The World Health Organization (WHO) has just released a curriculum guide for patient safety (WHO 2011). It is accompanied by a set of tools and resources (WHO 2011b), including slide presentations corresponding to key chapters of the guide. Though it is aimed primarily at education of students in the various healthcare professional schools, many of the principles and learning techniques are equally applicable to training in patient safety at any level.
Part A of the guide is aimed at the educators who will be teaching the patient safety curriculum. It includes many useful tips on best methods to teach to concepts of patient safety, including good use of stories and narratives, case studies and practical examples. They discuss various delivery methods such as a combination of lectures, small group discussions, project work, practical workshops, or simulation-based exercises. They also discuss how to integrate patient safety education into procedural skills training programs.
While doing the curriculum as a stand-alone is mentioned, they favor integrating the curriculum into the various other curricula. They provide examples of how patient safety concepts can be woven into other traditional medical or nursing school courses. However, they note that in doing so it is critical to keep track of what elements are covered in the various courses.
They stress the need to put the training in context and use examples that are realistic for the setting, of interest to the parties, and likely to be relevant to the student in the near future. While they discuss a variety of teaching styles, they stress the importance of being interactive. And they provide some good advice: Don’t tell students when you can show them, and don’t show them when they can do it themselves. They recommend lectures be limited to about 45 minutes as concentration falls after this time. And they recommend you aim for four or five key points at most. These recommendations, of course, are really applicable to almost any audience you are engaging. Of interest, while most of us are big advocates of simulation, they advocate simulation but with a word of caution. They note that the simulation needs to be realistic and practical and cite the example of a nursing student talking to a fake practice IV insertion arm as if it were a real patient can be embarrassing.
Part B deals with specific patient safety topics. Topic #1 is a general introduction to patient safety. They recommend practical examples such as the case of nurse, pharmacist or medical student being assertive and speaking up. Several of the sections do discuss the issue of hierarchy in healthcare. One section provides some practical examples of “the old way” vs. “the new way”. For example, in observing a senior clinician fail to wash his hands between patients, the “old way” was to say nothing and participate in the inadequate practice but the “new way” might be to seek clarification from the senior clinician as to the “when and how” of hand hygiene or to respectfully comment and continue to use good hand hygiene techniques.
When we discuss root cause analyses after an untoward event, one of the “big three” root causes we find in almost every case is failure to buck the authority gradient, i.e. someone recognized that an error or problem was occurring yet failed to speak up. The hierarchical structure of healthcare, whether formal or tacit, continues to be one of the biggest impediments to patient safety. Interesting in this vein was a recent survey presented at the American College of Clinical Pharmacy (ACCP) 2011 Annual Meeting (Kann 2011). Five hypothetical scenarios were presented to almost 600 pharmacists who responded to the survey. They found that large percentages of the pharmacists would fill inappropriate or potentially dangerous prescriptions after verifying the prescription with the prescriber. 43% of respondents actually recalled actually doing so in real-life situations and 74% of those deferred to the prescribing physician because they assumed that he/she knew more about a particular patient and situation than they did. Of the clinical scenarios presented, almost 20% would have filled inappropriate prescriptions for digoxin and methotrexate and almost 40% would have filled a prescription for a fentanyl patch in a patient who had taken other opiates for only 7 days.
And, of course, we previously discussed problems with the hierarchy of medicine in our March 29, 2011 Patient Safety Tip of the Week “The Silent Treatment: A Dose of Reality” and July 19, 2011 Patient Safety Tip of the Week “Communication Across Professions”.
But back to the WHO guide. Topic #2 is on the role of human factors and is very good. It discusses important principles like avoiding reliance on memory, making things visible, simplifying, standardizing, using checklists, and reduced reliance on vigilance. They provide case studies showing how contributing factors, such as fatigue, may impact patient safety. They point out that human beings make “silly” mistakes all the time, regardless of their level of experience. As part of the teaching techniques they recommend you discuss any “silly” mistakes you recently made outside work or study. We can think of lots of those!
Topic #3 deals with the concepts of systems thinking and complexity. It draws heavily on the work of James Reason and Charles Perrow.
Topic #4 is all about teamwork and being an effective team player. They focus on communication, handoffs, and conflict resolution. They note the stages of team development (forming, storming, norming, and performing) and the characteristics of successful teams (common purpose, measurable goals, effective leadership, effective communication, cohesion, mutual respect, flexibility, conflict resolution, etc.). Communication techniques such as ISBAR, callout, check-back, and handoff formats such as “I PASS the BATON” are discussed.
In our own work with housestaff or nursing staff we discuss ways in which you can usually get someone’s attention and force further review of a situation. Sometimes that can be as simple as “I’ve just got a funny feeling we’re missing something”. In the WHO guide they describe multiple techniques that can be used. They describe the “2-challenge rule” where all members of the team are empowered to stop an activity if they perceive an essential safety breach. It is “2-challenge” because the first challenge is in the form of a question (eg. “I’m worried about Mrs. Jones. Can you take a look at her?”) and the second challenge provides support for the team member’s concern (eg. “I’m very worried about Mrs. Jones. Her symptoms are worsening. I think you should see her now.”). Key to the 2-challenge rule is that the concern has been heard, understood, and acknowledged.
Next they note the “CUS” approach:
I am Concerned
I am Uneasy
This is a Safety Issue
And then the “DESC” approach:
Describe the specific situation or behavior and provide concrete evidence or data.
Express how the situation makes you feel and what your concerns are.
Suggest other alternatives and seek agreement.
Consequences should be stated in terms of their effect on established team goals or patient safety.
Topic #5 is Learning from Errors. This begins with a description of the various types of error, acknowledgement that errors occur, and situations in which errors are more likely. They have good sections on root cause analysis (RCA), case studies, and failure mode and effects analysis (FMEA).
Topic #6 Understanding and Managing Clinical Risk discusses the variety of sources of information that helps identify patient safety risks in your organization, including RCA’s, incident reports, sentinel events, patient complaints, and others. It discusses some of the factors that contribute to adverse events, such as fatigue, communication issues, and others.
Topic #7 is all about quality improvement. It relies heavily on the principles in The Improvement Guide (Langley 1996), including measurement, PDSA cycles, rapid change, and sustaining improvement. It has good discussions about tools such as flow charts, run charts, cause and effect diagrams, Pareto charts, root cause analysis (RCA), and failure mode and effects analysis (FMEA).
Topic #8 Engaging with Patients and Carers is about getting patients and their families involved in their own care and promoting their own safety. It has good discussions on disclosure and apology when adverse events occur. The latter is a topic we’ve discussed on several occasions (see our June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It” and our November 2010 What’s New in the Patient Safety World column “One of the resources we noted in the latter column, IHI’s “ ”). Respectful Management of Serious Clinical Adverse Events” has recently been updated (Conway 2011). The WHO guide discusses the Harvard disclosure framework and a disclosure process from New Wales, Australia. They also provide a good discussion about the SPIKES (Setting, Perception, Information, Knowledge, Empathy, Strategy and Summary) communication tool that can help guide communication with patients and their caregivers over a wide range of topics and issues.
The last three topics deal with some specific clinical issues. Topic #9 Infection Prevention and Control focuses on healthcare-associated infections (HAI’s) and especially on hand hygiene. Topic #10 Patient Safety and Invasive Procedures, as you’d expect, deals with wrong site surgery and the WHO Surgical Safety Checklist, along with a host of issues arising in the perioperative period. Topic #11 Improving Medication Safety is an excellent chapter dealing with the gamut of problems in medication safety. The slide set accompanying the latter chapter is especially useful.
Whether you are and educator in academic medicine at a medical, nursing or pharmacy school or other healthcare professional school or a clinician in any healthcare setting, the new WHO Patient Safety Curriculum Guide is a very valuable resource for your patient safety programs.
WHO. Patient Safety Curriculum Guide: Multi-Professional Edition. 2011
WHO. Patient Safety Curriculum Guide Tools and Resources. 2011
Kann C, Hoehms J. American College of Clinical Pharmacy (ACCP) 2011 Annual Meeting; Abstract #173. Presented on October 18, 2011 as reported by Goodman A. Many Pharmacists Likely to Fill Dangerous Prescriptions. An Expert Interview With James Hoehns, PharmD. Medscape Medical News. October 25, 2011
Langley GJ, Nolan KM, Norman CL, Provost LP, Nolan TW. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. New York, NY; Jossey-Bass, 1996
Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. IHI Innovations Series 2010. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2010
Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011