I. Dror

Introduction

Patient safety is obviously not only paramount, but stands at the very crux of medical care. Why then, despite huge investments and efforts, does patient harm resulting from medical care remain a problem (Landrigan et al 2010)? What is the role of medical teachers in achieving patient safety? And how can they contribute to patient safety?

When thinking of teaching patient safety we need to realize that it mostly relates to dealing with avoidance of unintentional error and patient harm by those who are there to actually provide patient care. Understanding the obstacles and difficulties in achieving patient safety will lead the way to teaching this elusive topic. Many of the failures to combat patient harm stem from misconceptions as to the root of the problems and how to deal with them most effectively.

To begin with, where is patient safety within the teaching curriculum? Is patient safety a topic that requires its own dedicated specialized educational module, or a designated lecture added within each topic taught? Or is patient safety a theme that cuts across modules and lectures and is ‘everywhere’? And if so, how is it accomplished?

In addition, achieving patient safety is a challenge because most often patient safety is compromised unintentionally, within a highly qualified, motivated and caring environment. If (when) patient harm is a result of intentional behaviour or incompetence, then the problem is relatively simple and easy to deal with. However, when patient harm results from attentive and professional medical care, then it is harder to see how education can contribute to patient safety (Dror 2011a).

Even when considering one’s own personal self-regarding life behaviours, people often compromise their own safety, for example, crossing a road in a red light or having unprotected sex. The point is that if one’s self-regarding behaviours are lacking in safety, then it is no surprise that there are also deficiencies in other-regarding behaviours.

Finally, actions and efforts to reduce unsafe behaviours (such as TV commercials) are not very effective. The multi-million advertisements and campaigns aimed at increasing awareness and changing behaviours – even those that use disturbing emotional images – have for the most part failed (e.g. people continue to drink and drive, have unprotected sex, etc.).

These are some of the reasons that patient safety is an elusive objective, and teaching it in a way that makes a difference is no small headache. I say this not to discourage medical teachers, but to lay out the challenges and difficulties, so that innovative and effective ways to teach and increase patient safety are utilized. It is not straightforward, but it is possible, and I will suggest some very practical ways to go about it.

Causes of problems with patient safety

Any effective teaching aimed at increasing patient safety must be underpinned by an understanding of the issues and causes that result in patient harm/safety. However, these must be in depth, looking at and understanding the environment in which they occur, as well as the underlying cognitive processes that lead to patient safety/harm. One must get into the practical and effective ways of actually creating awareness and a culture of safety, and get beyond directive approaches of avoiding errors, such as instructing health professionals to ‘wash their hands’ or to ‘make sure they give the correct medication, to the correct patient, at the correct time, and in the correct dosage’. Understanding cognition of errors, and why and how they occur in the medical environment, will lead to new and better teaching of patient safety. Current approaches have not been very effective (Landrigan et al 2010). Even with extensive teaching and comprehensive programmes (that include visible posters and reinforcing a supportive culture) the effectiveness – for example, of simple checklists – still encompassed 30% noncompliance with following all the steps in a checklist (Pape et al 2005).

Human cognition

Cognition involves perception of information, judgement, interpretation and decision making that determines if and what actions should be taken. The human cognitive system has limited resources and therefore cannot process all the information provided by the environment. Therefore, it has developed a variety of mechanisms that enable it to operate effectively, despite the lack of sufficient computational resources. In a nutshell, the human mind is not a camera. For example, it actively interacts with information and is conceptually driven, uses selective attention and specialized cognitive modules (e.g. distinct decision-making modules: one for rational/analytic choices and another for intuitive/experiential ones) (Payne & Bettman 2004).

The organization of the brain and the cognitive mechanisms that allow intelligence also mean that errors occur. In fact, expertise entails greater use and reliance on these mechanisms, allowing greater and superior performance, but at the same time it introduces vulnerabilities and more opportunities to make mistakes (Dror 2011b). This is an important point in medical teaching, a highly skilled domain that requires expertise.

The medical environment

We also need to remember that medical professions work within challenging cognitive demands, such as:

When error-prone cognitive systems operate within such an environment, it is not a surprise that patient safety is an issue. But by understanding the cognitive weaknesses and how they are manifested in the medical profession, one can develop proper and effective teaching of patient safety.

Teaching patient safety

Even with the good intentions of both the teachers and the learners (as well as administrators), it is hard to ‘get the message home’ when it comes to patient safety. There is huge pressure on the brain’s resources, with many things continuously competing and fighting for its attention. Expecting that health professionals will have patient safety in the forefront of everything they do, at every moment, every time, during every action, just as a result of instructional learning is optimistic at best, if not naïve.

Even the most elaborate patient safety teaching that motivates and reinforces patient safety issues can easily be pushed aside by competing demands during actual patient care. Patient safety teaching must form mental representations that not only are long lasting, but also are cognitively salient. Training must encompass some pedagogical, cognitively effective ways to ensure (or at least encourage) that patient safety issues are well engrained in the learners’ cognitive system. Such cognitive enhancement approaches have been used in training military fighter pilots (Dror et al 2008).

In this chapter I suggest an approach to teaching patient safety, a cognitively informed approach that is applicable across the medical curriculum and training. I will first explain the approach and then discuss practical ways and tools to achieve it.

To illustrate the approach, consider, for instance, that it is usually ineffective to teach by instructing people to ‘save’ their work while working on the computer, so as to avoid the loss of work in case the computer crashes. No matter how many times you teach them, explain to them, motivate them, people working on computers often do not save properly at regular intervals. How do people effectively learn to save properly? Not by directive instruction, but by experiencing failure! All it takes is one time for the computer to crash and for people to lose work. Then, they change, and learn: no matter how engaged they are, no matter how many competing tasks are fighting for their attention, they remember to save. This transformation occurs usually with a single crash, even if a small and insignificant amount of work is lost: quite impressive!

‘Failures’, and especially self-experienced ones, leave powerful and long-lasting impressions. Experiencing even a small and symbolic failure forms salient mental representations that shape future behaviour. Perhaps evolution and survival have taught us that it is critical to learn from mistakes, and therefore they are very effective ways of learning. Everyday life is full of personal examples of how well people remember mistakes they made, and how they shaped their future behaviour.

Errors can be an important tool for achieving learning (Marroua 1974), especially for elusive constructs and objectives, such as reliance on rigor rather than intuition (Ginat 2003), and – as suggested in this chapter – for teaching patient safety.

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