Patient safety has become an important aspect of national health care initiatives and has been described as the prevention of health care errors and the elimination or mitigation of patient injury caused by health care errors. Patient safety further contends operational systems and processes should be established that promote the interception and minimization of errors (Institute of Medicine [IOM], 2000). The groundbreaking report, To Err Is Human: Building a Safer Health System, estimated that up to 98,000 people die each year as a result of medical errors (IOM, 2000). This important report spawned a new evolution in health care delivery and demonstrated that major change was needed at many levels of health care (Clancy, Farquhar, & Sharp, 2005; Reason, 2005; Scott, Mannion, Davies, & Marshall, 2003).
In 2005, Leape and Berwick published a report to gauge the progress of health care’s safety initiatives since the initial IOM report. Their report indicated there have been small substantive changes since the IOM report; however, it also highlighted that multiple barriers exist to implementing change in the health care environment, including the culture of health care.
One technique to successfully change organizational culture is to provide clinicians with the skill set to promote a culture of safety. Hazards, near misses, and errors may not always be prevented, but with systematic education, individuals can be trained to identify methods to overcome potential barriers (Bakken, 2006).
One approach that may contribute to creating and sustaining a safety culture in health care organizations could be a comprehensive program of patient safety education during formative professional education (Clancy et al., 2005; Maddox, Wakefield, & Bull, 2001; Manojlovich, Barnsteiner, Bolton, Disch, & Saint, 2008; Scott et al., 2003). At a minimum, the strategy should occur across many facets of nursing education in both the classroom and clinical arena, and should be formalized and incorporate different teaching modalities to engage learners (Cronenwett et al., 2007).
The specialty practice of anesthesia has long been recognized as a leader in patient safety initiatives (Gaba, 2000). The Anesthesia Patient Safety Foundation, established in 1985, was the first independent multidisciplinary organization created specifically to prevent adverse clinical outcomes, particularly those related to human error (Anesthesia Patient Safety Foundation, 2009).
Anesthesia providers also have transformed their practice via the dissemination of the results of the American Society of Anesthesiologists Closed Claims Project, which maintains a database that consists of in-depth investigations of “closed” insurance claims from anesthesia-related errors. The purpose of the closed claims database is to analyze reported errors and develop strategies for prevention of future errors (American Society of Anesthesiologists, 2009; Petty, Kremer, & Biddle, 2002; Reason, 2005). Despite these efforts, nurse anesthesia educational programs have individualized curricular designs in which they integrate patient safety content into their curriculum, and there has been a limited evaluation of these designs (Council on Accreditation, 2004).
Leaders in nursing education recently have addressed patient safety as a necessary component of baccalaureate nurse education and have proposed competencies. However, a specific curricular blueprint or standardized methods for evaluation of current curricular designs has not been established (American Association of Colleges of Nursing, 2008; Cronenwett et al., 2007; Gregory, Guse, Dick, & Russell, 2007; Maddox et al., 2001).
In 2006, we implemented a curricular innovation to provide patient safety education and use informatics technology to encourage patient safety and enhance evidence-based practice. The patient safety curriculum was provided to all students enrolled in BS-MS (bachelor of science-master of science) entry to practice program, master’s specialties, and doctor of nursing practice studies; the curriculum was tailored where needed. The series provided to the nurse anesthesia cohort occurred during students’ second year and included three lectures that provided anesthesia-specific safety content. Lecture one consisted of an introduction to patient safety and promotion of mindfulness in health care settings. Lecture two discussed hazard, near-miss, and error reporting as well as ethical principles as they relate to disclosure for anesthesia-specific cases. The last lecture included a discussion of modeling of health care errors and monitoring of quality indicators in health care (Clancy et al., 2005; Madigosky, Headrick, Nelson, Cox, & Anderson, 2006).
In addition to the main lecture series, adverse event modeling techniques were integrated throughout the second year curriculum for two class projects. Subsequent to the lecture series, the cohort of students was invited to report hazard and near-miss incidents using a Web-based portal for each clinical day during 9 months of full-time clinical education (Currie et al., 2007).
A 52-question survey that measured attitudes, skills, and knowledge about patient safety was developed. Senior-level graduate nurse anesthesia students who were in full-time clinical residency in major academic medical centers were invited to complete the survey immediately before and 8 months after the patient safety curriculum was delivered.
The survey included 31 general patient safety items and 21 anesthesia-specific patient safety items. Seventeen of the general patient safety items were derived from a survey developed by Madigoksy et al. (2006) that measured medical students’ attitudes, skills, and knowledge about patient safety and medical errors. The additional 14 general patient safety items were derived from recommendations by Shojania, Duncan, McDonald, Wachter, and Markowitz (2001) and agreed on by the project team.
The survey used a 5-point Likert scale to measure three domains. Domain one measured students’ attitudes or opinions about errors and included 15 general patient safety questions in which students were asked to rate their opinion of each item (1 = strongly disagree, 5 = strongly agree).
Domain two consisted of 22 questions in which students were asked to rate their competency level for skills related to error reporting and participation in patient safety activities (1 = not competent, 5 = expert). Twelve skill-item questions were general patient safety items, and the remaining 10 were anesthesia-specific questions.
Domain three evaluated students’ knowledge related to aspects of patient safety culture. This domain was evaluated via 13 questions, and students were asked to rate their level of knowledge about patient safety content (1 = not knowledgeable, 5 = very knowledgeable). Four of the domain three questions were general patient safety items, and the remaining nine questions were anesthesia-specific items.
The 31 general patient safety items were used for all cohorts of students in this curricular innovation project, including combined BS-MS students, nurse practitioner students, nurse anesthesia students, and doctor of nursing practice students. Concurrent to our activities, the combined BS-MS survey was validated via factor analysis. The combined BS-MS tool had the 31 core general patient safety items and 4 BS-MS-specific items, such as fall injury and pressure ulcer prevention skills.
Psychometric analysis was performed on the 35-item BS-MS tool, which resulted in a 26-item survey including 22 general patient safety items and the 4 cohort-specific skills (Schnall et al., 2008). Results of the psychometric testing were domain one (attitudes) had three subscales: error detection (four items, alpha = 0.57), time investment (two items, alpha = 0.76), and creating a culture of safety (three items, alpha = 0.49). The skills domain also had three sub-scales: error analysis (six items, alpha = 0.84), decision support technology (three items, alpha = 0.82), and threats to patient safety (four items, alpha = 0.71). The knowledge domain had a Cronbach’s alpha of 0.86 (four items). The full results of the psychometric testing were reported previously by Schnall et al. (2008).
This curricular project was designated exempt by the institutional review board. All surveys were reported in an anonymous fashion. Mean pretest and posttest scores for the 22 items that were validated and used as part of the larger survey for this cohort were compared between the two samples and across the three domains using independent samples t tests with the significance level set at alpha = 0.01.
Twenty-seven students completed the baseline surveys (pretest), and 23 students completed the postsurveys (posttest). Table 1 displays the overall scores. The overall mean score from pretest to posttest increased, but this change was not statistically significant (pretest = 2.80, posttest = 3.06).
Table 1: Results of Pretest and Posttest Surveys
Analysis of specific domains indicated overall attitudes scores (domain one) did not change from pretest to posttest (3.59 for both). Mean scores for skills (domain two) increased between the two time points (pretest = 2.34, posttest = 2.59). In the knowledge domain, mean scores also increased (pretest = 2.58, posttest = 2.98). None of the results showed a statistically significant difference.
Individual questions also were examined for pretest-posttest mean differences. Of interest, several individual questions showed relatively large differences. For example, the question from the attitudes domain, “In my clinical experience so far, clinical faculty and staff communicate to me that patient safety is a high priority,” students’ responses indicated they agreed less strongly with this statement from pretest to posttest (pretest = 4.48, posttest = 4.04).
Specific questions in the skills domain that had interesting results included how “competent” students felt about the following: “Participating as a team member in a failure mode and effect team,” “Participating as a team member of a root cause analysis,” and “Participating in morbidity and mortality conferences.” Overall trends for these questions showed an increase in self-reported competency for students from the pretest to posttest.
In the knowledge domain, students reported an increase in “knowledge” compared to pretest means for the following: “Defining the key aspects of safety culture,” and “Summarizing the published evidence about [the] relationship between nurse staffing and overall hospital morbidity and mortality.” Table 2 displays pretest and posttest data for the 31 general patient safety items and notes which items were eliminated after the factor analysis on the BS-MS student data and used in the overall analysis.
Table 2: General Patient Safety Survey Items for Attitudes, Skills, and Knowledge Domains
This study examined the impact of a formal patient safety curriculum on attitudes, skills, and knowledge related to patient safety for a small cohort of nurse anesthesia students enrolled in graduate studies. Attitude scores did not change between the pretest and posttest time points (9 months), but the cohort scored higher on posttest means for the skills and knowledge domains related to patient safety.
As other researchers have identified, changing attitudes and beliefs is a daunting task (Leape & Berwick, 2005). The nurse anesthesia cohort includes practicing clinicians with 1 to several years of experience. Perhaps the lack of change in the attitudes score represents the difficulty with changing the culture after it has been ingrained in a clinician’s practice. Indeed, three structured lectures on patient safety and reporting hazards and near misses are a small part of raising awareness of patient safety. However, our results indicate structured lectures can increase skills and knowledge related to patient safety.
Several of the individual questions had large changes between the pretest and posttest time points. For example, the question that examined the attitude toward staff knowledge (“In my clinical experience so far, clinical faculty and staff communicate to me that patient safety is a high priority”) had a large decrease from pretest to posttest. This result may reflect the research by Leape and Berwick (2005), in which the major barrier to promoting safety culture was organizational culture. It is possible that after students, who are also clinicians, were educated about patient safety, they identified more flaws in the system. In addition, this result might be interpreted in relation to current nursing workforce literature that acknowledges the nursing workforce is overburdened in the clinical arena with a multitude of responsibilities and thus they may not have had formal patient safety education (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Buerhaus, 2008).
One solution to alleviate this burden is to adopt a patient safety education curriculum that occurs systematically prior to the clinician entering the workforce rather than ad hoc “on-the-job training.” On-the-job training can be difficult to schedule and adopt as overloaded clinicians have limited time to devote to additional training (Clancy et al., 2005; Cronenwett et al., 2007; Gregory et al., 2007; Manojlovich et al., 2008). For questions in the skills and knowledge domains that showed an increase in scores, the lecture series and integration of patient safety modeling throughout the curriculum may have given students increased understanding and confidence in the use of these activities.
With regard to the survey that was used, the psychometric testing was simultaneous with the administration of our survey; therefore, we were unable to benefit from the refinement of the tool by Schnall et al. (2008) during the administration of the survey. Further modifications of the tool to quantify attitude changes over time are warranted, and the revised survey by Schnall et al. (2008) should be used and repeated on a larger cohort.
The format of the patient safety curriculum may be a limitation to this evaluation. In response, the faculty has made some curricular modifications to address these issues in our program. New curriculum is being developed in the nurse anesthesia program that will make the patient safety education series more interactive instead of a one-sided lecture series. It is well documented that problem-based learning techniques as well as alternate methods of knowledge delivery in addition to lecture formats are effective and engage learners (Beers, 2005; Brunton, Morrow, Hoad-Reddick, McCord, & Wilson, 2000; Ghosh, 2007; Lu, Lin, & Li, 2009). The patient safety series will be woven throughout the curricular design so students gain knowledge and skills related to patient safety and use these skills throughout the program via case studies, small group learning, and presentations.
We provided a formal teaching strategy that educates professional nurses about patient safety. This training gives professional nurses the skill set to review hazards and near misses in a logical manner. Our results, along with previous inquiries of other health care specialties, indicates necessary components of patient safety curriculum should be formally taught, cultivated, and emphasized during the formative education process of our next generation of clinicians (Currie et al., 2007; Madigosky et al., 2006). Establishing a patient safety culture is a necessary component of the health care system, and the development and use of a formalized patient safety curriculum is important and may be effective during the educational process.
- Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J. & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. The Journal of the American Medical Association, 288, 1987–1993. doi:10.1001/jama.288.16.1987 [CrossRef]
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved on March 25, 2008, from http://www.aacn.nche.edu/education/pdf/BaccEssentials08.pdf.
- American Society of Anesthesiologists. (2009). The ASA Closed Claims Project. Retrieved March 5, 2009, from http://depts.washington.edu/asaccp/ASA/index.shtml
- Anesthesia Patient Safety Foundation. (2009). Anesthesia Patient Safety Foundation. Retrieved March 1, 2009, from http://www.apsf.org/about/brief_history.mspx
- Bakken, S. (2006). Informatics for patient safety: A nursing research perspective. Annual Review of Nursing Research, 24, 219–254.
- Beers, G.W. (2005). The effect of teaching method on objective test scores: Problem-based learning versus lecture. Journal of Nursing Education, 44, 305–309.
- Brunton, P.A., Morrow, L.A., Hoad-Reddick, G., McCord, J.F. & Wilson, N.H. (2000). Students’ perceptions of seminar and lecture-based teaching in restorative dentistry. European Journal of Dental Education, 4, 108–111. doi:10.1034/j.1600-0579.2000.040303.x [CrossRef]
- Buerhaus, P.I. (2008). Current and future state of the U.S. nursing workforce. The Journal of the American Medical Association, 300, 2422–2424. doi:10.1001/jama.2008.729 [CrossRef]
- Clancy, C.M., Farquhar, M.B. & Sharp, B.A. (2005). Patient safety in nursing practice. Journal of Nursing Care Quality, 20, 193–197.
- Council on Accreditation. (2004). Standards for accreditation of nurse anesthesia educational programs. Park Ridge, IL: Author.
- Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J. & Mitchell, P. et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
- Currie, L.M., Desjardins, K.S., Stone, P.W., Lai, T.Y., Schwartz, E. & Schnall, R. et al. (2007). Near-miss and hazard reporting: Promoting mindfulness in patient safety education. Studies in Health Technology and Informatics, 129(Pt. 1), 285–290.
- Gaba, D.M. (2000). Anaesthesiology as a model for patient safety in health care. BMJ, 320(7237), 785–788. doi:10.1136/bmj.320.7237.785 [CrossRef]
- Ghosh, S. (2007). Combination of didactic lectures and case-oriented problem-solving tutorials toward better learning: Perceptions of students from a conventional medical curriculum. Advances in Physiology Education, 31, 193–197. doi:10.1152/advan.00040.2006 [CrossRef]
- Gregory, D.M., Guse, L.W., Dick, D.D. & Russell, C.K. (2007). Patient safety: Where is nursing education?Journal of Nursing Education, 46, 79–82.
- Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
- Leape, L.L. & Berwick, D.M. (2005). Five years after To Err Is Human: What have we learned?The Journal of the American Medical Association, 293, 2384–2390. doi:10.1001/jama.293.19.2384 [CrossRef]
- Lu, D.F., Lin, Z.C. & Li, Y.J. (2009). Effects of a Web-based course on nursing skills and knowledge learning. Journal of Nursing Education, 48, 70–77. doi:10.3928/01484834-20090201-10 [CrossRef]
- Maddox, P.J., Wakefield, M. & Bull, J. (2001). Patient safety and the need for professional and educational change. Nursing Outlook, 49, 8–13. doi:10.1067/mno.2001.113642 [CrossRef]
- Madigosky, W.S., Headrick, L.A., Nelson, K., Cox, K.R. & Anderson, T. (2006). Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Academic Medicine, 81, 94–101. doi:10.1097/00001888-200601000-00022 [CrossRef]
- Manojlovich, M., Barnsteiner, J., Bolton, L.B., Disch, J. & Saint, S. (2008). Nursing practice and work environment issues in the 21st century: A leadership challenge. Nursing Research, 57(1 Suppl.), S11–S14. doi:10.1097/01.NNR.0000280648.91438.fe [CrossRef]
- Petty, W.C., Kremer, M. & Biddle, C. (2002). A synthesis of the Australian Patient Safety Foundation Anesthesia Incident Monitoring Study, the American Society of Anesthesiologists Closed Claims Project, and the American Association Of Nurse Anesthetists Closed Claims Study. AANA Journal, 70, 193–202.
- Reason, J. (2005). Safety in the operating theatre—Part 2: Human error and organisational failure. Quality & Safety in Health Care, 14, 56–60.
- Schnall, R., Stone, P., Currie, L., Desjardins, K., John, R.M. & Bakken, S. (2008). Development of a self-report instrument to measure patient safety attitudes, skills, and knowledge. Journal of Nursing Scholarship, 40, 391–394. doi:10.1111/j.1547-5069.2008.00256.x [CrossRef]
- Scott, T., Mannion, R., Davies, H.T. & Marshall, M.N. (2003). Implementing culture change in health care: theory and practice. International Journal for Quality in Health Care, 15, 111–118. doi:10.1093/intqhc/mzg021 [CrossRef]
- Shojania, K.G., Duncan, B.W., McDonald, K.M., Wachter, R.M. & Markowitz, A.J. (2001). Making health care safer: A critical analysis of patient safety practices. Evidence Report/Technology Assessment (Summary), 43, i–x, 1–668.
Results of Pretest and Posttest Surveys
|Pretest Score Mean (SD) (n= 27)||Posttest Score Mean (SD) (n= 23)||Mean Difference (95% CI)||p|
|Overall survey||2.80 (0.35)||3.06 (0.45)||0.26 (−0.51 to −0.004)||0.046|
|Attitudes||3.59 (0.27)||3.59 (0.23)||0 (−0.15 to 0.15)||0.99|
|Skills||2.34 (0.52)||2.59 (0.65)||0.25 (−0.60 to 0.09)||0.15|
|Knowledge||2.58 (0.77)||2.98 (0.71)||0.4 (−0.83 to 0.03)||0.07|
General Patient Safety Survey Items for Attitudes, Skills, and Knowledge Domains
|Domain & Survey Item||Pretest Score Mean (SD)||Posttest Score Mean (SD)||Mean Difference|
|1. Making errors in health care is inevitablea||3.19 (1.27)||2.91 (1.28)||−0.28|
|2. After an error occurs, an effective strategy is to work harder to be more carefula,b||1.93 (1.0)||1.87 (0.63)||−0.06|
|3. Competent clinicians do not make errors that lead to patient harma,b||4.19 (0.74)||4.22 (0.60)||0.03|
|4. Clinicians routinely share information about errors and what caused thema||2.63 (1.15)||2.52 (0.90)||−0.11|
|5. Existing reporting systems do little to reduce future errors||2.85 (0.93)||2.91 (0.97)||0.06|
|6. There is a gap between what we know as “best care” and what we provide on a day-to-day basis||3.30 (0.91)||3.39 (0.78)||0.09|
|7. Most errors are due to things that clinicians cannot do anything aboutb||3.44 (0.97)||3.87 (0.76)||0.43|
|8. Only clinicians can determine the causes of clinical errorsb||2.04 (0.59)||2.00 (0.67)||−0.04|
|9. Clinicians routinely report errorsa,b||3.96 (0.59)||4.00 (0.67)||0.04|
|10. In my clinical experience so far, faculty and staff communicate to me that patient safety is a high prioritya||4.48 (0.51)||4.04 (0.56)||−0.44|
|11. Learning how to improve patient safety is an appropriate use of time in nursing educational programs||4.37 (0.49)||4.35 (0.65)||−0.02|
|12. Clinicians should routinely spend part of their professional time working to improve patient care||4.44 (0.58)||4.26 (0.62)||−0.18|
|13. The culture of health care makes it easy for clinicians to deal constructively with errorsb||3.70 (0.78)||3.72 (0.83)||0.02|
|14. If I saw an error, I would keep it to myselfb||3.74 (0.86)||3.78 (0.80)||0.04|
|15. If there is no harm to the patient, there is no need to report an errorb||4.22 (0.64)||3.91 (0.60)||−0.31|
|16. Accurately entering an error report||2.37 (0.84)||2.83 (0.83)||0.46|
|17. Interpreting aggregate error report data||2.04 (0.94)||2.22 (0.80)||0.18|
|18. Disclosing an error to a patient or family member||2.00 (0.96)||2.17 (0.78)||0.17|
|19. Disclosing an error to a physiciana||2.67 (0.73)||2.91 (0.73)||0.24|
|20. Disclosing an error to a preceptor or faculty membera||3.04 (0.81)||3.04 (0.77)||0|
|21. Disclosing an error to a peera||3.37 (0.69)||3.35 (0.65)||−0.02|
|22. Supporting and advising a peer who must decide how to respond to an error||2.96 (0.90)||3.00 (0.93)||0.04|
|23. Participating as a team member of a failure mode and effect analysis||1.74 (0.90)||2.04 (1.02)||0.30|
|24. Participating as a team member of a root cause analysis||1.44 (0.70)||1.78 (0.85)||0.34|
|25. Participating in morbidity and mortality conferences||1.93 (0.83)||2.39 (1.16)||0.46|
|26. Asking patients to recall and restate what they have been told during the informed consent process||2.74 (0.86)||2.78 (0.95)||0.04|
|27. Using antimicrobial handwashing substances||3.96 (0.82)||3.87 (0.82)||−0.09|
|28. Distinguishing among errors, adverse events, near misses, and hazards||3.15 (0.82)||3.39 (0.89)||0.24|
|29. Defining the characteristics of high reliability organizations||2.31 (0.93)||2.74 (0.92)||0.43|
|30. Defining the key dimensions of patient safety culture||2.48 (0.89)||2.91 (0.85)||0.43|
|31. Summarizing the published evidence about relationships between nurse staffing and overall hospital morbidity and mortality||2.35 (0.98)||2.87 (0.76)||0.52|