- Email: [email protected]
Assessing the Impact of Teaching Patient Safety Principles to Medical Students During Surgical Clerkships
Journal of Surgical Research 170, e29–e40 (2011) doi:10.1016/j.jss.2011.04.031
Assessing the Impact of Teaching Patient Safety Principles to Medical Students During Surgical Clerkships Kenneth Stahl, M.D., F.A.C.S.,*,1 Jeffrey Augenstein, M.D., Ph.D., F.A.C.S.,* Carl I. Schulman, M.D., F.A.C.S.,* Katherine Wilson, Ph.D.,† Mark McKenney, M.D., F.A.C.S.,* and Alan Livingstone, M.D., F.A.C.S.* *The University of Miami Miller School of Medicine, The DeWitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care, Miami, Florida; and †National Transportation Safety Board, Washington, DC Submitted for publication November 3, 2010
Background. A critical aspect of enhancing patient safety is modifying the healthcare safety culture. We hypothesize that students who participate in safety curricula are knowledgeable regarding patient safety and likely to intervene to avoid patient errors. Methods. A two-part patient safety curriculum was taught: introductory theories (first year) and a clinically oriented course during surgery rotations (third year). All students participated in the first year introduction and a random cohort of students (62.6%, N [ 67) participated in the third year program. Multiple choice tests and web-based surveys were administered. Statistical analysis was carried out using Student’s t-test for comparisons of test mean scores and z-test for comparison of the survey data. Results. Students who participated in both years’ curricula scored higher on didactic test than those who participated in only the first year course (82.9% versus 75.5%, P < 0.001). More students participating in both portions of the curricula intervened during at least one clinical encounter to avoid a patient error (77% versus 61%, P < 0.05). Students rated junior house-staff more receptive to patient safety suggestions than surgical fellows and faculty (84% versus 66%, P < 0.05); 75% of students rated their surgical clerkship exposure to patient safety somewhat/extremely valuable compared with 54% students who rated the first year exposure as somewhat/extremely valuable (P < 0.05). Conclusion. Medical students who have practical applications of patient safety education reinforced
1 To whom correspondence and reprint requests should be addressed at The University of Miami Miller School of Medicine, The DeWitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care, P.O. Box 016960 (D-40), Miami, FL 33101. E-mail: [email protected].
during surgery rotations are knowledgeable and willing to intervene in patient safety concerns. Teaching clinically relevant patient safety skills influences positive behavioral changes in medical students’ performance on surgical teams. Ó 2011 Elsevier Inc. All rights reserved. Key Words: patient safety; medical student education; crew resource management; team training; culture patient safety residents and staff.
INTRODUCTION
Errors in patient care are common and well recognized by society in general, and the government and insurance companies that pay for medical services. In the care of injured patients at Level I trauma centers, preventable deaths due to errors account for up to 10% of fatalities in patients who might otherwise survive [1, 2, 3]. The number of fatal errors equates to as many as 15,000 lost lives per year in the U.S [4], which is two to four times more frequent than deaths due to errors in the general hospital patient population [5]. The reasons for this rate of errors are complex and multifactorial, and include a variety of individual and system factors. The situations that are most conducive to producing errors are the very environments in which trauma victims present; unstable patients, fatigued operators, incomplete histories, time-critical decisions, concurrent tasks, involvement of many disciplines, complex teams, transportation of unstable patients, and multiple hand-offs of patient management. This environment provides the perfect background to emphasize patient safety principles with multiple surgical examples to physicians in training as they learn other basics of surgical care. We hypothesize that teaching clinically relevant and useable safety skills based on
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JOURNAL OF SURGICAL RESEARCH: VOL. 170, NO. 1, SEPTEMBER 2011
established ‘‘Crew Resource Management’’ curricula to third year medical students during their surgical clerkships will encourage them to participate as active members of the surgery team and aid in avoiding some of these adverse outcomes. ‘‘High Reliability Organizations’’ (HROs) such as commercial aviation have succeeded in reducing errors and enhancing operational safety through the science of high reliability theory. Important components of safety solutions have been bundled into a broad curriculum of human and system error avoidance strategies that is known as ‘‘Crew Resource Management’’ (CRM). This work originated with research at NASA in 1980 [6]. The principles embodied in CRM have been described for decades for cockpit use with well documented successes [7]. There are several studies that have identified aspects of high reliability and CRM training as solutions to avoiding mistakes in similar environments such as surgical critical care and trauma [8, 9]. Teamwork and team skills are central tenets of CRM training and skills that can be adapted as solutions to avoiding errors in healthcare. Among the most important of these team skills are early recognition of evolving error patterns and timely intervention to avoid propagation of small missteps before they can become lifethreatening events [10]. All team members at every level of experience are essential elements of this ‘‘early warning system.’’ In order to accomplish the aim of early intervention, team members must be aware of safety issues, empowered to participate, and confident their suggestions will elicit an appropriate response. Other aspects of CRM training include a thorough understanding of error mechanisms [10], preoccupation with error avoidance, flattening of hierarchical leadership pyramid, empowerment to speak up regarding safety risks, and use of advanced communication skills [11]. Differences between HROs and healthcare in cultural and personal attitudes towards errors can make some of these CRM principles difficult to propagate into the healthcare system. HROs manage risks by understanding how errors occur and anticipating all possible chances for errors. This points out an important difference between safety designs in healthcare and HROs in that HRO systems are engineered with the expectation that individuals can and will make mistakes and that the system itself must be engineered to catch these mistakes (Nance J. Personal communication, 2007). Physicians and nurses have been granted a loftier status. We are expected not to make mistakes despite operating under stressful conditions in a system that is not specifically attuned to catching small missteps. For this reason, it is important to enhance this CRM mindset that makes awareness of the potential for errors part of daily surgical care. In order to reduce patient errors,
modifications in the culture of healthcare towards error awareness will be necessary [12]. An important way to change our culture is to train new generations of patient safety oriented physicians [13]. The future generations of physicians are today’s medical students who can enhance patient safety when presented an effective curriculum of patient safety methods. This has been shown to be effective in changing perceptions of patient harm and the provider’s role in patient safety [12, 13]. During their clinical rotations, they also function as important members of medical team structure. Published data suggest that medical students want to contribute to the healthcare team, but their inexperience and lack of clinical knowledge lead to a lack of confidence to participate. This, coupled with the fact that they are not licensed providers, lead to an unwillingness or hesitancy to speak up [14]. In certain circumstances, it could also be rooted in fear of negative evaluation or other consequences such as ridicule. Furthermore, our current healthcare culture and the medical hierarchy discourage error identification by student communication of observed errors [15]. Commercial aviation and HROs succeeded in changing their safety culture and adopting principles of empowerment in large part by training incoming generations of flight crews [16]. It can be anticipated that medical students who are taught a clinically relevant curriculum of error awareness and proven methods of recognizing and early error trapping skills will mature into patient safety concerned physicians. Adoption of patient safety principles into the healthcare culture and eventual reduction in the number of adverse outcomes can be enhanced by new generations of young physicians advancing through their training years and eventually entering practice with these principles, skills, and goals firmly embraced. METHODS Over a 1-y period, 110 third year medical students participated in a clinical rotation on the trauma surgery service. Students rotated for 4 wk of their surgical clerkships on the surgical trauma service in groups of 8–12 students. All medical students began their third year clinical rotations after having received a first year introduction to patient safety principles in a didactic lecture format that was based on the ‘‘soft skills in anesthesia’’ model [17]. This 1 d lecture was held during the orientation period and focused on team skills, task management, and situational awareness. The students were also shown a movie on patient safety and errors in patient care and, in a group discussion format, were encouraged to offer ways these safety principles could be used to have avoided the errors. Prior to the start of the trauma clerkship, a web based opinion survey and a 24-question patient safety science knowledge test was distributed to all students (see Appendix 1). This survey was based on knowledge testing metrics from previous studies that established a basis for medical student patient safety [18]. Students who did not complete the web based testing were offered paper test booklets of the same material during the first week of their rotation. During the first week of their trauma rotation, a group of 67 (62.6% of the third year
STAHL ET AL.: TEACHING PATIENT SAFETY TO MEDICAL STUDENTS surgery students) attended an additional 1.5–2.0 h classroom discussion. The lecture focused on a deeper background of safety science and examples of clinical applications of crew resource management principles and communication skills. This course material was based on our own and other published methods of bringing basic high reliability theory from aviation for use in patient safety [7, 8]. Clinical material for this course was taken from trauma surgery and emergency surgery scenarios in which the students were currently involved. We believe that trauma and emergency surgery provide the perfect background for teaching patient safety lessons due to the multifactorial nature of errors and adverse outcomes in this patient population as described above. The program also included video clips of safety scenarios, basic simulation and role-play, review and debriefs of personal safety experiences, and examples of effective communication techniques. In addition, discussions with students included types of medical errors, reportable medical mistakes, and near misses. Patient safety risks and errors were carefully described in didactic and classroom discussions and followed the template of Joint Commission reportable events (wrong medication, wrong patient, missed diagnosis, etc.) [19]. All medical students participated in the same clinical responsibilities for a period of 1 mo. At the conclusion of the rotation, all students were retested on their knowledge of basic patient safety science and opinion surveys on the value of their patient safety training to performance during the clinical rotation. The two groups made up of those who attended both first and third year training versus those who only participated in first year training were compared at the end of each month. We measured medical student adoption of principles of crew resource management by web-based self-reporting during their clinical rotation, by assessing the number of times they had observed and intervened in a patient safety risk as described during classroom work to more senior members of the health care team. These observations were reviewed and discussed with a trauma attending surgeon. Statistical analysis was carried out using Student’s t-test for comparisons of test mean scores and z-test for comparison of the survey data. This research protocol meets exemption criteria (Category 1 and Category 2) from the University of Miami institutional review board as it is research conducted in a commonly accepted educational setting involving normal educational practices and limited to educational testing with survey, interview procedures, and observation of public behavior with none of the 18 specific subject identifiers noted in the Privacy Rule.
RESULTS
The two groups of third year medical students comprised 67 (62.6%) students who participated in both portions of a two-part patient safety curriculum during the first and third years of medical school (2 y group) and a second group 40 (37.4%) attended only the first year portion of the curriculum (1 y group). Opinion survey results found that 98.1% of third year medical students (105/107) were conscious of patient safety concerns. Data on knowledge test scores were compared, and we found an increase in theoretical knowledge of patient safety principles (75.5% first year group versus 82.9% 2 y group P < 0.001) during the trauma surgery rotation. Test results on three students were incomplete and discarded. One hundred seven completed surveys were then analyzed and, overall, 76.6% of students in the 2 y group reported they had actually spoken up and intervened during a clinical
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situation to avoid a patient care error compared with 61% who had participated in only the first year portion of the curriculum (P < 0.05). A large majority of students thought that younger house staff and fellow students were somewhat or very receptive to their patient safety suggestions (83.8%), whereas significantly fewer surgical fellows (63.2%) and surgical attendings (69.7%) were accepting of their patient safety input (P < 0.05). In the 2 y group of medical students, 74.5% rated their clinical exposure to patient safety during their surgical rotation as somewhat or extremely valuable to clinical medicine compared with 53.9% of students in the 1 y group, who rated the first year patient safety exposure as somewhat or extremely valuable to their clinical rotations (P < 0.05). See Appendix 2 and Figure 1.
DISCUSSION
The relevance and importance of changing the healthcare culture towards patient safety and error reduction with its attendant cost effectiveness is gaining acceptance. This has risen to a level that is not only an imperative for our patients but an obligation to society that is demanding change. High Reliability Organizations (HROs) have accomplished the goal of error avoidance with remarkable degrees of success but these successes have at times involved painful cultural and attitude changes have taken over 30 y to ingrain [20, 21]. Fortunately, we do not have to repeat the tedious discovery process since lessons learned in those organizations have applications in healthcare and, specifically, in delivery of surgical services [10]. We do need to adopt some of these risk reduction strategies that have come about largely by managing safety threats, and enhancing team function and communication. Other lessons we can adopt into the healthcare system are early recognition of error patterns and timely system and individual interventions to interrupt the error process before disaster strikes [22]. Our study demonstrates that CRM based safety principles can be taught to medical students both during their early basic science years and reinforced with more clinically relevant courseware during clinical surgical rotation. The fact that students did significantly better in didactic testing after exposure during both first year and third year is not surprising as we reinforced and reminded them of earlier lessons. However, it is demonstrated with these data that a second clinical curriculum is more valuable for learning useable clinical CRM tools than just the first year basic course. This closely parallels the standard model of teaching basic sciences during the first 2 y of medical school followed by clinical applications of this material on the
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FIG. 1. Comparison of Safety Training to First Year Medical Students vs. Addition of Clinical Patient Safety Training Program and comparison of Junior vs. Senior Staff willingness to accept Safety Suggestions.
wards during the third and fourth years. These data also demonstrate that we were able to effect a cultural change in physician trainees to enhance their intervention in safety matters that is significantly improved with a two-level course approach. This reflects key principles of CRM material that stresses participation by all team members regardless of experience, empowerment to speak up and point out early safety risks, and further shows evidence of a change in the usual culture in healthcare teamwork. The importance of emphasizing communication skills in CRM medical training is stressed in Joint Commission data on medical errors that cites miscommunication and poor accessibility of information as the root cause of 67% of these incidents [23]. Published data from advanced medical school programs have designed a curriculum of team skills and communication training courses for all 4 y of medical education and described positive results. This curriculum has been guided by evidenced based targeted needs assessment [12]. Medical students may be as adept at preventing certain types of errors as other members of the healthcare team. Because students usually follow fewer patients than house staff, they can afford greater attention to details that may fail to gain attention and otherwise lead to medical errors. Moreover, the inclusion of medical students in the care of the patient affords increased redundancy to catching medical errors and mitigating their consequences [24]. Our data show that we were able to overcome some of the challenges for adoption of CRM principles in medicine. However, cultural differences between HROs and healthcare remain broad. Our opinion survey data on hierarchy and acceptance of junior level input closely parallels work by Sexton and colleagues who compared
flight crews with operating room personnel on several measures, including attitudes toward teamwork [25]. The study included more than 30,000 cockpit crew members (captains, first officers, and second officers) and 1033 operating room personnel (attending surgeons, attending anesthesiologists, surgical residents, anesthesia residents, surgical nurses, anesthesia nurses). In their study, only a slight majority (55%) of attending surgeons rejected steep hierarchies (determined by whether they thought junior team members should question the decisions of senior team members). In contrast, 94% of airline crew members preferred flat hierarchies. It is precisely this culture in healthcare that needs to change in order to enhance safe and error free care of complex surgical and trauma patients. CRM course material that was taught to medical students was designed to recognize the importance of their input into the surgery team efforts to recognize and avoid errors. Our program focused on individual attitudes and awareness to a broad curriculum of behavioral skills, communication, and teamwork attitudes integrated with technical competencies. Joint Commission data suggest that CRM training results in positive reactions to teamwork concepts, increased knowledge of teamwork principles, improved communication, and teamwork performance [15]. CRM as taught to our medical students encompassed skills such as clearly defining team roles and duties, enhancing communication, managing distractions, prioritizing tasks, and empowering team members at all skill levels to participate in safety management, all of which are integral components of a well functioning surgical team. This important set of skills has also been emphasized in the medical
STAHL ET AL.: TEACHING PATIENT SAFETY TO MEDICAL STUDENTS
literature to optimize and manage workload and task assignments, clinical task planning, and review and critique strategies [26]. CRM skills are an indispensable element of communication in the operating room, and Level II data support the conclusion that these skills enhance the performance of the operating team and patient outcomes [7]. Medical students can contribute to patient safety in the operating room, especially during trauma surgery, when multiple tasks are required of the attending and senior resident staff under timecompressed conditions, and where their attention is focused on a very narrow field. Under these circumstances, the medical students may actually possess the best view of ‘‘the big picture’’ of a patient’s status and thus may have the best situational awareness as stressed in CRM course teaching. Their contributions and observations to safe outcomes are unavailable to the attending and senior resident surgeons unless the students are taught how to communicate their concerns and feel enabled and empowered to do so AND senior team members are receptive to their input. These are the specific, clinically relevant skills that were taught to our medical students during their surgical rotations. Their participation in interrupting the chain of events that start with small missteps and end in clinical failures is crucial, and has been documented by these data. There are several limitations to the design of this study. Establishing metrics to assess clinical adoption of crew resource management principles used by medical students needed to take into account that students do not have unsupervised patient care responsibilities nor do they perform surgical procedures. Metrics that assess the effectiveness of patient safety lessons taught as a part of the medical school curricula are difficult to quantify, and the usual outcomes measures likely do not apply. The metric we chose to measure is selfreported interventions on the part of the medical students when they saw a patient safety risk. This metric is based on published studies that have established ‘‘intervention’’ as a key benchmark for adoption of CRM principles in cross-cultural groups of commercial aviators. Although this is not a metric that has previously been establish to measure adoption of CRM skills in healthcare, we believe it is cross-applicable for use in this study because of the similarity of the team interactions. The tool has been validated in seminal research studies by Helmreich et al., who have used this metric in other similar situations [27]. Additionally, self-reported interventions were confirmed with interviews of the students and the events discussed, but their perceptions of errors are limited by their lack of clinical experience. The observed incidents were all subjective on the part of the students, and were discussed with the trauma faculty in a Mor-
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bidity and Mortality format. Feedback was provided to the trauma service, and these observations were also discussed during formal QA discussion where appropriate in order to eliminate these perceived sources of error. The nature of each incident did conform to JCAHO standards of ‘‘reportable’’ incidents but were not debriefed with the specific senior members of the healthcare team who were directly involved and might have had a different view of the event. Another assumption we have made is that identifying and calling attention to small patient safety risks might equate to better overall clinical outcomes in these patients. We did not verify this assumption with actual patient outcome data as our study group was medical students and their safety attitudes. Lastly, any observational experiment suffers from the possible introduction of the ‘‘Hawthorne Effect’’ [28], whereby observation alone can modify behavior, and we acknowledge that our interventions might have positively influenced the behaviors that were the subject of this study. CONCLUSION
Teaching medical students CRM principles and clinical applications of patient safety and error avoidance can be accomplished with excellent acceptance on their part. A second clinically focused course enhances lessons learned earlier in medical school and teaches important tools that are used in real life patient encounters. Younger house staff and fellow students who have been educated in the new era of patient safety are more receptive to safety concerns than senior house staff and attending physicians. These data suggest that an education program aimed at shifting the culture of hierarchy and enhancing information sharing can be accomplished. It is likely that senior physician training is needed to supplement the ‘‘bottom up’’ patient safety efforts with a ‘‘top down’’ effort to accomplish the needed end point of reducing if not eliminating patient errors. REFERENCES 1. Ivatury RR, Guilford K, Malhotra AK, et al. Patient safety in trauma: Maximal impact management errors at a level I trauma center. J Trauma 2008;64:265. 2. Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of errors contributing to trauma mortality: Lessons learned from 2594 deaths. Ann Surg 2006;244:371. 3. Teixeira PG, Inaba K, Hadjizacharia P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma 2007;63:1338. 4. Mini~ no AM, Anderson RN, Fingerhut LA, et al. National Vital Statistics Reports. 2006 (54). No.10. Calculation based on 161,269 resident deaths in the United States as the result of injuries. 5. Institute of Medicine. To err is human: Building a safer health system. Washington DC: National Academy Press, 2000. 6. Cooper G, White M, Lauber J. Resource management on the flight deck: Proceedings of a NASA/Industry Workshop. (NASA CP-2120). Moffett Field, CA: NASA-Ames Research Center, 1980.
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7. Stahl K, Brien S. Reducing patient errors in trauma care. In: Cohn S, ed. Acute care surgery: Evidenced-based practice. New York, NY: Informa Healthcare USA Inc., 2009:276–87. 8. Helmreich R. On error management: Lessons from aviation. Br Med J 2000;320:781. 9. Stahl K, Palileo A, Schulman C, et al. Enhancing patient safety in the trauma/surgical intensive care unit. J Trauma 2009; 67:430. 10. Sundt TM, Brown JP, Uhlig PN. STS Workforce on Patient Advocacy, Communications, and Safety. Focus on patient safety: Good news for the practicing surgeon. Ann Thorac Surg 2005; 79:11. 11. Salas E, Burke SC, Bowers CA, et al. Team training in the skies: Does crew resource management (CRM) training work? Hum Factors 2001;43:641. 12. Thompson D, Cowan J, Holzmueller C, et al. Planning and implementing a systems-based patient safety curriculum in medical education. Am J Med Qual 2008;23:271. 13. Sandars J, Bax N, Mayer D, et al. Educating undergraduate medical students about patient safety: Priority areas for curriculum development. Medl Teacher 2007;29:60. 14. Seiden S, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient safety. Qual Saf Health Care 2006;15:272. 15. Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med 2006;81:94. 16. Kern T. Redefining airmanship. New York, NY: McGraw-Hill, 1997. 17. Reader T, Flin R, Lauche K, et al. Non-technical skills in the intensive care unit. Br J Anaesthesia 2006;96:551.
18. Walton M. Teaching patient safety to clinicians and medical students. Clin Teacher 2007;4:224. 19. Available at: http://www.jointcommission.org/SentinelEvents/ SentinelEventAlert/. Accessed April 11, 2008. 20. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviation Psych 1999;9:19. 21. Kern T. Controlling pilot error: Culture, environment, and CRM (Crew Resource Management). New York, NY: McGraw-Hill, 2001. 22. Reason J. Human error: Models and management. Br Med J 2000;320:768. 23. Available at: http://www.jcaho.org/accredited+organizations. htm. Accessed March 21, 2008. 24. Morrison G, Goldfarb S, Lanken P. Team training of medical students in the 21st century: Would flexner approve? Acad Med 2010;85:254. 25. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: Cross-sectional surveys. BMJ 2000;320:745. 26. Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Resarch Consortium. Ann Emerg Med 1999;34:373. 27. Helmreich R, Wilhelm J, Klinect J, et al. Culture, error, and crew resource management. In: Salas E, Bowers CA, Edens E, eds. Applying resource management in organizations: A guide for professionals. Hillsdale, NJ: Erlbaum (in press). 28. Mayo E. Hawthorne and the Western Electric Company, The social problems of an industrial civilization. London: Routledge, 1949.
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APPENDIX 1
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APPENDIX 2
Question (N ¼ 107) Do yon consider yourself conscious of patient safety and medical error concerns as you participate in your clinical rotations? Have your clinical rotations been influenced by your participation in the patient safety courses? Do you feel free to speak up if you see a potential patient safety risk? Have you intervened in a patient care event during your clinical rotation to enhance safety or avoid a medical error in the care of that patient? Has your participation in the safety curriculum made you more aware the importance of accurate communication about patient information? Have you intervened to correct information you knew was wrong during a clinical encounter? Do you consider yourself conscious of the impact of fatigue on your clinical performance?
Yes (%) first year Only
Yes (%) two year
No (%) first year Only
No (%) two year
p
NA
98.1
NA
1.9
-
53.9
74.5
46.1
25.5
<0.05
NA 61.1
80.4 76.6
NA 38.9
19.6 23.4
<0.05
NA
86.9
NA
13.1
-
59.4
79.4
40.6
20.6
<0.05
NA
95.3
NA
4.7
-
Above Negative Average average
Question (N ¼ 107) How valuable was your introduction to patient safety in your 1st year of medical school to your clinical rotations? How valuable was your clinical patient safety course during the trauma surgery rotation to your clinical rotations? p value
Question (N ¼ 107) When you have spoken up about a patient safety concern during your clinical rotation, were your concerns accepted by interns and junior residents? When you have spoken up about a patient safety concern during your clinical rotation, were your concerns accepted by surgical fellows? When you have spoken up about a patient safety concern during your clinical rotation, were your concerns accepted by surgical attendings? p value
6.5
36.6
53.9
4.3
21.3
74.5 <0.05
Rejected or ambivalent
Somewhat or very much accepted
15.2
83.8
36.8
63.2
30.3
69.7 <0.05
Assessing the Impact of Teaching Patient Safety Principles to Medical Students During Surgical Clerkships Kenneth Stahl, M.D., F.A.C.S.,*,1 Jeffrey Augenstein, M.D., Ph.D., F.A.C.S.,* Carl I. Schulman, M.D., F.A.C.S.,* Katherine Wilson, Ph.D.,† Mark McKenney, M.D., F.A.C.S.,* and Alan Livingstone, M.D., F.A.C.S.* *The University of Miami Miller School of Medicine, The DeWitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care, Miami, Florida; and †National Transportation Safety Board, Washington, DC Submitted for publication November 3, 2010
Background. A critical aspect of enhancing patient safety is modifying the healthcare safety culture. We hypothesize that students who participate in safety curricula are knowledgeable regarding patient safety and likely to intervene to avoid patient errors. Methods. A two-part patient safety curriculum was taught: introductory theories (first year) and a clinically oriented course during surgery rotations (third year). All students participated in the first year introduction and a random cohort of students (62.6%, N [ 67) participated in the third year program. Multiple choice tests and web-based surveys were administered. Statistical analysis was carried out using Student’s t-test for comparisons of test mean scores and z-test for comparison of the survey data. Results. Students who participated in both years’ curricula scored higher on didactic test than those who participated in only the first year course (82.9% versus 75.5%, P < 0.001). More students participating in both portions of the curricula intervened during at least one clinical encounter to avoid a patient error (77% versus 61%, P < 0.05). Students rated junior house-staff more receptive to patient safety suggestions than surgical fellows and faculty (84% versus 66%, P < 0.05); 75% of students rated their surgical clerkship exposure to patient safety somewhat/extremely valuable compared with 54% students who rated the first year exposure as somewhat/extremely valuable (P < 0.05). Conclusion. Medical students who have practical applications of patient safety education reinforced
1 To whom correspondence and reprint requests should be addressed at The University of Miami Miller School of Medicine, The DeWitt Daughtry Family Department of Surgery, Division of Trauma and Surgical Critical Care, P.O. Box 016960 (D-40), Miami, FL 33101. E-mail: [email protected].
during surgery rotations are knowledgeable and willing to intervene in patient safety concerns. Teaching clinically relevant patient safety skills influences positive behavioral changes in medical students’ performance on surgical teams. Ó 2011 Elsevier Inc. All rights reserved. Key Words: patient safety; medical student education; crew resource management; team training; culture patient safety residents and staff.
INTRODUCTION
Errors in patient care are common and well recognized by society in general, and the government and insurance companies that pay for medical services. In the care of injured patients at Level I trauma centers, preventable deaths due to errors account for up to 10% of fatalities in patients who might otherwise survive [1, 2, 3]. The number of fatal errors equates to as many as 15,000 lost lives per year in the U.S [4], which is two to four times more frequent than deaths due to errors in the general hospital patient population [5]. The reasons for this rate of errors are complex and multifactorial, and include a variety of individual and system factors. The situations that are most conducive to producing errors are the very environments in which trauma victims present; unstable patients, fatigued operators, incomplete histories, time-critical decisions, concurrent tasks, involvement of many disciplines, complex teams, transportation of unstable patients, and multiple hand-offs of patient management. This environment provides the perfect background to emphasize patient safety principles with multiple surgical examples to physicians in training as they learn other basics of surgical care. We hypothesize that teaching clinically relevant and useable safety skills based on
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established ‘‘Crew Resource Management’’ curricula to third year medical students during their surgical clerkships will encourage them to participate as active members of the surgery team and aid in avoiding some of these adverse outcomes. ‘‘High Reliability Organizations’’ (HROs) such as commercial aviation have succeeded in reducing errors and enhancing operational safety through the science of high reliability theory. Important components of safety solutions have been bundled into a broad curriculum of human and system error avoidance strategies that is known as ‘‘Crew Resource Management’’ (CRM). This work originated with research at NASA in 1980 [6]. The principles embodied in CRM have been described for decades for cockpit use with well documented successes [7]. There are several studies that have identified aspects of high reliability and CRM training as solutions to avoiding mistakes in similar environments such as surgical critical care and trauma [8, 9]. Teamwork and team skills are central tenets of CRM training and skills that can be adapted as solutions to avoiding errors in healthcare. Among the most important of these team skills are early recognition of evolving error patterns and timely intervention to avoid propagation of small missteps before they can become lifethreatening events [10]. All team members at every level of experience are essential elements of this ‘‘early warning system.’’ In order to accomplish the aim of early intervention, team members must be aware of safety issues, empowered to participate, and confident their suggestions will elicit an appropriate response. Other aspects of CRM training include a thorough understanding of error mechanisms [10], preoccupation with error avoidance, flattening of hierarchical leadership pyramid, empowerment to speak up regarding safety risks, and use of advanced communication skills [11]. Differences between HROs and healthcare in cultural and personal attitudes towards errors can make some of these CRM principles difficult to propagate into the healthcare system. HROs manage risks by understanding how errors occur and anticipating all possible chances for errors. This points out an important difference between safety designs in healthcare and HROs in that HRO systems are engineered with the expectation that individuals can and will make mistakes and that the system itself must be engineered to catch these mistakes (Nance J. Personal communication, 2007). Physicians and nurses have been granted a loftier status. We are expected not to make mistakes despite operating under stressful conditions in a system that is not specifically attuned to catching small missteps. For this reason, it is important to enhance this CRM mindset that makes awareness of the potential for errors part of daily surgical care. In order to reduce patient errors,
modifications in the culture of healthcare towards error awareness will be necessary [12]. An important way to change our culture is to train new generations of patient safety oriented physicians [13]. The future generations of physicians are today’s medical students who can enhance patient safety when presented an effective curriculum of patient safety methods. This has been shown to be effective in changing perceptions of patient harm and the provider’s role in patient safety [12, 13]. During their clinical rotations, they also function as important members of medical team structure. Published data suggest that medical students want to contribute to the healthcare team, but their inexperience and lack of clinical knowledge lead to a lack of confidence to participate. This, coupled with the fact that they are not licensed providers, lead to an unwillingness or hesitancy to speak up [14]. In certain circumstances, it could also be rooted in fear of negative evaluation or other consequences such as ridicule. Furthermore, our current healthcare culture and the medical hierarchy discourage error identification by student communication of observed errors [15]. Commercial aviation and HROs succeeded in changing their safety culture and adopting principles of empowerment in large part by training incoming generations of flight crews [16]. It can be anticipated that medical students who are taught a clinically relevant curriculum of error awareness and proven methods of recognizing and early error trapping skills will mature into patient safety concerned physicians. Adoption of patient safety principles into the healthcare culture and eventual reduction in the number of adverse outcomes can be enhanced by new generations of young physicians advancing through their training years and eventually entering practice with these principles, skills, and goals firmly embraced. METHODS Over a 1-y period, 110 third year medical students participated in a clinical rotation on the trauma surgery service. Students rotated for 4 wk of their surgical clerkships on the surgical trauma service in groups of 8–12 students. All medical students began their third year clinical rotations after having received a first year introduction to patient safety principles in a didactic lecture format that was based on the ‘‘soft skills in anesthesia’’ model [17]. This 1 d lecture was held during the orientation period and focused on team skills, task management, and situational awareness. The students were also shown a movie on patient safety and errors in patient care and, in a group discussion format, were encouraged to offer ways these safety principles could be used to have avoided the errors. Prior to the start of the trauma clerkship, a web based opinion survey and a 24-question patient safety science knowledge test was distributed to all students (see Appendix 1). This survey was based on knowledge testing metrics from previous studies that established a basis for medical student patient safety [18]. Students who did not complete the web based testing were offered paper test booklets of the same material during the first week of their rotation. During the first week of their trauma rotation, a group of 67 (62.6% of the third year
STAHL ET AL.: TEACHING PATIENT SAFETY TO MEDICAL STUDENTS surgery students) attended an additional 1.5–2.0 h classroom discussion. The lecture focused on a deeper background of safety science and examples of clinical applications of crew resource management principles and communication skills. This course material was based on our own and other published methods of bringing basic high reliability theory from aviation for use in patient safety [7, 8]. Clinical material for this course was taken from trauma surgery and emergency surgery scenarios in which the students were currently involved. We believe that trauma and emergency surgery provide the perfect background for teaching patient safety lessons due to the multifactorial nature of errors and adverse outcomes in this patient population as described above. The program also included video clips of safety scenarios, basic simulation and role-play, review and debriefs of personal safety experiences, and examples of effective communication techniques. In addition, discussions with students included types of medical errors, reportable medical mistakes, and near misses. Patient safety risks and errors were carefully described in didactic and classroom discussions and followed the template of Joint Commission reportable events (wrong medication, wrong patient, missed diagnosis, etc.) [19]. All medical students participated in the same clinical responsibilities for a period of 1 mo. At the conclusion of the rotation, all students were retested on their knowledge of basic patient safety science and opinion surveys on the value of their patient safety training to performance during the clinical rotation. The two groups made up of those who attended both first and third year training versus those who only participated in first year training were compared at the end of each month. We measured medical student adoption of principles of crew resource management by web-based self-reporting during their clinical rotation, by assessing the number of times they had observed and intervened in a patient safety risk as described during classroom work to more senior members of the health care team. These observations were reviewed and discussed with a trauma attending surgeon. Statistical analysis was carried out using Student’s t-test for comparisons of test mean scores and z-test for comparison of the survey data. This research protocol meets exemption criteria (Category 1 and Category 2) from the University of Miami institutional review board as it is research conducted in a commonly accepted educational setting involving normal educational practices and limited to educational testing with survey, interview procedures, and observation of public behavior with none of the 18 specific subject identifiers noted in the Privacy Rule.
RESULTS
The two groups of third year medical students comprised 67 (62.6%) students who participated in both portions of a two-part patient safety curriculum during the first and third years of medical school (2 y group) and a second group 40 (37.4%) attended only the first year portion of the curriculum (1 y group). Opinion survey results found that 98.1% of third year medical students (105/107) were conscious of patient safety concerns. Data on knowledge test scores were compared, and we found an increase in theoretical knowledge of patient safety principles (75.5% first year group versus 82.9% 2 y group P < 0.001) during the trauma surgery rotation. Test results on three students were incomplete and discarded. One hundred seven completed surveys were then analyzed and, overall, 76.6% of students in the 2 y group reported they had actually spoken up and intervened during a clinical
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situation to avoid a patient care error compared with 61% who had participated in only the first year portion of the curriculum (P < 0.05). A large majority of students thought that younger house staff and fellow students were somewhat or very receptive to their patient safety suggestions (83.8%), whereas significantly fewer surgical fellows (63.2%) and surgical attendings (69.7%) were accepting of their patient safety input (P < 0.05). In the 2 y group of medical students, 74.5% rated their clinical exposure to patient safety during their surgical rotation as somewhat or extremely valuable to clinical medicine compared with 53.9% of students in the 1 y group, who rated the first year patient safety exposure as somewhat or extremely valuable to their clinical rotations (P < 0.05). See Appendix 2 and Figure 1.
DISCUSSION
The relevance and importance of changing the healthcare culture towards patient safety and error reduction with its attendant cost effectiveness is gaining acceptance. This has risen to a level that is not only an imperative for our patients but an obligation to society that is demanding change. High Reliability Organizations (HROs) have accomplished the goal of error avoidance with remarkable degrees of success but these successes have at times involved painful cultural and attitude changes have taken over 30 y to ingrain [20, 21]. Fortunately, we do not have to repeat the tedious discovery process since lessons learned in those organizations have applications in healthcare and, specifically, in delivery of surgical services [10]. We do need to adopt some of these risk reduction strategies that have come about largely by managing safety threats, and enhancing team function and communication. Other lessons we can adopt into the healthcare system are early recognition of error patterns and timely system and individual interventions to interrupt the error process before disaster strikes [22]. Our study demonstrates that CRM based safety principles can be taught to medical students both during their early basic science years and reinforced with more clinically relevant courseware during clinical surgical rotation. The fact that students did significantly better in didactic testing after exposure during both first year and third year is not surprising as we reinforced and reminded them of earlier lessons. However, it is demonstrated with these data that a second clinical curriculum is more valuable for learning useable clinical CRM tools than just the first year basic course. This closely parallels the standard model of teaching basic sciences during the first 2 y of medical school followed by clinical applications of this material on the
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FIG. 1. Comparison of Safety Training to First Year Medical Students vs. Addition of Clinical Patient Safety Training Program and comparison of Junior vs. Senior Staff willingness to accept Safety Suggestions.
wards during the third and fourth years. These data also demonstrate that we were able to effect a cultural change in physician trainees to enhance their intervention in safety matters that is significantly improved with a two-level course approach. This reflects key principles of CRM material that stresses participation by all team members regardless of experience, empowerment to speak up and point out early safety risks, and further shows evidence of a change in the usual culture in healthcare teamwork. The importance of emphasizing communication skills in CRM medical training is stressed in Joint Commission data on medical errors that cites miscommunication and poor accessibility of information as the root cause of 67% of these incidents [23]. Published data from advanced medical school programs have designed a curriculum of team skills and communication training courses for all 4 y of medical education and described positive results. This curriculum has been guided by evidenced based targeted needs assessment [12]. Medical students may be as adept at preventing certain types of errors as other members of the healthcare team. Because students usually follow fewer patients than house staff, they can afford greater attention to details that may fail to gain attention and otherwise lead to medical errors. Moreover, the inclusion of medical students in the care of the patient affords increased redundancy to catching medical errors and mitigating their consequences [24]. Our data show that we were able to overcome some of the challenges for adoption of CRM principles in medicine. However, cultural differences between HROs and healthcare remain broad. Our opinion survey data on hierarchy and acceptance of junior level input closely parallels work by Sexton and colleagues who compared
flight crews with operating room personnel on several measures, including attitudes toward teamwork [25]. The study included more than 30,000 cockpit crew members (captains, first officers, and second officers) and 1033 operating room personnel (attending surgeons, attending anesthesiologists, surgical residents, anesthesia residents, surgical nurses, anesthesia nurses). In their study, only a slight majority (55%) of attending surgeons rejected steep hierarchies (determined by whether they thought junior team members should question the decisions of senior team members). In contrast, 94% of airline crew members preferred flat hierarchies. It is precisely this culture in healthcare that needs to change in order to enhance safe and error free care of complex surgical and trauma patients. CRM course material that was taught to medical students was designed to recognize the importance of their input into the surgery team efforts to recognize and avoid errors. Our program focused on individual attitudes and awareness to a broad curriculum of behavioral skills, communication, and teamwork attitudes integrated with technical competencies. Joint Commission data suggest that CRM training results in positive reactions to teamwork concepts, increased knowledge of teamwork principles, improved communication, and teamwork performance [15]. CRM as taught to our medical students encompassed skills such as clearly defining team roles and duties, enhancing communication, managing distractions, prioritizing tasks, and empowering team members at all skill levels to participate in safety management, all of which are integral components of a well functioning surgical team. This important set of skills has also been emphasized in the medical
STAHL ET AL.: TEACHING PATIENT SAFETY TO MEDICAL STUDENTS
literature to optimize and manage workload and task assignments, clinical task planning, and review and critique strategies [26]. CRM skills are an indispensable element of communication in the operating room, and Level II data support the conclusion that these skills enhance the performance of the operating team and patient outcomes [7]. Medical students can contribute to patient safety in the operating room, especially during trauma surgery, when multiple tasks are required of the attending and senior resident staff under timecompressed conditions, and where their attention is focused on a very narrow field. Under these circumstances, the medical students may actually possess the best view of ‘‘the big picture’’ of a patient’s status and thus may have the best situational awareness as stressed in CRM course teaching. Their contributions and observations to safe outcomes are unavailable to the attending and senior resident surgeons unless the students are taught how to communicate their concerns and feel enabled and empowered to do so AND senior team members are receptive to their input. These are the specific, clinically relevant skills that were taught to our medical students during their surgical rotations. Their participation in interrupting the chain of events that start with small missteps and end in clinical failures is crucial, and has been documented by these data. There are several limitations to the design of this study. Establishing metrics to assess clinical adoption of crew resource management principles used by medical students needed to take into account that students do not have unsupervised patient care responsibilities nor do they perform surgical procedures. Metrics that assess the effectiveness of patient safety lessons taught as a part of the medical school curricula are difficult to quantify, and the usual outcomes measures likely do not apply. The metric we chose to measure is selfreported interventions on the part of the medical students when they saw a patient safety risk. This metric is based on published studies that have established ‘‘intervention’’ as a key benchmark for adoption of CRM principles in cross-cultural groups of commercial aviators. Although this is not a metric that has previously been establish to measure adoption of CRM skills in healthcare, we believe it is cross-applicable for use in this study because of the similarity of the team interactions. The tool has been validated in seminal research studies by Helmreich et al., who have used this metric in other similar situations [27]. Additionally, self-reported interventions were confirmed with interviews of the students and the events discussed, but their perceptions of errors are limited by their lack of clinical experience. The observed incidents were all subjective on the part of the students, and were discussed with the trauma faculty in a Mor-
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bidity and Mortality format. Feedback was provided to the trauma service, and these observations were also discussed during formal QA discussion where appropriate in order to eliminate these perceived sources of error. The nature of each incident did conform to JCAHO standards of ‘‘reportable’’ incidents but were not debriefed with the specific senior members of the healthcare team who were directly involved and might have had a different view of the event. Another assumption we have made is that identifying and calling attention to small patient safety risks might equate to better overall clinical outcomes in these patients. We did not verify this assumption with actual patient outcome data as our study group was medical students and their safety attitudes. Lastly, any observational experiment suffers from the possible introduction of the ‘‘Hawthorne Effect’’ [28], whereby observation alone can modify behavior, and we acknowledge that our interventions might have positively influenced the behaviors that were the subject of this study. CONCLUSION
Teaching medical students CRM principles and clinical applications of patient safety and error avoidance can be accomplished with excellent acceptance on their part. A second clinically focused course enhances lessons learned earlier in medical school and teaches important tools that are used in real life patient encounters. Younger house staff and fellow students who have been educated in the new era of patient safety are more receptive to safety concerns than senior house staff and attending physicians. These data suggest that an education program aimed at shifting the culture of hierarchy and enhancing information sharing can be accomplished. It is likely that senior physician training is needed to supplement the ‘‘bottom up’’ patient safety efforts with a ‘‘top down’’ effort to accomplish the needed end point of reducing if not eliminating patient errors. REFERENCES 1. Ivatury RR, Guilford K, Malhotra AK, et al. Patient safety in trauma: Maximal impact management errors at a level I trauma center. J Trauma 2008;64:265. 2. Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of errors contributing to trauma mortality: Lessons learned from 2594 deaths. Ann Surg 2006;244:371. 3. Teixeira PG, Inaba K, Hadjizacharia P, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma 2007;63:1338. 4. Mini~ no AM, Anderson RN, Fingerhut LA, et al. National Vital Statistics Reports. 2006 (54). No.10. Calculation based on 161,269 resident deaths in the United States as the result of injuries. 5. Institute of Medicine. To err is human: Building a safer health system. Washington DC: National Academy Press, 2000. 6. Cooper G, White M, Lauber J. Resource management on the flight deck: Proceedings of a NASA/Industry Workshop. (NASA CP-2120). Moffett Field, CA: NASA-Ames Research Center, 1980.
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7. Stahl K, Brien S. Reducing patient errors in trauma care. In: Cohn S, ed. Acute care surgery: Evidenced-based practice. New York, NY: Informa Healthcare USA Inc., 2009:276–87. 8. Helmreich R. On error management: Lessons from aviation. Br Med J 2000;320:781. 9. Stahl K, Palileo A, Schulman C, et al. Enhancing patient safety in the trauma/surgical intensive care unit. J Trauma 2009; 67:430. 10. Sundt TM, Brown JP, Uhlig PN. STS Workforce on Patient Advocacy, Communications, and Safety. Focus on patient safety: Good news for the practicing surgeon. Ann Thorac Surg 2005; 79:11. 11. Salas E, Burke SC, Bowers CA, et al. Team training in the skies: Does crew resource management (CRM) training work? Hum Factors 2001;43:641. 12. Thompson D, Cowan J, Holzmueller C, et al. Planning and implementing a systems-based patient safety curriculum in medical education. Am J Med Qual 2008;23:271. 13. Sandars J, Bax N, Mayer D, et al. Educating undergraduate medical students about patient safety: Priority areas for curriculum development. Medl Teacher 2007;29:60. 14. Seiden S, Galvan C, Lamm R. Role of medical students in preventing patient harm and enhancing patient safety. Qual Saf Health Care 2006;15:272. 15. Madigosky WS, Headrick LA, Nelson K, et al. Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad Med 2006;81:94. 16. Kern T. Redefining airmanship. New York, NY: McGraw-Hill, 1997. 17. Reader T, Flin R, Lauche K, et al. Non-technical skills in the intensive care unit. Br J Anaesthesia 2006;96:551.
18. Walton M. Teaching patient safety to clinicians and medical students. Clin Teacher 2007;4:224. 19. Available at: http://www.jointcommission.org/SentinelEvents/ SentinelEventAlert/. Accessed April 11, 2008. 20. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviation Psych 1999;9:19. 21. Kern T. Controlling pilot error: Culture, environment, and CRM (Crew Resource Management). New York, NY: McGraw-Hill, 2001. 22. Reason J. Human error: Models and management. Br Med J 2000;320:768. 23. Available at: http://www.jcaho.org/accredited+organizations. htm. Accessed March 21, 2008. 24. Morrison G, Goldfarb S, Lanken P. Team training of medical students in the 21st century: Would flexner approve? Acad Med 2010;85:254. 25. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: Cross-sectional surveys. BMJ 2000;320:745. 26. Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Resarch Consortium. Ann Emerg Med 1999;34:373. 27. Helmreich R, Wilhelm J, Klinect J, et al. Culture, error, and crew resource management. In: Salas E, Bowers CA, Edens E, eds. Applying resource management in organizations: A guide for professionals. Hillsdale, NJ: Erlbaum (in press). 28. Mayo E. Hawthorne and the Western Electric Company, The social problems of an industrial civilization. London: Routledge, 1949.
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APPENDIX 1
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APPENDIX 2
Question (N ¼ 107) Do yon consider yourself conscious of patient safety and medical error concerns as you participate in your clinical rotations? Have your clinical rotations been influenced by your participation in the patient safety courses? Do you feel free to speak up if you see a potential patient safety risk? Have you intervened in a patient care event during your clinical rotation to enhance safety or avoid a medical error in the care of that patient? Has your participation in the safety curriculum made you more aware the importance of accurate communication about patient information? Have you intervened to correct information you knew was wrong during a clinical encounter? Do you consider yourself conscious of the impact of fatigue on your clinical performance?
Yes (%) first year Only
Yes (%) two year
No (%) first year Only
No (%) two year
p
NA
98.1
NA
1.9
-
53.9
74.5
46.1
25.5
<0.05
NA 61.1
80.4 76.6
NA 38.9
19.6 23.4
<0.05
NA
86.9
NA
13.1
-
59.4
79.4
40.6
20.6
<0.05
NA
95.3
NA
4.7
-
Above Negative Average average
Question (N ¼ 107) How valuable was your introduction to patient safety in your 1st year of medical school to your clinical rotations? How valuable was your clinical patient safety course during the trauma surgery rotation to your clinical rotations? p value
Question (N ¼ 107) When you have spoken up about a patient safety concern during your clinical rotation, were your concerns accepted by interns and junior residents? When you have spoken up about a patient safety concern during your clinical rotation, were your concerns accepted by surgical fellows? When you have spoken up about a patient safety concern during your clinical rotation, were your concerns accepted by surgical attendings? p value
6.5
36.6
53.9
4.3
21.3
74.5 <0.05
Rejected or ambivalent
Somewhat or very much accepted
15.2
83.8
36.8
63.2
30.3
69.7 <0.05