Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions.

OBJECTIVES: In an effort to improve patient safety attitudes and skills among third-year medical students, two patient safety training sessions were added to their curriculum, complementing a previously implemented second-year curriculum on quality improvement, patient safety and teamwork. METHODS: Safety attitudes and skills were assessed before and after students completed the medicine clerkship training and were compared with historical controls. Students identified and reported on observed safety events, with their reports matched to event type and harm score with contemporaneous safety reports from University of Missouri's Patient Safety Network (PSN). Comparisons were assessed by five internal safety experts using criteria for report submission "worthiness", blame tone, target of blame and presence/strength of proposed solutions. RESULTS: Students completing the third-year safety booster conferences expressed statistically higher comfort levels with identifying the cause of an error than did the student control group (p<0.05). Medical students proposed safety interventions that were more robust than those suggested by event reporters regarding similar events within our health system (p<0.0001). The worthiness and blame tone of medical student reports were not statistically different than event reports in PSN. CONCLUSIONS: Completion of two 1-h patient safety booster conferences in the third year of medical school led to increased student comfort in safety event analysis. Students documented stronger resolution robustness scores, suggesting similar training should be offered to PSN reporters. Medical students represent an underutilised resource for identifying and proposing solutions for patient safety issues.

The natural history of recovery for the healthcare provider "second victim" after adverse patient events.

BACKGROUND: When patients experience unexpected events, some health professionals become "second victims". These care givers feel as though they have failed the patient, second guessing clinical skills, knowledge base and career choice. Although some information exists, a complete understanding of this phenomenon is essential to design and test supportive interventions that achieve a healthy recovery. METHODS: The purpose of this article is to report interview findings with 31 second victims. After institutional review board approval, second victim volunteers representing different professional groups were solicited for private, hour-long interviews. The semistructured interview covered demographics, participant recount of event, symptoms experienced and recommendations for improving institutional support. After interviews, transcripts were analyzed independently for themes, followed by group deliberation and reflective use with current victims. RESULTS: Participants experienced various symptoms that did not differ by sex or professional group. Our analysis identified six stages that delineate the natural history of the second victim phenomenon. These are (1) chaos and accident response, (2) intrusive reflections, (3) restoring personal integrity, (4) enduring the inquisition, (5) obtaining emotional first aid and (6) moving on. We defined the characteristics and typical questions second victims are desperate to have answered during these stages. Several reported that involvement in improvement work or patient safety advocacy helped them to once again enjoy their work. CONCLUSIONS: We now believe the post-event trajectory is largely predictable. Institutional programs could be developed to successfully screen at-risk professionals immediately after an event, and appropriate support could be deployed to expedite recovery and mitigate adverse career outcomes.

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety.

PROBLEM: Although Morbidity and Mortality conferences (MMC) were originally designed to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes. DESIGN: Pre- and post-intervention assessments of participant attitudes toward patient safety and conference redesign were performed utilizing an attitudinal survey. Participants provided a unique identifier for paired-means procedure. A list of contributing factors, recommended solutions, and targeted system improvements was maintained with ongoing progress recorded. SETTING: Department of Internal Medicine training program at University of Missouri-Columbia, an academic health care center affiliated with the University of Missouri Hospitals and Clinics and the Harry S. Truman Veteran's Administration Hospital. PARTICIPANTS: Residents and fellows from the Department of Internal Medicine residency program. EDUCATIONAL OBJECTIVES: (1) Distinguish between culture of blame/shame and patient safety culture, (2) Identify gaps in quality contributing to adverse outcomes, (3) Identify strategies to close gaps, (4) Participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan. STRATEGIES FOR CHANGE: An interdisciplinary team modified the internal medicine MMC to emphasize a better understanding of patient safety principles and system-based practice interventions. For each adverse event analyzed, root causes were identified, followed by discussion of system interventions that might prevent future such events. KEY MEASURES FOR IMPROVEMENT: (1) Attitudes of residents and fellows regarding patient safety, as measured on a 20 item, five-point ordinal scale (strongly disagree to strongly agree) survey, (2) System improvements generated from the Patient Safety M&M Conferences (PSMMC), and (3) Attendance at PSMMC. EFFECTS OF CHANGE: Clinical outcomes: Conference participants offered 121 system improvement recommendations; 39 suggested system interventions were pursued based upon the likelihood of achieving high impact changes. These targeted changes were assigned to department/facility representatives with 23 (59%) improvements implemented, 11 (28%) partially implemented or in progress, and five (13%) abandoned due to impracticality or redundancy. Educational outcomes: Surveys were completed by 58 residents and fellows before and after modification of conference format. Six of the 20 survey items showed significant change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction, but did not reach statistical significance. Average MMC attendance increased from 41+/-8 to 50+/-10 (p<0.03) participants. LESSONS LEARNT: The new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety.

PROBLEM: Although morbidity and mortality conferences (MMCs) are meant to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes. DESIGN: Participant attitudes before and after the intervention towards patient safety and conference redesign were assessed using an attitudinal survey. A list of contributing factors, recommended solutions and targeted system improvements was maintained with ongoing progress recorded. SETTING: Department of Internal Medicine training programme at University of Missouri-Columbia. PARTICIPANTS: Residents and fellows from the above residency programme. EDUCATIONAL OBJECTIVES: (1) Distinguish between culture of blame/shame and patient safety culture, (2) identify gaps in quality contributing to adverse outcomes (3) identify strategies to close gaps and (4) participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan. STRATEGIES FOR CHANGE: An interdisciplinary team modified the internal medicine MMC to emphasise a better understanding of patient safety principles and system-based practice interventions. For each adverse event analysed, root causes were identified, followed by discussion of system interventions that might prevent future such events. KEY MEASURES FOR IMPROVEMENT: (1) Attitudes of residents and fellows regarding patient safety, as measured on a 20-item, five-point ordinal scale survey, (2) system improvements generated from the patient safety MMC (PSMMC) and (3) attendance at PSMMC. EFFECTS OF CHANGE: Clinical outcomes: 121 system improvement recommendations were made and 39 were pursued on the basis of likelihood of achieving high impact changes. 23 improvements were implemented, 11 were partially implemented or in progress, and 5 were abandoned due to impracticality or redundancy. Educational outcomes: 58 residents and fellows completed surveys before and after modification of conference format. 6/20 survey items showed substantial change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction. Average MMC attendance increased from 41+/-8 to 50+/-10 participants (p<0.03). LESSONS LEARNT: The new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.

Evaluation of physician preferences for guideline implementation.

Although current literature supports the use of evidence-based clinical practice guidelines (CPGs) by physicians, there is limited research concerning operational issues that may be inhibiting effective CPG implementation. The objective of our research was to increase understanding of clinical practice patterns by identifying physician preferences for CPG accessibility, format, content and learning strategies. Semistructured interviews were conducted with resident and faculty physicians in an academic medical center after they were presented with a CPG during treatment of a patient with acute pancreatitis. The results of our study revealed that physicians prefer CPGs in the form of evidence-based algorithms with treatment-specific information that is placed on the front of the patient chart during treatment. In addition, they felt that discussion of the guideline with colleagues, reminder notes/stickers on front of the patient chart, and verbal reminders from a nurse were the most effective means of encouraging utilization.

Predicting and preventing pressure ulcers in adults.

Advanced practice nurses and staff nurse skin-care team members provided the necessary expertise and information to integrate AHCPR recommendations in a protocol for patients at risk for skin impairment. Regular practice monitoring and education regarding skin management have proven to be successful strategies. A skin-impairment management protocol is provided.

Use of theory to guide nurses in the design of health messages for children.

To be effective, presentation of health messages for development of self-care agency must be age and developmentally appropriate. Blending cognitive development theories with selected foundational capabilities and dispositions from Self-Care Deficit Nursing Theory (SCDNT) has resulted in five concrete factors for successfully designing and delivering health messages for optimal learning in children. The capacity to learn requires perception, attention, play, communication, and memory. Actual evidence of learning about healthy choices by elementary school-aged children is illustrated. Indications of successes and deficiencies in design and delivery of health promotion messages during a school health fair are presented.

Dust off the policy and procedure manual to develop an orientation program.

With clear and accurate peritoneal dialysis departmental policies, procedures, and patient care standards, the creation of an orientation module with objective and measurable patient care and staff performance outcomes is easily produced. This article describes revision of policies, procedures, and patient care standards, and an approach for building linkages with the employee orientation program. No formal classroom time is required, and the level of orientee experience is accommodated. All peritoneal dialysis staff members are capable of equal preceptor participation.

Organization and development of a pediatric end stage renal disease teaching protocol for peritoneal dialysis.

Peritoneal dialysis is one of the treatments for end stage renal disease that requires considerable expertise. When neonates or children develop end stage renal disease, both the patient and family members must be provided with substantial education and training. The organization of education and training is paramount, especially as length of stay is limited with managed care. The development of an organized interdisciplinary approach for this instruction and pediatric patient teaching protocol for management of home peritoneal dialysis therapy is discussed in this article. The protocol provides learning content, methodologies and patient/family outcomes and is accompanied by a documentation tool that serves as communication for directing team member reinforcement of content until outcomes are met. Since completion of the protocol, eight pediatric patients have been placed on this teaching plan with extremely positive outcomes.

Development, implementation, and evaluation of a confusion protocol.

Because the phenomena of managing and therapeutically responding to confused elderly hospitalized patients is complex and difficult, a group of advanced practice nurses, supported by a pharmacist, nursing administration, and a School of Nursing professor, was commissioned to explore the research-based literature and provide practice recommendations for these patients. This article identifies one process undertaken for synthesizing and grounding an immense body of literature related to confused elderly patients. The literature review served to begin clarifying the differences between the diagnosis and required interventions for managing either acute or chronic confusion. These interventions were articulated within a protocol format (Marker model) familiar to staff members at our institution. The development, implementation, and evaluation of the protocol is presented, as well as suggestions for further research.

Campaign '92: three more years!

Creative planning and well-executed graphics produced an upbeat approach to preparing staff for a JCAHO accreditation visit. Five humorous and highly visible strategies were used in a coordinated eight-week "campaign." Not only did the institution "pass the test" but there was a consensus among staff nurses that they had felt comfortable, confident and in control during interviews with the JCAHO surveyor.

Improving the effectiveness of Society meetings and stimulating surgical research: an overview of a Surgical Research Society of Australasia workshop.

The Surgical Research Society of Australasia organized a workshop in October 1984 to consider how to maximize the effectiveness of the Society and its meetings. Four working parties addressed the aims and directions of the Society, the planning of meeting, the selection and presentation of papers, and education in surgical research. An overview of the workshop is presented in abbreviated form.

A community of scholars or scholars of the community? A note on the limits of relevance.

Universities are increasingly expected to be accountable for the large sums of public money they spend. Universities in Australia are currently under pressure to turn out graduates who are technically trained for immediate entry into the work force. Universities are expected to teach knowledge and skills which are relevant to what the community needs now. If the universities accept such obligations of accountability and relevance, what are the implications for the university enterprise? Over the past decade, medical schools have attempted to spell out their purposes, writing their overall goals and then specific objectives to guide teaching in all departments. These lists of goals and objectives usually incorporate a strong orientation to meeting current community needs. One expression of these community needs is the call for 'Health for all by the year 2000', supported by all governments through the World Health Organization. Turning out graduates to provide community health care would be a relevant goal which an accountable medical school could hardly deny. What evidence is available about university responses to such needs?

From whom the bell tolls: WHO and health care in the developing world.

Per capita expenditure on health is low in developing countries. Distribution of health care resources reflects the tension among perceived health priorities. Medical perceptions of "best care" generate expectations of technologically advanced, hospital-based, urban care within a staged referral system. World Health Organization presses a decentralized model for accessible, acceptable illness care linked with education for prevention, infrastructure development and peripheral responsibility.

The organization and management of medical education in Australia.

The review highlights the interdependence among the various subsystems involved in medical education and hence the need for coordination. Observations and perceptions derived from interviews and the review of the literature were reported to underline the existing difficulties and factors which impede the integration of efforts of the various subsystems. Problems of coordination seem to relate to the functioning of the existing mechanisms rather than to the absence of structural arrangements. Hence, it seems necessary to improve the skill of committees and other coordinating bodies in the processes of mutual adjustment and responsiveness to changing conditions.

Measurement plus judgement in examinations.

All examinations require the exercise of judgement at many points, whatever the method of scoring. In the Part 1 Examination of the Royal Australasian College of Surgeons these judgements are inextricably linked with policies on what is being tested (basic science or basic surgery, knowledge or application), what are the needs of practice and what must be covered in the discipline (choices of inclusion/exclusion on breadth/depth, core material/growing edge), and what are the levels of expectation (difficulty of questions, pass level). Examination scores have a measurable reliability. Confidence limits can be calculated on each candidate's score, but decisions must be made in the grey zone around the pass mark. If candidates did not enter the examination with equal chances because of external circumstances, judgements must be made about the level of disadvantage before deciding how to weight their score.

Intern training in New South Wales.

The process of intern training in New South Wales is at present undergoing critical examination. This article is a brief review of the status of intern training in Australia and New Zealand as revealed by a survey of accredited hospitals and the medical boards. Also reported are the results of a questionnaire widely distributed to the medical profession in New South Wales which sought its views on the nature of, and problems with, the internship.