Twelve tips for implementing a patient safety curriculum in an undergraduate program in medicine

Abstract

Patient safety is a major priority for health services. It is a multi-disciplinary problem and requires a multi-disciplinary solution; any education should therefore be a multi-disciplinary endeavour, from conception to implementation. The starting point should be at undergraduate level and medical education should not be an exception. It is apparent that current educational provision in patient safety lacks a systematic approach, is not linked to formal assessment and is detached from the reality of practice. If patient safety education is to be fit for purpose, it should link theory and the reality of practice; a human factors approach offers a framework to create this linkage. Learning outcomes should be competency based and generic content explicitly linked to specific patient safety content. Students should ultimately be able to demonstrate the impact of what they learn in improving their clinical performance. It is essential that the patient safety curriculum spans the entire undergraduate programme; we argue here for a spiral model incorporating innovative, multi-method assessment which examines knowledge, skills, attitudes and values. Students are increasingly learning from patient experiences, we advocate learning directly from patients wherever possible. Undergraduate provision should provide a platform for continuing education in patient safety, all of which should be subject to periodic evaluation with a particular emphasis on practice impact.

Full text

2011; 33: 535–540
TWELVE TIPS
Twelve tips for implementing a patient safety
curriculum in an undergraduate programme
in medicine
GERRY ARMITAGE
1
, ALISON CRACKNELL
2
, KIRSTY FORREST
2
& JOHN SANDARS
3
1
Bradford Institute for Health Research, Bradford Teaching Hospitals, NHS Foundation Trust; and School of Health,
University of Bradford, Bradford, UK,
2
Leeds Teaching Hospital, NHS Trust, Leeds, UK,
3
University of Leeds, Leeds, UK
Abstract
Patient safety is a major priority for health services. It is a multi-disciplinary problem and requires a multi-disciplinary solution; any
education should therefore be a multi-disciplinary endeavour, from conception to implementation. The starting point should be at
undergraduate level and medical education should not be an exception. It is apparent that current educational provision in patient
safety lacks a systematic approach, is not linked to formal assessment and is detached from the reality of practice.
If patient safety education is to be fit for purpose, it should link theory and the reality of practice; a human factors approach offers a
framework to create this linkage. Learning outcomes should be competency based and generic content explicitly linked to specific
patient safety content. Students should ultimately be able to demonstrate the impact of what they learn in improving their clinical
performance. It is essential that the patient safety curriculum spans the entire undergraduate programme; we argue here for a spiral
model incorporating innovative, multi-method assessment which examines knowledge, skills, attitudes and values. Students are
increasingly learning from patient experiences, we advocate learning directly from patients wherever possible.
Undergraduate provision should provide a platform for continuing education in patient safety, all of which should be subject to
periodic evaluation with a particular emphasis on practice impact.
Introduction
Patient safety is a major priority for healthcare. Modern
medicine has contributed to enormous advances in healthcare,
but the incidence of medical error frequently undermines
progress, and serious adverse events can cause irreparable
damage to all those involved.
The National Patient Safety Foundation and the Lucian
Leape Institute advocate that an essential first step to improve
patient safety is to reform undergraduate medical education.
They highlight the need for new content, but also emphasise
the need for a new focus on mentorship and the development
of attitudes as well as skills (Piankiewicz et al. 2008). However,
any long-term improvements in patient safety will only be
achieved if the students learn the craft of medicine in organi-
sational cultures that have patient safety as their first priority.
This requires the parallel development of medical teachers and
mentors, who have a strong understanding of patient safety
and can equip students with the skills to reduce the risk of
preventable harm (Institute of Medicine 2001).
A recent in-depth survey of pre-registration health profes-
sional curricula in England and Scotland (Ashcroft et al. 2008)
found that patient safety is often implicit rather than explicit,
usually excluded from the assessment process, and lacks
organisational context. Moreover, it would seem that curricula
are not capturing the sense of reality that patient safety can
bring to student learning which, if carefully and consistently
synthesised into a programme of study, could convince
students and their clinical mentors of its intrinsic value.
Patient safety warrants an explicit place in the curriculum, a
position also taken by UK Government in the Health Select
Committee Report on Patient Safety (2009); the same position
has been taken by the World Health Organisation (WHO),
who has also published a Patient Safety Curriculum Guide
(WHO 2009). Such guidance is particularly welcome when the
UK General Medical Council emphasises the need for safe
practice but adds little detail on how this might be achieved
Practice points
.Safer healthcare requires that undergraduate medical
programmes include a patient safety curriculum.
.Human factors provide a useful framework for devel-
oping a systematic curriculum planning process.
.A spiral curriculum is recommended with definitive
competencies and innovative assessment to reflect the
realities of practice.
.Patient safety education offers an opportunity to
advance multi-disciplinary working and should continue
beyond initial qualification.
Correspondence: G. Armitage, School of Health, University of Bradford, BD5 0BB, UK. Tel: 44 01274 383428; fax: 44 01274 382640;
email: Gerry.armitage@bradfordhospitals.nhs.uk
ISSN 0142–159X print/ISSN 1466–187X online/11/070535–6 ß2011 Informa UK Ltd. 535
DOI: 10.3109/0142159X.2010.546449

(Tomorrow’s Doctors 2009). Other medical education pro-
viders, to our knowledge, have also implemented patient
safety curricula, but in specific modules, in a specific year
(Finn & Patey 2009).
In this article, we describe how an undergraduate pro-
gramme in medicine has embedded the theory and practice
of patient safety in a spiral curriculum model from years one
to five of the curriculum as part of a recent curriculum
review. The principles we drew upon and the actions we
have taken are combined to suggest 12 tips for developing
an integrated patient safety curriculum for medical students.
Tip 1
Develop a multidisciplinary curriculum development
team with representation from primary and second-
ary care
The provision of safe and effective healthcare is complex
and numerous personnel are involved. However, healthcare
education is traditionally organised around specific depart-
ments or specialties with little inter-professional education
and minimal attention to how various systems link together
into an integrated whole. If we are to accept the premise
that inter-professional education is a valid means of laying
the foundations of good teamwork skills beyond traditional
professional boundaries, i.e. ‘those who work together should
train together’ (House of Commons Health Select Committee
2009, Section 196), it is self-evident that the curriculum
development team reflects this broader perspective. The exact
composition of the curriculum development team will vary
across different contexts; the development team for the
Leeds curriculum included a nurse, an anaesthetist, a medical
internist and a general practitioner. Each has a passion
for improving patient safety, possesses a substantial under-
standing of human error and importantly holds educational
expertise. Although we did not include a patient in the team,
we are now drawing on parallel work with a partner organi-
sation, currently carrying out a large scale nationally funded
programme of research on patient involvement in patient
safety including involvement in medical education.
1
Tip 2
Decide on content using human factors as a
framework
Human factors theory acknowledges that people and their
behaviour are influenced by a whole range of factors. They
can be organisational, environmental, arise from local condi-
tions, relate to individual human characteristics and can
sometimes lead to human error. The additional premise of
accepting the natural human tendency to err is critical to
understanding the human factors perspective (Reason 2008).
As human factors is fast becoming the predominant
approach to managing medical error across many health
services, the human factors perspective should certainly be
included in any undergraduate teaching. While we will employ
human factors in delivering the curriculum, we also used
human factors to inform our curriculum framework.
In our initial planning meetings, we agreed on four
domains of competence upon which to build the curriculum
content: knowledge, communication and cooperation, situa-
tional awareness, decision making and accountability, all
linked to a key overarching, underpinning concept of
‘systems’. Figure 1 shows the building blocks.
Tip 3
Identify learning outcomes through
competencies based on human factors
Knowledge for safety is the foundation for each of the
domains; students should understand the language of safety
(e.g. near misses, adverse events and the notion of harm), and
the epidemiology of medical error. Additionally, they should
recognise failure, the nature of causation, and the role of
patient safety interventions. We based communication content
on the principles of crew resource management – an approach
grounded in human factors – to improve 1:1 and team
communication processes (Helmreich & Foushee 1993).
Consequently, students will be expected to demonstrate
effective handover skills and use specific patient safety tools
such as checklists.
Figure 1. Building blocks for patient safety in the Leeds undergraduate medical curriculum.
G. Armitage et al.
536

Situational awareness is also a skill-based domain; students
must develop a dynamic awareness of their surrounding
environment, colleagues, and time, ultimately being able to
assess a given situation and how it might change. Decision
making and accountability is grounded in professional respon-
sibility. Students should recognise the importance of clinical
evidence to inform their decisions and actions, and if an error
occurs – acknowledge the duty to be open with colleagues
about the circumstances and learn from the action taken –
appreciating that patient safety is a cross-professional priority.
Inculcating the students with these values through defin-
itive competences is also designed to relieve the on-going
problem of some doctors being disengaged from reporting
(Evans et al. 2006; Miller et al. 2006; Evans et al. 2007; Armitage
et al. 2010), and others being reluctant to recognise their
limitations and seek assistance from senior colleagues
(Franklin and Matthew 1994). Furthermore, we are aware
that for some time, doctors have perceived a systems approach
as a potential threat to clinical autonomy (Esmail 2006).
However, such an approach can again engender in students a
whole organisation perspective i.e. errors are seen as a
product of the organisation in which they occur rather than a
direct consequence of individuals’ actions (Reason 2000).
Tip 4
Consider the relationship between generic and
specific safety competencies
The scope of an undergraduate patient safety curriculum is
vast since numerous factors interplay to produce and reduce
threats to patient safety. The obvious response is to produce a
lengthy and comprehensive curriculum, such as the Australian
Patient Safety Education Framework (2005). Yet it is unlikely
that all of the detailed curriculum statements could be
implemented in an already crowded undergraduate curricu-
lum with competing demands for importance.
Generic competencies were identified from the wider
undergraduate medical curriculum and we mapped how
these competencies related to the patient safety curriculum.
Generic competencies will be identified early in the pro-
gramme with non-clinical scenarios and then applied to
clinical practice, e.g. the lack of collective responsibility in
the Herald of Free Enterprise disaster was also apparent in the
Wayne Jowett case where vincristine was incorrectly admin-
istered into the patient’s intrathecal space. However, in line
with the House of Commons Select Committee Report, we
emphasise application, and transference of skills rather than a
simple list of competencies required by the end of training, e.g.
maintenance of a clinical pharmacy module but explicitly
linked to safe prescribing skills.
Tip 5
Integrate the new curriculum within the existing
curriculum
The domains of competence described above are not tradi-
tionally taught in medical school but are fast becoming a
consideration for many education providers, driven by larger
scale developments. However, patient safety also links with
many existing subjects, especially within the personal and
professional development, and ethical themes. Examples
include personal conduct, whistle blowing and taking respon-
sibility for one’s own mistakes.
For any new aspect of a curriculum to succeed, it is
important that its principles are integrated and contextualised
through those components of the existing curriculum that
consistently evaluate well. We were fortunate in that the Leeds
undergraduate curriculum was undergoing a major review of
content during this time. Patient safety was situated in a new
theme called IDEALS (innovation, development, enterprise,
leadership and safety) that runs across the programme
(Figure 2). However, many principles overlapped and it was
quickly evident that close working was required to prevent
unnecessary repetition and develop a truly integrated spiral
curriculum.
Tip 6
Plan stepwise/spiral curriculum
We chose a spiral curriculum, a description given to the
process whereby topics are revisited over time with increasing
levels of difficulty, new applications and ongoing practical
experience. New learning is related to previous learning, to
increase competence. It is based on the constructivist model of
learning – that is, the learning takes place by building
individual concepts that are added to or revised as new
information arises. The major components of a spiral curric-
ulum as described by Cooper and Forrest (2009) include:
.revisiting clinical and professional practice, and studying at
increasingly complex levels;
.practising with decreasing supervision;
Figure 2. The IDEALS octagon (permission to reproduce
kindly given by the School of Medicine at the University of
Leeds).
Implementing a patient safety curriculum
537

.building on existing levels of understanding; and
.recognising that levels of expertise generally increase with
practice and reflection.
Tip 7
Identify and train facilitators
We recognise that simply filling students with knowledge will
not produce junior doctors whose practice is orientated to
team working. Although the curriculum framework advocated
here goes beyond the delivery of knowledge, the impact on
medical practice can only be realised if an equivalent safety
culture exists in student placements. A recent study has
demonstrated the resistance to advancing non-technical skills
among surgeons (McCulloch et al. 2009). Some facilitators are
then likely to require support, and this may need to be
formalised, e.g. a short course in human factors and patient
safety will also require expert facilitators as some aspects of the
patient safety curriculum are especially challenging such as
developing situational awareness and decision-making skills.
Tip 8
Involve healthcare professionals in the curriculum
delivery
The complexity of modern healthcare requires effective team
working across a variety of different professional groups, and
research on patient safety has clearly identified that many
threats occur when there is a breakdown in team working
(Carthey et al. 2003). Involving different healthcare profes-
sionals in the delivery of a patient safety curriculum not only
provides students with a range of different perspectives
but also has the potential of eroding any ritualised medi-
cal identity, engaging these professionals in improving the
safety of the care that they provide. This can be achieved
by joint tutor development sessions, collaborative delivery
of training workshops and giving feedback as part of
the assessment process in, e.g. problem based, or action,
learning sets.
Tip 9
Involve patients in the curriculum delivery
It is essential to include experiences of patients in all patient
safety topics to highlight the relevance and bring theory to life.
Hearing first hand from a patient or relative involved in an
adverse event is an effective tool for students to understand the
complexities of error; reflect on the patient (and family) impact
and appreciate the need for effective communication following
the event. Real patients will be invited to take part in case
discussions early in the curriculum, helping the student
understand the importance, relevance and impact of error.
Videos/DVDs and case studies of patients’ experiences are
also used. They are available from such agencies as the
National Patient Safety Agency (e.g. Just an Ordinary Day)
and in the WHO Patient Safety Curriculum Guide (WHO 2009).
The curriculum development team included a patient safety
researcher who is a co-applicant in the previously mentioned
research programme (Note 1), part of which will evaluate the
role of patients in teaching junior doctors using personal
narratives. The research findings from this programme will
inform any further enhancements to patient involvement in the
curriculum.
Tip 10
Develop assessments
Assessment is instrumental in motivating students and is an
integral part of any curriculum. Students need to be assessed
on their knowledge and understanding of the generic princi-
ples of patient safety, human error and evidence-based safety
interventions. Over the duration of the course, students will be
expected to demonstrate an increasing level of self-awareness,
critical analysis, application of theory to practice and ultimately
the principles of management in acute situations. Assessments
Figure 3. Our current spiral, starting from year one, and continuing throughout postgraduate medical education.
G. Armitage et al.
538

will mirror topics and match their learning outcomes on the
spiral curriculum map (Figure 3).
Introducing a new curriculum has required the design and
validation of new assessment tools. In the early years, all
students at Leeds will have an electronic portfolio to record
reflective logs after each patient safety session and clinical
situations where they have observed a patient safety incident.
A structured written assignment will be attached to the e-
portfolio for summative assessment to demonstrate an under-
standing of the generic principles of patient safety. We are
currently developing innovative assessments for the latter
years including: root cause analysis of previous (anonymised)
incidents from partnering organisations; detecting and correct-
ing prescribing errors in complex prescribing regimes as part
of a problem-based learning (PBL) exercise; managing the
deteriorating patient; and further reflective assignments based
on real world case studies. The prescribing and root cause
analysis assignments will be led by experienced facilitators;
students will be expected to identify objectives, problems,
implications and solutions. There are already developed and
validated novel OSCE assessments for the final MBChB
Assessing Patient Safety Skills Essential for Professional
Practice, including: clinical handover; safe prescribing;
record keeping; and open disclosure. These involve simulated
patients and video components; they elicit and test a range of
abilities such as decision making, practical skills and profes-
sionalism. To advance the multi-disciplinarity of the curricu-
lum, we will also include a range of different health
professionals and academic staff in assessing the PBL and
the root cause analysis assignments.
Tip 11
Map on to local postgraduate patient safety provision
Dynamic undergraduate medical education should provide a
suitable platform for subsequent postgraduate education and a
seamless transition between the two. The Leeds University
curriculum has attempted to do this by developing the IDEALS
theme referred to above; patient safety being appropriately
embedded in IDEALS across 5 years. However, in order to
realise the maxim of life-long learning, local medical deaneries
should also be mindful of postgraduate patient safety educa-
tion, thereby continually re-enforcing safety as a core attitude
(Ellis 2009). We advocate a regional approach based on our
previously argued emphasis on human factors and inter-
professional learning. Such an approach has recently been
launched in the Yorkshire and Humber Deanery – in
conjunction with the authors of this article, the Bradford
Institute for Health Research, and the Strategic Health
Authority.
2
Tip 12
Evaluate the curriculum
An essential aspect of evaluating the patient safety curriculum
is to consider its impact on improving patient safety. A widely
used approach to evaluate any training intervention considers
its impact at several levels: reaction, learning, behaviour and
results (Kirkpatrick 1998). Reaction is the level of satisfaction
that participants feel about the training and is the most
commonly used method. Evaluating the learning is usually a
self-perception of change in knowledge, skills or attitudes.
Measurement of knowledge, such as by a multiple choice test,
can be performed but an important aspect of patient safety
education is to increase awareness and produce a cultural
change that recognises that patient safety is paramount in any
clinical interaction. A validated questionnaire has recently
been developed to measure the attitudes to patient safety of
both students and tutors (Carrruthers et al. 2009). This
questionnaire will be used to measure attitudinal change.
It would also be helpful to know whether a curriculum
actually changes the way that professionals behave in clinical
practice, but such an evaluation would be inevitably complex
as a consequence of the many variables that impact on the
delivery of care. The ultimate aim of a patient safety
curriculum is to reduce the massive extent of harm and
potential harm that is associated with healthcare, but this may,
of course, take several years to achieve. However, combined
with new inter-professional postgraduate training we could
envisage a critical mass of patient safety advocates in the near
future.
Conclusion
The curriculum we designed between 2008 and 2009 is being
implemented from September 2010. Future students will be
likely to share the goals of their many predecessors – passing
the final examinations and working as a doctor. Although
these goals are eminently understandable, the curriculum
proposed here, using patient safety as a vehicle, seeks to
develop students who, from the early years of training, will
begin to understand the inevitability of human error, recognise
the need for constant vigilance, and practice as part of a
clinical team and not as individuals.
We are now also aware that both the curriculum content
and process we have described has considerable overlap with
the WHO Patient Safety Curriculum Guidance, which we view
as strength. Both curricula deliver a specific knowledge base
but also the acquisition of particular skills; perhaps most
importantly, we aim to inculcate the maxims of patient safety
and human factors as cultural norms in contemporary practice.
This curriculum is not an isolated initiative and has been
developed as part of a region-wide initiative to improve patient
safety education for future and existing medical practitioners
and their professional colleagues.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the article.
Notes on contributors
GERRY ARMITAGE, BSc (Hons) MSc PhD FIHE RN, is a senior fellow at the
Bradford Institute for Health Research. He is a nurse by background, has
led and taught higher education programmes, and spent the last 7 years
Implementing a patient safety curriculum
539

carrying out and publishing patient safety research. Gerry is a member of
the Clinical Human Factors Group.
ALISON CRACKNELL, MBChB (Hons), MRCP (UK), is a consultant
geriatrician at Leeds Teaching Hospitals NHS Trust and also teaches on
the undergraduate medical curriculum at Leeds; Alison is actively involved
in both patient safety education and research.
KIRSTY FORREST, FAcadMed, MMEd, FRCA, MBChB, BSc Hons, is a
consultant anaesthetist who actively teaches on the undergraduate medical
curriculum at Leeds University; she leads a patient safety and human factors
programme for qualified staff at the Leeds Teaching Hospitals NHS Trust.
Kirsty’s articles are widely published in medical education.
JOHN SANDARS, MBChB (Hons), MSc, MD, MRCP (UK), FRCGP, NHS, is a
general practitioner and senior lecturer at Leeds Institute of Medical
Education. John has an international profile in patient safety and works
extensively in advancing patient safety education in the developing world.
He has published widely on patient safety, medical education and e-
learning.
Notes
1. Bradford Institute for Health Research, Bradford Teaching
Hospitals NHS Foundation Trust. Patient Involvement in
Patient Safety. A five-year programme of study funded by
the National Institute for Health Research 2009–2014.
2. Training and action for patient safety (TAPS): training
specialty teams across healthcare economies to learn about
safety, find solutions to local problems and measure any
improvement.
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