|Year : 2014 | Volume
| Issue : 2 | Page : 213-216
Improving awareness of patient safety in a peer-led pilot educational programme for undergraduate medical students
Adrian J Hayes, Poppy Roberts, Adam Figgins, Rosalind Pool, Siobhan Reilly, Christopher Roughley, Thomas Salter, Jessica Scott, Sarah Watson, Rebecca Woodside, Vinod Patel
Warwick Medical School, University of Warwick, Warwick, United Kingdom
|Date of Web Publication||31-Oct-2014|
Adrian J Hayes
6 Grenada Drive, Whitley Bay
Source of Support: IATL Collaboration Fund, University of Warwick,, Conflict of Interest: None
Background: Patient safety is becoming an important but under-emphasised topic in medical education. Despite high-profile recommendations, it has not yet been ingrained in the medical undergraduate curriculum. We designed and evaluated an educational intervention on patient safety to pre-clinical undergraduate medical students, devised and run entirely by medical students in their clinical years. The aim was to raise awareness of patient safety, and provide the opportunity to practice specific skills useful as medical students and junior doctors. Methods: We designed a two hour seminar consisting of a brief lecture on the principles of patient safety, followed by a carousel of interactive activities in small groups. Attendance was voluntary. The effects were evaluated by questionnaires addressing satisfaction, attitudes and self-efficacy completed before, after and six months following the seminar. Results: A total of 86 students attended, with a reserve list of interested students in place. A total of 92% completed the pre- and post-evaluation, of whom 100% enjoyed the seminar, 99% recommended other students to take part and 92% thought it should be a mandatory part of the curriculum. A total of 64% completed follow-up questionnaires at six months and showed significant maintenance of skills taught. Discussion: Student tutors can deliver effective and engaging teaching on patient safety and should be utilised as part of the existing medical curriculum. Patient safety should be taught at medical schools using interactive methodologies to promote interest.
Keywords: Clinical skills, medical education, peer-led, patient safety
|How to cite this article:|
Hayes AJ, Roberts P, Figgins A, Pool R, Reilly S, Roughley C, Salter T, Scott J, Watson S, Woodside R, Patel V. Improving awareness of patient safety in a peer-led pilot educational programme for undergraduate medical students. Educ Health 2014;27:213-6
|How to cite this URL:|
Hayes AJ, Roberts P, Figgins A, Pool R, Reilly S, Roughley C, Salter T, Scott J, Watson S, Woodside R, Patel V. Improving awareness of patient safety in a peer-led pilot educational programme for undergraduate medical students. Educ Health [serial online] 2014 [cited 2019 Nov 19];27:213-6. Available from: http://www.educationforhealth.net/text.asp?2014/27/2/213/143775
| Background|| |
Patient safety has recently been recognised as a crucial aspect of health care. The United Kingdom Department of Health estimated that 10% of inpatient stays included an adverse incident, of which 50% could have been avoided, with 1% resulting in serious harm.  It has been recommended that awareness of patient safety needs to begin in undergraduate and postgraduate education.  A number of initiatives for formal training in aspects of patient safety have been suggested and piloted both in the UK and internationally, most notably by the World Health Organisation.  A systematic review of relevant interventions for medical trainees found 41 robust studies, of which 27 included an evaluation and 14 focussed on medical students.  In general, these interventions were judged as successful with the exception of two initiatives involving pre-clinical students where satisfaction was low due to perceived lack of enthusiasm.
Peer-assisted learning has recently experienced a revival in the teaching of clinical skills in medical education.  This approach can be effective,  and student tutors could even be more effective than faculty teachers with equal long-term success. To-date there are no published descriptions of peer-led educational interventions in the area of patient safety.
The current project was initiated, implemented and evaluated by a group of medical students who were interested in both patient safety and peer-led teaching. In a pilot project, we designed an interactive seminar for pre-clinical medical students offered as a voluntary activity outside of normal teaching hours, intending to explore whether such a programme could be effective and relevant.
| Methods|| |
The intervention consisted of a two hour seminar entitled CHiPS (Clinical Hazards in Patient Safety). The content of the seminar was designed by the authors, based on determination of skills relevant to patient safety we believed to be absent from the current undergraduate curriculum. The seminar began with an initial 30-min lecture on principles of patient safety, including case studies of high-profile errors including those experienced by Martin Bromiley,  Wayne Jowett  and Graham Reeves.  Participants then split into small groups for a range of activities lasting 15 min each (see below), with refreshments halfway through. Sessions were recorded and a training DVD was created.
- Preparing for Surgery: Participants coated their hands in dry poster paint then simulated 'scrubbing in' to surgery with contamination indicated by visible paint on gowns/gloves. The World Health Organisation (WHO) Surgical Safety Checklist was then introduced to minimise mistakes in patient identification and site of surgery
- Patient Handover: Handover of patient information between staff was discussed and demonstrated in a video simulation. Participants commented on these videos before handing over information to each other with feedback from tutors
- Clinical Error: In this activity, student tutors first outlined different types of error (slips, lapses, mistakes and violations)  before asking participants to identify errors in a case study. Participants discussed errors seen in their own experience and strategies for speaking up if errors are witnessed in clinical placements
- MEWS (Modified Early Warning Score) and SBAR (Situation-Background-Assessment-Recommendation): Following verbal introduction and video demonstration, participants practiced using the Early Warning System for identifying an unwell patient and the SBAR communication tool to request help. They then reviewed potential for error in simulated case notes.
Questionnaires were developed specifically for the study, including attitudes towards patient safety and perceived self-efficacy in the taught skills. The concept of self-efficacy was used as a proxy for confidence and skill, defined as "the belief in one's capabilities to organise and execute the sources of action required to manage prospective situations".  There were eight questions scored from one to ten, with the two extreme categories labelled 'Not at All' and 'Very Much'. This was completed before, after and six-eight months following the seminar. An additional questionnaire on satisfaction was completed after the seminar. This was composed of 11 questions scored on a Likert scale (strongly disagree to strongly agree), with open-ended questions for positive and negative comments plus recommendations for improvement.
Participants and Setting
All participants were first or second-year medical students at a graduate-entry medical school. We aimed for 40 students at each seminar but over-booked up to 50 as we anticipated some would not attend. Participation in the seminar and evaluation was entirely voluntary. Participants who completed the entire seminar received a certificate signed by the faculty lead for clinical skills. Ethics approval was sought from the University of Warwick Biomedical Research Ethics Committee, but we were advised that approval was not required for this study.
Data were analysed using SPSS v17. Descriptive statistics are presented for satisfaction scores. Repeated- measures analysis of variance (ANOVA) was used to analyse attitude and self-efficacy scores. For open-ended questions, comments were grouped broadly into positive and negative feedback, then a qualitative thematic analysis was used to further divide comments into categories. These are described in full with frequencies.
| Results|| |
One hundred students signed up to attend the seminar with a reserve list of another 20 for each seminar. Ultimately, 86 attended and 79 (92%) completed the evaluation questionnaires both before and immediately after the seminar. A total of 55 completed the follow-up questionnaire six-eight months later (64%), after up to five reminder emails.
One-way ANOVA did not show any statistically significant difference between those who completed the follow-up questionnaire related to before or after scores on either of the scales used (P > 0.05). For this reason, it was deemed appropriate to conduct analyses only of those with full data using repeated measures ANOVA [Table 1].
|Table 1: Medical students' attitude and self-efficacy scores regarding patient safety by time-point|
Click here to view
Analysis of internal reliability for the attitude questionnaire revealed a Cronbach's alpha of 0.65 for values on 'before' data and 0.83 for 'after' data. Comparison showed statistically significant main effects for two of the four items, with post-hoc analysis showing significant differences between all three time-points. Hence, scores significantly improved at the end of the seminar, then significantly declined over 6-8 months, but remained significantly higher than original scores. The overall effect for the other two attitude items (3 and 4) was not statistically significant, though they were at higher levels than the first two items before the seminar.
All four self-efficacy items showed statistically significant main effects, with significant improvements after the seminar. Scores for two of the items (7 and 8) were maintained at follow-up with no significant deterioration. Scores for the other two items (5 and 6) declined significantly, but still remained significantly higher than original scores. Hence skills at six-eight months all remained higher than before the seminar, but two had dropped somewhat from their post-seminar levels. It should be noted that scores for self-efficacy on these four skills were very low before the seminar (3-5 out of 10).
The satisfaction scale showed good internal reliability (Cronbach's alpha 0.93). Scores were mainly positive for all items, except that stating the course was long enough to cover the material where 26% disagreed. Taking 'agree' and 'strongly agree' as approval, the data show that 100% enjoyed the seminar, 99% would recommend it to other students and 92% felt it should be made a mandatory part of the curriculum [Table 2].
|Table 2: Medical students' satisfaction scores related to a patient safety programme|
Click here to view
In open-ended questions, 57 participants (72%) gave positive comments. These were categorised into eight themes mentioned by at least five participants. These were that the seminar was useful (mentioned by 21 participants) and enjoyable (21 participants), topics were well-presented (14), interactive (13), interesting (12) and knowledge was increased (10). Overall, 53 participants (63%) made negative comments or recommendations. When categorised into themes, the only two areas mentioned by five or more participants were that the seminar should be longer (mentioned independently by 37 participants) and that more topics should be covered.
| Discussion|| |
Overall, we found that a pilot peer-led seminar could improve attitudes and self-efficacy in patient safety, be enjoyable for pre-clinical medical students and that skills could be maintained in the medium term. The design of the study (before-after) with no control group is a clear limitation as it is possible students would have developed these skills as part of their training, and we cannot demonstrate that improvements were due to attendance at the seminar. We assessed self-efficacy rather than objective measures of performance in the skills taught. The sample volunteered to take part, raising potential selection bias. Finally, the population of graduate medical students make up only a small proportion of medical students nationally. 
Despite these limitations, this is the first report and evaluation of a student-led intervention in patient safety, and feedback appeared to support this approach. Although pre-clinical students can be difficult to engage in this area,  our seminar was greatly over-subscribed, with high satisfaction scores and positive feedback. Peer-led teaching may be especially suitable in patient safety, and we found that students were more engaged and willing to ask us questions than in traditional teaching environments. 
The use of interactive and multi-media teaching methods was central to our approach, and feedback reflected this. Research shows that teaching methods should encompass all learning styles to encourage deep learning, , and WHO recommends the use of experiential learning for critical thinking in this area.  While this may require teaching in small groups, which can be expensive, use of student facilitators can potentially ameliorate this issue.
Self-efficacy on the four selected skills was extremely low before the seminar, signifying areas where students had little experience and were not confident. The significant rise and maintenance of these scores suggested that we were effective in teaching these skills. While attitudes did not all show significant improvements, these were already at a high level; perhaps not surprising among students who had elected to attend a voluntary seminar held in the evening. It would be interesting to see how these scores would differ in a mandatory version of the training.
Following this pilot, the 'CHiPS' approach should now be further investigated using large-scale, robust methodology and concrete measures of improvement. Peer-led teaching could also be extended to other clinical skills, both as an aid to engaging students and in improving teaching skills, which are also important for trainee doctors. Most importantly, however, patient safety needs to be brought to the forefront of the curriculum in keeping with the prevailing agenda in health care development. 
| References|| |
Department of Health. An organisation with a memory. London: Department of Health; 2000.
Walton M, Woodward H, Van Staalduinen S, Lemer C, Greaves F, Noble D, et al
. The WHO patient safety curriculum guide for medical schools; Expert Group convened by the World Alliance of Patient Safety, as Expert Lead for the Sub-Programme. Qual Saf Health Care 2010;19:542-6.
Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Teaching quality improvement and patient safety to trainees: A systematic review. Acad Med 2010;85:1425-39.
Yu TC, Wilson NC, Singh PP, Lemanu DP, Hawken SJ, Hill AG. Medical Students-as-Teachers: A systematic review of peer-assisted teaching during medical school. Adv Med Educ Pract 2011;2:157-72.
Field M, Burke JM, McAllister D, Lloyd DM. Peer-assisted learning: A novel approach to clinical skills learning for medical students. Med Educ 2007;41:411-8.
Dyer C. Surgeons cleared of manslaughter after removing wrong kidney. BMJ 2002;325:9.
Reason JT. Human Error. Cambridge: Cambridge University Press; 1990.
Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. New Jersey: Prentice Hall; 1986.
Mathers J, Sitch A, Marsh JL, Parry J. Widening access to medical education for under-represented socioeconomic groups: Population based cross sectional analysis of UK data, 2002-6. Br Med J. 2011;342:d918.
Newble DI, Entwistle NJ. Learning styles and approaches: Implications for medical education. Med Educ 1986;20:162-75.
Curry L. Cognitive and learning styles in medical education. Acad Med 1999;74:409-13.
World Health Organisation. WHO Patient Safety Curriculum Guide for Medical Schools. Geneva: World Health Organisation; 2009.
General Medical Council. Tomorrow′s Doctors. London: General Medical Council; 2009.
[Table 1], [Table 2]