|ORIGINAL RESEARCH ARTICLE
|Year : 2017 | Volume
| Issue : 1 | Page : 44-49
Implementation and evaluation of a patient safety course in a problem-based learning program
Sarah Ahmed Eltony1, Nahla Hassan El-Sayed1, Shimaa El-Sayed El-Araby1, Salah Eldin Kassab2
1 Department of Medical Education, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
2 Department of Basic Medical Sciences, College of Medicine, University, Doha, Qatar
|Date of Web Publication||13-Jul-2017|
Shimaa El-Sayed El-Araby
Department of Medical Education, Faculty of Medicine, Suez Canal University, P.O. Box 41111, Ring Road, Ismailia
Source of Support: None, Conflict of Interest: None
Background: Since the development of the WHO patient safety curriculum guide, there has been insufficient reporting regarding the implementation and evaluation of patient safety courses in undergraduate problem-based learning (PBL) programs. This study is designed to implement a patient safety course to undergraduate students in a PBL medical school and evaluate this course by examining its effects on students' knowledge and satisfaction. Methods: The target population included year 6 medical students (n = 71) at the Faculty of Medicine, Suez Canal University in Egypt. A 3-day course was conducted addressing three principal topics from the WHO patient safety curriculum guide. The methods of instruction included reflection on students' past experiences, PBL case discussions, and tasks with incident report cards. A pre- and post-test design was used to assess the effect of the course on students' knowledge of inpatient safety topics. Furthermore, students' perceptions of the quality of the course were assessed through a structured self-administered course evaluation questionnaire. Results: The results of the pre- and post-test demonstrated a significant increase (P < 0.05) in the students' mean multiple choice question (MCQ) scores. The MCQ scores for “what is patient safety” topic increased by 50% (P < 0.01). Similarly, the MCQ scores for the “infection control” topic increased by 39% (P < 0.01), and scores for the “medication safety” topic increased by 45% (P < 0.01). The majority of students perceived the different aspects of the course positively, including the structure and introduction of the course (75%) and the communication skills (83.2%) and teamwork skills they had developed (94.4%). The findings of the incident report cards indicated that 46.7% of the students perceived that incidents most commonly take place in the emergency room while only 6.7% in the outpatient clinic. Discussion: This patient safety education program within a PBL curriculum is positively perceived by students. Furthermore, patient safety education in clinical settings should focus on emergencies, where students perceive most errors.
Keywords: Curriculum, evaluation, health-care providers, medical education, patient safety
|How to cite this article:|
Eltony SA, El-Sayed NH, El-Araby SE, Kassab SE. Implementation and evaluation of a patient safety course in a problem-based learning program. Educ Health 2017;30:44-9
| Background|| |
The goal of patient safety is to reduce the risk of unnecessary harm to patients associated with health care to an acceptable minimum. It has been recognized for the past 20 years that adverse events occur not because health professionals intentionally hurt patients, but due to the complexity of health-care systems where treatment and care depend on many factors, in addition to the competence of health-care providers. Reducing harm caused during health care is a global priority. There has been an increase in patient safety enhancement efforts over the past decade with the development of science of patient safety. However, most published studies are from developed countries with almost no reports from developing or transitional economies. This acknowledged gap is limits understanding the extent of the problem of medical errors at the global level and more importantly, in specific countries. Health systems in developing and transitional countries face health threats and challenges in a context of scarce resources and weak infrastructure. When so many types of health-care providers, including dentists, dieticians, doctors, midwives, nurses, pharmacists, social workers, and others, are involved, it can be difficult to ensure safe care unless the system is designed to enable the delivery of quality and safe services.
Despite the importance of patient safety and the recognized need for patient safety education, few health professions schools deal with this participant in their curriculum. Traditionally, training of medical and other health professional students has focused on pure clinical skills, such as diagnosis and treatment of disease and medical follow-up. Systems thinking, root cause analysis, and use of human factor science and communication skills have been largely ignored. These skills are fundamental to patient safety, and all undergraduate medical students should have the necessary competencies to minimize harm to patients.,
The WHO curriculum guide was developed in 2009 to fill the gap in patient safety education by providing a comprehensive curriculum designed to shape foundation knowledge and skills for all health-care students to prepare them for clinical practice in a range of settings. Unfortunately, a number of factors have impeded the implementation of patient safety education. First, there is a lack of recognition by health-care educators that teaching and learning patient safety should be an essential part of the undergraduate curricula for health-care students and that patient safety skills can be taught., Second, the educators need to be open to new areas of knowledge.
A study conducted by faculty of the Maastricht University found that students that participated in a patient safety course found that it built their awareness, attitudes, and behavior toward patient safety. However, taking into consideration culture differences in learning, we are not aware of previous studies conducted in the Arab world to address the issue of patient safety in undergraduate medical curriculum. Therefore, this study was designed with the aim of implementing and evaluating a patient safety course in a problem-based learning (PBL) program using student reflection and PBL case discussion.
| Methods|| |
This study was conducted on year 6 medical students (n = 71) at the Faculty of Medicine Suez Canal University (FOMSCU) in Egypt. The college has employed a PBL strategy and community-based education in its program since its inception in 1978. The college program is divided into three phases spanning the 6 years curriculum. The First phase (year 1) is 35 weeks duration and consists of seven blocks addressing the normal phases of human life (e.g., antenatal block, childhood block, adolescence block, and geriatric block). The second phase (years 2 and 3) is 72 weeks duration and includes 12 system-based blocks. The third or clinical phase (years 4, 5, and 6) is 36 weeks duration in each year. Student training starts from Phase I in community settings, principally in primary health-care units; other clinical settings including hospitals and family medicine centers are used as training sites in Phase III. Horizontal integration and vertical integration are emphasized throughout the curriculum.
Design and implementation of the patient safety course
The implemented course was designed using three topics of the WHO patient safety curriculum guide: topic 1, what is patient safety; topic 9, minimizing infection through improving infection control; and topic 11, medication safety. These three topics were selected for a phase in piloting of the course. The learning outcomes of the selected three topics are shown in [Appendix 1].
The course was designed in a workshop format of 3 days duration, with each of three topics addressed in 1 day. Methods of instruction included interactive talks, reflection on students' past experiences, PBL case discussions, small, large small discussions, and tasks with incident report cards. Permission for conducting the course was obtained from the Vice Dean for student affairs of the faculty. The instructors of the course were faculty members who are qualified with Diploma degree in the infection control or medication safety. The other tutors were faculty members in the medical education department who received training on the main principles of patient safety. The sample card template used in the study is included in [Appendix 2]. The course was repeated in two successive weeks to avoid clashing with other learning activities for the students.
Course evaluation instruments
Two types of instruments were used in this study. The First was a written test composed of 27 multiple choice questions (MCQs) administered before and after implementation of the course. The test items were designed to address the core knowledge domains related to three topics of the course. Furthermore, content validity was ensured by reviewing the test items by experts in subject matter and medical education.
The second instrument was a course evaluation questionnaire including 17 items to assess students' overall perceptions of the quality of the course. The questionnaire was adopted from a previously published study. The questionnaire was composed of 17 items to measure six constructs. Structure of the course included four items: (1) the content of the course lived up to my expectations, (2) the design of the course lived up to my expectation, (12) the length of the course was good, and (13) the intensity of the course was good; introduction of the course included: (3) the presentation during the introductory meeting gave sufficient insight into patient safety and (4) the case discussion about supervision during the introductory meeting was useful; communication during the course included: (6) outside the classroom I had regular contact with other course participants and (11) it is instructive to collaborate with interns participating in clerkships in different disciplines; working with incident report cards included: (5) working with incident report cards was a good way to become aware of patient safety in practice and (10) discussing the incident report cards in the final meeting was instructive; teamwork during the course included: (7) collaborating with my partner for the final assignment went well and (8) the final assignment was instructive; student's personal interest included: (9) the course provides sufficient options to connect to my personal interests, (14) the information about the course on the electronic learning environment was clear, (15) the provided literature suggestions gave sufficient insight in the content of the course, and (16) I have searched for additional literature outside the suggested literature. Students responded on a 5-point Likert-type scale (5 = strongly agree, 1 = strongly disagree). At the end of the questionnaire, students were asked to rate the overall instructiveness of the course on a 1–10 scale (1 = very poor; 10 = excellent).
Data analysis was performed with using the Statistical Package for the Social Sciences (SPSS, version 20, IBM (SPSS, Inc., Chicago, IL, USA). Both descriptive and inferential statistics were used for analyzing the study findings. Means, standard deviations, frequencies, and percentages were used for presenting the data from the questionnaires. In addition, paired t- test was used for examining differences in knowledge before and after the course. Furthermore, bivariate correlations were measured using Pearson product-moment correlation coefficient. Internal consistency reliability of the questionnaire was measured using Cronbach's alpha statistics. P < 0.05 was considered statistically significant.
The research protocol was approved by the Research and Ethics Committee at FOMSCU.
| Results|| |
The sample was 71 students, including 33 males (46.5%) and 38 females (53.5%). Their ages ranged from 21 to 23.
Students' knowledge about patient safety before and after the course
As shown in [Table 1], there was a significant increase in the mean MCQ scores of students after the patient safety course. The MCQ scores for “what is patient safety” topic increased by 50%, the MCQ scores for the “infection control” topic increased by 39%, and the MCQ scores for the “medication safety” topic increased by 45%.
|Table 1: Difference between knowledge of the students (n=71) after and before the patient safety course|
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Students' perceptions of the course
The majority of the students (75%) agreed that the structure and introduction of the course were good. In addition, 83.2% agreed that they were satisfied with the communications, they had with colleagues during the course, and 94.4% were satisfied with the teamwork. Only 39.4% agreed that the course affected their personal interest [Table 2]. Students were generally positive about presenting and discussing information from the incident cards (4.3 ± 0.8 on 1–5 Likert scale), they were positive about the length of the course (4.4 ± 0.8), and they were positive about working together with other students in the final assignment (4.4 ± 0.8).
|Table 2: Frequency distribution of the students' evaluation of the different aspects of the patient safety course (n=71)|
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Another condition for reflection was experiencing, analyzing, and reflecting on a number of incidents. The students recorded errors retrospectively on the past situations and they were encountered. Incidents cards were distributed to the students, of whom 46.7% agreed that incidents affecting safety most commonly take place in the emergency room while only 6.7% agreed that incidents take place in the outpatient clinic. Although 40% of the students agreed that errors are encountered in the treatment phase, only 20% of students said the errors are encountered in the follow-up phase [Table 3].
|Table 3: Frequency distribution of students' responses (n=45) regarding the completed incident report cards|
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Relationships between knowledge acquisition and perceptions of the course
There were statistically significant relationships between knowledge outcomes after the course (results of the posttest) and different evaluation form constructs. As evidence of construct validity, but only overall instructiveness of the course showed no statistically significant relation with the knowledge outcome [Table 4]. Internal consistency reliability of the evaluation form was 0.92.
|Table 4: The relationship between the multiple choice question scores of medical students (n=71) after the implemented patient safety course and their satisfaction with the course|
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| Discussion|| |
This study was designed to evaluate a part of the patient safety curriculum for students at the FOMSCU that emphasized active learning and experiential activities to reinforce safety principles. The evaluation examined the effect of the patient safety course on students' knowledge and perceptions of the implemented course.
Students generally positively regarded the program structure and content. Overall, students indicated that the patient safety courses provided a good opportunity for increasing their awareness of medical errors and patient safety issues within the existing health-care system. These findings are congruent with a similar study conducted by de Feijter et al. using the same validated evaluation form. Students of that study believed that the course was instructive overall, and they were very positive about learning with other students who participated in clerkships of different specialties. Like students of the present study, students of the earlier study were also positive about presenting and discussing information from the incident cards and using the incident report cards to become aware of patient safety in practice.
Most students in the current study positively perceived the length and intensity of the patient safety course. These findings are congruent with a study conducted by Wet  of a Scottish patient safety program, where trainees' satisfaction ratings of their course content presented in various sessions ranged from 65% to 87%. Similarly, 72% of second-year medical students in a study by Madigosky et al. (2006) agreed that the course content improved their ability to meet the learning objectives.
In the current study, more than half of the students agreed that working with incident report cards was a good way to become aware of patient safety in practice, and most students were positive about discussing the incident report cards in the final meeting. A similar study by Halbach and Sullivan (2005) found 94% of students strongly agreed that the standardized patient and feedback exercise were a useful learning experience. A pre- and post-questionnaire data in that study found significant increases in the self-reported awareness of students' strengths and weaknesses in communicating medical errors to patients.
The majorities of students in the current study were also positive about collaborating with partners for the final assignment and were positive about the final assignment. These findings were similar to Wet (2009) study where small teams reported benefitting from the course through their opportunities to discuss the course content as it applied to their local situations, by sharing a common terminology and by developing and agreeing their action plan together.
The second level in Kirkpatrick  model of course evaluation is “learning,” examining the effect of the patient safety course on the students' knowledge using paper and pencil written test (pretest/posttest). The results demonstrated significant differences between the students' mean MCQ scores of the pre- and the post-tests for the three topics. These results were in accordance with Patey et al. as the results of the first topic “what is patient safety” showed significantly increased levels of knowledge of error and patient safety from each of the schools who returned before and after questionnaires, while in the “Infection control” topic, the specific item of “knowing how” to perform appropriate actions showed increased level of knowledge; finally, in the “medication safety” topic, no statistically significant changes were observed in all measures except self-efficacy; also in Farley et al. study, similar findings were recorded as there was a statistically significant difference between pre- and post-teaching in a 508 students answering “what is patient safety” topic, while in 286 students answering “infection control” topic, there was the highest improvement; this is inconsistent with our study that showed the lowest improvement in “infection control” topic that might be due to the current study's small sample in comparison with Farley et al. study. In the last topic “medication safety” topic, there was a statistically significant difference between pre- and post-teachings in a 325 students. These findings were congruent with Gunderson et al. study that included a 3-h interactive discussion, practice of full disclosure using standardized patients, and facilitated reflection. Students were assessed pre- and post-using a self-administered confidence survey. Knowledge among students improved significantly after the module.
This study has limitations. The study has used only the first two levels of Kirkpatrick model of program evaluation, specifically satisfaction and learning, which leaves the effect of the patient safety curriculum on other levels untested. Furthermore, the use of only three topics of the patient safety curriculum and conducting the study in only one PBL medical school could limit the generalizability of its findings to other topics and settings. Therefore, further larger-scale studies are required to quantify the changes in learning and behavior of medical students after applying patient safety curriculum in multiple health professions institutions.
| Conclusion|| |
We conclude that applying patient safety education longitudinally into the six medical years due to great deal of the importance of patient safety as a discipline that now raises concern worldwide due to efforts made to reduce harm caused by health care and to prepare the students to deal with workplace environment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]