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Educating future leaders in patient safety

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Journal of Multidisciplinary Healthcare
19 September 2014
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Agnès Leotsakos 1 Abstract: Education of health care professionals has given little attention to patient safety,
Antonella Ardolino 2 resulting in limited understanding of the nature of risk in health care and the importance of
Ronny Cheung 3 strengthening systems. The World Health Organization developed the Patient Safety Curriculum
Hao Zheng 1 Guide: Multiprofessional Edition to accelerate the incorporation of patient safety teaching into
Bruce Barraclough 4 higher educational curricula. The World Health Organization Curriculum Guide uses a health
system-focused, team-dependent approach, which impacts all health care professionals and
Merrilyn Walton 5
students learning in an integrated way about how to operate within a culture of safety. The
1
Patient Safety Programme, World
guide is pertinent in the context of global educational reforms and growing recognition of
Health Organization, Geneva,
Switzerland; 2Wessex Deanery, the need to introduce patient safety into health care professionals’ curricula. The guide helps
Winchester, UK; 3Imperial Healthcare to advance patient safety education worldwide in five ways. First, it addresses the variety of
NHS, London, UK; 4The Australian
E Health Research Centre, Royal
opportunities and contexts in which health care educators teach, and provides practical rec-
Brisbane and Women’s Hospital, ommendations to learning. Second, it recommends shared learning by students of different
Brisbane, Australia; 5Sydney School professions, thus enhancing student capacity to work together effectively in multidisciplinary
of Public Health, Faculty of Medicine,
University of Sydney, Sydney, Australia teams. Third, it provides guidance on a range of teaching methods and pedagogical activities
to ensure that students understand that patient safety is a practical science teaching them to act
in evidence-based ways to reduce patient risk. Fourth, it encourages supportive teaching and
learning, emphasizing the need to establishing teaching environments in which students feel
comfortable to learn and practice patient safety. Finally, it helps educators incorporate patient
safety topics across all areas of clinical practice.
Keywords: patient safety education, WHO Patient Safety Curriculum Guide: Multiprofessional
Edition

Introduction
Patient safety is fundamental to safe patient care. Although the principles and concepts
of patient safety are acknowledged as a critical part of health professional education
and training, many health care providers and academics remain uncertain as to how
to integrate patient safety into health care education and clinical care, and are yet to
integrate patient safety knowledge into bedside practice.
The importance of education and training in patient safety has been acknowledged
for over a decade,1 yet, in most countries, it remains underutilized and undervalued
as a method of addressing the many challenges facing contemporary health care. The
Correspondence: Agnès Leotsakos
Patient Safety Programme, World Health
World Health Organization (WHO) Patient Safety Curriculum Guide: Multiprofes-
Organization, WHO/HIS/PSP, Avenue sional edition is a comprehensive curriculum designed to achieve that improvement
Appia 20, CH-1211, Geneva, Switzerland
Tel +41 22 791 2567
in health care. The curriculum, when implemented, has the capacity to provide health
Email [email protected] care professionals with the underpinning and applied knowledge to incorporate patient

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Leotsakos et al Dovepress

safety principles into their practice, in a range of health care patient safety) highlighted the weaknesses of health care
contexts. professional training, including:
The WHO Patient Safety Curriculum Guide: Multi-
a mismatch of competencies to patient needs; curricular
professional Edition was launched in October 2011. It was
rigidities and static pedagogy, poor teamwork ­learning;
based on the 2009 Patient Safety Curriculum Guide for
narrow technical focus without broader contextual
Medical Schools,2 which was a first step in the process of
­understanding; and weak leadership to improve health-
establishing a patient safety curriculum for all health care
system performance.26
professionals.3
The Commission recommended a system-wide reform
Patient safety education worldwide to encourage adaptation, improvement, and flexibility in
Over the last decade, national patient safety and quality health care education generally and to create a health care
agencies as well as regional and global bodies have initiated professional workforce prepared for collaboration and
Patient Safety Programs and have galvanized the support of trans- and interprofessional teamwork who are able to adapt
political and health leaders worldwide (see Table 1). Patient to local requirements and needs. More recently, the WHO
safety learning in the workplace,4 coupled with greater rec- presented the general requirements necessary for incorpo-
ognition of the need to prepare health professional students rating patient safety in education and the skills inherent in
for safe practice during their education, have led to a gradual that, such as teamwork and communication, human factors
transformation in the way that patient safety is viewed. While and safety, engagement of patients in their care, and wider
we are yet to reach a tipping point, many clinicians and contextual awareness and system-wide understanding of
leaders know that adverse events will only be reduced and health care.27
managed effectively by health professionals when they are Patient safety education in the developing world merits
aware of and integrate patient safety principles and concepts particular attention. Poor educational infrastructure, lack of
into their daily practice. resources and education materials, shortcomings of qualified
Despite a plethora of patient safety initiatives, patient educators because of low motivation or insufficient skills, and
safety education for health professionals in the higher underfinancing of the higher education sector for health care
education sector has not kept up with workforce require- professionals make patient safety education more challenging
ments.20–22 In developed countries, medication errors and than in resource-rich countries.27 Integrating patient safety into
surgical mistakes are routinely documented using incident undergraduate education in developing countries and in some
reporting systems, but we are yet to see curricula contain transitional countries, which have advanced health care and
the knowledge and skills required by health professional education systems, is a significant challenge. A recent study in
students to address and reduce patient harm.22 Patient safety the People’s Republic of China reported that, in addition to an
has been incorporated into the higher education curricula already busy curriculum, leadership support, faculty engage-
slowly and somewhat sporadically. For example, a media ment, course design, and teaching formats presented major
article recently cited a leader’s view that “patient safety challenges that deter the integration of patient safety education
is not incorporated fast enough in medical schools”. 23 into existing curricula.28
A 2007 multi-institutional assessment of patient safety In higher education for health care professionals, pro-
knowledge among medical trainee clinicians confirmed the fessionalism generally, but patient safety specifically, has
need for patient safety education, but found that patient been overlooked by many academic institutions.7,29 Inte-
safety knowledge across a broad range of training, types grating new patient safety and patient-centered curricula
of qualification, and specialties were substantially limited is important if education is to contribute to improving
and that trainees were unable to self-assess their knowledge patient safety. Patient safety is not another subject to add
deficits.24 to an already over-packed curricula, but serious thought
A UK study of the impact of teaching, learning, and prac- is required as to how health professional teachers can
ticing patient safety in academic, organizational, and practice integrate patient safety competencies into their clinical
contexts highlighted that patient safety education needs to teaching and learning. Each health care profession should
be more explicitly and integrated in health care ­curricula.25 tailor patient safety principles and concepts to their own
The Commission on Education of ­Healthcare ­Professionals needs, limitations, and culture for positive changes to
for the 21st Century (although not focused specifically on occur.30,31

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Dovepress Educating future leaders in patient safety

Table 1 Some examples from a long list of national and global initiatives offering patient safety courses to health-care providers
Institution Country Initiative Reference
National Health Service for Scotland Scotland, UK NHS Scotland recommends multi-professional group 5
meetings and provides tools to educate health-care
workers in patient safety
National Patient Safety Foundation USA The Foundation has its own patient safety curriculum 6
with Continuing Medical Education (CME) modules to
complete
Australian Commission on Safety Australia The Council has a syllabus for education and training in 7
and Quality in Health Care patient safety;
Canadian Patient Safety Institute Canada CPSI runs patient safety course for health-care leaders 8
(CPSI)
Betsy Lehman Center for Patient USA This Center was established by the Massachusetts 9
Safety and Medical Error Prevention Department of Public Health and sponsors patient safety
education and training programmes
Parliament, UK UK The Parliament recognizes the need for incorporation of 10
education in patient safety for all health-care providers
Agency for Healthcare Research USA AHRQ provides a wealth of information, tools and 11
and Quality (AHRQ) resources for training in patient safety
Society for Quality in Healthcare Nigeria SQHN facilitates the continuous improvement of quality 12
(SQHN) and safety in health care in Nigeria through education
and accreditation
Council for Health Service South Africa Through its SafeCare initiative, COHSASA, assists African 13
Accreditation of Southern Africa health-care facilities to provide safe and quality health care
(COHSASA) by providing technical resources, training
and financial incentives
World Organization of Family Doctors Global WONCA, provides resources and training for Quality 14
(WONCA) and Safety in family medicine worldwide
Ministry of Health Singapore Patient safety education is provided to hospital health- Personal e-mail
care providers communication, January
2013, by Dr Ong Biauw
Chi, Yong Loo Lin School of
Medicine, Singapore General
Hospital, Singapore
Patient Safety Education Global Is an international collaboration for the education of 15
Project (PSEP) teams of healthcare professionals and administrators in
patient safety issues
Institute for Healthcare USA The ‘Open School’ for Health Professions is a hub of 16
Improvement (IHI) free online courses on quality improvement topics and
patient safety
Organization for Safety and Prevention Global Both professional organizations address issues related Personal e-mail
(OSAP) and the International Dental to the WHO Patient Safety Curriculum Guide and communication, June 2013,
Federation (FDI) deliver educational sessions on patient safety by Professor Enrique Acosta,
National Autonomous
University of Mexico
International Alliance of Patients’ Global IAPO provides patient safety resources and a toolkit for 17
Organizations (IAPO) patients and health-care professionals
World Health Organization’s PSP provides webinars and educational materials in its 18,19
Patient Safety Programme (PSP) quest to strengthen and improve patient safety research
in all countries around the world.

The role of education and training of strengthening systems. Furthermore, the professional ethos
in patient safety of extending a health care provider’s responsibilities beyond
Patient safety education of health care professionals has the care of their individual patients to ensuring safe delivery
been given little attention, resulting in students’ limited of health care as a whole is not often conveyed or obvious to
understanding of the risk in health care and the importance students. There is also little emphasis in much curricula or

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Leotsakos et al Dovepress

practice of multi-professional teamwork and communication therefore, all health professional learning should integrate
about the causes of harm and how to protect patients. Some patient safety competencies into clinical teaching and skills
of the factors that contribute to this situation are: development.
• Lack of recognition by health care educators that teaching The 2011 WHO Multi-professional Patient Safety
and learning patient safety should be an essential part of Curriculum Guide was developed to satisfy the demand
the undergraduate curricula for health care students, and for a single coordinated, systems-based, team-dependent
that patient safety skills can be taught.29,32 approach, to ensure patient safety learning is delivered in
• Lack of familiarity of educators or trainers to teach patient an integrated way. This encourages shared learning across
safety as a new area of knowledge and learning.33 professions, as well as building an organizational culture of
• Reluctance by academic institutions and educators to safety in all health care systems - a need highlighted by the
teach health care students knowledge that is outside Commission on Education of Healthcare Professionals for
the clinical discipline, often because of existing full the 21st Century.26
curricula.29 The WHO Patient Safety Curriculum Guide: Multiprofes-
• A historical emphasis on treatment of disease rather than sional Edition is an updated, evidence-based edition of the
prevention of illness creates a culture that finds it difficult WHO Patient Safety Curriculum Guide for Medical Schools.
to give merit to a “non-event” (ie, a preventable adverse It is divided into two parts. Part A provides practical support
event).34 and guidance to educators on how to deliver the patient safety
• Educational silos when different disciplines are taught topics described in Part B and also offers background informa-
separately, which is contrary to the interdisciplinary team tion to educators on how to select and teach each topic, makes
approach stressed by patient safety education.35,36 suggestions on how to integrate patient safety teaching, and
• Entrenched attitudes regarding the traditional teacher–stu- provides techniques for exploring how patient safety learn-
dent relationship – a relationship that may be hierarchical ing could fit into the institution’s existing curricula. Clear
and competitive,32 and in which an “expert” disseminates examples are provided throughout Part A on how patient safety
information to the student.21,34 might be taught. Part B describes eleven patient safety topics
Undergraduate education plays a major role in the prom- (see Table 2) that cover a wide range of contexts in which
ulgation of evidence-based competencies incorporating patient safety learning can occur.27 The ready-to-teach topics
concepts, knowledge, and skills in patient safety.21,37 Teaching can be used either as a whole or on a per-topic basis. They
patient safety can have a positive impact by promoting the provide the foundation for undergraduate and graduate health
competencies needed for safe health care. care students to obtain the core knowledge and skills required
to practice safely. Educators can choose topics to introduce
The WHO Patient Safety Curriculum into their curricula as guided by institutional requirements,
Guide: Multiprofessional Edition resources, and their capacity. A number of different educa-
Patient safety is recognized as the responsibility of all health tional approaches are suggested for each topic.
care professionals38–42 and not specific to one profession; The underpinning principles of the WHO Curriculum
Guide are to support educators to teach patient safety. It
Table 2 The WHO Patient Safety Curriculum Guide: Multi­ is easily adaptable to local patient safety requirements and
professional Edition written in an easily understood language so that it applies to
  1.  What is patient safety? all countries, cultures, and contexts.
  2.  Why applying human factors is important for patient safety Evaluation of WHO Patient Safety Curriculum Guide:
  3.  Understanding systems and the effect of complexity on patient care Multiprofessional Edition took place in 12 pilot sites, which
  4.  Being an effective team player
included dental, nursing, midwifery, and pharmacy schools
  5.  Learning from errors to prevent harm
  6.  Understanding and managing clinical harm around the world, and ten complementary test sites. Outcomes
  7.  Using quality-improvement methods to improve care of the evaluation study are available at the WHO website.43
  8. Engaging with patients and carers
  9.  Infection prevention and control How to advance patient safety
10.  Patient safety and invasive procedures
11.  Improving medication safety education
Note: Copyright 2011. World Health Organization. Patient Safety Curriculum Guide: Multi- Taking into account the suggestions of The ­Commission on
professional Edition. Geneva: World Health Organization; 2011. Available from: http://
Education of Healthcare Professionals for the 21st Century,
whqlibdoc.who.int/publications/2011/9789241501958_eng.pdf. Accessed November 15,
2012.27 the WHO Curriculum Guide provides instructions, practical

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Dovepress Educating future leaders in patient safety

recommendations, and technical content to address teamworking is increasingly part of the role of doctors, mid-
educational weaknesses that include the mismatch of com- wives, nurses, pharmacists, and even dentists, who have tradi-
petencies to patient needs, the rigidity of curricula and static tionally provided their services in isolation from other health
pedagogy, and poor teamwork learning. care services. The multi-professional WHO Curriculum Guide
In addition, the Curriculum Guide helps build capacity is the first ­coordinated product of its kind to embrace a global
for patient safety education in all countries across the whole outlook and a multi-professional perspective within a systems
socioeconomic spectrum. It prioritizes and describes what to approach. It demonstrates how patient safety learning can
teach and how to teach, in terms of patient safety, in a single be delivered in an integrated way. This approach encourages
volume. The guide helps in five ways (described below) to shared learning by students of different professions and a better
advance patient safety education, taking advantage of global understanding of the need for joint working, thus enhancing
trends and opportunities for educational reforms, focusing student capacity to work together effectively in future practice.
particularly on the need to introduce patient safety into health This perspective pervades all of the guide’s topic chapters.
care professionals’ curricula. Knowledge and skill requirements are described for students to
enable them to become effective team players, deliver accurate
International scope and context and timely cross-disciplinary communication, and act ethically
The Commission on Education of Healthcare Professionals with respect for colleagues. It also prepares them for working
for the 21st Century states that, because of global interdepen- in a culture that does not identify all errors and mistakes as
dence in health and the fact that universities and educational blameworthy but only those made in the context of working
institutions are broadening their traditional roles, “educa- in a complex system. Within this context, each topic chapter
tional reforms are timely for health professional education to provides examples of case studies drawn from different health
meet standards and needs of 21st century”.26 The Curriculum care settings and professional groups and highlights a range
Guide attempts to encourage both health care educators of tools and resources reflecting the multi-professional view-
and students worldwide to share common understanding, point. Case studies are regarded as an effective learning tool
knowledge, and skills in patient safety to assure coverage of in interdisciplinary education. In the Curriculum Guide, case
high-quality and safe services, as members of locally respon- studies have been described to highlight the risks to patients
sive teams operating within a culture of safety and globally from a multi-professional perspective and to bring the Curricu-
connected members advancing patient safety definitions, lum to life by giving real examples of what can go wrong and
content, and solutions. The content of the ­Curriculum Guide how effective teamwork can have an immediate and positive
takes into account the wide variety of contexts in which health impact on patient safety.
care educators and students teach and learn. The WHO Expert
Working Group, composed of more than 50 international Patient safety beyond the classroom
experts, was involved in the development of the curriculum To address the challenge of rigid curricula and static pedagogy,
to ensure its cultural appropriateness and global reach. the WHO Curriculum Guide recommends the use of many,
Teaching and assessment strategies are designed to take into different learning channels to provide balanced guidance for
account both the diversity in available resources and cultural didactic teaching. Recommended teaching methods include
differences that could affect the learning ­environment. As active instruction of students through a range of pedagogical
a resource that is freely available to all health care systems activities, including patient and health professional buddy-
globally, the Curriculum Guide reinforces the ethos that ing, role-modeling, undertaking hospital-based improvement
safety is a right for all patients, and not a luxury confined to and team-based learning projects, independent studies, and
better-resourced health care systems. participating in simulation training. The WHO Curriculum
Guide provides lists of websites and links to resources and
Team-based approach to patient safety information on patient safety for both learners and ­teachers.
The second aspect of the Curriculum Guide is about build- The theme of educational collaboration runs across all the
ing student competencies in relation to patient needs. This is topic chapters as an instrument for enhancing the sharing of
reflected in the multi-professional perspective of the Curricu- information, experiences, and synergies between institutions.
lum Guide, and the context of educating health care students, The importance of extending educational activities beyond
irrespective of their chosen profession, to understand and the use of static curricula and the university boundaries is
practice patient safety. It supports and promotes a collabora- highlighted, and educators are encouraged to use instruments
tive, nonhierarchical way of delivering care. Multidisciplinary such as networking and partnerships with other universities in

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Leotsakos et al Dovepress

the same country and internationally for academic exchange Conclusion

and practical learning. The WHO Curriculum Guide is a freely available resource for
The Curriculum Guide is designed to make use of multiple implementing patient safety education. As a comprehensive
dissemination channels so that its teaching resources, tools, guide, it contains information for all levels of faculty and
slides, case studies, and references are available worldwide students and lays the foundation for capacity-building in the
through printed copies, websites (for example, http://www.who. essential patient safety principles and concepts. Part A of the
int/patientsafety/education/curriculum/en/index.html, http:// Curriculum Guide is a rich resource for educators involved
www.who.int/patientsafety/education/vincristine_download/ in the development of health care curricula.
en/index.html, http://www.who.int/patientsafety/research/ Its global, multi-professional perspective reflects the need
online_course/en/index.html), CD-ROMs, instruction in WHO to address patient safety on a system-wide basis, involving all
workshops, and WHO e-learning. health care professionals and students learning in an integrated
way how to operate within a culture of safety, openness, and
Grounded in sound educational theory reporting, which should be the cornerstones of future health care
and practice systems worldwide. It is through such an integrated approach
Every country and institution has its own unique tradi- including all future health care professionals that we can
tions and culture of educating health care professionals. change, at pace and scale, the global health care environment
­Hierarchical teaching styles, stagnant pedagogy, and profes- to one in which health-related harm becomes a rare event.
sional silos have a negative impact on student learning gener-
ally, but specifically for patient safety. The Curriculum Guide Author contributions
encourages supportive teaching and learning, emphasizing Agnès Leotsakos (main author): writing of the paper; execu-
the importance of establishing an environment in which tion of the study. Antonella Ardolino: desk research and writ-
students feel comfortable to learn and practice patient safety. ing of the paper; Ronny Cheung: desk research and writing
The chapters emphasize that educators are role models for of the paper; Hao Zheng: writing of the paper, execution of
students; their clinical knowledge and patient safety skills the study; Bruce Barraclough: execution of the study, revised
are explicit within training the next generation of health and approved final version of the paper; Merrilyn Walton:
care providers. At the same time, WHO Curriculum Guide editing of the paper and execution of the study.
empowers students to recognize their educators as embodying
an open safety culture and instilling the professional ethos of
Acknowledgments
Enrique Acosta-Gio, National Autonomous University of
open reporting and safety consciousness in them.
Mexico, Mexico; Jean Barry, International Council of Nurses,
Integration into existing curricula Switzerland; Jiri Vlcek, Charles University, Czech Republic;
The content and structure of the WHO Curriculum Guide Nermin Yamalik, Hacettepe University, Turkey, Eleni Azarias
is designed to support educators in incorporating priority and Reema Harrison, Sydney University, Australia.
patient safety topics into all areas of practice and all health
Disclosure
care professions. The topic modules of the Curriculum
The authors report no conflicts of interest in this work.
Guide are not taught as a stand alone course, but can be
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