The Key to Change: Introducing Patient Safety Early in the Education Process

According to the WHO, whereas our chance of being harmed while traveling by airplane is 1 in a million, the likelihood of being harmed during a healthcare experience is 1 in 300! We have the know-how and technology to eliminate preventable medical errors, but change is happening slower than we can accept. The good news is that a new resource to facilitate change is here!

This year marks the twentieth anniversary of the eye-opening Institute of Medicine’s publication To Err is Human: Building a Safer Health System. Certainly, tremendous progress has been made. A new field of study, Patient Safety, has been developed. Diligent work has informed our understanding of the science of unintended medical error. Health insurers are working to incentivize improvement in their payment models. Health care delivery systems are working to improve processes and communication to benefit patient safety. Curricula for healthcare professionals have stepped up content in interprofessional teamwork and communication.  Patients and their advocates work tirelessly to garner government support for this effort for safer care at state and national levels. Despite these efforts medical error continues to lead to a tragic number of preventable deaths, and in fact was reported to be the 3rd leading cause of death (Makary and Daniel, BMJ 2016) in the recent past.

Unfortunately, there is a deadly gap between what we have learned from patient safety science and its effective application to clinical care.  We cannot achieve meaningful benefits in harm reduction until we understand the inherent risks associated with imperfect humans working in complex systems and make necessary efforts to minimize them.   Critical to   the ability to recognize and minimize these risks is  early education. For the past eighteen months  I’ve been working  closely with the Patient Safety Movement and an inter-professional team of leaders in healthcare education to create the PSMF’s new Patient Safety Curriculum. This resource is now posted on the PSMF site as Actionable Patient Safety Solutions (APSS) #17 and is available to everyone without charge:    (https://patientsafetymovement.org/actionable-solutions/challenge-solutions/patient-safety-curriculum/).  This curricular resource was designed to be unique!  It is applicable across healthcare professions, adaptable to learners across the spectrum from novice to expert, experiential whenever possible and may be facilitated by clinicians who themselves are students of Patient Safety. 

Curriculum content is organized in eight domain modules: Error Science, System Science, Technology, Human Factors, Leadership and Leading Change, Teamwork and Communication, Culture of Safety, and Patient-oriented Safe Care.  Each domain is further defined by subdomains.  Learning objectives for the subdomains are provided, along with examples of how learners might demonstrate competency of that objective in a practical setting (Figure 1)

Figure 1: Teamwork and Communication.  Subdomain 1: “Teams” in Healthcare

Learner Level Learning Objective Outcome Example 1 Outcome Example 2
Novice Recognizes the benefits of effective interprofessional (IP) teams and their role in patient safety Following a case discussion identifies benefits of IP teams
In patient care
Following observation in clinical setting reports out on benefits of  IPteams in patient care
Advanced Beginner Articulates the benefits of effective IP teams and their role in patient safety Following case discussion learner articulates rationale for including patients and IP colleagues as active members of team Following clinical experience, compares and contrasts observations of IP colleagues and patients as team members and impact on care
Competent Values the benefits of effective  IPl teams and their role in patient safety Demonstrates respect for contribution of all team members in clinical care Actively participates in  IP team and includes patient as team member
Proficient Models the benefits of effective IP teams and their role in patient safety Proposes creation of IP teams that include patient and families to benefit care Models interactions with patients as members of the team to benefit care
Expert Teaches the benefits of effective IP teams and their role in patient safety Offers formative feedback in clinical settings to learners who are developing IP team skills Applies a process of ongoing self-evaluation and personal performance improvement that promote effective teamwork

Modules also provide domain specific resources to facilitate learner competencies including  videos, cases, on line resources (drawn from well recognized sources such as WHO and Institute for Healthcare Improvement Open School), materials for didactics, role play materials, and supplemental readings.  The preselection of resources reduces prework for facilitators while a broad variety of formats allows for a spectrum of teaching methods.   The curriculum will continue to be updated and new resources added.  We welcome your feedback and suggestions (info@patientsafetymovement.org)

The PSMF requests that you and your curriculum team review patient safety content of your current program and identify gaps and opportunities for improvement. We hope this resource will facilitate incorporation of patient safety principles for your learners and faculty.

We invite you to work with us, join the movement and help us advance practical, clinically-based patient safety education and the goal of zero preventable deaths in our hospitals.