Article (PDF Available)

A patient safety course for preclinical medical students

University of Miami - Jackson Memorial Hospital Center for Patient Safety, Miami, Florida, USA.
The Clinical Teacher 12/2012; 9(6):376-81. DOI: 10.1111/j.1743-498X.2012.00592.x
Source: PubMed
ABSTRACT
Background:
We developed a course to introduce incoming third-year medical students to the subject of patient safety, to focus their attention on teamwork and communication, and to create an awareness of patient-safe practices that will positively impact their performance as clinicians.

Methods:
The course, held prior to the start of clinical rotations, consisted of lectures, web-based didactic materials, small group activities and simulation exercises, with an emphasis on experiential learning. First, students inspected a 'room of horrors', which is a simulated clinical environment riddled with errors. Second, we used lenticular puzzles in small groups to elicit teamwork behaviours that parallel real-life interactions in health care. Each team was given 8 minutes to complete a 48-piece puzzle, with five pieces removed at random and given to other teams. The salient teaching point of this exercise is that for a team to complete the task, team members must communicate with members of their own team as well as with other teams. Last, simulation scenarios provided a clinical context to reinforce the skills introduced through the puzzle exercise and lectures. The students were split into groups of six or seven members and challenged with two scenarios. Both scenarios focused on a 56-year-old man in respiratory distress. The teams were debriefed on both clinical management and teamwork.

Results:
The vast majority of the students (93%) agreed that the course improved their patient safety knowledge and skills.

Discussion:
The positive response from students to the introductory course is an important step in fostering a culture of patient safety.

Full-text (PDF)

Available from: Ilya Shekhter
A patient safety course
for preclinical medical
students
Ilya Shekhter, Lisa Rosen, Jill Sanko, Ruth Everett-Thomas, Maureen Fitzpatrick and
David Birnbach, University of Miami Jackson Memorial Hospital Center for Patient
Safety, Miami, Florida, USA
SUMMARY
Background: We developed a
course to introduce incoming
third-year medical students to the
subject of patient safety, to focus
their attention on teamwork and
communication, and to create an
awareness of patient-safe prac-
tices that will positively impact
their performance as clinicians.
Methods: The course, held prior
to the start of clinical rotations,
consisted of lectures, web-based
didactic materials, small group
activities and simulation exer-
cises, with an emphasis on expe-
riential learning. First, students
inspected a ‘room of horrors’,
which is a simulated clinical
environment riddled with errors.
Second, we used lenticular puzzles
in small groups to elicit teamwork
behaviours that parallel real-life
interactions in health care. Each
team was given 8 minutes to
complete a 48-piece puzzle, with
five pieces removed at random
and given to other teams. The
salient teaching point of this
exercise is that for a team to
complete the task, team members
must communicate with members
of their own team as well as with
other teams. Last, simulation
scenarios provided a clinical con-
text to reinforce the skills
introduced through the puzzle
exercise and lectures. The stu-
dents were split into groups of six
or seven members and challenged
with two scenarios. Both scenar-
ios focused on a 56-year-old man
in respiratory distress. The teams
were debriefed on both clinical
management and teamwork.
Results: The vast majority of the
students (93%) agreed that the
course improved their patient
safety knowledge and skills.
Discussion: The positive response
from students to the introductory
course is an important step in
fostering a culture of patient
safety.
We developed a
course to
introduce
medical
students to the
subject of
patient safety
Acquiring
skills
376 Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 376–381
Page 1
INTRODUCTION
A
dvances in modern medi-
cine have dramatically
improved patient outcomes.
However, with these benefits come
significant risks, leading to the
development of patient safety as a
specialised discipline. Ideally,
students’ knowledge, skills and
attitudes regarding patient safety
need to be developed throughout
medical school.
Surveys of US, Canadian and
European medical schools reveal
that, despite the recognised need
for patient safety training, few
schools have formally included this
subject into their regular curricula.
These surveys show wide variations
in approaches to patient safety
training for students.
1,2
Such
programmes range from individual
lectures, comprehensive patient
safety modules and other safety-
focused learning activities.
3–9
Some schools mandate patient
safety training for their stu-
dents.
3,4,7–10
Others offer patient
safety electives.
4
Furthermore,
some curricula target pre-clinical
medical students,
3,9
whereas many
target students on clinical
clerkships.
5–8,10
At the University of Miami, we
developed a mandatory week-long
patient safety course for incoming
third-year medical students. The
goals of this course, scheduled
right before the start of clinical
rotations, are to introduce stu-
dents to the subject of patient
safety, focus their attention on
the role of teamwork and com-
munication in providing quality
care, and create an awareness of
safe practices. Furthermore, the
course lays the foundation for the
patient safety training they will
encounter in their clinical educa-
tion.
METHODS
The course consists of lectures,
web-based didactic materials,
small group activities and
simulation exercises, designed to
address both cognitive and atti-
tudinal competencies (Table 1).
In all, 144 students participated
in the course.
Didactic learning
A series of lectures by a multi-
professional team of instructors
covered systems-based approach-
es to adverse event prevention
and mitigation, root cause analy-
sis, teamwork and team training,
human factors and ethical con-
siderations in patient safety.
Web-based materials focused on
medication errors and infection
control.
Experiential learning
Room of horrors
A ‘room of horrors is a novel
way to educate students about
the hidden dangers commonly
found in a clinical setting. This
exercise affords students an
opportunity to investigate a
clinical environment riddled with
errors that may cause patient
harm. For this exercise, a ‘room
of horrors with an interactive
patient simulator (SimMan) was
set up in a mock patient room.
Table 2 contains examples of
hazards found in the ‘room of
horrors’. Each student was
instructed to identify and docu-
ment any observations that
might pose a risk to a patient.
The students were given 8 min-
utes to complete this activity,
followed by immediate debrief-
ing. Observation sheets were
tabulated and results were dis-
cussed in a subsequent lecture.
In addition to exposing
patient safety hazards, the ‘room
of horrors’ fulfils an important
secondary function, orienting the
students to the simulation envi-
ronment in preparation for the
clinical scenarios 2 days later.
Puzzles
Although we often teach team-
work, communication and leader-
Table 1. Structure of the patient safety course
Day 1 Lecture: Introduction to patient safety 1 hour
Simulation: ‘Room of horrors’ 8 hours
Day 2 Lecture: Introduction to teamwork 1 hour
Group exercise: Puzzles 2 hours
Lecture: Team training 1 hour
Lecture: Why mistakes happen? Human factors
engineering
1 hour
Lecture: Transforming medicine to high reliability 1 hour
Day 3 Simulation: Team exercise 10 hours
Day 4 Lecture: Sleep deprivation and patient safety 1 hour
Lecture: Communication skills, teamwork and
professionalism
1 hour
Lecture: The ethics of patient safety 1 hour
Lecture: After the error: disclosure and root
cause analysis
1 hour
Day 5 Course wrap-up 1 hour
Final exam 1 hour
Few schools
have formally
included
[patient
safety] into
their regular
curricula
Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 376–381 377
Page 2
ship skills to residents and ad-
vanced students, developing
appropriate exercises for pre-
clinical medical students has
numerous challenges. We have
found that commercially available
lenticular puzzles (with images
that appear different when viewed
from different angles) are useful
in teaching teamwork and other
patient safety concepts to stu-
dents with little or no clinical
experience. Using puzzles in a
small group setting, we elicited
teamwork behaviours that might
parallel interactions in an actual
health care setting.
For this exercise, the students
were split into four large groups
of approximately 36 students
each; each of these groups was
guided into a separate room and
further divided into six teams,
each with six or seven students at
a table. Each team received a
48-piece lenticular puzzle (Dis-
ney, Burbank, California, USA) to
complete. Unbeknownst to them,
five pieces were removed at ran-
dom from each puzzle and placed
in another five teams’ puzzle sets,
so that each team had puzzle
pieces from other teams. Teams
were told that to win, they
needed to complete the puzzle in
8 minutes. At the 8-minute mark,
the activity was stopped, and a
15-minute debriefing followed.
After debriefing, teams were given
a different puzzle, again modified
as described above.
The salient teaching point of
this exercise is that for a team to
complete the task, team members
must communicate within their
team as well as with other teams
(to locate and ‘trade’ the removed
puzzle pieces). There need not be
only one winner: if the teams
communicate, they can all win.
The perception that competition
within the group and between
groups may present a barrier to
collaboration is discussed, in
relation to the safe practice of
medicine. Another feature of
these puzzles is that team mem-
bers see the image differently
depending on their location
around the table. This feature
correlates to patient care,
because different observations,
experiences and biases may lead
to different conclusions.
The debriefing focused on
communication and coordination
both within each team and among
teams.
The teams were asked to dis-
cuss: (1) overall teamwork; (2) the
presence or absence of a leader
and ways the leader was effective
or ineffective; (3) role clarity and
workload distribution; (4) com-
munication strategies; (5) situa-
tional awareness; (6) perception
of competition between teams and
whether it was justified; and
(7) parallels between the puzzle
exercise and working in a health
care organisation.
Simulation exercises
The simulation scenarios provided
a clinical context to reinforce the
skills introduced through the
puzzle exercise. The students were
again split into groups of six or
seven members. Two similar clin-
ical scenarios were presented,
with a debriefing session between
simulations. Both scenarios fo-
cused on a 56-year-old patient in
respiratory distress. In the first
scenario, the symptoms were
accompanied by hypotension; in
the second, the blood pressure
was elevated. The patient was
portrayed either by a high-tech-
nology simulator (SimMan, Laer-
dal) or by a standardised patient,
with a nurse available to help with
patient care tasks. During the
scenarios, the students were
tasked with assessing the pa-
Table 2. Checklist of patient safety errors in the
‘Room of horrors’
Error Percentage
missed
Chart error: wrong patient name on one page of the medication
record
40.7%
Critical test report listed in labs, but not commented upon in
the chart
95.2%
Doctor order: illegible handwriting and inappropriate
abbreviations were used
98.6%
Medication administration record: patient given Ampicillin
despite documented penicillin allergy
45.5%
Low oxygen saturation (92%) on pulse oximeter and no oxygen
being administered to the patient, despite this saturation
level
64.8%
Foley collector bag on the floor; tube under the wheel of
the bed
35.9%
Alcohol-based hand sanitiser canister empty 64.1%
Allergy bracelet incompletely filled out 53.1%
Overflowing sharps container 20.7%
Intravenous (IV) drip site not dated 96.2%
Soiled dressing on surgical site 28.3%
Fall bracelet not on the patient 65.5%
Siderails down, even through patient is a ‘fall risk’ 42.1%
Unlabelled pills and syringes in the room 29.7%
Lenticular
puzzles are
useful in
teaching
teamwork and
other patient
safety concepts
378 Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 376–381
Page 3
tient’s condition and initiating
appropriate treatment.
Following each scenario,
students were debriefed and were
provided feedback for improve-
ment. In particular, the impor-
tance of understanding their
environment was emphasised, as
was the need to ask questions
about anything unfamiliar to
them. During debriefing, specific
teamwork and communication
competencies were emphasised:
introducing oneself to the
patient and to other team
members; calling out orders to
specific individuals; verbally
confirming orders; assignment of
roles; and delegation of tasks. A
key concept introduced during
this segment of the course is the
importance of cooperating with
nurses.
After each encounter, prior to
debriefing, the participants
completed a written questionnaire
to gauge their comfort and
competence.
Evaluation
Two weeks after the course, the
students were asked to complete a
four-point Likert scale survey to
evaluate the course and its
components (Table 3).
RESULTS
Student satisfaction
A total of 122 students completed
the end-of-the-course survey,
summarised in Table 3. The vast
majority of the students (93%)
responded that the course im-
proved their patient safety
knowledge and skills. Samples of
student feedback are given in
Figure 1.
Room of horrors
Commonly missed patient safety
hazards included: use of inappro-
priate abbreviations (98.6%); low
oxygen saturation (65.3%); and
missing fall-risk bracelet (66.0%).
Table 3. Evaluation form for the patient safety course
Question Strongly
agree
Agree Disagree Strongly
disagree
Not
applicable
1. The orientation overview of the course was
communicated effectively
49 39 7 1 5
2. The objectives and goals for the course were clearly
defined
46 42 4 3 6
3. The course provided you with ample opportunities
to gain knowledge and skills
56 37 2 1 5
4. The course was well organised 57 34 3 2 5
5. The expectations for student performance were
known to you
45 43 2 2 8
6. The instructors were responsive to student feedback 70 25 0 0 5
7. Lectures were effective at presenting concepts
and principles
31 58 3 3 5
8. Sufficient opportunities were provided to ask
questions during lectures
47 48 1 0 5
9. Simulation activities provided you with valuable
learning opportunities on patient safety
67 26 1 1 5
10. The format for simulation activities was user friendly 50 41 3 1 5
11. Critical thinking skills were emphasised in studying
the course
53 39 3 2 4
12. Efforts were made to integrate and synthesise
various concepts introduced in the course
52 43 1 0 5
13. The timing of the course offering is appropriate for
this stage of your education
55 39 0 0 7
14. The final exam was well constructed (e.g. clarity,
format, representation and length)
38 48 7 2 9
15. The content of the final exam was consistent with
the course objectives
31 45 15 5 4
The numbers shown are the percentages of student responses (n = 122) rounded to the closest integer.
The simulation
scenarios
provided a
clinical context
to reinforce the
skills
introduced
through the
puzzle exercise
Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 376–381 379
Page 4
A review of these missed hazards
was the subject of a subsequent
lecture.
Puzzles
Students were enthusiastic about
this segment of the course, giving
it the highest rating of the vari-
ous course activities. One com-
ment from the course evaluation
indicated that ‘The puzzle activity
was a great way to teach the
team leadership skills, because
there wasn’t as much of a knowl-
edge gap, and it was easy enough
to move on to thinking about
team leadership concepts’.
Simulated experience
Based on the post-simulation
questionnaire, participants felt
more comfortable with the simu-
lation (scored 2.9 versus 2.6 on a
five-point Likert scale, p < 0.01),
and more competent in managing
the clinical scenario (scored 2.6
versus 2.2 on a five-point Likert
scale, p < 0.01) after the second
scenario.
DISCUSSION
The US and Canadian medical
schools have not fully incorpo-
rated patient safety material into
core pre-clinical or clinical
curricula, and there is a large
discrepancy between a doctor’s
training and the safety man-
dates placed on practising
doctors.
1,2
Despite the success of our
course, some questions remain
unanswered. For example, at what
point in the medical school cur-
riculum should this material be
taught? Based on our experience
with previous courses, we deter-
mined that a dedicated week
immediately prior to students
beginning third-year clinical
rotations is ideal. Undistracted by
pressing academic commitments,
they are free to focus on the
critical nature of patient safety
presented through the exercises.
Delivering the patient safety
curriculum in a short time period
may limit students’ opportunity to
practise their skills and retain
core concepts. We believe that
the curriculum, especially team-
work and communication mod-
ules, should be reinforced
throughout their education and
clinical practice. As part of the
evolution of our patient safety
curriculum, these modules have
recently been added to the core
clinical clerkships.
The paramount objective of
the course is for medical students
to internalise patient safety pre-
cepts, and act on them as they
start their clinical rotations. The
extent to which this objective has
been achieved is difficult to
measure in the short-term, and
requires further evaluation by
tracking students performance,
attitudes and culture over time.
Nonetheless, the students’ posi-
tive response to the introductory
course reflects a significant step
in fostering a culture of patient
safety.
REFERENCES
1. Alper E, Rosenberg EI, O’Brien KE,
Fischer M, Durning SJ. Patient safety
education at U.S. and Canadian
Students are
free to focus on
the critical
nature of
patient safety
presented
through the
exercises
What did you
like?
Very applicable
to clinical
setting
Good to be put
in a difficult
situation
It was a nice
dose of reality
The
simulations
were effective
The
puzzle activity
and the
simulations
What could be
better?
Fewer lectures
More
simulations,
smaller groups
Another
chance
to do a
simulation
More
simulations and
the opportunity
to get better
Less repetition
Figure 1. Examples of student feedback about the course
380 Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 376–381
Page 5
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Corresponding author’s contact details: David Birnbach, University of Miami, Jackson Memorial Hospital, Center for Patient Safety, 1611 NW
12th Avenue, Miami, FL 33136 USA. E-mail: dbirnbach@med.miami.edu
Funding: This study was funded internally by the University of Miami Miller School of Medicine.
Conflict of interest: None.
Ethical approval: The study describes a portion of a mandatory curriculum, and is therefore exempt.
doi: 10.1111/j.1743-498X.2012.00592.x
Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 376–381 381
Page 6
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