Issue 21 / 4 June 2012

YOU could drown in the sea of clinical guidelines produced by multiple authorities, yet only rarely has their implementation been evaluated.

The same can be said about the teaching of patient safety.

The Australian National Patient Safety Education Framework was promulgated in 2005 by the Australian Council for Safety and Quality in Health Care. It aimed to provide a simple and accessible framework that identified the knowledge, skills, behaviours and attitudes, and performance that everyone who works in health care requires to optimise patient safety.

The Australian framework informed the development of the WHO Patient Safety Curriculum Guide, released late last year, which was also developed with the aim of integrating the teaching of patient safety into undergraduate medical curricula.

Our team at the University of NSW has just reported the results of a 2010 analysis of how Australian medical deans, educators and students perceive the teaching of the 22 learning topics included in the Australian framework.

All but one Australian medical school agreed to participate, and there were 2413 eligible responses from the three target groups, which included 2301 students.

While there was significant agreement that teaching about effective communication with patients took place, respondents were unconvinced that teaching occurred on the management of complaints (50% disagreed or neutral) and adverse events (35% disagreed or neutral).

These results contributed to the learning area “Managing errors, adverse events, risk and complaints” receiving the greatest proportion of negative responses from students and staff. However, “Open disclosure” after an adverse event received the most positive responses.

There were consistent and significant differences across the stakeholder groups, with the deans being more positive about the teaching of patient safety than educators, who in turn were more positive about it than the students. This may reflect a disparity between what is believed to be taught and what is actually being taught — rhetoric versus reality.

A similar disconnect has been discerned between consultant surgeons and their trainees in the UK, with the former having a rosier picture of the patient safety culture in their hospitals than their trainees.

Given that our Australian study was conducted in the context of the current dearth of evaluation of the implementation of guidelines, it is noteworthy that the majority of respondents were not aware of the National Patient Safety Education Framework. Despite this, most, but not all, of that curriculum is perceived as being taught.

The areas of weakness in medical undergraduate education that were identified and should be targeted include adverse event prevention and management, and management of complaints.

Australian medical schools will need to improve, as the accreditation of medical schools now requires that new doctors have “the skills needed to work safely as an intern”, as outlined in the National Patient Safety Education Framework.

It may also be worth extending enquiries into how doctors are educated in patient safety to the postgraduate domain — both pre- and post-fellowship — currently under the umbrella of the professional colleges, departments of health (by appointment, credentialling and reaccreditation processes), and their various bodies charged with enforcing clinical excellence, as well as the risk management arms of medical defence organisations.

A concerted effort is needed from all stakeholders so that we know what we are teaching, and if we are teaching it well, since eliminating preventable harm is the goal of everyone involved in health care.

Professor Allan Spigelman is professor of surgery at the University of NSW and clinical associate dean at the St Vincent’s Clinical School, Sydney. He previously established Australia’s first Clinical Governance Unit (Hunter Area Health Service, NSW) and is regional editor of the International Journal of Clinical Governance.

Posted 4 June 2012

2 thoughts on “Allan Spigelman: Patient safety disconnect

  1. Sue Ieraci says:

    One of the real questions about patient safety education is this: who has the appropriate skills to teach this discipline? My experience of the public hospital workplace is that clinical governance is carried out essentially by self-taught amateurs – generally ex-clinicians with no specific training in risk-management. The result is often rigidity and risk-aversion, neither of which are good styles in which to teach medical students to practice well. It would be good to see some suggestions about how to “train the trainers” in risk management and patient safety, understanding that there is no “zero risk” situation in life.

  2. Christine Jorm says:

    The briefest examination of the AMC documentation that pertains to medical schools reveals it to be highly variable in regard to the extent to which the Curriculum is described. Item 21 ‘The skills needed to work safely as an intern, as outlined in the National Patient Safety Education Framework developed by the Australian Council for Quality and Safety in Health Care’ is one of a mere 13 skill items that include such critical elements of medical practice as: ‘The ability to perform an accurate physical and mental state examination’, ‘The ability to interpret common diagnostic procedures’, ‘The ability to formulate a management plan, and to plan management in concert with the patient’.

    Detailed description is available to Australian medical schools on patient safety and also for indigenous education, both areas where funding enabled the development of curricula and resources. By stark comparison there is regrettably little available in the area of medical ethics.

    Maybe Professor Spigelman would consider calling for detailed elaboration of the entire AMC curriculum and evaluation of the teaching of the entire content. If not, I would suggest that consideration of postgraduate domain he mentions is indeed a very important focus for patient safety education.

    In a 2010 letter to the MJA I suggested:

    ‘Provision of appropriate experiential learning [also] requires links to the … clinical workplace. Rather than a standalone communication syllabus, the medical students in Queensland, for example, should receive the same teaching about clinical handover as the junior (and senior) medical staff of Queensland Health. Handover is then perceived as a highly relevant skill.’

    We know patient safety is a system property. An intern simply cannot be safe in an unsafe system. Additionally, the ‘hidden curriculum’ in the workplace has a powerful influence and has been shown to able to rapidly ‘overwrite’ medical student education. Therefore, maximum potential for productive student education will come from real links to workplace safety priorities. This will also ensure that workplace education in safety is not neglected and that we don’t build wasteful overlap into our educational processes.

    Christine Jorm
    Sydney Medical School

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