Some medical specialties have successfully used closed claims analysis to improve outcomes. In 1982, a media exposé reported the risk of death or serious brain injury in normal preoperative patients undergoing general anesthesia was approximately 1 in 3,000. In 1983, the American Society of Anesthesiology (ASA) safety committee was formed to investigate why a healthy patient undergoing a standard general anesthetic faced such an inordinate risk. The ASA safety committee performed an extensive analysis of closed medical liability claims, which led to the development of guidelines for increased monitoring and preoperative safety assessments based on identified errors, oversights and systems problems. The ASA Patient Safety Foundation was formed in 1985 and continues to perform detailed analysis of all anesthesia-related medical liability closed claims. The ASA analysis led to the implementation of education, training, and guidelines now used by the entire specialty. The dramatic success of such programs in unparalleled in health care: Today, the risk for complications in a healthy patient undergoing standard general anesthetic has been reduced to 1 in 300,000—a 100-fold decrease and an incidence nearly approximating six sigma [5].

The aviation industry has successfully incorporated transparency and the assessment of safety event data into its business practices and culture. The industry has transformed itself into a “high-reliability organization,” meaning it operates with remarkable consistency and effectiveness. Aviation’s model can serve as a framework for safety training and educational principles in health care.

A pilot’s training is centered on safety. It includes extensive simulation, crew resource management, principles of effective communication and effective re-engineering of unsafe systems. Most importantly, the training fosters a culture of change for furthering safety. Every day, nearly 36,000 commercial flights take off and land worldwide; yet, a passenger’s risk of dying in a crash is 1 in 1,000,000—or six sigma.

Learning from adverse event data has been central to the aviation industry’s successful safety initiatives that led to more than six sigma reliability. Physicians and health care leaders would marvel at the public transparency of aviation incident reports: Anyone can access information from transcripts of the cockpit communication, engineering reports, and safety analysis of the crash (Fig. 15.1). An introduction to their transparent approach can be found on the Federal Aviation Administration incident reporting website at http://​www.​faa.​gov/​data_​research/​accident_​incident/​ [6].

While there are many parallels, there are also many crucial differences between health care and aviation. Both are industries which depend on an inherent trust of their people (whether patients or passengers) that coexists with the possibility for catastrophic harm. Yet, the differences in implementation of safety measures from aviation to healthcare are more glaring and argue against simply applying an “if you can fly a plane, you can do safe surgery” mentality. This is not a value judgment relative to the skills of a pilot vs. a surgeon; physicians are notoriously likely to die from single engine pilot error crashes, and pilots have no corollary since they do not perform surgery on their passengers [7–10].

While a full discussion of what constitutes effective pedagogy is beyond the scope of this chapter, education that modifies behavior is most successful when it incorporates effective methods with inherent motivators. Experiential learning via the study of actual cases has been a traditional method of medical education, and for good reason: When a resident tries to solve a patient-specific diagnostic dilemma by reading related literature or assisting in a surgery, the resident tends to retain the information. The motivation of fear: fear of failure, fear of harm, and fear of adverse effects on one’s reputation are also very potent.

While some positive outcomes have been achieved from education provided by traditional morbidity and mortality conferences, much could be improved when using adverse patient safety events in education and as a process improvement for prevention.

Currently, most morbidity and mortality discussions focus on fear-based motivators, including:

An improved approach that uses PSEs from various institutions provides a wealth of material to analyze. Serious PSEs are fortunately a rare event for a given institution or system; however, broad data exists nationally via patient safety organizations or medical professional liability insurance carriers that require detailed information and analysis of each adverse PSE. There is enormous untapped potential in the data collected by entities tasked with managing risk in medicine. A proposed framework has been included of different approaches to achieving the ultimate goal of a safer health care system.

The number of curricula has greatly increased since the IOM report. Small, institution-specific programs multiplied; Large, national and international curriculum followed. The following provides an overview of the progression.

One of the earliest approaches described in the literature following the IOM report was a half-day curriculum proposed, described, and implemented by Halbach et al. [12]. The abstract of this work appears in Table 15.2.

Subsequent to this, Mayer et al. [13], described the design of a patient safety undergraduate medical curriculum. It included the following critical factors:

Mayer and his team also synthesized a “Specific Content for a Patient Safety Curriculum” in which roundtable participants agreed on 11 specific elements of curriculum content that they believed were essential for an effective patient safety curriculum at the undergraduate medical education level. The roundtable agreed the following aspects should be included:

More recently, Kirch, president and CEO of Association of American Medical Colleges (AAMC) and Boysen, executive associate dean of medical education at the University of North Carolina-Chapel Hill, described the five factors they deemed critical to changing the culture of medical education to teach patient safety [14].

The World Health Organization (WHO) prepared a comprehensive curriculum titled “Patient Safety Curriculum Guide for Medical Schools” [15]. It includes 11 topics, listed in Table 15.3.

Another patient safety curriculum has been developed by the U.S. Department of Veteran’s Affairs, and was one of the original efforts all the other curricula summarized above [16].

The VA National Center for Patient Safety (NCPS) was founded in 1999. This curriculum includes resources directed at three audiences:

The topics of the curriculum are grouped into five general areas and include extensive resources to reach of the different target audiences.

There has been much progress in the education of medical students in patient safety. Hopefully, the seed of the principles of patient safety planted in medical school will be nurtured in the subsequent training in residency, which is described next.

Many residencies are being thrust to the forefront by adherence to the American College of Graduate Medical Education (ACGME) [2] core competencies. Recently the Clinical Learning Environment Review (CLER) [17] assessment has been added to further motivate incorporation of just culture and a safe environment. The study of PSEs and the discussions, processes, and improvements that occur following that analysis bring together all of the core competencies in a unique way.

The following outlines the six core competencies of the ACGME and include the following core competencies. We address specific uses of patient safety event information and techniques to meet each of these core competencies.

Much of medical education either in training or in continuing medical education centers on how to deliver appropriate and effective treatment. The study of adverse events, and particularly the skills of disclosure following an adverse event, are critical to teaching providers to be compassionate. Through the study of patients and their families who chose to take legal action following an adverse event, one can see how the difference between a patient’s “chief complaint” is not often his or her “chief concern.” Failure to address the chief concern, either before or after an adverse event, is often the triggering factor to litigation. Analysis of liability claims allows for a subset of patient safety events in which opportunities for compassion may have been missed prior to entry into the adversarial tort system.

Not all medical knowledge is equal in the delivery of quality medical care and in avoiding serious adverse events.

The clustering of liability cases in primary care is in the failure to diagnose certain conditions as listed in Table 15.4 [18].

Liability cases in the procedural specialties are grouped around seven elements, listed in Table 15.5 [18].

The study of adverse patient safety events is often the best and most motivating practice-based learning. The analysis of the root causes of PSEs involves all elements of care—not just medical knowledge. This core competency can be developed through the learning techniques using PSEs and liability claims throughout this chapter. These are examined in case studies, outlines of existing programs, and exploration of the ideal program later in this chapter.

The Joint Commission attributed communication failures as part of the cause of a sentinel event in more than 70 % of adverse events [19]. Providers currently receive very little training that focuses on team communication. Medical professionals are trained in professional silos: physicians in their medical schools, nurses in their nursing schools, therapists in their given professional track, and pharmacists in schools of pharmacy. Rarely does the team come together in training; yet, teamwork failure often causes adverse events. Teamwork resources, culture, and empowerment advances more quickly the recognition and rescue of an event prior to harm.

A critical element of teamwork is the debriefing that occurs following a PSE. Ideally, this debriefing process will be extended to the “near-miss” so that unsafe systems can be improved.

Analysis of PSEs often show elements that were not medical knowledge or traditional training, but included elements of professionalism. These include disruptive behaviour, adherence to safe practices, building a culture of safety, lifelong improvement and ethical responsibilities. Often, the most critical pieces of the disclosure and resolution process involve professionalism.