The WHO patient safety curriculum guide
for medical schools
Merrilyn Walton,1Helen Woodward,2Samantha Van Staalduinen,3C Lemer,4
F Greaves,4D Noble,4B Ellis,4L Donaldson,5B Barraclough,6for and on behalf of the
Expert Group convened by the World Alliance of Patient Safety, as Expert Lead for the
Background The urgent need for patient safety
education for healthcare students has been recognised
by many accreditation bodies, but to date there has been
sporadic attention to undergraduate/graduate medical
programmes. Medical students themselves have
identified quality and safety of care as an important area
of instruction; as future doctors and healthcare leaders,
they must be prepared to practise safe healthcare.
Medical education has yet to fully embrace patient
safety concepts and principles into existing medical
curricula. Universities are continuing to produce graduate
doctors lacking in the patient safety knowledge, skills
and behaviours thought necessary to deliver safe care.
A significant challenge is that patient safety is still
a relatively new concept and area of study; thus, many
medical educators are unfamiliar with the literature and
unsure how to integrate patient safety learning into
Design To address this gap and provide a foothold for
medical schools all around the world, the WHO’s World
Alliance for Patient Safety sponsored the development of
a patient safety curriculum guide for medical students.
The WHO Patient Safety Curriculum Guide for Medical
Schools adopts a ‘one-stop-shop’ approach in that it
includes a teacher’s manual providing a step-by-step
guide for teachers new to patient safety learning as well
as a comprehensive curriculum on the main patient safety
areas. This paper establishes the need for patient safety
education of medical students, describes the
development of the WHO Patient Safety Curriculum Guide
for Medical Schools and outlines the content of the Guide.
Patient safety has been on the reform agenda of
many countries since the publication of studies
documenting the extent of harm caused by
training of healthcare students in patient safety
first formally recognised nearly a decade ago in the
report To Err is Human3is only now gathering
momentum. Since then, other reports4
echoed the need for patient safety education.
Medical students have identified the absence of
patient safety education and voted in 2004 for
increased attention to quality and safety,6and
again in 2007 when the Association for Medical
Education in Europe7recommended that patient
safety education be integrated from the start of
existing undergraduate courses.
2but the case for education and
Despite this groundswell of opinion, little coor-
dinated international effort has occurred to inte-
grate patient safety science and practice into
undergraduate medical curricula. Trainees have
identified substantial deficiencies in patient safety
knowledge across a range of training areas and
specialties.8This lag between learners’ desires and
faculty delivery is perhaps understandable, consid-
ering that medical schools find it difficult to
translate patient safety knowledge into curricular
change.9 10What patient safety knowledge and
skills should we teach? What competencies do
healthcare professionals need to keep patients safe?
The Australian Patient Safety Education Frame-
(APSEF), published in 2005, presented
a potential solution. The APSEF is an evidence-
based description of the knowledge, skills and
behaviours that healthcare professionals need to
ensure safe patient care12according to their level of
experience and supervision. In 2008, The WHO
World Alliance for Patient Safety acted to fill the
gap in patient safety education for medical
a universal patient safety curriculum guide for
medical schools worldwide. While it is clearly
recognised that nursing and allied healthcare
professions would also benefit from such a guide
and that the gold standard is a multiprofessional
integrated curriculum, a pragmatic decision was
made to first pilot and focus internationally on
Context for patient safety education
While patient safety is a relatively new concept, it
embraces many medical education principles first
considered by Flexner in the early 20th century, the
need for a strong scientific basis alongside analytical
and critical thinking.13He also recognised attri-
butes such as ethical practice, professionalism,
population health, compassion and integrity to be
The main difference between patient safety
requirements and the list of ethical attributes
described above15 16is that many of the ethical
codes have developed from the perspective of the
doctor while patient safety attributes are designed
from the perspective of the patient. The discipline
of patient safety offers a new framework for
delivering healthcare, one that merges traditional
obligations and duties of doctors with a contem-
porary recognition of the complex environment and
the needs of patients.
1Sydney School of Public Health,
Faculty of Medicine, University
of Sydney, Sydney, Australia
2St Mary’s Hospital, Imperial
College, Healthcare NHS Trust,
St Mary’s Hospital, London, UK
3Office of Postgraduate Medical
Education, University of Sydney,
4Patient Safety Programme,
World Health Organization,
Department of Health, London,
5World Alliance for Patient
Safety, World Health
Organization, Department of
Health, London, UK
6International Society for Quality
in Health Care, Wahroonga,
Professor Merrilyn Walton,
Sydney School of Public Health,
Faculty of Medicine, University
of Sydney, Edward Ford Building
(A27), Sydney 2006, Australia;
For author footnote see end of
Accepted 20 June 2010
542Qual Saf Health Care 2010;19:542e546. doi:10.1136/qshc.2009.036970
Education and training
Patient safety is the freedom for a patient from unnecessary
harm or potential harm associated with healthcare.17It refo-
cuses learning on the patient and the multiple interactions that
can either heal or harm them. Many studies1 18 19highlight that
alongside the enormous benefits of medical care are significant
risks for patients. Managing these risks is a great challenge that
requires a culture of safety to be established throughout medi-
cine, from redesigning health systems to training doctors
competent in both the clinical sciences and safety sciences.20
Why do medical students need to know about patient safety?
Patient safety education and training is required learning for all
levels of training but particularly during the early years when
students are establishing the foundations for their clinical prac-
tice. They need underpinning knowledge about patient safety as
well as know how to apply the principles and concepts at the
bedside. Students can begin to learn practical lessons about
patient safety as soon as they enter the classroom, ward or clinic.
Patient safety should not be approached as yet another subject to
teach; rather, it applies to all areas of clinical medicine. Being
aware that errors occur is not enough. A safe practitioner inte-
grates patient safety concepts and principles into their clinical
practice. This requires more than classroom teaching: it requires
teachers to demonstrate how they act to keep patients safe.
By helping students to recognise each patient as an individual
and to see how that patient’s safety depends on more than any
one person’s clinical skills in isolation, medical students them-
selves can be role models. As future doctors and leaders, they
must be aware of the multiple factors that influence healthcare
outcomes and act to reduce the opportunities for errors. They
need to know how the system of healthcare operates and
impacts on the quality and safety of healthcare.
How ready are medical schools for patient safety education?
Patient safety is a complex topic which includes new areas of
knowledge such as human factors, systems, root cause analysis
and risk reduction. Itsprinciples andconcepts apply to allareas of
medicine. This makes it a challenge to teach and to integrate into
the medical curriculum. The literature on patient safety educa-
tion in medical schools is underdeveloped and shows that patient
safety teaching is varied and ranges from single-session inter-
ventions9 21to educational programmes fully integrated across all
years of school-based training.22Some medical schools have
adapted a modular approach to patient safety education, deliv-
ering content in either a single session or several sessions within
a narrow time frame.9 21 23e25Others have introduced 1- or 2-day
intensive courses.26 27While these are pragmatic ways of intro-
ducing new material without major curricular redesign, patient
safety and its education are ideally integrative in nature. Very few
medical schools have an integrated approach with examples
describing patient safety teaching across two existing blocks
(6 months) of a second-year medical programme,28across an
entire second year of another programme,29and even across all
the years of medical training.22Many more medical schools teach
patient safety than are described in the literature; however, this is
far from universal. Some medical faculties and medical educators
are yet to be convinced that patient safety is an essential part of
the undergraduate medical curriculum and remain reluctant to
incorporate knowledge that originates from outside medicine,
such as systems thinking and quality-improvement methods.30
A central motivation for the WHO in selecting this project was
to encourage and assist medical schools to develop patient safety
education in their medical schools. One cannot expect medical
schools to redesign or adapt curricula if they are unfamiliar with
the requirements of the discipline of patient safety. Medical
educators come from varied backgrounds (clinicians, clinician
educators, non-clinician educators, managers, health profes-
sionals), and their collective experience is necessary to deliver
a rigorous medical programme. Many are experts in their
particular disciplines and usually keep up to date using the
accepted professional pathways for their area, but patient safety
knowledge requires additional learning outside these traditional
routes. To be an effective patient safety teacher, health profes-
sionals need the knowledge, tools and skills to enable them to
teach about patient safety in their institutions.
WHO Patient Safety Curriculum Guide for Medical Schools
The WHO Patient Safety Curriculum Guide for Medical Schools is
a comprehensive curriculum guide designed to be implemented
either in part or in whole by any medical school irrespective of
geography or culture. The WHO Curriculum Guide project team
was guided by three principles: producing a curricular guide for
medical schools worldwide on patient safety; creating a learning
environment where teachers can access resources to teach
patient safety to medical students; and supporting an evidence
base for effective use of a patient safety curriculum in medical
The Curriculum Guide was developed by a team from the
University of Sydney and Monash University and assisted by an
Expert Consensus Working Group with representatives from the
six WHO regions. The Curriculum Guide writing team used the
students under clinical supervision. The APSEF was used because
it provided a comprehensive evidenced based description of the
competencies required by students under clinical supervision.
Each topic was developed into a chapter using a standardised
template (see box 1) by the team member expert in that area and
reviewed by the team during regular face-to-face/teleconferenced
meetings held throughout the Curriculum Guide’s development.
The expert group provided review and comment on the
curriculum, case studies and region-specific advice and resources.
The Curriculum Guide recognises that there is a divide between
the real world of the hospital and clinic compared with the
lecture halls at a university. It addresses this divide by
acknowledging the varying levels of preparedness of hospitals or
clinics to adapt to patient safety principles. We know that
students will see behaviours that are unsafe and contrary to the
patient safety learning outcomes set out in the Curriculum Guide.
We address this by identifying patient safety areas that are
known to be routinely violated. We suggest new ways for the
Box 1 Topics in the WHO Curriculum Guide
1. What is patient safety?
2. What is human factors engineering, and why is it important to
3. Understanding systems and the impact of complexity on
4. Being an effective team player
5. Understanding and learning from errors
6. Understanding and managing clinical risk
7. Introduction to quality improvement methods
8. Engaging with patients and carers
9. Minimising infection through improved infection control
10. Patient safety and invasive procedures
11. Improving medication safety
Qual Saf Health Care 2010;19:542e546. doi:10.1136/qshc.2009.036970543
Education and training
students to approach old problems. Table 1 gives two examples
of two topics out of a set of 11.
Challenges to patient safety education
Discussions about adverse events and medical errors are
universally difficult. In some cultures and hospitals, openness
about errors may be new with no systems in place for reporting
and analysing errors. In other places, systems may exist but are
largely ignored by the health professionals.
Most organisations, irrespective of their location, find any
change difficult, particularly when they are not convinced of the
need to change. Understandably, healthcare workers can feel
threatened or challenged when someone, particular a junior, sees
and does things differently. Therefore, patient safety education
requires an additional layerdthat of a supportive faculty. Unless
students are supported with positive coaching and discussion
about their experiences, much of the teaching and learning about
patient safety at medical school will be undermined. Many
students are reluctant to talk about their concerns when they
observe unethical or unprofessional behaviour. The Curriculum
Guide includes tips for students in managing workplace cultures.
Content and structure
Box 2 sets out the objectives of the WHO Curriculum Guide.
The WHO Curriculum Guide is in two parts: the Teacher’s
Guide (Part A) and the Curriculum Topics (Part B). Part A is
designed to support Part B, providing practical advice and
information to teachers for each stage of the curriculum and
laying the foundations for capacity-building in patient safety
education by providing information and guidance on the struc-
ture of the curriculum, how to implement it, curriculum inte-
gration, curriculum development, use of narrative, assessment,
evaluation, the hidden culture, available resources and activities
to assist student learning. The rationale for each of the topics is
Part B comprises the Curriculum topics. Eleven topics were
selected for inclusion in the Curriculum Guide (see box 1),
covering 16 of the 22 learning topics that make up the APSEF.
Topics not included in the Curriculum Guide were those that
would already be covered in a medical school curriculum such as
consent, evidence-based practice and learning and teaching.
Information technology was excluded because of the disparity in
access to technology among university medical schools and
Each topic follows a standard educational format as
described in box 3. The content of the topic is designed for
both students and teachers. Each topic can be adapted to suit
the medical school and teachers’ needs, whether delivered as
web-based Learning Topics with activities designed around
the learning outcomes, or as lectures using the power point
slides designed to accompany the content. Some of the
teaching and learning activities suggested in the Curriculum
Guide include interactive or didactic lectures, case-based
examples, small group discussions, simulation exercises,
role-play scenarios, team-building exercises and reflective
Framework for managing conflicts in medical situations
Area or attributeExamplesOld way New way
Paternalism consent Student asked to get consent from a patient
for a surgical procedure the student has never
heard of before
Accept task, do not let senior staff know level
of ignorance about procedure, talk to the
patient about the procedure in a vague and
superficial way so as to get the patient’s
signature on the consent form
Decline the task and suggest that a doctor
with some familiarity with the procedure
would be more appropriate for this task.
Accept the task, but explain you know little
about the procedure so will need some
teaching about it first and request that one of
the doctors comes along to help/supervise.
Understand that everyone will make mistakes
at some time and that the causes of errors are
multifactorial involving latent factors not
immediately obvious at the time the error was
made. Look after your patients, yourself and
your colleagues in the event of an error and
actively promote learning from error.
Infallibility of doctors;
attitude to mistakes
Mistakes are only made by people who are
incompetent or unethical. Good doctors do not
Accept the culture that says doctors who
make mistakes are ‘bad’ or ‘incompetent.’ Try
harder to avoid making a mistake. Remain
silent, or find someone or something else to
blame when you have made a mistake.
Look at the mistakes others make and tell
yourself you wouldn’t be that stupid.
Box 2 Objectives of the WHO Patient Safety Curriculum
Guide for Medical Schools
< To prepare medical students for safe practice in the workplace
< To inform medical schools of the key topics in patient safety
< To enhance patient safety as a theme throughout the medical
< To provide a comprehensive curriculum to assist teaching and
integrating patient safety learning
< To further develop capacity for patient safety educators in
< To promote a safe and supportive environment for teaching
students about patient safety.
< To introduce or strengthen patient safety education in medical
< To raise the international profile of patient safety teaching and
< To foster international collaboration on patient safety
education research in the higher education sector.
Box 3 Template used for each topic
What students need to do (performance requirements)
What students need to know (knowledge requirements)
How to teach this topic
Teaching strategies and formats
Teaching and learning activities
Tools and resources
How to evaluate this topic
How to assess this topic
Slides for topic
544Qual Saf Health Care 2010;19:542e546. doi:10.1136/qshc.2009.036970
Education and training
Integration and application
The Curriculum Guide recognises that most medical curricula
are already filled beyond capacity; thus, topics were designed to
be either integrated into existing teaching or introduced as
stand-alone modules. Table 2 shows how a patient safety
principle (correct patient identification) has specific application
in established disciplines. Table 3 provides for several Curric-
ulum Guide topics examples of subject areas in which these
topics may be integrated, demonstrating the wide range of
options for incorporating patient safety content into existing
An example of an opportunity for integration of Curriculum
Guide content into existing medical school curricula is the
revision of problem-based learning (PBL) cases to include patient
safety topics. The PBL format reflects principles and activities
that promote patient safety in the workplacedincluding
collaboration and teamwork, clarification and respect of each
person’s roles and responsibilities, identification of problems and
solutions, and peer-to-peer teaching and learningdand thus
represents an excellent vehicle for patient safety education.
Patient safety-related objectives can be added to those described
for the case, and the trigger can be expanded or altered to elicit
additional discussion on patient safety topics without sacrificing
the original content of the case. Table 4 describes the revision of
a respiratory sciences case to incorporate learning related to
The final draft of the WHO Curriculum Guide was produced in
2008 after validation by a worldwide panel of medical educa-
tors and patient safety experts. The Guide is currently being
piloted and evaluated in each of the six WHO regions within
a variety of different medical schools. The number of topics
implemented (minimum of three) and modes of delivery
adopted vary between participating medical schools, but each
pilot site follows a standardised approach to evaluation that
includes pre- and postdelivery questionnaires, focus groups
and online discussion forums for students and teachers. The
pilot and evaluation are scheduled to be completed by the end
The availability of a universal patient safety curriculum guide
provides universities with an opportunity to develop their own
patient safety curriculum. The WHO Curriculum Guide aims to
assist faculties in demystifying patient safety knowledge and
skills, and is designed to help medical school teachers to deliver
patient safety learning. The Curriculum Guide is freely available
on the WHO website for any medical school to use, and has
already been downloaded in hundreds of countries. Patient
safety is a worldwide problem, and collaborative efforts have the
potential to enhance medical education at a rapid rate. This
project has the potential to break down competitive barriers and
share resources that ultimately will benefit patients from all over
The Expert Group convened by the World Alliance of Patient Safety comprises the
following: B Flanagan, Monash University, Victoria, Australia; J Harrison, Monash
University, Victoria, Australia; T Shaw, University of Sydney, New South Wales,
Australia; C Roberts, University of Sydney, New South Wales, Australia; S Barnet,
University of Sydney, New South Wales, Australia; R De Alwis, International
Medical University, Kuala Lumpur, Malaysia; M Saad Al-Moamary, King Saud Bin
Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; A Eid, International
Federation of Medical Students’ Associations (IFMSA); R Flin, University of Aberdeen,
Old Aberdeen, UK; P Claver Kariyo, School of Medicine, Bujumbura; BL Lingard,
University of Toronto, Toronto, Canada; J Martinez, Universidad Del Salvador, Buenos
Aires, Argentina; C Soe, Ministry of Health, Myanmar; L Young-Mee, Korea University
College of Medical Education, Seoul, Republic of Korea; M Zhang, Sichuan University,
Chengdu, China; A Ziv, The Israel Centre for Medical Simulation, Sheba Medical
Centre, Tel Hashomer, Israel.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Wilson RM, Runciman W, Gibberd R, et al. The quality in Australian Health Care
Study. Med J Aust 1995;163:458e71.
Leape L. Reporting of adverse events. N Engl J Med 2002;347:1633e38.
Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health
System. Washington, DC: National Academy Press, 2000.
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the
21st Century. Washington, DC: National Academy Press, 2001.
Griener AC, Knebel E, eds. Health Professions Education: A Bridge to Quality.
Washington, DC: The National Academy Press, 2003.
Application of correct patient identification principles across
DisciplinePatient 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
If a patient needs a blood transfusion, what checking processes are in
place to ensure they receive the correct blood type?
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?
Examples of integration areas for Curriculum Guide topics
Curriculum guide topic Potential subject areas for integration
Minimising infection through
improved infection control (Topic 9)
Procedural skill training
Introduction to the clinical environment
Clinical and procedural skills training
Improving medication safety (Topic 11)
What is patient safety? (Topic 1)
based learning cases
Example of incorporating patient safety learning into problem-
Trigger James is a 15-year-old boy. He arrives at the hospital from
a local clinic with noisy breathing and an itch. James’
father reports he was fine 30 min earlier and suddenly
became unwell. On examination, James looks distressed
and nervous; he has a puffy face, enlarged lips, swollen
eyes and red blotches on his skin.
The father tells you James was like this once before after
having penicillin; he says James was told not to take the
drug again. James had seen a doctor earlier today for
a runny nose, sore throat and fever, and was prescribed
amoxicillin. James’ father is worried his son might be
allergic to this new medication.
< How might James been given amoxicillin when he has
a known allergy to penicillin?
< Why was James prescribed an antibiotic when the
most likely cause of his symptoms is a viral upper
respiratory tract infection?
< This problem was preventable; has someone made
< How can this be prevented?
< What is the doctor’s role; what is the patient’s role?
< List a doctor’s responsibilities when prescribing
< List strategies to minimise patients being given the
wrong medications that might harm them
Qual Saf Health Care 2010;19:542e546. doi:10.1136/qshc.2009.036970545
Education and training
6. Download full-text
Lockwood L, Sabharwal R, Danoff D, et al. Quality improvement in medical
students’ education: the AAMC medical school graduation questionnaire. Med Educ
Association for Medical Education in Europe, Trondheim, Norway: 2007 Aug 25e29,
Kerfoot BP, Conlin PR, Travison TT, et al. Patient safety knowledge and its
determinants in medical trainees. J Gen Intern Med 2007;22:1150e4.
Halbach JL, Sullivan LL. Teaching medical students about medical errors and patient
safety: evaluation of a required curriculum. Acad Med 2005;80:600e6.
Walton M, Elliot E. Improving safety and quality: how can education help? Med J
Walton M, Shaw T, Barnett S, et al. Developing a national patient safety education
framework for Australian. Qual Saf Health Care 2006;15:437e42.
Walton M. National Patient Safety Education Framework. Canberra: The Australian
Council for Safety and Quality in Health Care, 2005:202.
Cooke M, Irby D, Sullivan W, et al. American medical education 100 years after the
flexner report. N Engl J Med 2006;355:1339e44.
Flexner A. Medical Education: A Comparative Study. New York: Macmillan, 1925.
Anon. Project of the ABIM Foundation AAF, and European Federation of Internal
Medicine. Medical Professionalism in the New Millennium: A Physician Charter. Ann
Intern Med 2002;136:243e6.
Frank JR. ed. The CanMEDS Physician Competency Framework. Ottawa:
Royal College of Physicians and Surgeons of Canada, 2005.
The World Health Organization. International Classification for Patient Safety for
Use in Field Testing in 2007e2008 (ICPS). Geneva: WHO, 2008.
Brennan TA, Leape LL, Laird N, et al. Incidence of adverse events and negligence in
hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med
Davis P, Lay Lee R, Briant R, et al. Adverse events in New Zealand public hospitals:
principal findings from a National Survey. Wellington, New Zealand: New Zealand
Ministry of Health, 2001.
Emanuel L, Berwick D, Conway J, et al, eds. What exactly is patient safety?
Rockville, MD: Agency for Healthcare Research and Quality, 2008.
Fulton J. A curriculum for patient safety. Med Educ 2004;38:1014e15.
Varkey P. Educating to improve patient care: integrating quality improvement in to
medical school curriculum. Am J Med Qual 2007;22:112e16.
Gunderson A, Mayer D, Tekian A. Breaking the cycle of error: patient safety training.
Med Educ 2007;41:518e19.
Scobie S, Lawson M, Cavell G, et al. Meeting the challenge of prescribing and
administering medicines safely: structured teaching and assessment for final year
medical students. Med Educ 2003;37:434e7.
Patey R, Flin R, Cutherbertson BH, et al. Patient safety: helping medical students
understand error in healthcare. Qual Saf Health Care 2007;16:256e9.
Horsburgh M, Merry AF, Seddon M. Patient safety in an interprofessional learning
environment. Med Educ 2005;39:512e13.
Moskowitz E, Veloski JJ, Fields SK, et al. Development and evaluation of a 1-day
interclerkship program for medical students on medical errors and patient safety.
Am J Med Qual 2007;22:13e23.
Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical
students’ knowledge, skills and attitudes about patient safety and medical fallibility.
Acad Med 2006;81:94e101.
Gould BE, Grey MR, Huntington CG, et al. Improving patient care outcomes by
teaching quality improvement to medical students in community-based practices.
Acad Med 2002;77:1011e18.
Walton M. Teaching patient safety to clinicians and medical students. Clin Teacher
546Qual Saf Health Care 2010;19:542e546. doi:10.1136/qshc.2009.036970
Education and training