Abstract Introduction: While learning the basics of patient safety, students can also learn about the contribution members of the various health professions can make to patient safety, which is why we stress the importance of interprofessional interactions in this Introduction to Patient Safety Symposium.
Methods: This 4-hour symposium is designed as an introduction to patient safety presented in a classroom setting, with students seated in groups made up of representatives of each health profession. The course revolves around a case scenario presentation of a hypothetical patient who has had his knee replaced and is the victim of a series of medical errors, with consequent deep vein thrombosis and pulmonary embolism. The course is taught through four modules: (1) Culture of Health Team Communication and Conflict Management, (2) Root Cause Analysis and System Problems, (3) Error Disclosure, and (4) Second Victim Trajectory. Each module begins with a didactic presentation, and then learners apply their knowledge in an interactive learning activity with their interprofessional colleagues. Following the fourth module, students complete a pre-/posttest, satisfaction survey, and reflection paper.
Results: The course has been presented to 305 students in the schools of medicine, nursing, occupational therapy, pharmacy, physical therapy (PT), and radiologic sciences at Thomas Jefferson University. While results of the pretest revealed that many students arrived with some knowledge of medical errors and the importance of communication, the posttest showed increased knowledge in how to report an error, root cause analysis, and the term second victim. In response to the satisfaction survey, 80%-100% of radiologic science, nursing, pharmacy, and PT students reported they were satisfied or very satisfied, but only 36% of medical students reported that level of satisfaction. Stated reasons for medical student satisfaction level included redundant material and session length. When asked if at least 40% of the material was new, more than 65% of nursing, PT, and radiologic science students agreed, whereas only 54% of pharmacy students and 25% of medical students did. The themes on the individual reflection papers from all students included the importance of communication, teamwork, a culture that promotes acknowledgment of errors, and knowledge of policies and procedures.
Discussion: This symposium effectively increased the students' knowledge of the meaning and process of medical errors/patient safety. Since students came from different disciplines and different programs, their knowledge base regarding patient safety was variable. This created a challenge when deciding at what level to teach. Although this symposium was the first interprofessional patient safety experience for all students, some of those who had been taught patient safety in their own disciplines were less satisfied with the course.
By the end of this session, learners will be able to:
Discuss patient safety issues, including barriers and systems solutions.
Describe the definition of medical error and types of sentinel events.
Apply information to know when and how to report medical errors.
Promote interprofessional collaboration and communication to improve patient safety.
Analyze sentinel events using the process of root cause analysis.
Discuss issues of error disclosure.
Describe closure and needs of staff who were involved in the error.
Recommended CitationForstater, Alan; Levinson, Marcia; Bellot, Jennifer; Hess, Mary; and Spandorfer, John, "Patient Safety Symposium: Issues, Analyses, Prevention" (2013). Department of Medicine Presentations and Grand Rounds. Paper 3.
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Citations for Intro Analyses and Sum semifinal.docx (20 kB)
Communication Conflict Management.ppt (668 kB)
Error Disclosure.mp4 (140694 kB)
Error Disclosure.ppt (299 kB)
Evaluation of Format of Symposium.doc (45 kB)
For You.mp4 (81766 kB)
Intro Patient Safety.ppt (838 kB)
Medical Error DVT Case 1-2012.doc (29 kB)
Patient Safety Symposium Summary.ppt (659 kB)
Post Test Content Pt Safety Symposium NO Answers.doc (29 kB)
Pre-Post Test Key.docx (59 kB)
Pretest Content Pt Safety Symposium NO Answers.doc (30 kB)
Pronovost.mp4 (71611 kB)
Reflection Paper.doc (26 kB)
Root Cause Analysis.ppt (926 kB)
SAMPLE COURSE AGENDA with ASSIGNED RESOURCES.doc (50 kB)
Second Victim Recovery.ppt (704 kB)
Susan Scott.mp4 (3617 kB)
Table Worksheet for Symposium with Fishbone.doc (38 kB)