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Patient safety: Do nursing and medical curricula address this theme?
Nurse Education Today (2005) 25, 333–340
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Patient safety: Do nursing and medical curricula address this theme? Ann Wakefield a,*, Moira Attree a, Isobel Braidman b, Caroline Carlisle a, Martin Johnson c, Hannah Cooke a a
School of Nursing Midwifery and Health Visiting, The University of Manchester, Coupland Building 3, Manchester M13 9PL, UK b School of Medicine, The University of Manchester, UK c Salford University, UK Accepted 18 February 2005
KEYWORDS
Summary In this literature review, we examine to what extent patient safety is addressed within medical and nursing curricula. Patient safety is the foundation of healthcare practice and education both in the UK and internationally. Recent research and policy initiatives have highlighted this issue. The paper highlights the significance of this topic as an aspect of study in its own right by examining not only the fiscal but also the human costs such events invite. In the United Kingdom patient safety issues feature prominently in the (Department of Health, 2000a. An organisation with a memory. The report of an expert group on learning from adverse events. The Stationery Office, London, Department of Health, 2000b. Handling complaints: monitoring the NHS complaints procedures (England, Financial year 1998–99). The Stationery Office, London.) policy documentation but this is not reflected within the formal curricula guidelines issued by the NMC and GMC. Yet if healthcare educational curricula were to recognise the value of learning from errors, such events could become part of a wider educational resource enabling both students and facilitators to prevent threats to patient safety. For this reason, the paper attempts to articulate why patient safety should be afforded greater prominence within medical and nursing curricula. We argue that learning how to manage errors effectively would enable trainee practitioners to improve patient care, reduce the burden on an overstretched health care system and engage in dynamic as opposed to defensive practice. c 2005 Elsevier Ltd. All rights reserved.
Patients safety; Educational curricula; Adverse event; Near miss
* Corresponding author. Tel.: +1 611 275 7007; fax: +1 161 275 7566. E-mail address: [email protected] (A. Wakefield).
0260-6917/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2005.02.004
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Introduction Everyday more than one million people are treated safely and successfully in the NHS. But . . . in complex health care systems things will and do go wrong, no matter how dedicated and professional the staff. The effects of harming a patient are widespread . . . devastating consequences can ensue and staff can become demoralised and disaffected (National Patient Safety Agency, 2003a, p. 3) According to the Chief Medical Officer’s Report, the vast majority of NHS care meets the high clinical standards expected by the public (Department of Health, 2000a; National Patient Safety Agency, 2003a). Although the vast majority of health professionals are committed to attaining excellence when caring for patients, enquiries into adverse events have too often shown that failure is largely tolerated by medical/nursing staff (Department of Health, 2000a; Lester and Tritter, 2001; Maddox et al., 2001; Neale et al., 2001; The Bristol Infirmary Inquiry 2001). The notion of failure when used in this context denotes an adverse event or error, which the Department of Health (2000a) defines as an event or omission arising during clinical care and causing physical or psychological injury to a patient. Thus, patient safety is defined as freedom from accidental injury of any kind (Kohn et al., 1999; Weinger et al., 2003, p. 106). Within the literature, there is a lack of a common definition for the terms error, adverse event and patient safety. While the Department of Health (2000a) do not distinguish between adverse events or errors, Kohn et al. (1999, p. 3) have attempted to distinguish between them by defining errors as the failure of a planned action to be completed as intended (an error of execution) or the use of the wrong plan to achieve an aim (an error of planning). For the purpose of this review, we define an adverse event as any occurrence leading to iatrogenic injury. When there are operational and organisational breakdowns, whatever their cause and however they are defined, devastating and distressing consequences can ensue not only for patients and their families, but also for staff (Houston and Allt, 1997; National Patient Safety Agency, 2003a). In particular, the psychological impact of failure exerts additional pressure upon organisations that are already challenged, given that such events have the potential to demoralise staff and undermine public confidence (Aron and Headrick, 2002; Department of Health, 2000a; Department of Health, 2001a; National Patient Safety Agency, 2003a; The Bristol Infirmary Inquiry, 2001). Never-
A. Wakefield et al. theless, the delivery of top quality evidence-based care ultimately depends on the competence of practitioners and the nature of the organisational milieu supporting their work (Ziv et al., 2000).
Patient safety: the extent of the problem, policy relevance and related research The cumulative financial burdens incurred by organisations such as the United Kingdom National Health Service (NHS) following adverse events are enormous. For example, in 1998/1999 the Department of Health paid out an estimated £400 million to settle its clinical negligence claims (National Audit Office, 2000a). This is in addition to having to set aside a further £2.4 billion to meet existing and expected liability claims. A further £2 billion per year was also required to fund extra hospital bed days caused by adverse events (Department of Health, 2000a); with another £1 billion earmarked to fund the cost of hospital acquired infections (Vincent et al., 2001). Reinforcing this bleak representation of the status of the NHS, the best available research-based evidence suggests that in NHS hospitals alone adverse events or errors may occur in around 10% of admissions, a figure equating to over 850,000 patients with an additional: 400 people dying or being seriously injured by adverse events involving medical devices (Medical Devices Agency, 2000). 10,000 people reported as having experienced serious adverse reactions to drugs. 1150 people in recent contact with mental health services having committed suicide. 28,000 written complaints being made about aspects of hospital treatment (National Audit Office, 2000b; Department of Health, 2000b). 38,000 complaints received relating to family health services (National Audit Office, 2000b; Department of Health, 2000a). Although these figures appear alarming they are not unique to the NHS, given that research undertaken in the United States by Kohn et al. (1999), and the Institute of Medicine (2001) as well as that carried out in Australia by Runciman and Moller (1999) reports similar findings. In particular, the Harvard Medical Practice Study, which extrapolated retrospective data from hospital case records, painted an equally depressing picture highlighting that 3.7% of hospital admissions culminated in an adverse event (Brennan et al., 1991; Leape, 1991).
Patient safety: Do nursing and medical curricula address this theme? Indeed, a discussion paper by Wakefield and Maddox (2000), highlights that in the United States medical errors are estimated to be the cause of more deaths per year than road traffic accidents, breast cancer or AIDS, with medication errors alone accounting for 7000 deaths per year. Reinforcing this point, a study in Colorado and another in Utah mirrored the evidence citied by Kohn et al. (1999), suggesting that 70% of patients experiencing an adverse event were likely to manifest with a slight or a short-lived disability (Brennan et al., 1991; Leape et al., 1991; Gwande et al., 1999; Vincent et al., 2001). Perhaps what is even more disturbing, however, is the fact that 7% of patients experiencing an adverse event developed a permanent disability with a further 14% dying in circumstances directly attributable to the adverse event. In Australia, adverse events account for 8% of the total hospital bed days at a cost of AUS$4.7billion per year, a factor that has also had a detrimental effect on staff (Aron and Headrick, 2002; Houston and Allt, 1997; Vincent, 1997). The economic costs are undoubtedly important but are superseded by the cost in terms of human suffering, which is not readily quantifiable. For example, there are difficulties in extracting accurate data as many studies conflate the terms adverse event and error. Furthermore, most leading studies rely on retrospective analysis of patient records, which have their own inherent biases. Hence, what is revealed in the literature is arguably the ‘tip of the iceberg’ (O’Neil et al., 1993) and may overstate some problems while ignoring others. In addition to taking note of adverse events, ‘near misses’ also need to be considered. The Department of Health (2000a, p. xii) define ‘near miss’ as situations in which an event or omission, or a sequence of events or omissions, arising during clinical care fails to develop further, whether or not as the result of compensating action, thus preventing injury to a patient From an educational perspective, we argue that the ability to learn from near misses is an underdeveloped attribute.
Learning from adverse events To learn from adverse events and near misses, the health service needs an accurate reporting system. In the UK, reporting systems for adverse events and near misses are still in their infancy. When self-report methods of data collection were used, adverse events well in excess of those studies drawing on
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patient records, such as the Harvard study, were produced (Classen et al., 1991; Bates et al., 1995). When observational methods were employed, error rates rose even more markedly (Andrews et al., 1997; Donchin et al., 1995). Thus, it should come as no surprise when Rall et al. (2001) point out that errors in medicine are among the ten major causes of death (USA Today, 1999). Maddox et al. (2001) therefore advocate that safety and error reduction must become a central tenet in health care professionals’ educational programmes. Organisational factors have been found to affect the occurrence of adverse events and near misses, indeed, Reason et al. (2001) suggest that the distribution of adverse events is not random. There are clusters of organisational pathologies that render some systems more vulnerable to the manifestation of adverse events than others. They call this susceptibility to adverse events, ‘‘vulnerable systems syndrome’’ with three pathological entities lying at its core: blame, denial and a ‘‘singleminded pursuit of the wrong kind of excellence’’ (Reason et al., 2001), for example the blinkered pursuit of narrow performance targets. Each of these attributes interacts with the other to undermine and impede the introduction of effective risk management programmes. In the same way, Benner et al. (2002) argue that responsibility for correcting errors is focused towards either the system or the individual. Individual approaches reflect Reason et al.’s (2001) notion of blame while a systems approach examining the internal and external forces focuses on those factors impinging on the organisation to make it vulnerable. Benner et al. (2002) propose an alternative method of investigating risk, which they term a practice responsibility model of analysis. Benner et al.’s (2002) framework combines both the individual and systems approach to error reduction by examining an individual’s practice responsibility, systems analysis and shared practice responsibility. In essence, the model examines both the organisational culture and learning milieu as a way of understanding what individuals and organisations value, in order to understand how hazards manifest and are subsequently dealt with. Thus, in order to make health service organisations more robust and with it, less vulnerable, recent policy initiatives called for the reporting of errors to be more open (National Patient Safety Agency, 2003a). The NPSA National Learning and Reporting System, which aims to encourage open reporting, was implemented in 2004. The Department of Health (2000a) recommend that the NHS should modernise its approach to dealing with
336 adverse events in order to learn from its failures. The four key areas to be addressed included the need to develop: unified mechanisms for reporting and analysing when things went wrong; a more open culture, in which errors or service failures could be reported and discussed; mechanisms for ensuring that, where lessons are identified, the necessary changes could be put into practice; a much wider appreciation of the value of a systems approach to preventing, analysing and learning from errors (Department of Health, 2000a, p. xi). In response to this recommendation, the National Patient Safety Agency set up a series of National Reporting and Learning Systems first piloted in 2001–2002. One of the pilot sites reported that the Trust were hearing about more ‘near misses’ than ever before with treble the amount of reports being filed over one eight month period (National Patient Safety Agency, 2003b, p. 5). Despite this rise in reported incidents, it was not an indication of a decline in Trust standards; rather that people felt more empowered to voice their concerns (National Patient Safety Agency, 2003b, p. 5). The impact of the new reporting system has yet to be evaluated, particularly as increased reporting does not automatically lead to organisational learning. Consequently, health professionals need to be educated in how to use the systems if they are to learn from adverse events.
Educational response to policy initiatives Although detailed work needs to be undertaken, there is little evidence that undergraduate, preregistration, postgraduate and post-registration programmes equip students with the skills necessary to examine patient safety issues, as an integral part of their practice. Several potentially beneficial processes have been introduced. These include root cause analysis programmes, national learning and reporting systems, and human factor engineering (the study of the impact of workplace design and workplace environment on people) as well as involving patients as partners in improving practice. These initiatives are clearly not yet embedded within clinical and educational practice. Moreover, human factor engineering alone cannot bring about the required transformation given
A. Wakefield et al. that such fundamental changes in philosophy need to be underpinned by an associated cultural and attitudinal change. If new ways of looking at risk and patient safety are to have maximum impact, they need to form an integral part of the framework for life long learning (Department of Health, 2001b). For this reason, educational developments cannot simply comprise in-house training sessions based in local NHS Trusts. Rather, patient safety issues need to be reflected across the broad spectrum of educational curricula designed to prepare health care students for their future practice. Although more research is required in this respect, the clear evidence of harms facing patients suggests that professionals are insufficiently prepared to control risks. This latter aspect is a particularly important consideration for all health professional educators, given that poor patient safety has been identified as a ‘‘systemic disease,’’ which needs to be afforded greater significance within health care curricula (Weinger et al., 2003). Yet, if we analyse the content of the curricula guidelines issued for undergraduate nursing and medical education, the ideas currently championed in practice are not explicitly addressed in these formal documents.
Nursing curriculum guidelines The low degree of emphasis on patient safety is exemplified by the Nursing and Midwifery Council’s 21-page document outlining the Requirements for Pre-Registration Nursing Programmes Protecting the Public through Professional Standards (NMC, 2002). In this document, only four recommendations overtly refer to issues of patient safety. Yet much of the evidence on patient safety and the systematic management of medical error had already started to emerge within the academic literature prior to its publication. Of those topics that relate to patient safety, educators are directed to consider the following aspects; namely, that they should encourage students to be able to: Identify unsafe practice and respond appropriately to ensure a safe outcome. Demonstrate a range of essential nursing skills, under the supervision of a registered nurse, to meet individual’s needs, which include: maintaining dignity, privacy and confidentiality; effective communication and observational skills, including listening and taking physiological measurements; safety and health, including
Patient safety: Do nursing and medical curricula address this theme? moving and handling and infection control; essential first aid and emergency procedures; administration of medicines; emotional, physical and personal care, including meeting the need for comfort, nutrition and personal hygiene. Contribute to the identification of actual and potential risks to patients, clients and their carers, to oneself and to others and participate in measures to promote and ensure health and safety. Understand and implement health and safety principles and policies. Recognise and report situations with are potentially unsafe for patients, clients, oneself and others. Contribute to public protection by creating and maintaining a safe environment of care through the use of quality assurance and risk management strategies. Apply relevant principles to ensure the safe administration of therapeutic substances. Use appropriate risk assessment tools to identify actual and potential risks. Identify environmental hazards and eliminate and/or prevent them where possible. Communicate safety concerns to a relevant authority. Manage risk to provide care which best meets the needs and interests of patients, clients and the public. (Nursing and midwifery council: requirements for pre-registration nursing programmes protecting the public through professional standards, 2002)
Medical curriculum guidelines Likewise, the General Medical Council’s document is equally broad ranging. For example, in its 24page document, Tomorrow’s Doctors: Recommendations of Undergraduate Medical Education (GMC, 2003) five areas are identified as guiding statements that relate to issues of patient safety, these being that students should: Know about and understand the following – how errors can happen in practice and the principles of managing risks. Be able to perform clinical skills safely. Know and understand the principles of treatment including the effective and safe use of medicines as a basis for prescribing, including
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side effects, harmful interactions, antibiotic resistance and genetic indications of the appropriateness of drugs. Follow the principles of risk management when they practice. Be aware of current developments and guiding principles in the NHS for example risk assessment and management strategies for health care professionals. (General medical council: tomorrow’s doctors: recommendations of undergraduate medical education, 2003). Although the nursing and medical curricular guidelines address issues of risk and safety, both lack the level of detail necessary for the reader to evaluate how these might be operationalised in practice. For example, the documents cover a comprehensive range of topics yet they do not indicate which topics are of vital import or how educationalists might address the themes outlined. More importantly perhaps, it is not clear how the guidelines are actually translated into module content or how they might be delivered in practice or to what extent the learning milieu might influence how when where and why certain aspects might be afforded greater importance than others.
Are educators doing safety justice? Some have argued that nursing and medical students, though well prepared in the art and science base of their respective disciplines in order to look after individual patients, have few of the skills necessary to improve care and patient safety (Aron and Headrick, 2002; Maddox et al., 2001). Nevertheless, if we re-examine the guiding principles outlined above, neither document recommends students should examine topics such as interdisciplinarity and interdependence. Yet both of these aspects have been identified as essential ingredients for the successful management of risk and improved patient safety as they facilitate enhancement of team working skills enabling individuals to draw on collaborative as opposed to solitary forms of knowledge (Firth-Cozens, 2001; Mizrahi, 1984). Furthermore, there is a need for students to understand work as a process; that is to develop skills in collecting, aggregating, analysing and displaying data on outcomes of care; designing health care processes; working in teams and collaborating with managers and patients. Examining problems honestly and learning from mistakes are all equally absent from both the GMC (2003) and the NMC (2002) documents. Despite this, Aron and Headrick
338 (2002); Berwick et al., 1992 and Reason (1997) all suggest that such topics should form an integral part of any curriculum that is serious about improving patient safety. In order to reinforce this point, there is growing evidence to suggest that despite the focus on patient safety gaining increased attention in clinical practice (Department of Health, 2000a; National Patient Safety Agency, 2003b) similar initiatives are slow to achieve strategic recognition within medical and nursing education (Stevens, 2002). Perhaps the latter situation arises because patient safety issues push nursing and medical education towards unfamiliar territory given that for the most part neither group of students focus on analysing complex systems, organisational culture or the importance of teamwork (Aron and Headrick, 2002; Davidoff, 2002; Mohr and Batalen, 2002).
A. Wakefield et al. Educational curricula need to recognise the importance of errors, allowing them to be drawn upon as part of a wider educational activity. This would facilitate discussion regarding the construction of adverse events as part of a root cause analysis, enabling many to learn from the experience (Lester and Tritter, 2001; National Patient Safety Agency, 2003b; Department of Health, 2000a). This latter modus operandi embraces the type of reporting culture where the root cause of adverse events or near misses are seen as important, enabling individuals to be in a position to evaluate what has taken place and generate new ways of working (Boyer, 2001). Thus if students could be encouraged to examine adverse events in this way, it is suggested that learning could be more effective and the risk of recurrence reduced (Department of Health, 2000a; Nievea and Sorra, 2003).
Improving practice by learning from adverse events
Conclusion
Despite the above, the central tenet of ‘near misses,’ and ‘adverse events’ is the need to learn from the situation, in order to improve practice and prevent the same situation arising in the future. For example, in ‘high reliability’ organisations such as the airline, navy and nuclear industry, where mistakes are minimised because of their overwhelming implications, a culture that is constantly alert to the possibility of failure has developed. This means that the root cause of adverse events can be isolated and exploited as part of an organisational learning opportunity (Reason et al., 2001; Stevens, 2002; Weick and Sutcliffe, 2001). Here the notion of reliability equates to a ‘dynamic non-event’ in other words, when adverse events are prevented, nothing happens (Weick and Sutcliffe, 2001). In contrast, when healthcare educators put disease treatment before illness prevention, the significance of ‘dynamic non-events’ go unrecognised. Instead, a ‘‘name, blame and shame’’ culture prevails in clinical practice; a factor which Reason et al. (2001) suggest renders an organisation vulnerable (National Patient Safety Agency, 2003b). In such circumstances, although learning by the person responsible for the mistake is both powerful and long lasting, only the individual involved gains additional knowledge from what has taken place (Aron and Headrick, 2002; Firth-Cozens and Greenhalgh, 1997; Mizrahi, 1984). More importantly, this form of learning may also have a negative effect on the individual’s practice given that it may become inappropriately defensive (Firth-Cozens, 2001).
We have shown that whilst a first principle of health care is ‘primum non nocere’, or first do no harm, the reality of modern health care is that adverse events of many kinds threaten patient safety. There are deficiencies in definitions of errors and adverse events and a lack of accurate data sources but it remains clear that the degree to which harms come to people using health services is currently unacceptable. This has the consequences of both large economic costs and great suffering. Health professionals undergo relatively little education in harm reduction and error management techniques and organisational cultures often lead to even simple measures (like hand washing) being unsatisfactory. At the wider strategic level, health professionals have benefited little from advances in organisational learning and human factor engineering. In particular, modern medical and nursing curricula address these matters in too little depth and with insufficient recognition of their importance. If educators are unfamiliar with or do not value these forms of learning, it unlikely that patient safety issues will be addressed within the curriculum in a meaningful and effective manner. Furthermore, if practitioners and educators alike fail to use a systems approach to analysing the context of an adverse event – a form of learning, which analyses the conditions under which individuals work in order to build defences to avert error or alleviate their effects, no improvements will be made (Reason, 2000; Reason et al., 2001). Like-
Patient safety: Do nursing and medical curricula address this theme? wise, if methods for learning from real adverse events via the application of frameworks such as human factor engineering (Gosbee, 2002) are not incorporated into healthcare programmes, students will not develop the necessary constructive thinking skills required to undertake a detailed safety analysis of their practice in order to reduce risks to patients.
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Nurse Education Today intl.elsevierhealth.com/journals/nedt
Patient safety: Do nursing and medical curricula address this theme? Ann Wakefield a,*, Moira Attree a, Isobel Braidman b, Caroline Carlisle a, Martin Johnson c, Hannah Cooke a a
School of Nursing Midwifery and Health Visiting, The University of Manchester, Coupland Building 3, Manchester M13 9PL, UK b School of Medicine, The University of Manchester, UK c Salford University, UK Accepted 18 February 2005
KEYWORDS
Summary In this literature review, we examine to what extent patient safety is addressed within medical and nursing curricula. Patient safety is the foundation of healthcare practice and education both in the UK and internationally. Recent research and policy initiatives have highlighted this issue. The paper highlights the significance of this topic as an aspect of study in its own right by examining not only the fiscal but also the human costs such events invite. In the United Kingdom patient safety issues feature prominently in the (Department of Health, 2000a. An organisation with a memory. The report of an expert group on learning from adverse events. The Stationery Office, London, Department of Health, 2000b. Handling complaints: monitoring the NHS complaints procedures (England, Financial year 1998–99). The Stationery Office, London.) policy documentation but this is not reflected within the formal curricula guidelines issued by the NMC and GMC. Yet if healthcare educational curricula were to recognise the value of learning from errors, such events could become part of a wider educational resource enabling both students and facilitators to prevent threats to patient safety. For this reason, the paper attempts to articulate why patient safety should be afforded greater prominence within medical and nursing curricula. We argue that learning how to manage errors effectively would enable trainee practitioners to improve patient care, reduce the burden on an overstretched health care system and engage in dynamic as opposed to defensive practice. c 2005 Elsevier Ltd. All rights reserved.
Patients safety; Educational curricula; Adverse event; Near miss
* Corresponding author. Tel.: +1 611 275 7007; fax: +1 161 275 7566. E-mail address: [email protected] (A. Wakefield).
0260-6917/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2005.02.004
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Introduction Everyday more than one million people are treated safely and successfully in the NHS. But . . . in complex health care systems things will and do go wrong, no matter how dedicated and professional the staff. The effects of harming a patient are widespread . . . devastating consequences can ensue and staff can become demoralised and disaffected (National Patient Safety Agency, 2003a, p. 3) According to the Chief Medical Officer’s Report, the vast majority of NHS care meets the high clinical standards expected by the public (Department of Health, 2000a; National Patient Safety Agency, 2003a). Although the vast majority of health professionals are committed to attaining excellence when caring for patients, enquiries into adverse events have too often shown that failure is largely tolerated by medical/nursing staff (Department of Health, 2000a; Lester and Tritter, 2001; Maddox et al., 2001; Neale et al., 2001; The Bristol Infirmary Inquiry 2001). The notion of failure when used in this context denotes an adverse event or error, which the Department of Health (2000a) defines as an event or omission arising during clinical care and causing physical or psychological injury to a patient. Thus, patient safety is defined as freedom from accidental injury of any kind (Kohn et al., 1999; Weinger et al., 2003, p. 106). Within the literature, there is a lack of a common definition for the terms error, adverse event and patient safety. While the Department of Health (2000a) do not distinguish between adverse events or errors, Kohn et al. (1999, p. 3) have attempted to distinguish between them by defining errors as the failure of a planned action to be completed as intended (an error of execution) or the use of the wrong plan to achieve an aim (an error of planning). For the purpose of this review, we define an adverse event as any occurrence leading to iatrogenic injury. When there are operational and organisational breakdowns, whatever their cause and however they are defined, devastating and distressing consequences can ensue not only for patients and their families, but also for staff (Houston and Allt, 1997; National Patient Safety Agency, 2003a). In particular, the psychological impact of failure exerts additional pressure upon organisations that are already challenged, given that such events have the potential to demoralise staff and undermine public confidence (Aron and Headrick, 2002; Department of Health, 2000a; Department of Health, 2001a; National Patient Safety Agency, 2003a; The Bristol Infirmary Inquiry, 2001). Never-
A. Wakefield et al. theless, the delivery of top quality evidence-based care ultimately depends on the competence of practitioners and the nature of the organisational milieu supporting their work (Ziv et al., 2000).
Patient safety: the extent of the problem, policy relevance and related research The cumulative financial burdens incurred by organisations such as the United Kingdom National Health Service (NHS) following adverse events are enormous. For example, in 1998/1999 the Department of Health paid out an estimated £400 million to settle its clinical negligence claims (National Audit Office, 2000a). This is in addition to having to set aside a further £2.4 billion to meet existing and expected liability claims. A further £2 billion per year was also required to fund extra hospital bed days caused by adverse events (Department of Health, 2000a); with another £1 billion earmarked to fund the cost of hospital acquired infections (Vincent et al., 2001). Reinforcing this bleak representation of the status of the NHS, the best available research-based evidence suggests that in NHS hospitals alone adverse events or errors may occur in around 10% of admissions, a figure equating to over 850,000 patients with an additional: 400 people dying or being seriously injured by adverse events involving medical devices (Medical Devices Agency, 2000). 10,000 people reported as having experienced serious adverse reactions to drugs. 1150 people in recent contact with mental health services having committed suicide. 28,000 written complaints being made about aspects of hospital treatment (National Audit Office, 2000b; Department of Health, 2000b). 38,000 complaints received relating to family health services (National Audit Office, 2000b; Department of Health, 2000a). Although these figures appear alarming they are not unique to the NHS, given that research undertaken in the United States by Kohn et al. (1999), and the Institute of Medicine (2001) as well as that carried out in Australia by Runciman and Moller (1999) reports similar findings. In particular, the Harvard Medical Practice Study, which extrapolated retrospective data from hospital case records, painted an equally depressing picture highlighting that 3.7% of hospital admissions culminated in an adverse event (Brennan et al., 1991; Leape, 1991).
Patient safety: Do nursing and medical curricula address this theme? Indeed, a discussion paper by Wakefield and Maddox (2000), highlights that in the United States medical errors are estimated to be the cause of more deaths per year than road traffic accidents, breast cancer or AIDS, with medication errors alone accounting for 7000 deaths per year. Reinforcing this point, a study in Colorado and another in Utah mirrored the evidence citied by Kohn et al. (1999), suggesting that 70% of patients experiencing an adverse event were likely to manifest with a slight or a short-lived disability (Brennan et al., 1991; Leape et al., 1991; Gwande et al., 1999; Vincent et al., 2001). Perhaps what is even more disturbing, however, is the fact that 7% of patients experiencing an adverse event developed a permanent disability with a further 14% dying in circumstances directly attributable to the adverse event. In Australia, adverse events account for 8% of the total hospital bed days at a cost of AUS$4.7billion per year, a factor that has also had a detrimental effect on staff (Aron and Headrick, 2002; Houston and Allt, 1997; Vincent, 1997). The economic costs are undoubtedly important but are superseded by the cost in terms of human suffering, which is not readily quantifiable. For example, there are difficulties in extracting accurate data as many studies conflate the terms adverse event and error. Furthermore, most leading studies rely on retrospective analysis of patient records, which have their own inherent biases. Hence, what is revealed in the literature is arguably the ‘tip of the iceberg’ (O’Neil et al., 1993) and may overstate some problems while ignoring others. In addition to taking note of adverse events, ‘near misses’ also need to be considered. The Department of Health (2000a, p. xii) define ‘near miss’ as situations in which an event or omission, or a sequence of events or omissions, arising during clinical care fails to develop further, whether or not as the result of compensating action, thus preventing injury to a patient From an educational perspective, we argue that the ability to learn from near misses is an underdeveloped attribute.
Learning from adverse events To learn from adverse events and near misses, the health service needs an accurate reporting system. In the UK, reporting systems for adverse events and near misses are still in their infancy. When self-report methods of data collection were used, adverse events well in excess of those studies drawing on
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patient records, such as the Harvard study, were produced (Classen et al., 1991; Bates et al., 1995). When observational methods were employed, error rates rose even more markedly (Andrews et al., 1997; Donchin et al., 1995). Thus, it should come as no surprise when Rall et al. (2001) point out that errors in medicine are among the ten major causes of death (USA Today, 1999). Maddox et al. (2001) therefore advocate that safety and error reduction must become a central tenet in health care professionals’ educational programmes. Organisational factors have been found to affect the occurrence of adverse events and near misses, indeed, Reason et al. (2001) suggest that the distribution of adverse events is not random. There are clusters of organisational pathologies that render some systems more vulnerable to the manifestation of adverse events than others. They call this susceptibility to adverse events, ‘‘vulnerable systems syndrome’’ with three pathological entities lying at its core: blame, denial and a ‘‘singleminded pursuit of the wrong kind of excellence’’ (Reason et al., 2001), for example the blinkered pursuit of narrow performance targets. Each of these attributes interacts with the other to undermine and impede the introduction of effective risk management programmes. In the same way, Benner et al. (2002) argue that responsibility for correcting errors is focused towards either the system or the individual. Individual approaches reflect Reason et al.’s (2001) notion of blame while a systems approach examining the internal and external forces focuses on those factors impinging on the organisation to make it vulnerable. Benner et al. (2002) propose an alternative method of investigating risk, which they term a practice responsibility model of analysis. Benner et al.’s (2002) framework combines both the individual and systems approach to error reduction by examining an individual’s practice responsibility, systems analysis and shared practice responsibility. In essence, the model examines both the organisational culture and learning milieu as a way of understanding what individuals and organisations value, in order to understand how hazards manifest and are subsequently dealt with. Thus, in order to make health service organisations more robust and with it, less vulnerable, recent policy initiatives called for the reporting of errors to be more open (National Patient Safety Agency, 2003a). The NPSA National Learning and Reporting System, which aims to encourage open reporting, was implemented in 2004. The Department of Health (2000a) recommend that the NHS should modernise its approach to dealing with
336 adverse events in order to learn from its failures. The four key areas to be addressed included the need to develop: unified mechanisms for reporting and analysing when things went wrong; a more open culture, in which errors or service failures could be reported and discussed; mechanisms for ensuring that, where lessons are identified, the necessary changes could be put into practice; a much wider appreciation of the value of a systems approach to preventing, analysing and learning from errors (Department of Health, 2000a, p. xi). In response to this recommendation, the National Patient Safety Agency set up a series of National Reporting and Learning Systems first piloted in 2001–2002. One of the pilot sites reported that the Trust were hearing about more ‘near misses’ than ever before with treble the amount of reports being filed over one eight month period (National Patient Safety Agency, 2003b, p. 5). Despite this rise in reported incidents, it was not an indication of a decline in Trust standards; rather that people felt more empowered to voice their concerns (National Patient Safety Agency, 2003b, p. 5). The impact of the new reporting system has yet to be evaluated, particularly as increased reporting does not automatically lead to organisational learning. Consequently, health professionals need to be educated in how to use the systems if they are to learn from adverse events.
Educational response to policy initiatives Although detailed work needs to be undertaken, there is little evidence that undergraduate, preregistration, postgraduate and post-registration programmes equip students with the skills necessary to examine patient safety issues, as an integral part of their practice. Several potentially beneficial processes have been introduced. These include root cause analysis programmes, national learning and reporting systems, and human factor engineering (the study of the impact of workplace design and workplace environment on people) as well as involving patients as partners in improving practice. These initiatives are clearly not yet embedded within clinical and educational practice. Moreover, human factor engineering alone cannot bring about the required transformation given
A. Wakefield et al. that such fundamental changes in philosophy need to be underpinned by an associated cultural and attitudinal change. If new ways of looking at risk and patient safety are to have maximum impact, they need to form an integral part of the framework for life long learning (Department of Health, 2001b). For this reason, educational developments cannot simply comprise in-house training sessions based in local NHS Trusts. Rather, patient safety issues need to be reflected across the broad spectrum of educational curricula designed to prepare health care students for their future practice. Although more research is required in this respect, the clear evidence of harms facing patients suggests that professionals are insufficiently prepared to control risks. This latter aspect is a particularly important consideration for all health professional educators, given that poor patient safety has been identified as a ‘‘systemic disease,’’ which needs to be afforded greater significance within health care curricula (Weinger et al., 2003). Yet, if we analyse the content of the curricula guidelines issued for undergraduate nursing and medical education, the ideas currently championed in practice are not explicitly addressed in these formal documents.
Nursing curriculum guidelines The low degree of emphasis on patient safety is exemplified by the Nursing and Midwifery Council’s 21-page document outlining the Requirements for Pre-Registration Nursing Programmes Protecting the Public through Professional Standards (NMC, 2002). In this document, only four recommendations overtly refer to issues of patient safety. Yet much of the evidence on patient safety and the systematic management of medical error had already started to emerge within the academic literature prior to its publication. Of those topics that relate to patient safety, educators are directed to consider the following aspects; namely, that they should encourage students to be able to: Identify unsafe practice and respond appropriately to ensure a safe outcome. Demonstrate a range of essential nursing skills, under the supervision of a registered nurse, to meet individual’s needs, which include: maintaining dignity, privacy and confidentiality; effective communication and observational skills, including listening and taking physiological measurements; safety and health, including
Patient safety: Do nursing and medical curricula address this theme? moving and handling and infection control; essential first aid and emergency procedures; administration of medicines; emotional, physical and personal care, including meeting the need for comfort, nutrition and personal hygiene. Contribute to the identification of actual and potential risks to patients, clients and their carers, to oneself and to others and participate in measures to promote and ensure health and safety. Understand and implement health and safety principles and policies. Recognise and report situations with are potentially unsafe for patients, clients, oneself and others. Contribute to public protection by creating and maintaining a safe environment of care through the use of quality assurance and risk management strategies. Apply relevant principles to ensure the safe administration of therapeutic substances. Use appropriate risk assessment tools to identify actual and potential risks. Identify environmental hazards and eliminate and/or prevent them where possible. Communicate safety concerns to a relevant authority. Manage risk to provide care which best meets the needs and interests of patients, clients and the public. (Nursing and midwifery council: requirements for pre-registration nursing programmes protecting the public through professional standards, 2002)
Medical curriculum guidelines Likewise, the General Medical Council’s document is equally broad ranging. For example, in its 24page document, Tomorrow’s Doctors: Recommendations of Undergraduate Medical Education (GMC, 2003) five areas are identified as guiding statements that relate to issues of patient safety, these being that students should: Know about and understand the following – how errors can happen in practice and the principles of managing risks. Be able to perform clinical skills safely. Know and understand the principles of treatment including the effective and safe use of medicines as a basis for prescribing, including
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side effects, harmful interactions, antibiotic resistance and genetic indications of the appropriateness of drugs. Follow the principles of risk management when they practice. Be aware of current developments and guiding principles in the NHS for example risk assessment and management strategies for health care professionals. (General medical council: tomorrow’s doctors: recommendations of undergraduate medical education, 2003). Although the nursing and medical curricular guidelines address issues of risk and safety, both lack the level of detail necessary for the reader to evaluate how these might be operationalised in practice. For example, the documents cover a comprehensive range of topics yet they do not indicate which topics are of vital import or how educationalists might address the themes outlined. More importantly perhaps, it is not clear how the guidelines are actually translated into module content or how they might be delivered in practice or to what extent the learning milieu might influence how when where and why certain aspects might be afforded greater importance than others.
Are educators doing safety justice? Some have argued that nursing and medical students, though well prepared in the art and science base of their respective disciplines in order to look after individual patients, have few of the skills necessary to improve care and patient safety (Aron and Headrick, 2002; Maddox et al., 2001). Nevertheless, if we re-examine the guiding principles outlined above, neither document recommends students should examine topics such as interdisciplinarity and interdependence. Yet both of these aspects have been identified as essential ingredients for the successful management of risk and improved patient safety as they facilitate enhancement of team working skills enabling individuals to draw on collaborative as opposed to solitary forms of knowledge (Firth-Cozens, 2001; Mizrahi, 1984). Furthermore, there is a need for students to understand work as a process; that is to develop skills in collecting, aggregating, analysing and displaying data on outcomes of care; designing health care processes; working in teams and collaborating with managers and patients. Examining problems honestly and learning from mistakes are all equally absent from both the GMC (2003) and the NMC (2002) documents. Despite this, Aron and Headrick
338 (2002); Berwick et al., 1992 and Reason (1997) all suggest that such topics should form an integral part of any curriculum that is serious about improving patient safety. In order to reinforce this point, there is growing evidence to suggest that despite the focus on patient safety gaining increased attention in clinical practice (Department of Health, 2000a; National Patient Safety Agency, 2003b) similar initiatives are slow to achieve strategic recognition within medical and nursing education (Stevens, 2002). Perhaps the latter situation arises because patient safety issues push nursing and medical education towards unfamiliar territory given that for the most part neither group of students focus on analysing complex systems, organisational culture or the importance of teamwork (Aron and Headrick, 2002; Davidoff, 2002; Mohr and Batalen, 2002).
A. Wakefield et al. Educational curricula need to recognise the importance of errors, allowing them to be drawn upon as part of a wider educational activity. This would facilitate discussion regarding the construction of adverse events as part of a root cause analysis, enabling many to learn from the experience (Lester and Tritter, 2001; National Patient Safety Agency, 2003b; Department of Health, 2000a). This latter modus operandi embraces the type of reporting culture where the root cause of adverse events or near misses are seen as important, enabling individuals to be in a position to evaluate what has taken place and generate new ways of working (Boyer, 2001). Thus if students could be encouraged to examine adverse events in this way, it is suggested that learning could be more effective and the risk of recurrence reduced (Department of Health, 2000a; Nievea and Sorra, 2003).
Improving practice by learning from adverse events
Conclusion
Despite the above, the central tenet of ‘near misses,’ and ‘adverse events’ is the need to learn from the situation, in order to improve practice and prevent the same situation arising in the future. For example, in ‘high reliability’ organisations such as the airline, navy and nuclear industry, where mistakes are minimised because of their overwhelming implications, a culture that is constantly alert to the possibility of failure has developed. This means that the root cause of adverse events can be isolated and exploited as part of an organisational learning opportunity (Reason et al., 2001; Stevens, 2002; Weick and Sutcliffe, 2001). Here the notion of reliability equates to a ‘dynamic non-event’ in other words, when adverse events are prevented, nothing happens (Weick and Sutcliffe, 2001). In contrast, when healthcare educators put disease treatment before illness prevention, the significance of ‘dynamic non-events’ go unrecognised. Instead, a ‘‘name, blame and shame’’ culture prevails in clinical practice; a factor which Reason et al. (2001) suggest renders an organisation vulnerable (National Patient Safety Agency, 2003b). In such circumstances, although learning by the person responsible for the mistake is both powerful and long lasting, only the individual involved gains additional knowledge from what has taken place (Aron and Headrick, 2002; Firth-Cozens and Greenhalgh, 1997; Mizrahi, 1984). More importantly, this form of learning may also have a negative effect on the individual’s practice given that it may become inappropriately defensive (Firth-Cozens, 2001).
We have shown that whilst a first principle of health care is ‘primum non nocere’, or first do no harm, the reality of modern health care is that adverse events of many kinds threaten patient safety. There are deficiencies in definitions of errors and adverse events and a lack of accurate data sources but it remains clear that the degree to which harms come to people using health services is currently unacceptable. This has the consequences of both large economic costs and great suffering. Health professionals undergo relatively little education in harm reduction and error management techniques and organisational cultures often lead to even simple measures (like hand washing) being unsatisfactory. At the wider strategic level, health professionals have benefited little from advances in organisational learning and human factor engineering. In particular, modern medical and nursing curricula address these matters in too little depth and with insufficient recognition of their importance. If educators are unfamiliar with or do not value these forms of learning, it unlikely that patient safety issues will be addressed within the curriculum in a meaningful and effective manner. Furthermore, if practitioners and educators alike fail to use a systems approach to analysing the context of an adverse event – a form of learning, which analyses the conditions under which individuals work in order to build defences to avert error or alleviate their effects, no improvements will be made (Reason, 2000; Reason et al., 2001). Like-
Patient safety: Do nursing and medical curricula address this theme? wise, if methods for learning from real adverse events via the application of frameworks such as human factor engineering (Gosbee, 2002) are not incorporated into healthcare programmes, students will not develop the necessary constructive thinking skills required to undertake a detailed safety analysis of their practice in order to reduce risks to patients.
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