Safety for beginners: thoughts on teaching patient safety to medical undergraduates

The patient safety agenda has stalled simply from lack of doctor interest, and too many practising clinicians seem to be complacent, preoccupied by other concerns or overconfident.

Abstract

Can you teach an old dog new tricks? The answer may be as relevant to patient safety advocates as it is to pet owners. Exactly a decade after the Institute of Medicine’s noble cry to battle,1 patient safety is not where it needs to be. Without doubt, substantial progress has been made, but so much more remains to be done. Those who have become impatient with the halting pace may need to consider the possibility that the patient safety agenda has stalled simply from lack of doctor interest. Too many practising clinicians seem to be complacent, preoccupied by other concerns or overconfident.2 Safety, for them, is just not a priority. For this reason, we look with great hope at the possibility that the next generation of clinicians will ‘get it’, because so many of the current generation do not. The students themselves have eloquently expressed their keen desire to accept this challenge, as evidenced by an inspiring essay titled ‘Teach Us How’ by Alexander Nazem, a Year 3 medical student.3 Quality and safety are much higher priorities for clinicians-in-training because they want their new profession to match their idealistic expectations. We look with great hope at the possibility that the next generation of clinicians will ‘get it’ Enthusiasm to build patient safety curricula is essential and laudable. If we can just plant the patient safety bug in students, it may grow and flourish. The culture of safety will be part of their fibre; they will know how to learn from every close call and will look for every opportunity to continuously improve the health care system in the direction of reliable and safe health care.4 The challenge, then, is to create this new patient safety curriculum. We are just at the beginning of this process. The first step is to identify all the key domains relevant to a comprehensive patient safety education. The second step is to specify the competencies we want to see in the safety-savvy clinicians of the future. The third step is to construct evaluation tools that can be used for both formative and summative assessment. Enthusiasm to build patient safety curricula is essential and laudable The article by Flin et al.5 in this issue is a welcome and valuable contribution, focusing on a new safety curriculum evaluation tool designed for Year 1 medical students. The instrument assesses five key safety domains, can be completed in 15 minutes and has reasonably good psychometric characteristics. The assessment will be used to judge the impact of a proposed new patient safety curriculum. The importance of evaluation tools such as this one go far beyond the task of assessing whether the safety curriculum was successfully transferred. The instrument plays an important role in ‘blueprinting’ for trainees what we want and expect them to know. This may be a good time, however, to consider the possibility that we are reaching ahead of ourselves. Teaching patient safety is not like teaching biochemistry. Patient safety is hardly a mature field. Do we really know all the domains, all the competencies? As an example, diagnostic error is a major patient safety issue, but it isn’t included at all in this evaluation tool. The possibility that other elements might also be missing is suggested by reviewing the curriculum on patient safety recently developed by the World Health Organization, which lists 11 priority domains.6 The importance of evaluation tools such as this one go far beyond the task of assessing whether the safety curriculum was successfully transferred A second concern is that the safety classroom will extend far beyond the few hours granted by the curriculum committee. As they enter the real world of medical practice, trainees will see first hand how important safety is, or is not, to their role models, co-workers and peers. The first time they see a safety concern be ignored or be given short shrift, they will learn that a great many other matters take priority over redressing the safety problem at hand. Unfortunately, they will see this a hundred times. The idea, then, of using the new assessment tool to judge the impact of a new safety curriculum will be muddied by these powerful lessons taught through the ‘hidden’ curriculum.4,7 A final concern is that we may be woefully ill-equipped to teach the most important lessons needed to achieve a safety-conscious workforce. We know how to teach about medication errors and falls and wrong-site procedures, but do we know how to teach about preventing complacency, overconfidence and competing priorities? Using the new assessment tool to judge the impact of a new safety curriculum will be muddied by these powerful lessons taught through the ‘hidden’ curriculum These are all novel issues that will have to be confronted at some point if we are to ever succeed in constructing a truly effective patient safety curriculum. Assessment tools will be an essential element of these new programmes, especially if they are comprehensive in scope, and shed some light on how the enthusiastic learner of today becomes the complacent practitioner of tomorrow.