources, simulationreflection and team training should focus on as exercises can also be used for effective formative WHO Patient Safety Curriculum Guide: Multi-professional Edition 148
    • and summative assessments of health-care performance and training. In: Sweeney RW, teamwork. Salas E, eds. Teams: their training and performance. Norwood, NJ, Ablex, 1992. Ideally, some assessments would require 8. Agency for Health Care Quality and Research. students from different health professions to work TeamSTEPPSì: strategies and tools to enhance together. performance and patient safety. Rockville, MD, Agency for Healthcare Quality and Research, Evaluating the teaching of this topic 2007. As with any evaluation exercise, a number 9. Bogner M. Misadventures in health care. Mahwah, of evaluation phases need to be considered. NJ, Erlbaum, 2004. These include: 10. Lingard L et al. Communication failures in the ñ a needs analysis (or prospective evaluation) to judge how much teamwork instruction operating room: an observational classification currently exists and how much is needed; of recurrent types and effects. Quality and Safety in Health Care, 2004, 13:330–334. ñ a process evaluation during the delivery of any programme to maximize its effectiveness; 11. Mickan SM. Evaluating the effectiveness of ñ an impact evaluation to track the impact of the health care teams. Australian Health Review, 2005, programme on knowledge and competencies 29:211–217. gained during the programme. 12. Stevenson K et al. Features of primary health care teams associated with successful quality See the Teacher’s Guide (Part A) for more improvement of diabetes care: a qualitative information on evaluation. study. Family Practice, 2001, 18:21–26. 13. Junor EJ, Hole DJ, Gillis CR. Management of References ovarian cancer: referral to a multidisciplinary 1. Baker DP et al. Medical teamwork and patient team matters. British Journal of Cancer, 1994, safety: the evidence-based relation. Literature review. 70:363–370. AHRQ Publication No. 050053. Rockville, MD, 14. Morey JC, Simon R, Jay GD. Error reduction and Agency for Healthcare Research and Quality, performance improvement in the emergency 2005 (; department through formal teamwork training: accessed 20 February 2011). evaluation results of the MedTeams project. 2. Salas E, Dickinson TL, Converse SA. Toward an Health Services Research, 2002, 37:1553–1581. understanding of team performance and 15. Risser DT et al. The potential for improved training. In: Swezey RW, Salas E, eds. Teams: their teamwork to reduce medical errors in training and performance. Norwood, NJ, Ablex, the emergency department. The MedTeams 1992:3–29. Research Consortium. Annals of Emergency 3. Orasanu JM, Salas E. Team decision making Medicine, 1999, 34:373–383. in complex environments. In: Klein GA et al, 16. Mickan SM, Rodger SA. Effective health care eds. Decision making in action: models and methods. teams: a model of six characteristics developed Norwood, NJ, Ablex, 1993:327–345. from shared perceptions. Journal of 4. Cannon-Bowers JA, Tannenbaum SI, Salas E. Interprofessional Care, 2005, 19:358–370. Defining competencies and establishing team 17. Tuckman BW. Development sequence in small training requirements. In: Guzzo RA et al., eds. groups. Psychological Review, 1965, 63:384–399. Team effectiveness and decision-making in 18. Flin RH, O’Connoer P, Crichton M. Safety at the organizations. San Francisco, Jossey-Bass, sharp end: a guide to nontechnical skills. Aldershot, 1995:333–380. UK, Ashgate Publishing Ltd, 2008. 5. Bowers CA, Braun CC, Morgan BB. Team 19. Lingard L et al. A theory-based instrument workload: its meaning and measurement. to evaluate team communication in the In: Brannick MT, Salas E, Prince C, eds. Team operating room: balancing measurement performance assessment and measurement. authenticity and reliability. Quality and Safety Mahwah, NJ, Erlbaum, 1997:85–108. in Health Care, 2006, 15:422–426. 6. Brannick MT, Prince C. An overview of team 20. Lingard L et al. Perceptions of operating performance measurement. In: Brannick MT, room tension across professions: building Salas E, Prince C, eds. Team performance generalizable evidence and educational assessment and measurement. Mahwah, NJ, resources. Academic Medicine, 2005, 80 (Suppl. Erlbaum, 1997:3–16. 10): S75–S79. 7. Salas E et al. Toward an understanding of team 21. West M. Effective teamwork: practical lessons from149 Part B Topic 4. Being an effective team player
    • organisational research. Leicester, Blackwell Publishing, 2004.22. Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Quality and Safety in Health Care, 2009, 18:137–140.23. Barenfanger J et al. Improving patient safety by repeating (read-back) telephone reports of critical information. American Journal of Clinical Patholology, 2004, 121:801-803.24. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Quality and Safety in Health Care 2004;13:ii3-ii9.25. Rouse WB, Cannon Bowers J, Salas E. The role of mental models in team performance in complex systems. IEEE Transactions on Systems, Man and Cybernetics, 1992, 22:1295–1308.26. Stanton N et al. Human factors methods: a practical guide for engineering and design. Aldershot, UK, Ashgate Publishing Ltd, 2005.27. Salas E et al. Markers for enhancing team cognition in complex environments: the power of team performance diagnosis. Aviation, Space, and Environmental Medicine, 2007, 78:5 (Suppl. Sect. 11):B77–B85.28. Honey P, Mumford A. A manual of learning styles. Maidenhead, Peter Honey, 1986.29. Chakraborti C et al. A systematic review of teamwork training interventions in medical student and resident education. Journal of General Internal Medicine, 2008, 23:846–853.Slides for Topic 4: Being an effectiveteam playerDidactic lectures are not usually the best wayto teach students about patient safety. If alecture is being considered, it is a good ideato plan for student interaction and discussionduring the lecture. Using a case study is oneway to generate group discussion. Another wayis to ask the students questions about differentaspects of health care that will bring outthe issues contained in this topic.The slides for Topic 4 are designed to helpthe instructor deliver the content of this topic.The slides can be changed to suit the localenvironment and culture. Instructors do nothave to use all of the slides and it is best to tailorthe slides to the areas being covered in theteaching session. WHO Patient Safety Curriculum Guide: Multi-professional Edition 150
    • Topic 5 Learning from errors to prevent harm Distractions can lead to disastrous still not satisfied, and so the boy was sent consequences to the nearby ambulatory paediatric care unit in the same building. They waited there for A 3-year-old boy, on his first visit to the dentist, two and a half hours. Despite her appeals was examined by a dentist who found no for help, the child became progressively sicker dental caries and then handed over the boy and lapsed into what she thought was sleep, to a dental hygienist for routine teeth-cleaning. but was actually a coma. After cleaning the child’s teeth, the dental hygienist used a swab to spread a stannous Eventually, the boy was seen by a doctor fluoride gel over the boy’s teeth as a decay- who summoned the supervisor. The child was preventive measure. treated with an injection of adrenaline directly into his heart in an attempt to revive him. According to the mother, the hygienist was An ambulance was called and transferred engrossed in conversation while working the child to hospital, which was a five-minute on the child and, after handing him a cup drive away. of water, failed to instruct him to wash his mouth out and spit out the solution. After arriving at the hospital, the mother and She said that her child drank the water. child waited for more than an hour. By that time, the boy had lapsed back into a coma. The child began vomiting, sweating and The doctors tried to pump his stomach, but complaining of headache and dizziness. the boy went into cardiac arrest and died. His mother, appealing to the dentist, was told According to the county toxicologist, the child that the child had been given only routine ingested 40 ml of 2% stannous fluoride solution; treatment. However, the boy’s mother was triple the amount sufficient to have been fatal. Source: Case supplied by a WHO Expert Committee participant, Paris, October 2010. Introduction–Coming to terms recurrence. For this reason, it is crucial that all 1 with health-care errors health-care students have a basic understanding This case study reflects the underpinning factors of the nature of error. All health-care workers of the tragic death of a 3-year-old boy. If we need to understand different types of errors analyzed the above case study, we would and how they occur. This is essential for devising uncover the many errors that contributed strategies to prevent errors and/or intercept to the tragic and preventable outcome and them before they can cause harm to patients. identify the steps that could be taken to prevent it ever happening again. The most An equally important consideration is the issue important aspect of analysing errors is to discover of learning from errors–one’s own as well as those what happened and how to prevent their of others. It is through investigation of errors151 Part B Topic 5. Learning from errors to prevent harm
    • and error-causing conditions that improvements of any human error. Some treatments havein system design can be implemented, in well-recognized complications that can occurthe hope of decreasing the frequency and impact even in the best of hands and under the bestof errors. (This is further discussed in Topic 3: of circumstances. In other cases, numerous errorsUnderstanding systems and the effect of complexity may not lead to bad outcomes, as long as theyon patient care). are recognized in time and appropriate steps Τ3 are taken to counteract any damage that mayKeywords have been caused. Sometimes, as mentionedError, violation, near miss, hindsight bias, root in Topic 3, patients themselves are resilient andcause analysis. may be okay even though an error was made, because their own body or immune system 2Learning objective has withstood the incorrect treatment.Understand the nature of error and howhealth-care providers can learn from errors It is important to point out that there is noto improve patient safety. mention of outcome in this definition of error, though the fact of the (usually untoward)Learning outcomes: knowledge and outcome is often what draws our attentionperformance to the fact that an error has occurred. Indeed, most errors in health care do not lead to harmKnowledge requirements 3 for patients because they are recognized beforeKnowledge requirements for this topic include harm occurs and the situation is remedied.students understanding how they can learn from There is no doubt that the nature of the outcomeerrors. Understanding of the terms error, slip, usually influences our perception of the error,lapse, mistake, violation, near miss and hindsight often due to the phenomenon of “hindsightbias is essential. bias,” in which knowledge of the outcome of a situation influences our perception (usuallyPerformance requirements 4 unfavourably) of the standard of care beforeBy the end of the course students should be and during the incident in question [2].able to:ñ identify situational and personal factors that One only has to consider one’s last “silly 8 are associated with the increased risk of error; mistake” in everyday life to be remindedñ participate in analyses of adverse event of the inevitability of error as 9 10 and practise strategies to reduce errors. a fundamental fact of life (see Topic 2: Why applying human factors is importantErrors 5 for patient safety). Τ2In simple terms, an error occurs “when someoneis trying to do the right thing, but actually does The challenging reality for health-care workersthe wrong thing” [1]. In other words, there is is that the same mental processes that lead usa non-deliberate deviation from what was to make “silly mistakes” outside the workplaceintended. The cognitive psychologist, James are also in play when we are at work. However,Reason, stated this fact of life more formally the work context makes the consequences vastlyby defining errors as “planned sequences of different.mental or physical activities that fail to achievetheir intended outcomes, when these failures The terms medical error or health-care error arecannot be attributed to the intervention of some slightly misleading, as they may give thechance agency” [2]. Errors may occur when impression that the kinds of errors that can occurthe wrong thing is done (commission) or when in health care are unique to health care. Thisthe correct thing is not done (omission). is not the case. The patterns of errors that occur in health-care settings are no different from theA violation is different from errors sorts of problems and situations that exist in other 6caused by the system. Violations are settings. What is different about health careerrors caused by deliberate deviation is that there remains an element of a cultureby an individual from an accepted protocol of infallibility that denies the prevalence of error.or standard of care. Another unique feature of health care-associated errors is that when failure occurs (omission orErrors and outcomes are not inextricably commission), it is the patient(s) who suffer. 7linked. Students will often observepatients who have bad outcomes in the absence Errors occur because of one of two main types WHO Patient Safety Curriculum Guide: Multi-professional Edition 152
    • of failures: either actions do not go as intended is actually incorrect is called a mistake. A mistake or the intended action is the wrong one [3]. is a failure of planning (i.e. the plan is wrong). The former situation is a so-called error of This can be either rule-based, when the wrong execution and may be further described as being rule is applied, or knowledge-based, when either a slip, if the action is observable, or a lapse, a clinician does not take the correct course if it is not. An example of a slip is accidentally of action. An example of a rule-based mistake pushing the wrong button on a piece would be getting the diagnosis wrong and of equipment. An example of a lapse is a memory so embarking on an inappropriate treatment plan. failure, such as forgetting to administer Knowledge-based mistakes tend to occur a medication. when health-care providers are confronted with unfamiliar clinical situations (see Figure B.5.1 A failure that occurs when the intended action below).Figure B.5.1. Principal types of errors 11 Attentional slips of action Skill-based slips and lapses Lapses of memory Errors Rule-based mistakes Mistakes Knowledge-based mistakesSource: Reason JT. Human error: models and management. British Medical Journal, 2000 [4]. Slips, lapses and mistakes are all serious and Situations associated with 12 can potentially harm patients. The actual potential an increased risk of error for harm depends on the context in which We know from various studies that students the error occurs. and new clinicians are particularly vulnerable to errors under certain circumstances. Situations that increase the likelihood of error as well as personal error-reduction strategies Inexperience are described in Topic 2: Why applying It is very important that students not perform Τ2 human factors is important for patient a procedure on a patient or administer a treatment safety. Some other general error-reduction for the very first time without appropriate principles are outlined below. Reason has also preparation. Students need to first understand promoted the concept of “error wisdom” [4] what they are doing and to practise on for front-line workers, as a means to assess a mannequin or other prop in a simulated the risk present in different contexts depending environment. If it is his/her first time, the student on the current state of the individual involved, should be properly supervised and watched the nature of the context and the error potential while he/she performs the procedure or gives of the task at hand. the treatment. 153 Part B Topic 5. Learning from errors to prevent harm
    • Students are in a privileged position. Patients transmission of information is also crucial. Withdo not expect students to know much, they so many health professionals involved in caringappreciate that they are learning. This is why for patients it is essential that verbal and writtenit is very important they do not pretend or let communications are checked and accurate.others present them as having more experiencethan they do. Individual factors that predispose 13 students (and other health-careShortage of time workers) to errorsTime pressures encourage people to cut corners In addition to situations known to be proneand take shortcuts when they should not. to errors, there are also individual factors thatNot cleansing hands properly is an example of this. predispose for errors.Another example would be a pharmacist nottaking the time to properly counsel someone Limited memory capacityreceiving medication, or a midwife not properly How students perceive of themselves in theirinforming a woman about the different stages chosen health-care profession and the workplaceof delivery. hierarchy may relate to how confident and willing they are to ask for help. Asking for helpInadequate checking is expected of all students, yet many still findThe simple act of checking saves thousands this to be very challenging. This in turn may affectof patients from receiving the wrong medications. their ability to recognize their limitations. LackPharmacists routinely check drugs and assist the of confidence can be a significant factor inother members of the health-care team in making whether students ask for help in masteringsure each patient receives the correct dosage a new skill. If students are unwilling or lackof the correct drug by the correct route. Students the confidence to ask for help with simple tasks,(medical, dental, midwifery) should establish will they have the confidence to ask for helpgood relationships with pharmacists and nurses when they are in trouble?who have habitual checking routines built intotheir professional routines. Checking is a simple Learning to ask for help is an essential skill forthing that students can start practising as soon all students and new clinicians. Researchers haveas they are placed into a clinical environment examined the preparedness of medical andor community care setting. nursing students for clinical practice. These studies have revealed that many graduating medicalPoor procedures students in their early years have deficienciesThis can relate to a number of factors–inadequate in basic clinical skills. The first year of practice forpreparation, inadequate staffing and/or nurses is also a time of inadequate competenciesinadequate attention to the particular patient. and stress. This may be due to a reluctance toStudents may be required to use a piece ask for help as students. Inadequate understandingof equipment without fully understanding its of the crucial signs of acute illness, airwayfunction or how to use it. Before using any piece obstruction, fetal and maternal well-beingof equipment for the first time, students should and basic life support were examples of specificfamiliarize themselves with it. Watching someone areas in which new doctors had inadequateuse a piece of equipment and then talking knowledge and skills.with that person about the procedure for whichit is used is very instructive. Many students think that if they can regurgitate the technical information stored in textbooks,Inadequate information they will be good health professionals. However,Continuous quality health care and treatment this is not the case. The amount of informationdepends on each health-care professional that many health-care providers are requiredrecoding the patient details accurately, in a timely to know today is far beyond that which can beway and in legible handwriting in the patient memorized. The human brain is only capablerecord (medical record, drug chart or other of remembering a finite amount of information.method used for storing patient information). Students should not rely on memory, particularlyIt is crucial that students habitually check when there are a number of steps involved.the information being recorded and ensure that Guidelines and protocols have been developedthe information they write is legible, accurate to help health-care professionals provide careand up to date. Misinformation, incorrect and service following the best available evidence.and inadequate information are often factors Students should get into the habit of usingcontributing to adverse events. Accurate verbal checklists and not relying on memory. WHO Patient Safety Curriculum Guide: Multi-professional Edition 154
    • Fatigue Language or cultural factors Memory is affected by fatigue. Fatigue is a The potential for communication errors caused known factor in errors involving health-care by language and cultural factors is obvious, practitioners. In recognition of the problems but there are many interactions between patients caused by fatigue, many countries have already and their health-care providers that occur without or are in the process of reforming the excessive an interpreter or common language. Students hours worked by doctors [5]. The connection should appreciate the problems caused between sleep deprivation of interns due to long by language barriers and misunderstandings shifts and circadian interruption and well-being of cultural norms. Literacy is another important was made three decades ago, yet it is only issue to keep in mind. Health-care providers recently that governments and regulators have must be aware of how well patients and their become serious about limiting hours. A 2004 carers can understand written instructions. study by Landrigan et al. [6] was one of the first of its kind to measure the effects of sleep Hazardous attitudes deprivation on medical errors. This study found Students who perform procedures or interventions that interns working in the medical intensive for patients without supervision might be said unit and coronary care unit of Brigham and to display a hazardous attitude. These students Women’s Hospital (Boston, MA, United States) may be more interested in practising or getting made substantially more serious mistakes when experience than attending to the well-being they worked frequent shifts of 24 hours or of the patient. Students should always appreciate more as compared to when they worked shorter that contact with patients is a privilege shifts. Other studies show that sleep deprivation that should not be taken for granted. can have similar symptoms to alcohol intoxication [7-9]. Problems with nurses working 12-hour Ways to learn from errors shifts and the use of mandatory overtime and the fact that these practices can lead Incident reporting 16 17 18 to increased errors have been documented Incident reporting and monitoring involve in the professional literature. collecting and analysing information about any event that could have harmed or did harm Stress, hunger and illness a patient in a clinical setting or health-care When students feel stressed, hungry or ill, organization. An incident-reporting system is they will not function as well as when they a fundamental component of an organization’s have none of these issues. It is very important ability to learn from error. The lessons learned for students to monitor their own status through the use of these procedures allow and well-being. Students should be mindful the organization to identify and eliminate of the fact that if they are feeling unwell “error traps”. (More information on or stressed, they are more likely to make errors. organizational responsibility for incident Burnout in new nurses has led to errors monitoring is presented in Topic 6: Understanding and to nurses leaving the profession. Stress and and managing clinical risk). Τ6 burnout are related. Incidents are traditionally underreported, often There are many mnemonic devices to help students because the person approach to incident analysis monitor themselves. HALT is one such aid. is still pervasive in health care, whereby the front-line nurses, pharmacists, doctors, Pay attention to whether you are: 14 dentists or midwives –often the ones who report H Hungry the incident–are criticized for their role in the A Angry evolution of the incident. As mentioned above, L Late or this situation is often exacerbated by the T Tired phenomenon of hindsight bias. The person approach is counterproductive on several levels. Another memory tool for self-monitoring 15 (See Topic 3: Understanding systems and the effect is IM SAFE. of complexity on patient care). Τ3 I Illness M Medication (prescription and others) The frequency of reporting and the manner S Stress in which incidents are analysed–whether a systems A Alcohol approach or person approach is used–are heavily F Fatigue dependent on the leadership and culture of E Emotion an organization. In recent years, more attention155 Part B Topic 5. Learning from errors to prevent harm
    • has been paid to the importance of organizational the culture. If a student hears staff talking aboutculture in health care [10], reflecting lessons a particular staff member who has madelearned in other industries in relation to system a mistake, they can move the focus away fromsafety. There is likely to be a correlation between the individual to discussion about underlyingthe organizational culture of a health-care factors that may be involved.facility and the safety of patients being treatedat that facility. Other successful strategies in terms of incident reporting and monitoring include [7] 21An organization’s culture reflects the shared anonymous reporting, timely feedback,values and beliefs that interact with an open acknowledgement of successes resultingorganization’s structure and control systems from incident reporting and reporting of nearto produce behavioural norms [11]. misses. The reporting of near misses is useful 19Organizations with a strong reporting in that “free” lessons can be learned. That is,culture are well placed to learn from errors system improvements can be instituted as a resultbecause the staff members feel free to report of the investigation, without patients havingactual or potential problems without fear incurred any harm. 20of ridicule or reprimand. Students andnew clinicians are part of the work culture. Root cause analysis 22They may feel that they have no power to change See also Topic 7: Using quality-or affect anything in the work environment. improvement methods to improve care. Τ7However, they too can look for ways to improvethe system. This can be as simple as being A number of models have been developedrespectful to the other members of the using root cause analysis (RCA) team, including patients, in discussions One such model, called the London Protocol,about care or asking if other team members was developed by Charles Vincent and colleagues.would like a cup of coffee if the student is making This is an easy-to-understand model that takesa cup for himself/herself. Refraining from finger the team through each of the steps of a clinicalpointing to individuals involved in an adverse investigation. See Box B.5.1 for an outline ofevent is another way students can help change the steps involved.Box B.5.1. The London ProtocolDetails of investigation process Analysis of case If the protocol is followed systematicallyWhich incidents should be investigated? and the interview and analysis conducted thoroughly, the report and implications ofReviewing case records the incident should emerge from the analysis in a relatively straightforward fashion. WhenFraming the problem the composite is complete, there should be a clear summary of the problem and theInterviewing staff circumstances that led up to it, and the flaws in the care process should be readily apparent.How did it happen? – identifying the care The final section of the report will considermanagement problems what implications the incident has for theWhy did it happen? – identifying department or organization and will makethe contributory factors recommendations for remedial actions.Source: Vincent C et al. How to investigate and analyse clinical incidents: clinical risk unit and associationof litigation and risk management protocol. British Medical Journal, 2000, 320: 777–781. WHO Patient Safety Curriculum Guide: Multi-professional Edition 156
    • The Veterans Affairs National Center for ñ become familiar with the environment Patient Safety of the United States Department they work in; and of Veterans Affairs (VA) developed another ñ be prepared for the usual, knowing that model, which also uses a structured unusual things can happen. 23 approach of RCA to evaluate and analyse severe adverse events and develop system We know that it is impossible for any one 24 improvements to prevent their individual to know everything, so it is important reoccurrence [12]. All models that review retro- that students become accustomed to asking spectively ask the following set of questions [1]: questions whenever they do not know something ñ what happened? relevant and important to their patients. Here ñ who was involved? are some personal error-reduction strategies for ñ when did it happen? students: ñ where did it happen? ñ how severe was the actual or potential harm? ñ care for one’s self (eat well, sleep well and look ñ what is the likelihood of recurrence? after yourself); ñ what were the consequences? ñ know your environment; ñ know your task(s); RCA focuses on the system, not the individual ñ prepare and plan (what if...); worker, and assumes that the adverse event ñ build checks into your routine; that harmed a patient is a system failure. ñ ask if you do not know. The VA system and systems used in Australia and elsewhere use a severity assessment code Students should assume that errors will occur. to help triage reported incidents to ensure This will be a change for many because, in some that those indicating the most serious risks cultures, there is still the belief that only bad or are dealt with first. incompetent health-care providers make mistakes. Students should assume that errors will be made The RCA model focuses on prevention, not and prepare for them. This includes identifying blame or punishment. (Other processes are used those circumstances most likely to lead to errors when the focus of interest is holding people (e.g. high-risk times). accountable for their actions.) The focus of this type of analysis is on system-level vulnerabilities For example, research has identified high-risk as opposed to individual performance. The model situations in which the risk of nursing students examines multiple factors, such as communication, making errors as they administer medications training, fatigue, scheduling of tasks/activities increases [14]. These situations involve: and personnel, environment, equipment, rules, policies and barriers. ñ non-standard dosages and/or dosage times ordered; The defining characteristics of root cause analysis ñ non-standard or improper documentation; include [13]: ñ unavailable medical administration records; ñ review by an interprofessional team ñ partial drug administration ordered; knowledgeable about the processes involved ñ held or discontinued medications; in the event; ñ monitoring issues–for example, student needs to ñ analysis of systems and processes rather than check vital signs before administering the drug; individual performance; ñ use of liquids that are only for oral use, but are ñ deep analysis using “what” and “why” probes then given via a parenteral route. until all aspects of the process are reviewed and contributing factors are considered; It is important to have contingency plans in ñ identification of potential changes that could place to cope with problems, interruptions be made in systems or processes to improve and distractions. Students should always performance and reduce the likelihood of similar mentally rehearse complex procedures or any adverse events or close calls in the future. activity involving a patient that they are doing for the first time. Strategies to reduce errors 25 26 Students can immediately start practising Summary 27 error-reduction behaviours by looking after Medical error is a complex issue, but error itself their own health. Students should: is an inevitable part of being human. These tips are known to limit the potential errors ñ be aware of when they are tired; caused by humans [15].157 Part B Topic 5. Learning from errors to prevent harm
    • ñ Avoid reliance on memory Other teaching activitiesñ Simplify processs Different methods for generating discussion aboutñ Standardize common processes and procedures the areas in this topic include:ñ Routinely use checklists – asking students to keep journals in whichñ Decrease reliance on vigilance. they write about an observed error or near miss (what happened, categorize the type of error,See also the discussion in Topic 2: Why applying make recommendations as to what might behuman factors is important for patient safety. done to prevent a similar thing from happening Τ2 again);Learning from error can occur at both an – selecting a case study from those presentedindividual level and an organizational level above that sets the scene for a discussionthrough incident reporting and analysis. Barriers about the most common errors in health care;to learning from error include a blame culture – using examples that have beenthat applies a person approach to investigations, published/broadcast in the media;as well as the phenomenon of hindsight bias. – using de-identified case examples from yourA broadly based systemic approach is required own clinic or practice;for organizational learning and the possibility – using a case study to encourage students toof system change. brainstorm about possible errors and their associated factors;Root cause analysis (RCA) is a highly structured – considering examples of lessons about errorsystemic approach to incident analysis that is and system failure from other industries;generally reserved for the most serious patient- – inviting a professional from another discipline,harm episodes. Students may have little such as engineering or psychology, to discussopportunities to participate or observe a root error-causation theory, cultures of safety andcause analysis process but once employed in the role of error reporting in safety;the hospitals or health service newly qualified – inviting respected senior health professionalhealth professionals should seek out opportunities to talk about errors they have made;to join an RCA process. – asking the staff person responsible for quality improvement in a hospital to talk to studentsTeaching strategies and formats about data collection, analysis and outcomes, as well as the roles of different staff membersSimulation exercises in the quality-improvement process;Different scenarios could be developed concerning – inviting a quality and safety officer to talk aboutadverse events and the need to report and systems in place to minimize errors and manageanalyse errors. Practical exercises that show how adverse events in a particular facility/system;errors are avoided can be used and students – discussing the difference between systemshould also be encouraged to rehearse strategies failures, violations and errors (see Topic 4);for managing errors. – using a case study to analyse the different avenues for managing an adverse event;An interactive/didactic lecture – participating in or observing a RCA.Use the accompanying slides as a guide forcovering the whole topic. PowerPoint slides can Activities for students in their workplacebe used or converted to overhead slides for or clinical placementsa projector. Start the session with a case study Students might be asked to:from the Case Study Bank or have the students – attend a RCA investigation;identify some errors they have recently made. – find out whether their health-care facility conducts mortality and morbidity meetingsSmall group discussion or has other peer-review forums in whichA small group discussion could focus on adverse events are reviewed;common errors in the workplace. One or more – talk with each other about errors observed instudents could be asked to lead a discussion the work environment using a non-blamingabout the areas covered in this topic. approach. Ask students to identify not onlyThe students could follow the headings errors, but also possible strategies for theiras outlined above and present the material. prevention;The tutor facilitating this session should also – select a clinic or treatment setting in whichbe familiar with the content, so information they are training and inquire about the maincan be added about the local health system types of errors in that area and the steps thatand clinical environment. are taken to minimize and learn from them. WHO Patient Safety Curriculum Guide: Multi-professional Edition 158
    • Case studies 2 ml, he noticed the size of the syringe and ceased administration realizing the error. Vincristine administration alert The patient died approximately 100 days later. The following case studies relate to the administration of the drug vincristine and the adverse events that may Australia, 2004 follow. A 28-year-old male with Burkitt’s lymphoma Hong Kong, 7 July 2007 was receiving methotrexate via a spinal route. The doctor documented that “vincristine and A 21-year-old female has died after being methotrexate [were] given intrathecally as administered vincristine accidentally via a spinal requested”. The warning label on the vincristine route in error. An inquiry is under way. Vincristine was incomplete, in small print and read in (and other vinca alkaloids) should only be given a darkened room. The error was not recognized intravenously via a minibag. Vincristine, a widely- until five days later, after paralysis of the lower used chemotherapeutic agent, should only be limbs had occurred. The patient died after administered intravenously, and never by any other 28 days. route. Many patients receiving IV vincristine also receive other medication via a spinal route as part Questions of their treatment protocol. This has led to errors – What factors may have been present that where vincristine has been administered via caused the error in these above examples? a spinal route. Since 1968, this error has been reported 55 times in a variety of international – What steps could the organization take settings. There have been repeated warnings to ensure that the catastrophic events are not over time and extensive labelling requirements repeated? and standards. However, errors related to the accidental administration of vincristine via – If you were the hospital manager what would a spinal route continue to occur. you do in each of these cases? Other recent deaths and near misses: Source: World Health Organization, SM/MC/IEA.115 ( United States, November 2005 t_115_vincristine.pdf; accessed 20 February 2011). A 21-year-old male was being treated for A nurse speaks up to avoid further error and non-Hodgkin’s lymphoma. A syringe containing protect the patient from an adverse outcome vincristine for another patient had been This case illustrates the importance of speaking up accidentally delivered to the patient’s bedside. if there are concerns for the safety of patients. A physician administered vincristine via a spinal route, believing it was a different medication. As the preoperative team briefing (team The error was not recognized and the patient discussion before a surgical procedure) died three days later. was coming to an end, a nurse spoke up and reported that “The patient has a contact lens Spain, October 2005 in his left eye.” A 58-year-old female was being treated for The anaesthetist asked whether it was permanent non-Hodgkin’s lymphoma. Vincristine was and the nurse verified that it was disposable. prepared in a 20 ml syringe and delivered in The anaesthetist asked the patient why a package containing two other drugs, including the contact lens was being worn, but the patient methotrexate. Route of administration was not was sedated and not very coherent when he indicated on the solutions. The intrathecal attempted to respond. The nurse explained that treatment was administered at noon. The the patient was unable to see without the contact haematologist was particularly busy and requested lens. The anaesthetist explained to the operating help from another doctor who had not recently room team that the patient could not have participated in intrathecal procedures. The the contact lens with anaesthetic and that medication was delivered in the patient’s room. the patient should not have been sedated with it. The nurse who assists was not familiar with the One of the team members asked the anaesthetist intrathecal procedures. The 20 ml syringe with if he wanted the contact lens to be taken out vincristine was passed to the doctor who started and the anaesthetist replied, “Well, he cannot to inject it. After administering approximately have anaesthesia with it.”159 Part B Topic 5. Learning from errors to prevent harm
    • The surgical resident helped the patient remove Death of a childthe contact lens from his eye. The patient asked Read the case study in the introduction to this topic andfor something to put it in, so saline solution ask the students to discuss the following questions.was located and the contact lens was stored ina small container of saline solution. – Using a systems approach, consider what could have been done differently at different pointsQuestion in this story, in the dental office, ambulatory– What might be some preoperative nursing clinic and hospital. implications for this case? What might be done to prevent similar incidents from occurring in – How could the transfer (hand-over) between the future? the ambulatory clinic and the hospital have been handled differently to ensure that the patientSource: The WHO Patient Safety Curriculum Guide might have been treated more promptly?for Medical Schools working group. Case suppliedby Lorelei Lingard, Associate Professor, University of – What are some precautions that can beToronto, Toronto, Canada. taken in clinical settings to prevent accidental poisonings among children?Wrong medication in the labour wardThe following case study shows how multiple factors Source: Case supplied by Shan Ellahi, Patient Safetycan culminate in patient harm. Consultant, Ealing and Harrow Community Services, National Health Service, London, UK.A 25-year-old primipara at 32 gestational weeksarrived in the Emergency Department with severe Tools and resource materialback pain. She was triaged and sent to the busy, A range of resources on medical error and relatedunderstaffed labour ward. The fetal monitoring topics can be found on the website of the Agencystrip showed contractions every 8–10 minutes. for Healthcare Research and Quality, New YorkThe obstetrician examined the client and Medical College, New York, USArecommended a continuing infusion with tocolytic (; acesseddrugs to decrease the uterine activity and avoid 21 February 2011).the preterm birth of the infant. Assessing knowledge of this topicAll midwives were busy with other clients giving A range of assessment strategies are suitablebirth and a student midwife was asked to prepare for this topic, including MCQ, essays, short BAQ,the infusion. She did not know the case history CBD, and self-assessments. Having a studentand was anxious to ask her midwifery mentor. or a group of students lead an adverse eventDespite the woman being obviously pregnant investigation or even a mock root cause analysisat 32 weeks, the student failed to assess the is a highly engaging way to elicit understanding.fundal height. The student prepared and appliedan infusion with oxytocin (for labour augmentation) Evaluating the teaching of this topicinstead of the tocolytic drug. The error was not Evaluation is important for reviewing howrecognized for hours and the next day the client a teaching session went and how improvementsgave birth to a preterm baby who had to be can be made. See the Teacher’s Guide (Part A)transferred to the neonatal intensive care unit due for more information on severe breathing problems. ReferencesDiscussion 1. Runciman W, Merry A, Walton M. Safety and– Discuss this case by examining the following ethics in health-care: a guide to getting it right, 1st factors: student factors; patient factors; ed. Aldershot, UK, Ashgate Publishing Ltd, mentor factors; organizational factors; and 2007. environmental factors. 2. Reason JT. Human error. New York, Cambridge University Press, 1990.– How might this adverse event be avoided? 3. Reason JT. Human error: models andSource: Case supplied by Andrea Stiefel, MSc, management. British Medical Journal, 2000,Zurich University of Applied Sciences, Winterthur, 320:768–770.Switzerland. 4. Reason JT. Beyond the organisational accident: the need for “error wisdom” on the frontline. Quality and Safety in Health Care, 2004, 13:28–33. WHO Patient Safety Curriculum Guide: Multi-professional Edition 160
    • 5. Friedman RC, Kornfeld DS, Bigger TJ. Slides for Topic 5: Understanding Psychological problems associated with sleep and learning from errors deprivation in interns. Journal of Medical Didactic lectures are not usually the best way Education, 1973, 48:436-441. to teach students about patient safety. If a lecture 6. Landrigan CP et al. Effect of reducing interns’ is being considered, it is a good idea to plan working hours on serious medical errors for student interaction and discussion during in intensive care units. New England Journal of the lecture. Using a case study is one way to Medicine, 2004, 351:1838–1848. generate group discussion. Another way is to ask the students questions about different aspects 7. Dawson D, Reid K. Fatigue, alcohol and of health care that will bring out the issues performance impairment. Nature, 1997, contained in this topic, such as the blame culture, 388:235. nature of error and how errors are managed 8. Leonard C et al. The effect of fatigue, sleep in other industries. deprivation and onerous working hours on the physical and mental well being of pre- The slides for Topic 5 are designed to help registration house officers. Irish Journal of Medical the instructor deliver the content of this topic. Sciences, 1998, 176:22–25. The slides can be changed to fit the local 9. Larson EB. Measuring, monitoring, and reducing environment and culture. Teachers do not have medical harm from a systems perspective: to use all of the slides and it is best to tailor the a medical director’s personal reflections. slides to the areas being covered in the teaching Academic Medicine, 2002, 77:993–1000. session. 10. Flin R et al. Measuring safety climate in health care. Quality and Safety in Health Care, 2006. 11. Reason JT. Managing the risks of organisational accidents, 3rd ed. Aldershot, UK, Ashgate Publishing Ltd, 2000. 12. Root cause analysis. Washington, DC, Veterans Affairs National Center for Patient Safety, United States Department of Veterans Affairs ( html; accessed 20 February 2011). 13. University of Washington Center for Health Sciences. Best practices in patient safety education module handbook. Seattle, University of Washington Center for Health Sciences, 2005. 14. Institute for Safe Medication Practices. Error- prone conditions can lead to student nurse- related medication mistakes. Medical News Today, 20 October 2007 ( 83.php; accessed 20 February 2011). 15. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC, Committee on Quality of Health Care in America, Institute of Medicine, National Academies Press, 1999. Additional reading Symon A. Obstetric litigation from A-Z. Salisbury, UK, Quay Books, Mark Allen Publishing, 2001. Wilson JH, Symon A. eds. Clinical risk management in midwifery: the right to a perfect baby, Oxford, UK, Elsevier Science Limited, 2002.161 Part B Topic 5. Learning from errors to prevent harm
    • Topic 6Understanding & managingclinical riskAn unintended outcome from of nurses and a visiting medical officer. Theinattention to a bandaged foot bandage on her foot was not removed until early Sunday evening (nearly 48 hours later),A father brought his 2-year-old daughter, Hao, despite the fact that damage to the skin isinto the emergency department of a regional a known risk factor in infants that can occurhospital on a Friday evening. Hao had a recent within 8 to 12 hours. There was an areahistory of a “chesty cold” and had already of necrosis noted on the left heel and ulcersbeen seen as an outpatient. The medical officer developed later on the left upper foot. Afteradmitted Hao for treatment of pneumonia. discharge and outpatient treatment locally,An IV cannula was inserted in her left upper Hao was eventually admitted to a majorfoot and a bandage applied. She was children’s hospital where she required ongoingthen transferred to the ward for the weekend treatment. She also developed behaviouralwhere she was under the care of a team problems as a result of her experience.Source: Case studies – investigations, Health Care Complaints Commission Annual Report 1999-2000:59, Sydney,New South Wales, Australia.Introduction–Why clinical and health services have well-established systems 1 2risk is relevant to patient already in place such as reporting patient falls,safety medication errors, retained swabs andRisk management is routine in most industries misidentification of patients. Nevertheless,and has traditionally been associated with limiting most health services are only beginning to focuslitigation costs. In health care, this is usually on all aspects of clinical care in an effort toassociated with patients taking legal action reduce risks to patients.against a health professional or hospital allegingharm as a result of their care and treatment. Many Students, along with everyone else who workscorporations implement strategies to try to avoid in a health-care facility, have a responsibility tofinancial loss, fraud or failure to meet production take the correct action when they see an unsafeexpectations. To avoid problems, such as those situation or environment. Taking steps to ensuredescribed in the above-mentioned case study, a wet, slippery floor is dried and preventinghospitals and health organizations use a variety a patient from falling is as important as ensuringof methods to manage risks. However, the success that the medication a patient is taking is theof a risk-management programme depends on correct one. In the event of a patient falling oncreating and maintaining safe systems of care, a slippery floor or receiving the wrong medication,designed to reduce adverse events and improve it is important that students report the incidenthuman performance [1]. Many hospitals, clinics, so that steps can be taken to avoid similar WHO Patient Safety Curriculum Guide: Multi-professional Edition 162
    • incidents in the future. While nurses have long at risk of harm and then acting to prevent or been reporting certain types of incidents today control those risks. The following simple four-step all health-care professionals are expected process is commonly used to manage clinical risks: to report incidents and to learn from them. 1. identify the risk; Even if students observe some senior staff not 2. assess the frequency and severity of the risk; reporting, they should be mindful that a health 3. reduce or eliminate the risk; service with a culture of reporting is safer 4. assess the costs saved by reducing the risk than one where no reporting occurs. Leadership or the costs of not managing the risk. by senior health professionals will show students the value of a reporting culture. Students, along with all other health professionals will be mainly concerned about the risk to Effective risk management involves every level patients. Topic 1 in this Curriculum Guide outlines of the health service. For this reason, it is essential the extent of the harm done by health care. that all health-care workers understand risk It is against this backdrop that organizations are management and the objectives of risk- concerned about managing clinical risks. Clinical management strategies and their relevance in risk management allows identification of potential their own workplace. Unfortunately, even though errors. Health care itself is inherently risky and a clinic or hospital may have policies for reporting although it is impossible to eradicate all risk, incidents, such as medication errors and falls, there are many activities and actions that can be the actual reporting of these incidents is often introduced to minimize opportunities for errors. sporadic. Some nurses are diligent in reporting, Clinical risk management is relevant to students while doctors in the same unit can be sceptical because it recognizes that clinical care and of the benefit of reporting because they do not treatment are risky and negative incidents may see any improvement. Students can begin occur. Students (as well as all other health-care to practise reporting incidents by talking with professionals) must actively weigh the anticipated the health-care team about health-care risks risks and benefits of each clinical situation and and errors and the strategies in place to manage only then take action. This includes recognising and avoid them. one’s limitations and lack of experience and refraining from any unsupervised care and The role of the whistle-blower (a person who treatment. Students should seek out information raises a concern about alleged wrongdoing about past risks and actively participate in efforts occurring in an organization) in health care to prevent their reoccurrence. For example, has not had a good history, despite the evidence students might seek out information concerning that most whistle-blowers have usually tried compliance with hand hygiene protocols to to rectify the problems through the standard minimize the spread of infection. In this sense, channels. The refusal or inability of an students can act proactively to avoid problems, organization to fix the problem forces the as opposed to just reacting to problems as they concerned person to take the matter to higher appear. authorities. Not all countries have laws protecting whistle-blowers. While health-care professionals Keywords are not required to be heroic whistle-blowers, Clinical risk, reporting near misses, reporting they do have a duty to protect the patients errors, risk assessment, incident, incident they care for. Research shows that nurses are monitoring. more used to reporting incidents than other 4 health professionals. Inadequate reporting may be Learning objective because the blame culture in health care is Know how to apply risk-management principles a strong deterrent to reporting. Today, most by identifying, assessing and reporting hazards risk-management programmes aim to improve and potential risks in the workplace. safety and quality, in addition to minimizing the risk of litigation and other losses (staff morale, Learning outcomes: knowledge loss of staff, diminished reputation). However, and performance the success of these programmes depends on many factors. Knowledge requirements 5 Students need to: Clinical risk management is specifically ñ know how to gather information about risk; 3 concerned with improving the quality ñ understand fitness-to-practise requirements and safety of health-care services by identifying for their profession and personal accountability the circumstances and situations that put patients for managing clinical risk;163 Part B Topic 6. Understanding & managing clinical risk
    • ñ know how to report risks or hazards in the assessment code to help identify those incidents workplace; that indicate the most serious risk. However,ñ know when and how to ask for help from an even the introduction of a triage system to flag instructor, supervisor, senior health practitioner the most serious incidents has not resolved this or other health-care professional. dilemma in some systems.Performance requirements Some activities commonly used to manage clinical 6Students need to: risk are described below.ñ keep accurate and complete health-care records;ñ participate in meetings to discuss risk Incident monitoring management and patient safety; Incident reporting has existed for decades.ñ respond appropriately to patients and families Many countries now have national databases of after an adverse event; adverse events pertaining to different specialties,ñ respond appropriately to complaints; such as surgery, anaesthesia and maternal andñ maintain their own health and well-being. child health. WHO defines an incident as an event or circumstance that could have or did lead 7Gathering information about risk to unintended and/or unnecessary harm toStudents may not be immediately aware of a person and/or a complaint, loss or damage.a risk-management programme in their hospital, The main benefit of incident reporting lies inclinic or workplace. Nevertheless, health-care the collection of information useful for thefacilities in most countries employ a range of prevention of similar incidents in the future.mechanisms to measure harm caused to patients Other, quantitative methods are required forand staff, as well as avoid known problems. analyses of the frequencies of these incidents.Some countries have well-developed stateand national data sets of incidents. In Australia, Facilitated incident monitoring refers tothe Advanced Incident Management System mechanisms for identifying, processing, analysingis a comprehensive approach to reporting health- and reporting incidents with a view to preventingcare incidents and analysing them. In the United their reoccurrence [2]. The key to an effectiveStates, the Department of Veterans Affairs has reporting system is for staff to routinely reportestablished a National Center for Patient Safety incidents and near misses. However, unless staffthat uses a structured approach called root cause members trust that the organization will use theanalysis (RCA) to evaluate, analyse and treat information for improvement and not to blamethese types of problems. (See Topics 5 and 7 individuals, they are reluctant to report thesefor information about RCA). Τ5 Τ7 incidents. Trust also includes the belief that the organization will act upon the information.The principle underpinning RCA is that the actual If students report an incident to an instructor,(root) cause of a particular problem is rarely supervisor or other health professional whoimmediately recognizable at the time of the dismisses their effort, then those students will bemistake or incident. A superficial and biased less likely to make additional reports in the future.assessment of any problem usually does not fix Even when this happens, students should bethe problem and additional incidents will occur encouraged by faculty staff to continue to reportin similar situations. incidents. Today’s students will eventually become the senior health professionals of tomorrowAn essential part of any RCA is the whose actions will greatly influence youngerimplementation of the findings of the analysis. colleagues and students.Many clinics, hospitals and organizations failto complete the process either because Facilitated monitoring is a process for identifyingthe recommendations involve resources that and analysing a greater proportion of incidentsare not available or because there is no with a view to making improvements to care.commitment by the senior hospital management This type of monitoring is a continuous activityto carry through the recommendations. of the health-care team involving the following actions:Some health-care organizations that mandate ñ discussion about incidents as a standing itemreporting of incidents can become so overloaded at the weekly staff meetings;with reported incidents that many remain ñ a weekly review of areas where errors are knowunanalysed due to inadequate resources. to occur;To address this problem, many health-care ñ a detailed discussion about the facts of anorganizations have introduced a severity- incident and follow-up action required is held WHO Patient Safety Curriculum Guide: Multi-professional Edition 164
    • with the team–this discussion should be adverse event, but corrective action was taken just educational rather than focusing on attributing in time or the patient had no adverse reaction to blame; the incorrect treatment. In some environments in ñ identification of system-related issues, so they which there is a strong blame culture, talking can be addressed and other staff can be made about near misses may be easier than talking aware of the potential difficulties. about incidents that had negative outcomes because no one is available to blame as there was In addition to the reporting of actual incidents, no adverse outcome to the patient. For example, some organizations encourage the reporting of it may be easier for a pharmacist to discuss a near misses because of the value such reporting dispensing error involving a wrong drug in the holds for identifying new problems and the factors context of a wrong drug about to be dispensed that contribute to them and how they may be being captured through a checking system. In prevented before serious harm is done to a these cases, the errors are not made, but could patient. A near miss is an incident that did not have been if there were no systems in place to cause harm. Some people call near misses “near identify and prevent them. See Table B.6.1 for hits” because the actions may have caused an more analysis of incident monitoring.Table B.6.1. Types of issues identified by incident monitoring Type of incident % of reports a 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, incomplete, out-of-date, unclear) 8 Hazardous environment (e.g. contamination, inadequate cleaning or sterilization) 7 Inadequate resources (e.g. staff absent, unavailable, inexperienced, poor orientation) 5 Logistical problems (e.g. problems with admission, treatment, transport, response to an emergency) 4 Administrative problems (e.g. inadequate supervision, lack of resource, poor management decisions) 2 Infusion problems (e.g. omission, wrong rate) 1 Infrastructure problems (e.g. power failure, insufficient beds) 1 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) 1a An incident may be assigned to more than one category.Source: Runciman B, Merry A, Walton M. Safety and ethics in health care: a guide to getting it right, 2007 [3]. Sentinel events 8 Many health-care facilities have mandated A sentinel event is an “adverse event that the reporting of these types of events because should never be allowed to happen” [3] and of the significant risks associated with their is usually unexpected and involving a patient repetition. These events are often classified into death or serious physical or psychological categories (e.g. surgery on the wrong patient injury to a patient. The current trend in many or body site, incompatible blood transfusion, countries in analysing adverse events is to rank medication error leading to death, wrong tooth the seriousness of the event. The term sentinel being removed, wrong drug being dispensed, event is the designation reserved for the most newborn being given to the wrong mother, etc.). serious ones. Events that do not fit neatly into the established 165 Part B Topic 6. Understanding & managing clinical risk
    • categories are referred to as “other catastrophic Students should be aware that most health-careevents”. These “other catastrophic events” professionals will receive complaints duringaccount for half of all the sentinel events reported the course of their careers and that this is notin the United States and over two-thirds of those an indication of incompetence or that they arereported in Australia [3]. The causes of the bad people. Even the most conscientious andsentinel event may have been multiple and left skilful health-care professionals can and do makeunchecked, thus resulting in a catastrophic mistakes. Sometimes, patients may haveoutcome for the patient. unrealistic expectations of their health care. Health-care error is a subset of human error;The role of complaints in improving care 9 all humans make mistakes.A complaint is defined as an expressionof dissatisfaction by a patient, family member If a student is involved in a complaint or receivesor carer with the provided health care. Because one while working as a health-care professional,students will be treating patients under instruction he/she should be open to discussing the complaintor supervision, they may be named in a complaint with the person who made the complaint.about care and treatment. A student may feel It is a good idea to have a more senior personvulnerable when this happens and worry that present during these discussions. If the health-carethey will be blamed or that their career may suffer. organization requires a student to provide a written statement about his/her actions,Students, similar to health professionals, may it is important that the statement be factualfeel embarrassed, remorseful, angry or defensive and relate directly to their involvement. It isif they are named in a complaint and believe important to always check with an instructorthat the complaint is unjustified. While complaints or supervisor if a written complaint is receivedfrom patients or their families may be and a statement required. The health-careuncomfortable to deal with, they are a very good facility will most likely have a policy in place foropportunity for improving professional practice managing complaints.and restoring a trusting relationship betweenthe patient, the patient’s family and the health- Complaints and concerns of individualcare team [4]. Complaints often highlight responsibilityproblems that need addressing, such as poor From a patient’s perspective, individual patientscommunication or suboptimal decision making. should be able to have their concerns examinedCommunication problems are common causes to see if there has been a departure fromof complaints, as are problems with treatment professional standards. After examinationand diagnosis. Complaints can be avoided or investigation, it may become clear that system-if the student or health professional ensures that related issues are at the heart of the problem,their patient never leaves an encounter feeling but the treating professional or health-care teamdiscounted, dismissed or diminished in any way. may also have contributed to the poor outcome–for example, by cutting corners andStudents who are at the beginning of their breaching accepted protocols. The standard ofhealth-care careers are learning about clinical care may have been low, resulting in suboptimaldecision making and patient management and care. Guidelines may not have been followedare seeing just how complex these tasks can be. or facility rules broken.So, it is not surprising that miscommunicationor suboptimal care may sometimes occur. Patient For example, the failure of a staff member to usecomplaints help to identify areas in the processes appropriate hand hygiene might have resultedof care that could be improved. The complaint in the transmission of infection from one patientmay lead to better instruction or supervision to another. While the initial approach to theof students in a particular setting. The information investigation of this incident should by system-from complaints can also be used to educate and based, it is important to remember that individualsinform health professionals about problem areas. are also required to meet their professional responsibilities. It may be that the staff memberIn addition to the benefits described above, was indeed directly at fault through failingcomplaints also [4]: to adhere to accepted standards of care.ñ assist the maintenance of high standards;ñ reduce the frequency of litigation; Coronial investigationsñ help maintain trust in the profession; Most countries have some system for establishingñ encourage self-assessment; cause of death. Specifically appointed people,ñ protect the public. called coroners in many countries, are responsible WHO Patient Safety Curriculum Guide: Multi-professional Edition 166
    • for investigating deaths in situations where The duties of a health-care professional (and the cause of death is uncertain or thought to be student) include reporting a peer or colleague due to unethical or illegal activity. Coroners often who is unsafe because of either incompetence have broader powers than a court of law and, after or unprofessional or unethical behaviour. Some reporting the facts, will make recommendations countries require mandatory reporting of for addressing any system-wide problems. practitioners if they are unfit, while others rely on individuals to use their conscience in this regard. Fitness-to-practise requirements 10 Students and all health professionals are Health-care organizations are obligated to ensure accountable for their actions and conduct in the that health professionals who participate in health service environment. They are responsible patient care and treatment have the appropriate for their actions according to the circumstances qualifications and are competent. Health-care in which they find themselves. Related to services are required to check that a health-care accountability is the concept of fitness to practise. professional has the right qualifications and Why is fitness to practise an important experience to practise in the intended area. component of patient safety? The processes for doing this are presented below. Of the many factors underpinning adverse events, Credentialing one factor relates to the competence of health- The Australian Council on Healthcare Standards care professionals. Many mistakes leading defines credentialing as the process of assessing to adverse events are associated with the fitness and conferring approval on a person’s suitability of professionals to practise. Are they competent? to provide specific consumer/patient care and Are they practising beyond their level of treatment services, within defined limits, based experience and skill? Are they unwell, suffering on an individual’s licence, education, training, from stress or illness? Most countries will have experience, and competence. Many hospitals, a system for registering different types of health- clinics and health services have credentialing care professionals, dealing with complaints processes in place to check whether a professional and maintaining standards. It is important that has the required skills and knowledge to students understand why it is important to be undertake specific procedures or treatments. vigilant about their own fitness and that of their Clinics and hospitals will restrict the type of colleagues. The health-care professions place procedures they offer if there are no qualified duties and obligation upon practitioners with personnel or if the available resources are not the aim of keeping patients safe. available or appropriate for the particular condition or treatment. Selecting the right students for training in the health-care professions is the first step Accreditation in making sure that the people who are trained Accreditation is a formal process to ensure to work in these fields have the attributes delivery of safe, high-quality health care based on necessary for safe and ethical practice. Many standards and processes devised and developed training programmes now use OSCE-type by health-care professionals for health-care (Objective Structured Clinical Examination) services. It can also refer to public recognition processes to help identify those students who, of achievement by a health-care organization of in addition to their examination results, also requirements of national health-care standards. have the attitudes and behaviours best suited to work in health care. Attributes such as Registration (licensure) compassion, empathy and a vocational aspiration Most countries require health-care practitioners to provide benefit to society are the sustaining to be registered with a government authority qualities. or under a government instrument, such as the Australian Health Practitioners Registration It is important that health-care professionals Agency, which is responsible for the registration engage in learning activities throughout their of most of the health professions. The principal career, in order to properly maintain their skill purpose of a registration authority is to protect sets and remain current with developments the health and safety of the public through in their field of expertise. As students become mechanisms designed to ensure that health more familiar with the concepts and principles practitioners are fit to practise. It achieves this by described in this Curriculum Guide they will gain ensuring that only properly trained professionals deeper understanding and become more are registered and that registered professionals proficient and adept at performing safely. maintain proper standards of conduct and167 Part B Topic 6. Understanding & managing clinical risk
    • competence. Proper registration/licensure an accurate and complete list of therapiesis an important part of the credentialing and and medications including dose, route andaccreditation processes mentioned above. planned duration of therapy. It is very important that this letter be completely legible and signedPersonal accountability for managing risk by the responsible person.Most senior students will begin to establish ñ Know who the lead professionals are in anyclear roles and responsibilities as members given situation.of health-care teams when they spend more time 11in workplace settings and working with patients. The role of fatigue and fitness to practiseClose to the completion of their training, many There is strong scientific evidence linking fatiguewill be required to demonstrate competence in and performance. Students should be awarea number of basic technical tasks. The following that when they are fatigued they will be less alertactivities are not exhaustive or indeed prescriptive. and unable to perform as normal in a varietyThey are offered to give some idea of the of psychomotor tasks.competencies students need to have by the timethey complete their degrees and start working Studies conducted in Ireland and the Unitedin their chosen field. Kingdom have shown that fatigue can affect the mental well-being of medical residents (depression,Students should: anxiety, anger and confusion) [5]. Recent controlledñ Learn how to organize a referral or request for studies have confirmed that sleep deprivation can consultation from another health-care provider negatively affect clinical performance [6]. Fatigue or health-care team. These skills include using has also been linked to increased risk of errors [7-8] correct identification procedures and providing and motor vehicle accidents. A 2004 study by an accurate summary of the patient’s Landrigan et al. [8] was one of the first to measure background, current health/welfare problem, the effects of sleep deprivation on medical errors. and the results of any investigations. This study found that interns working in the It is important to only include relevant medical intensive unit and coronary care unit and necessary information in the referral of Brigham and Women’s Hospital (Boston, MA, or request for consultation and write legibly. United States) made substantially more seriousñ Learn how to make a telephone call to mistakes when they worked frequent shifts of a primary-care doctor or other professional 24 hours or more than when they worked shorter member of the health-care team. Initially shifts. Other studies have shown that sleep students should make sure they are supervised deprivation can have symptoms similar to those or observed by an experienced person during of alcohol intoxication [9]. this activity. They should practise providing accurate information about the patient, Studies of hours of work and nurses show correctly pronouncing relevant terminology, that risks of making an error were significantly using techniques to ensure the person they increased when work shifts were longer than are speaking with has understood what has twelve hours, when nurses worked overtime, been said, seeking information about concerns, or when they worked more than forty hours and writing a summary of the telephone per week [10]. conversation in the patient’s medical record. Some of these techniques are described Similarly pharmacists identified the main in Topic 4: Being an effective team player. Τ4 contributing factors in dispensing errors to beñ Learn how to write a referral letter when high prescription volumes, pharmacist fatigue, a patient’s care is being transferred to another pharmacist overwork, interruptions to dispensing, health-care provider or team. The letter should and similar or confusing drug names [11]. contain the relevant patient identification information, dates of admission and Students should know their rights concerning discharge/treatment and the name of the work and rest schedules. The organizations they professionals responsible for that treatment, work for have a duty to ensure that they do not an accurate summary of treatment provided, work more hours than permitted unless there the final diagnosis, key investigations, reason are extenuating circumstances or organizational for treatment, and the status of the patient’s permission. clinical problems. Describe the treatment and interventions undertaken, the outcome, follow-up arrangements and outstanding investigations. The letter should include WHO Patient Safety Curriculum Guide: Multi-professional Edition 168
    • Stress and mental health problems either by omission (failing to do something) Students are also prone to stress caused by or commission (doing the wrong thing). Students examinations, part-time work and family and should always request that a more experienced workplace concerns. Strong evidence suggests person be present if it is the first time that they physicians are prone to mental health problems are attempting a skill or procedure on a patient. [12], particularly depression, in their first They should also advise the patient that they are postgraduate years, as well as in later years. students and request their permission to proceed Students also suffer from stress and associated to treat them or perform the procedure. health problems that they carry with them when they start practising. Stressed staff and staff Poor interpersonal relationships between with low morale are to be expected in health care students, other health-care professionals, junior because as well as caring for the sick and staff, and instructors or supervisors are also vulnerable, they usually work with other contributing factors in errors. If a student overworked colleagues and have multiple tasks is having a problem with an instructor or to complete on an hourly basis. supervisor, he/she should seek help from another faculty member who may be able to mediate While rates of depression and mental health or help the student with techniques to improve problems among doctors are higher than those the relationship. The literature also shows that experienced by the general population, the students who have problems with inadequate literature shows that when interns and residents skills’ acquisition also have poor supervision. are supported by fellow house officers and senior Many health professionals who learned clinicians and are members of well-functioning to perform procedures while unsupervised have teams, they are less likely to feel isolated and later been judged by supervisors to have poor suffer stress. technique and inadequate mastery of those procedures. Students should never perform Performance is also affected by stress. There is a procedure or manipulate or examine a patient strong evidence to indicate that inadequate sleep without sufficient preparation and instruction. contributes to stress and depression, rather than the number of hours worked. Other stressors Communication issues Τ4 Τ8 identified in the literature include financial status, Multiple health professionals, such as nurses, educational debt and term allocation and midwives, doctors, dentists, pharmacists, emotional pressures caused by demands radiologists, are all required to make an accurate from patients, time pressures and interference recording of their communications in the with one’s social life. health-care records, including any liaison with laboratory personnel. Transferring information, Work environment and organization verbally and in writing is a complex process Health-care facilities can be very stressful places and not easy. Few health facilities have standard for newcomers. Unfamiliar work practices can be ways for such communications. The role of good very difficult in the early phase of a new job. communication in the provision of quality health In addition, long hours cause fatigue. care and the role poor communication plays in substandard care are both well documented. Certain factors and time periods, such as shift How successfully patients are treated will often work, overtime, shift changes, nights and depend on informal communications among staff weekends, are associated with increased numbers and their understanding of the workplace [13]. of errors. The factors underpinning these errors Treatment errors caused by miscommunication can range from lack of oversight and instruction and absent or inadequate communication occurs or supervision to tiredness. Students should be daily in all health-care settings. Checklists, extra vigilant during these times. protocols and care plans designed for particular categories of patients are effective ways Instruction and supervision of communicating patient-care orders. Good instruction or supervision is essential for every student and the quality of the instruction Additionally, the quality of the communication or supervision will determine, to a large extent, between patients and the health professionals how successfully a student integrates and adjusts providing their treatment strongly correlates to the hospital or health-care environment. with treatment outcomes. The failure of health professionals to provide adequate instruction or supervision to students makes them more vulnerable to making mistakes169 Part B Topic 6. Understanding & managing clinical risk
    • How to understand and manage 12 skills. It is essential that students ask for helpclinical risks even if they feel uncomfortable about doing so. All health professionals appreciate that studentsKnow how to report known risks or hazards are at the beginning stage of their careers andin the workplace will have limited knowledge and skills. They do notStudents should seek information on the incident- expect students or new health-care professionalsreporting system used in the facility where to have accumulated the depth of knowledgethey are training. There will usually be a specific required to independently treat patients. Theymethod for reporting–either an electronic expect students to ask for help. But it can beor paper form. Students should become familiar very difficult to have an instructor or supervisorwith the system in place and seek information who is rarely available. If this is the case,about how to report incidents. the student should seek out another appropriate person who is present on a regular basis. This canKeep accurate and complete health-care records be discussed with the supervisor, so that he/sheA health-care record (medical record, patient is aware of the arrangement.record, medication chart, drug chart) is adocument that contains different kinds and types Participate in meetings to discuss riskof information about a patient. Students should management and patient safetybe aware that good quality records are essential At first, it may not be obvious what risk-to the care and treatment of patients. Health-care management programmes exist in a particularrecords will be subject to a number of government health-care facility. Students can ask seniorand institutional/facility-specific requirements health professionals or managers aboutregarding who can have access to them, who can the risk-management programmes in placewrite in them, and where they are stored and and whether it is possible to attend a meetingfor how long. to see how the system works to protect patients.Students have an ethical and legal obligation to Respond appropriately to patients andaccurately record their observations and findings families after an adverse eventto ensure good patient care. When writing Students will not be expected to acceptin health-care records, students (and all other responsibility for disclosing adverse eventshealth-care professionals) should: to patients or their families. If they are askedñ provide sufficient information to identify to do this, they should immediately seek the patient to whom the record relates, so that assistance from a faculty member or senior other members of the health-care team can instructor. Many health-care organizations are continue caring for the patient; now introducing open-disclosure guidelinesñ note any information relevant to the patient’s (guidelines to assist honest communication with diagnosis or treatment and outcomes; a patient after an adverse event). It is vital thatñ make sure records are up-to-date and written any open-disclosure process not be rushed, be as close to the time of the event as possible; transparent, and involve taking steps to makeñ note any information or advice given to the sure that any mistakes that were made are not patient. made again.Know when and how to ask for help from Respond appropriately to complaintsan instructor, supervisor or appropriate senior All students who are involved in a complainthealth-care professional should write complete and factual statementsMany students fear that if they admit to not about what happened. They should be honestknowing something, their teachers will consider about their role or actions while minimizingthem as bad students and think less of them. subjective or emotional statements.It is important for students to recognize thelimitations associated with their lack of knowledge Summary 13and experience and the importance of seeking Health-care professionals are responsible for thehelp and asking for information; patients can be treatment, care and clinical outcomes of theirharmed by inexperienced health-care patients. This responsibility lies with all membersprofessionals. Students should clearly understand of the team–not just the most senior person.who they report to in the work setting and when Personal accountability is important, as any personand how that person can be contacted. This in the chain might expose a patient to risk.person will be able to assist them if they get into One way for professionals to help prevent adversesituations beyond their current knowledge and events is to identify areas prone to errors. WHO Patient Safety Curriculum Guide: Multi-professional Edition 170
    • The proactive intervention of a systems approach briefings, debriefings and assertiveness to improve for minimizing the opportunities for errors can communication. Additionally, students could role prevent adverse events. Individuals can also work play a peer-review meeting or a mortality and to maintain a safe clinical working environment morbidity meeting using a person approach by looking after their own health and responding and then a systems approach. Other role-playing appropriately to concerns from patients and activities could be based on situations in which colleagues. a student notices something is wrong and needs to speak up. Teaching strategies and formats Other teaching activities An interactive/didactic lecture – Students could observe a risk-management Use the accompanying slides as a guide meeting or meet with the people who manage for covering the whole topic. The PowerPoint complaints for the department or health-care slides can be used or the slides may be converted facility. Part of the exercise would be for for use with an overhead projector. Start the students to ask about the facility’s policy on session with a case study and ask the students complaints and what usually happens when to identify some of the issues presented in that a complaint is received. Alternatively, students case study. could take part in an open-disclosure process. Panel discussions – After these activities, students should be asked Invite a panel of respected health professionals to meet in pairs or sma