WHO Patient Safety Curriculum Guide for Medical Schools

Article (PDF Available)inQuality and Safety in Health Care 19(6):542-6 · December 2010with395 Reads
DOI: 10.1136/qshc.2009.036970 · Source: PubMed
Abstract
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 existing curriculum. 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.
The WHO patient safety curriculum guide
for medical schools
Merrilyn Walton,
1
Helen Woodward,
2
Samantha Van Staalduinen,
3
C Lemer,
4
F Greaves,
4
D Noble,
4
B Ellis,
4
L Donaldson,
5
B Barraclough,
6
for and on behalf of the
Expert Group convened by the World Alliance of Patient Safety, as Expert Lead for the
Sub-Programme
ABSTRACT
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
existing curriculum.
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.
INTRODUCTION
Patient safety has been on the reform agenda of
many countries since the publication of studies
documenting the extent of harm caused by
healthcare,
1 2
but the case for education and
training of healthcare students in patient safety
rst formally recognised nearly a decade ago in the
report To Err is Human
3
is only now gathering
momentum. Since then, other reports
45
have
echoed the need for patient safety education.
Medical students have identied the absence of
patient safety education and voted in 2004 for
increased attention to quality and safety,
6
and
again in 2007 when the Association for Medical
Education in Europe
7
recommended that patient
safety education be integrated from the start of
existing undergraduate courses.
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
identied substantial deciencies in patient safety
knowledge across a range of training areas and
specialties.
8
This lag between learners desires and
faculty delivery is perhaps understandable, consid-
ering that medical schools nd it difcult to
translate patient safety knowledge into curricular
change.
910
What patient safety knowledge and
skills should we teach? What competencies do
healthcare professionals need to keep patients safe?
The Australian Patient Safety Education Frame-
work
11
(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 care
12
according to their level of
experience and supervision. In 2008, The WHO
World Alliance for Patient Safety acted to ll the
gap in patient safety education for medical
students by sponsoring the development of
a universal patient safety curriculum guide for
medical schools worldwide. While it is clearly
recognised that nursing and allied healthcare
professions would also benet from such a guide
and that the gold standard is a multiprofessional
integrated curriculum, a pragmatic decision was
made to rst pilot and focus internationally on
medical students.
Context for patient safety education
While patient safety is a relatively new concept, it
embraces many medical education principles rst
considered by Flexner in the early 20th century, the
need for a strong scientic basis alongside analytical
and critical thinking.
13
He also recognised attri-
butes such as ethical practice, professionalism,
population health, compassion and integrity to be
equally important.
14
The main difference between patient safety
requirements and the list of ethical attributes
described above
15 16
is 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.
1
Sydney School of Public Health,
Faculty of Medicine, University
of Sydney, Sydney, Australia
2
St Mary’s Hospital, Imperial
College, Healthcare NHS Trust,
St Mary’s Hospital, London, UK
3
Office of Postgraduate Medical
Education, University of Sydney,
Sydney, Australia
4
Patient Safety Programme,
World Health Organization,
Department of Health, London,
UK
5
World Alliance for Patient
Safety, World Health
Organization, Department of
Health, London, UK
6
International Society for Quality
in Health Care, Wahroonga,
Australia
Correspondence to
Professor Merrilyn Walton,
Sydney School of Public Health,
Faculty of Medicine, University
of Sydney, Edward Ford Building
(A27), Sydney 2006, Australia;
merrilyn.walton@sydney.edu.au
For author footnote see end of
the article.
Accepted 20 June 2010
542 Qual 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.
17
It refo-
cuses learning on the patient and the multiple interactions that
can either heal or harm them. Many studies
11819
highlight that
alongside the enormous benets of medical care are signicant
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 patients safety depends on more than any
one persons 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 inuence 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. Its principles and concepts apply to all areas 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-
ventions
9 21
to educational programmes fully integrated across all
years of school-based training.
22
Some 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.
92123e25
Others have introduced 1- or 2-day
intensive courses.
26 27
While 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,
28
across an
entire second year of another programme,
29
and even across all
the years of medical training.
22
Many 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 Cur riculum 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
schools.
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
APSEF to identify the topic areas and competencies for the level of
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 Guides development.
The expert group provided review and comment on the
curriculum, case studies and region-specic 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
patient safety?
3. Understanding systems and the impact of complexity on
patient care
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.2009.036970 543
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 difcult. 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, nd any
change difcult, 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 Teachers
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
also included.
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
health services.
Each topic follows a standard educational format as
described i n box 3. The content of the topic is designed for
both students and teachers. Each topic can be adapted to s uit
the medical school and teachers needs, whether delivered as
web-based Learning Topics with activities designed around
the learn ing 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 reective
activities.
Table 1 Framework for managing conflicts in medical situations
Area or attribute Examples Old 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/sup ervise.
Infallibility of doctors;
attitude to mistakes
Mistakes are only made by people who are
incompetent or unethical. Good doctors do not
make mistakes.
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.
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.
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
curriculum
<
To provide a comprehensive curriculum to assist teaching and
integrating patient safety learning
<
To further develop capacity for patient safety educators in
medical schools
<
To promote a safe and supportive environment for teaching
students about patient safety.
<
To introduce or strengthen patient safety education in medical
schools worldwide
<
To raise the international profile of patient safety teaching and
learning
<
To foster international collaboration on patient safety
education research in the higher education sector.
Box 3 Template used for each topic
Learning objective
Learning outcomes
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
Case studies
Tools and resources
How to evaluate this topic
Electronic resources
How to assess this topic
Slides for topic
544 Qual 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 a lready lled beyond capacity; thus, topics were designed to
be either integrated into existing teaching or introduced as
stand-alone modules. Table 2 shows how a pati ent safety
principle (correct patient identication) has specicapplication
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
curricula.
An example of an opportunity for integration of Curriculum
Guide content into existing medical school cur ricula is the
revision of problem-based learning (PBL) cases to include patient
safety topics. The PBL format reects principles and activities
that promote patient safety in the workplacedincluding
collaboration and teamwork, clarication and respect of each
persons roles and responsibilities, identication 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 sacricing
the original content of the case. Table 4 describes the revision of
a respiratory sciences case to incorporate learning related to
medical error.
Evaluation
The nal draft o f 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 var iety of different medical schools. The number of topics
implemented (minimum o f 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 qu estionnaires, f ocus groups
and online discussion forums for students and teachers. The
pilot and evaluation are scheduled to be completed by the end
of 2010.
CONCLUSION
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 benet patients from all over
the world.
Author footnote
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.
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Table 2 Application of correct patient identification principles across
disciplines
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
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Surgery If a patient needs a blood transfusion, what checking processes are in
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Table 3 Examples of integration areas for Curriculum Guide topics
Curriculum guide topic Potential subject areas for integration
Minimising infection through
improved infection control (Topic 9)
Microbiology
Procedural skill training
Infectious diseases
Clinical placements
Improving medication safety (Topic 11) Pharmacology
Therapeutics
Clinical placements
What is patient safety? (Topic 1) Ethics
Introduction to the clinical environment
Clinical and procedural skills training
Table 4 Example of incorporating patient safety learning into problem-
based learning cases
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.
Additional information 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.
Additional discussion
questions
<
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
a mistake?
<
How can this be prevented?
<
What is the doctor’s role; what is the patient’s role?
Additional learning
objectives
<
List a doctor’s responsibilities when prescribing
medication
<
List strategies to minimise patients being given the
wrong medications that might harm them
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546 Qual Saf Health Care 2010;19:542e546. doi:10.1136/qshc.2009.036970
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    • "The WHO guide acknowledges that patient safety should be integrated , but recognises that most curricula are 'already filled beyond capacity' (Walton et al., 2010, p.545). While short term evaluation of the guide is reported as taking place, long term research into patient safety labelled curricula would be valuable in exploring impacts and consequences such as those predicted by participants in this study. "
    Full-text · Dataset · Sep 2014 · Nurse education today
    • "topic 2: What is human factors engineering, and why is it important to patient safety?, and (b) topic 3: Understanding systems and the impact of complexity on patient care (Walton et al., 2010). The US Agency for Healthcare Research and Quality (AHRQ) promotes an HFE approach to the design of health information technology (IT) (NRC Committee on the Role of Human Factors in Home Health Care, 2010, 2011) and has published a variety of guidance documents on using HFE systems models to analyze patient safety events in healthcare delivery (Henriksen et al., 2008, 2009). "
    [Show abstract] [Hide abstract] ABSTRACT: Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.
    Full-text · Article · Jul 2013
    • "The WHO guide acknowledges that patient safety should be integrated , but recognises that most curricula are 'already filled beyond capacity' (Walton et al., 2010, p.545). While short term evaluation of the guide is reported as taking place, long term research into patient safety labelled curricula would be valuable in exploring impacts and consequences such as those predicted by participants in this study. "
    [Show abstract] [Hide abstract] ABSTRACT: Education is crucial to how nurses practice, talk and write about keeping patients safe. The aim of this multisite study was to explore the formal and informal ways the pre-registration medical, nursing, pharmacy and physiotherapy students learn about patient safety. This paper focuses on findings from nursing. A multi-method design underpinned by the concept of knowledge contexts and illuminative evaluation was employed. Scoping of nursing curricula from four UK university programmes was followed by in-depth case studies of two programmes. Scoping involved analysing curriculum documents and interviews with 8 programme leaders. Case-study data collection included focus groups (24 students, 12 qualified nurses, 6 service users); practice placement observation (4 episodes=19hrs) and interviews (4 Health Service managers). Within academic contexts patient safety was not visible as a curricular theme: programme leaders struggled to define it and some felt labelling to be problematic. Litigation and the risk of losing authorisation to practise were drivers to update safety in the programmes. Students reported being taught idealised skills in university with an emphasis on 'what not to do'. In organisational contexts patient safety was conceptualised as a complicated problem, addressed via strategies, systems and procedures. A tension emerged between creating a 'no blame' culture and performance management. Few formal mechanisms appeared to exist for students to learn about organisational systems and procedures. In practice, students learnt by observing staff who acted as variable role models; challenging practice was problematic, since they needed to 'fit in' and mentors were viewed as deciding whether they passed or failed their placements. The study highlights tensions both between and across contexts, which link to formal and informal patient safety education and impact negatively on students' feelings of emotional safety in their learning.
    Full-text · Article · May 2013
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