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Introduction
Physicians are under the pledge to follow the Hippocratic
Oath of "first do no harm". However, the report from
Institute of Medicine in 1999, "To err is human: Building a
Safer Health System", showed that much harm is being
done by medical errors.1According to the report, around
98,000 people may be dying every year due to medical
errors in hospitals of the United States. This number was
more than deaths due to road traffic accidents (RTAs),
breast cancer, or acquired immunodeficiency syndrome
(AIDS), causes which receive much wider public attention.
If we add the financial burden, these huge mortality
figures make medical error one of the most urgent public
health problems.2
Significant improvement in healthcare has occurred as a
result of advances in medical science and technology.
However, this improvement has come at the cost of
patient safety, as patients increasingly suffer from adverse
events due to hospitalisation and medical management.
In response to this situation, 'patient safety' has emerged
as a new specialised discipline which can help health
professionals develop a culture of patient safety.3
It has been suggested that the healthcare system should
learn from the aviation experience which, by
implementing a system-based and team-based
management approach, has successfully developed a
culture of air travel safety.4
Traditionally, medical error has been blamed on a person
error. This approach, by naming, blaming, and shaming
individuals, may be psychologically more satisfying for
administrations as it absolves the institutions from any
responsibility. It focuses attention on unsafe acts or active
failures of people at the sharp end (nurses, trainees,
doctors, pharmacists etc.) and attributes these to human
factors e.g. forgetfulness, poor motivation, carelessness,
and negligence. On the other hand, the "systems
approach" is based on the premise that humans are
fallible and will make errors in the best of institutions.
Errors are actually related to weaknesses in the defence
system, including factors like time pressures,
understaffing, prolonged duty hours, sleep deprivation
and their consequent physical, mental, and emotional
fatigue. The key, therefore, lies in improving the working
conditions or the system defence as the important issue is
not about who did it, but how and why the system
J Pak Med Assoc
1261
ORIGINAL ARTICLE
Patient safety: Perceptions of Medical Students of Dow Medical College, Karachi
Nusrat Shah,1Masood Jawaid,2Nighat Shah,3Syed Moyn Ali4
Abstract
Objective: To assess medical students' perceptions about patient safety issues before the teaching of "patient
safety" can be recommended.
Methods: The cross-sectional survey was undertaken at the Dow Medical College and Civil Hospital, Karachi, in
September, 2013. Data collection tool was a structured questionnaire administered to medical students. The main
outcome measures were students' perceptions about patient safety issues and their attitude towards teaching of
patient safety curriculum.
Results: There were 229 medical students in the study with a response rate of 100%. Overall, 129(57%) students
agreed that medical errors were inevitable, but 106 (46.9) thought competent physicians do not make errors. While
167(74%) students said medical errors should be reported, 204(90%) thought reporting systems do not reduce
future errors. Besides, 90(40%) students thought only physicians can determine the causes of error and nearly
177(78%)% said physicians should not tolerate uncertainty in patient care. Overall, 217(96%) agreed that patient
safety is an important topic; 210(93%) agreed that it should be part of medical curriculum; 197(87%) said they would
like to learn how to disclose medical errors to patients and 203(90%) to faculty members.
Conclusion: A significant knowledge gap existed among medical students regarding patient safety issues. The
teaching of 'patient safety' was highly supported by students and needs to be included in medical curriculum on an
urgent basis.
Keywords: Patient safety, Medical error, Undergraduate Medical Curriculum, Pakistan. (JPMA 65: 1261; 2015)
1Department of Obstetrics & Gynecology, Dow University of Health Sciences,
Karachi, 2Department of Surgery, Dow International Medical College,
Karachi, 3Department of Ob-Gyn, Aga Khan University Hospital, Karachi,
Pakistan, 4Department of Medical Education, College of Medicine, Taif
University, Saudi Arabia.
Correspondence: Nusrat Shah. Email: nusrat61@gmail.com
defence failed.5,6
In Pakistan, millions of people suffer death or disability
directly attributed to medical care provided by hospitals
with poor or no patient safety protocols. Moreover, hardly
any physicians or hospitals maintain a record of the
outcomes of their surgical procedures, drug reactions and
other medical errors. Above all, there is no incident
reporting by the healthcare system which should ideally
be responsible for communicating such information to
the public.7,8
Medical students are the future healthcare providers and
leaders and they need to understand how systems affect
the quality and safety of healthcare and must prepare
themselves to practice safe care. The World Health
Organisation (WHO) has developed a Patient Safety
Curriculum Guide for medical students to help them meet
this future challenge.3
The current survey was planned to assess medical
students' perceptions about patient safety issues and
their attitudes to introduction of patient safety
programme in the undergraduate and postgraduate
curriculum.
Subjects and Methods
The cross-sectional survey was undertaken at the Dow
Medical College and Civil Hospital, Karachi, in September,
2013. A structured and anonymous self-administered
questionnaire was handed to medical students including
undergraduates (UGs), house officers (HOs) and Residents
posted in departments of Obstetrics and Gynaecology,
Surgery and Medicine. The questionnaire having 20 items
related to patient safety issues was adapted from one
used in an earlier study.9
Non-probability, purposive sampling was used and all
UGs, HOs and Residents present in the wards were
approached. Those who volunteered were included. No
sample size calculation was done.
The first 11 items in the questionnaire were about
students' perceptions about the causes and management
of medical errors, whereas, the last 9 items addressed
their perceptions about knowledge and skills related to
patient safety issues and their views on inclusion of
patient safety education in medical curriculum. Grading
of responses was done using a 5-point ordinal scale where
1=strongly disagree and 5= strongly agree.
The main outcome measures were students' knowledge
and attitudes about patient safety issues and their
attitude to the teaching of patient safety curriculum.
Data was analysed using SPSS 16. Frequency and percentage
was used to report categorical data. Chi-square was used to
find out significant difference between the responses of
different groups of students, with p<0.05 being significant.3
Results
All 229 participants responded. Three incomplete
Vol. 65, No. 12, December 2015
Patient safety: Perceptions of MedicalStudents of Dow Medical College, Karachi 1262
Table-1: Responses to items of the questionnaire on patient safety (n=226).
Item Item Question Disagree n(%) Neutral n (%) Agree n
(%)
1 Making errors in medicine is inevitable 51 (26.2) 46 (20.4) 129 (57.1)
2 There is a gap between what physicians know as "best care" and what is being provided on a day to day basis. 10 (4.4) 34 (15.0) 182 (80.5)
3 Competent physicians do not make errors that lead to patient harm. 76 (33.6) 44 (19.5) 106 (46.9)
4 Most errors are due to things that physicians cannot do anything about. 71 (31.4) 61 (27.0) 94 (41.6)
5 If I saw a medical error, I would keep it to myself. 167 (73.9) 41 (18.1) 18 (8.0)
6 If there is no harm to a patient, there is no need to address an error. 138 (61.5) 35 (15.5) 53 (23.5)
7 Only physicians can determine the causes of a medical error. 94 (41.6) 42 (18.6) 90 (39.8)
8 Reporting systems do little to reduce future errors 15 (6.6) 7 (3.1) 204 (90.3)
9 After an error occurs, an effective strategy is to work harder and to be more careful. 116 (51.3) 41 (18.1) 69 (30.5)
10 Physicians should not tolerate uncertainty in patient care. 16 (7.1) 33 (14.6) 177 (78.3)
11 The culture of medicine makes it easy for providers to deal constructively with errors. 34 (15.0) 91 (40.3) 101 (44.7)
12 I am well informed about patient safety issues. 60 (26.5) 72 (31.9) 94 (41.6)
13 'Patient safety' is an important topic. 6 (2.7) 3 (1.3) 217 (96.0)
14 Physicians should routinely spend part of their professional time for improving patient care 12 (5.3) 12 (5.3) 202 (89.4)
15 Learning how to improve patient safety is an appropriate use of time in medical school 7 (3.1) 9 (4.0) 210 (92.9)
16 I would like to receive further teaching on patient safety 11 (4.9) 10 (4.4) 205 (90.7)
17 I would like to learn how to support and advise a peer who has to respond to a medical error 11 (4.9) 21 (9.3) 194 (85.8)
18 I would like to learn how to analyze a case to find the cause of a medical error 10 (4.4) 10 (4.4) 206 (91.2)
19 I would like to learn how to disclose an error to a patient 15 (6.6) 14 (6.2) 197 (87.2)
questionnaires were discarded, and 226 were analyzed.
For the purpose of reporting we combined the responses
of 'agreed' and 'strongly agreed' to report them as
'agreed', while 'disagreed' and strongly disagreed' were
together reported as 'disagreed'.
Items1 to 4 were aimed at addressing students'
knowledge regarding medical errors (Table-1). Although
majority of students agreed that medical errors were
inevitable (129; 57%), 51 disagreed (26.2%) and another
46 were neutral (20%). The vast majority agreed that best
care is not always provided to patients (182; 80.5%),
however, a significant 106 students thought competent
physicians do not make errors (46.9%) (items 1,2,3). For
item 4, a significant number of students thought most
errors are not related to physicians (94; 41.6%) and this
misconception was more among residents (32; 55.2%)
than HOs (15; 33.3%) and UGs (47; 38.2%) (p value = 0.04)
(Table-2).
Items 5 to 8 were related to perceptions about reporting of
medical errors (Table 1). Majority of students thought
medical errors should be reported (167; 73.9%). However,
nearly one-fourth said there is no need to report a near
miss event (53; 23.5%) and this misconception was more
common among UGs (33; 26.8%) and HOs (11; 24.4%)
compared to residents (9; 15.5%) (p value = 0.01) (Table-2).
For item 7, a significant number of students thought, only
physicians can determine the causes of medical error (90;
39.8%) and this misconception was more common among
UGs (63; 51.2%) than among HOs (12;26.7%) and residents
(15; 25.9%) (p value = <0.001) (Table-2). Another common
misconception was that reporting systems do little to
reduce medical errors (Agreed: 204; 90.3%) [Item 8].
More than one-third students thought errors can be
prevented by working hard and being more careful (69;
30.5%) and majority thought uncertainty should not be
tolerated in patient care (177; 78.3%) (items 9 and 10). A
significant number of students thought culture of
medicine was supportive for dealing with errors (101;
44.7%), however, a significant number was also neutral
about this (91; 40.3%), showing the uncertainty students
felt about this item (item 11) (Table-1).
Item 12 asked about awareness of students regarding
patient safety issues. Ninety-four students thought they
were well informed (41.6%) and another 72 were neutral
(31.9%). Significantly more residents compared to HOs
and UGs thought they were well aware of this issue
(residents: 35; 60.3%, HOs: 17; 37.8%, UGs: 42; 34.1%),
however this was not borne out by the results (p value =
0.01) (Table-2).
The vast majority agreed that patient safety is an
J Pak Med Assoc
1263 N. Shah, M. Jawaid, N. Shah, et al
Table-2: Comparison of patient safety items among undergraduate students, house officers and residents (226).
item Undergraduate students (n=123) House officers (n=45) Residents (n=58) P value
Disagree Neutral Agree Disagree Neutral Agree Disagree Neutral Agree
n(%) n(%) n(%) n(%) n(%) n(%) n(%) n(%) n(%)
1 24(19.5) 25(20.3) 74(60.2) 8(17.8) 14(31.1) 23(51.1) 19(32.8) 7(12.1) 32(55.2) 0.07
2 8(6.5) 15(12.2) 100(81.3) 1(2.2) 8(17.8) 36(80.0) 1(1.7) 11(19.0) 46(79.3) 0.38
3 44(35.8) 24(19.5) 55(44.7) 13(28.9) 11(24.4) 21(46.7) 19(32.8) 9(15.5) 30(51.7) 0.74
4 42(34.1) 34(27.6) 47(38.2) 12(26.7) 18(40.0) 15(33.3) 17(29.3) 9(15.5) 32(55.2) 0.04
5 91(74.0) 23(18.7) 9(7.3) 34(75.6) 9(20.0) 2(4.4) 42(72.4) 9(15.5) 7(12.1) 0.67
6 73(59.3) 17(13.8) 33(26.8) 21(46.7) 13(28.9) 11(24.4) 44(75.9) 5(8.6) 9(15.5) 0.01
7 38(30.9) 22(17.9) 63(51.2) 20(44.4) 13(28.9) 12(26.7) 36(62.1) 7(12.1) 15(25.9) <0.001
8 8(6.5) 4(3.3) 111(90.2) 2(4.4) 1(2.2) 42(93.3) 5(8.6) 2(3.4) 51(87.9) 0.92
9 61(49.6) 21(17.1) 41(33.3) 28(62.2) 10(22.2) 7(15.6) 27(46.6) 10(17.2) 21(36.2) 0.19
10 10(8.1) 22(17.9) 91(74.0) 2(4.4) 5(11.1) 38(84.4) 4(6.9) 6(10.3) 48(82.8) 0.50
11 16(13.0) 53(43.1) 54(43.9) 7(15.6) 18(40.0) 20(44.4) 11(19.0) 20(34.5) 27(46.6) 0.78
12 35(28.5) 46(37.4) 42(34.1) 13(28.9) 15(33.3) 17(37.8) 12(20.7) 11(19.0) 35(60.3) 0.01
13 4(3.3) 2(1.6) 117(95.1) 0(0.0) 1(2.2) 44(97.8) 2(3.4) 0(0.0) 56(96.6) 0.61
14 7(5.7) 7(5.7) 109(88.6) 1(2.2) 3(6.7) 41(91.1) 4(6.9) 2(3.4) 52(89.7) 0.78
15 4(3.3) 7(5.7) 112(91.1) 0(0.0) 0(0.0) 45(100.0) 3(5.2) 2(3.4) 53(91.4) 0.26
16 8(6.5) 9(7.3) 106(86.2) 0(0.0) 0(0.0) 45(100.0) 3(5.2) 1(1.7) 54(93.1) 0.06
17 8(6.5) 11(8.9) 104(84.60) 0(0.0) 5(11.1) 40(88.9) 3(5.2) 5(8.6) 50(86.2) 0.53
18 6(4.9) 8(6.5) 109(88.6) 0(0.0) 1(2.2) 44(97.8) 4(6.9) 1(1.7) 53(91.4) 0.21
19 9(7.3) 7(5.7) 107(87.0) 1(2.2) 3(6.7) 41(91.1) 5(8.6) 4(6.9) 49(84.5) 0.73
20 6(4.9) 7(5.7) 110(89.4) 0(0.0) 2(4.4) 43(95.6) 5(8.6) 3(5.2) 50(86.2) 0.37
* Chi-square test was applied. P value significant at <0.05.
important topic (217; 96.0%), should be taught in medical
school (202; 89.4%), they would like to learn how to help
friends respond to error (194; 85.8%), how to analyze
errors (206; 91.2%) and how to disclose error to patients
(197; 87.2%) and to faculty (203; 89.8%) (Items 13-20)
(Table-1).
Discussion
Patient safety is still a relatively new concept, especially in
the context of Pakistan where the 'culture' of medical
training is still one of hiding medical errors, holding
individuals responsible and naming, blaming and
shaming them in the hope that error will not be repeated.
To avoid facing this blame-game, pages are torn from case
files, new notes written and documentation changed.
Enquiries are held in response to complaints by patients
and their families, but they are nothing more than an
exercise in trying to discipline individuals.5
Patient safety is a key component of one of the core
competencies of The Accreditation Council for Graduate
Medical Education (ACGME) which is system-based care
(SBC) and can be defined as the overall role and
responsibility of the healthcare system to avoid harm to
patients and provide high-quality care.10 Furthermore,
WHO has highlighted an urgent need for introducing
patient safety programmes in undergraduate and
graduate medical curriculum. This is a challenging task
since the concept of patient safety is still new to medical
education. Medical universities are uncertain about how
to incorporate these courses into their existing curricula
and hence continue to produce graduates who lack basic
knowledge, skills and attitudes necessary for providing
safe care.11,12
Several studies have compared outcomes before and after
introducing patient safety education programmes in the
curriculum, and have shown significant improvements in
students' knowledge, skills, and attitudes related to
medical error and patient safety. However, all changes
may not be sustained over the long term. Moreover, the
success of such programmes has been shown to depend
on teaching strategies based on adult learning principles
and experiential learning.13,14
Our study has shown several important misconceptions in
medical students' knowledge related to medical error and
patient safety. Although majority of students were correct
in thinking that medical errors are inevitable, about a
quarter did not agree with this and approximately 20%
remained neutral. In addition, nearly half the students
thought competent physicians do not make errors, which
is a basic misconception about the nature of human error.
A study from Hong Kong also reported similar results.9
It was encouraging to see that majority of our students
supported reporting of medical errors. However, around a
quarter, mostly UGs, felt there was no need to report near
misses, thus missing the importance of learning from such
cases. A qualitative study reported the effect of hidden
curriculum on students' perceptions, where students felt
that even though their ethical belief in the past was to
own up to mistakes and apologise, the 'culture' of
medicine has made them uncertain. Medical community
may not want them to speak in view of the risk of
litigation, and also to remain quiet and defend other
doctors who make mistakes.15
The majority of students attributed the causes of error to
the 'person approach' and was not aware of the
importance of 'systems approach' and of reporting
systems. For example, a common misconception,
especially among UGs, was that only physicians can
determine the causes of medical error. Furthermore, a
significant number of students thought working harder
and being more careful will prevent future errors.
However, evidence shows that the traditional
"perfectibility" model which assumed that errors can be
avoided by being careful enough and working hard can
be dangerous as the human infallibility is inevitable and a
major contributing factor for adverse events.3
The vast majority of students felt uncertainty should not
be tolerated in patient care, but evidence says all medical
interventions have an element of uncertainty. Therefore,
patients and their families have a right to receive useful
information which will help them in making decisions
about the care they receive.3
Responses to item 11 (which asked about the influence of
culture of medicine on the reporting of errors) showed
students' confusion about the implicit reference to the
"hidden curriculum". A study which evaluated the surgical
safety practices in tertiary care hospitals of Karachi,
Pakistan, found significant deficiencies in implementation
of WHO surgical safety checklist which may be due to a
hidden curriculum at work. Ensuring safe surgical
practices require an organisational structure having
leadership, teamwork, evidence-based management
protocols, ongoing teaching and training programmes,
and a proper system of incident reporting, adverse event
disclosure, and regular audit. Similar guidelines have been
developed by the international medical educators at the
Association for Medical Education in Europe (AMEE) 2006
conference, for prioritising areas for teaching patient
safety. These include providing knowledge about patient
safety, developing willingness to take responsibility,
developing self-awareness of the situations when patient
Vol. 65, No. 12, December 2015
Patient safety: Perceptions of MedicalStudents of Dow Medical College, Karachi 1264
safety is compromised, and developing inter-personnel
communication skills, and team-working skills.16-18
The good news from our study is that the vast majority of
students recognised the importance of patient safety
education, and highly supported its inclusion in the
medical curriculum. They also indicated that they would
like to learn how to analyse medical errors and how to
disclose these to patients and faculty members. However,
introducing patient safety teaching in undergraduate
curriculum poses considerable challenges as there are
significant differences in the development of course
design, content, stage of introduction in curriculum, and
methods for assessing the outcomes.
The WHO Patient Safety Curriculum Guide for Medical
Schools can serve as the standard guideline for
developing a uniform patient safety curriculum.
Furthermore, to make teaching of patient safety effective
and fit for purpose, theory has to be linked to real practice
by applying the human factor approach in order to have a
positive impact on students' future clinical
performance.19,20
The strength of this study is that we included participants
from a range of specialties and across different levels of
training. The main limitation is that we used a non-
standardised survey questionnaire and, secondly, since
the data was self-reported there could be an element of
recall bias.
We recommend that the Patient Safety Curriculum Guide
developed by WHO should be implemented in all medical
universities of Pakistan. This is a comprehensive
programme, having a Teachers' Guide as well as a ready-
to-teach, topic-based programme which can be
implemented as a whole or on a topic basis. This patient
safety education should begin as soon as students enter
their first clinical rotation so that they can apply their new
knowledge and skills to real patients.3
Today's students will be tomorrow's healthcare
professionals and it is imperative that we make them
competent and safe for ourselves and our future
generations.
Conclusion
A significant knowledge gap existed among medical
students regarding patient safety issues, particularly
about the system-based and team-based approach to
management of medical errors. The teaching of patient
safety was highly supported by students and needs to be
included in the curriculum on an urgent basis.
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