Patient Safety - Health Committee Contents


8  Education and training curricula

182. Our inquiry revealed that there are obvious deficiencies in medical curricula in several specific respects that are to the detriment of patient safety. In this chapter we discuss these; and we look at the broader question of the place that patient safety occupies in the education and training curricula of healthcare workers.

Non-technical skills

183. We have already noted that deficiencies in non-technical skills are a significant patient safety issue in the NHS. Education and training clearly have a big part to play in addressing this, as the Clinical Human Factors Group told us:

    Training in [Human Factors] skills such as teamwork and communication is virtually absent in healthcare. It should be mandated by regulation, taught and examined. The appropriate professional bodies should be active partners in examining and assessing competencies in non-technical skills (NTS) and [Human Factors] for both trainees and qualified staff. Those who work together should train together. Research has shown that teamwork training may reduce technical errors by 30-50% […] Effective education must be supported by regulation, an appropriate curriculum, time, and money. It also requires a workforce of trainers who have been selected and trained to teach. It must also be quality-assured, assessed and examined. In the generic and critically important field of [Human Factors] none of this has taken place.[185]

184. Captain Hirst and Captain Dale likewise advocated that "training of non-technical (teamworking) skills should be introduced immediately at all stages of medical education and across all disciplines".[186]

Clinical pharmacology and therapeutics

185. As we have mentioned, there is significant evidence that adverse drug events are widespread. Although errors can occur in the dispensing and administration of drugs, research indicates that there is a particular problem with prescribing. For some time, clinical pharmacology experts have been arguing that the undergraduate medical curriculum does not offer sufficient teaching in prescribing and appropriate use of medicines. The consequence is said to be significant potential for error and harm to patients. We heard from David Webb, Professor of Therapeutics at the University of Edinburgh, that, although there were now many more drugs available for doctors to prescribe, medical students were receiving less training than they once did in prescribing. This was partly due to the undergraduate curriculum (Tomorrow's Doctors, introduced in 1993) excluding the study of clinical pharmacology and therapeutics, and partly due to the lack of a practical element in the curriculum (which would allow students to prescribe under supervision).[187]

186. Professor Webb also told us that the General Medical Council (GMC) had now acknowledged this was an issue. However, Finlay Scott, the Chief Executive of the GMC, indicated that it had not yet been decided how to address the problem in the revised version of Tomorrow's Doctors. He cautioned against "rush[ing] to the conclusion that the solution to the perceived problem lies in more teaching of pharmacology per se".[188]

Diagnosis in general practice

187. We have already noted that delayed or missed diagnosis in general practice is a significant problem, generating many complaints and claims against GPs. Dr Kostopoulou, who has been researching this topic, told us that "prompt and accurate diagnosis of serious conditions in primary care […] is a very difficult job and sometimes it is not done well".[189] Experienced GPs tend to diagnose in an intuitive way, based on the types of case that they see most often. Whilst this is an effective and productive way of diagnosing in the great majority of cases, it can lead to delayed or mistaken diagnosis when a patient presents with a condition that is "slightly less common but more serious".[190]

188. According to Dr Kostopoulou, one solution to this is better medical education and training: "There are ways of getting them to become more aware of those situations, possibly through education and training, so we can 'de-bias' the way people think."[191] This would include simulation of clinical situations, using "computerised scenarios" (analogous to the use of flight simulators in aviation); and teaching "how to diagnose formally, how to form differential diagnoses, how to test diagnoses".[192]

Root-cause analysis

189. We have already noted the limited extent to which root-cause analysis is used in investigating patient safety incidents in the NHS. Professor Toft, who is developing a postgraduate course in root-cause analysis at Coventry University, told us that skills in this regard were widely lacking and advocated that:

    It should be in medical student training. Right from the very beginning that they start their training there should be a gradual build up of notions of error, how human error is created, how the whole system works together, how it leads to the creation of errors but, most importantly, everybody should be told directly that nobody is perfect—nobody.[193]

Patient safety in education and training curricula

190. The Quality, Reliability, Safety and Teamwork Unit at Oxford University have concluded from their research that the conventional model of medical training actually ingrains in healthcare workers a culture that is inimical to safer ways of working:

    Repeated experience […] reports strong negative staff reactions and resistance to practice change […] the problem appears to be rooted in the professional ethos of healthcare workers. The professional model for patient care assumes that individuals have a moral duty to ensure that no harm befalls each individual patient. It follows from this that the direct carers for a patient are individually and completely responsible for all aspects of their care, and that they are expected to be alert, vigilant and in full possession of all the relevant information at all times. How to achieve this is taught through an apprenticeship learning system, following the practices of respected and experienced practitioners.[194]

191. Reverend Dr Pauline Pearson, Deputy Director of CETL4HealthNE: Centre for Excellence in Healthcare Professional Education at Newcastle University, told us about Patient safety in health care professional educational curricula: examining the learning experience. This was a major research project, involving five universities, which examined the pre-registration education curricula of doctors, nurses, physiotherapists and pharmacists.

192. Dr Pearson stressed the importance of: clinical educators as role models; encouraging students to challenge unsafe practice; appropriate clinical placements for students; and interdisciplinary education, with different clinical groups training together, to help facilitate good teamworking.[195] She told us patient safety was:

    taken seriously by people providing courses for all the health professions that we have looked at, but it is often implicit rather than explicit, so it is there in the curriculum but it is not always made clear or clearly assessed.[196]

193. The junior doctors and nurses from whom we took oral evidence were agreed that patient safety as such had not been a formal part of their education:

    Q 410 […] Dr Long: I can only talk for my training, obviously. I qualified in 2002, so I started my training in 1994, in the old-style system, I think. Although I knew safety was of crucial importance, that everything I was learning was so that I could treat my patients safely, it was never really made explicit. I never really heard the expression "patient safety". The only thing I can vaguely remember is a talk given to us as undergraduates by one of the defence unions about prescribing safely and trying to avoid complaints. When I qualified, I was always very worried about making mistakes, but I never really stepped back and thought about why mistakes might occur or what the consequences might be or anything like that […]

    Dr Kreckler: I can certainly echo those views. In [Dr Pearson's evidence] it was said that it was very much implicit rather than explicit and that has certainly been my experience. There is a lot of activity going on now, particularly in the last couple of years, trying to bring patient safety to the undergraduate curriculum. I have been personally involved in training not only undergraduates but foundation year doctors, and when you start teaching about patient safety, they are completely unaware of safety as a concept in its own right.

194. The Imperial College researchers reported that:

    Interviewees were asked if they had any training or education about patient safety. It seems that some of the interviewees seemed confused about what actually constituted as 'patient safety training'. Some spoke about fire safety training, risk management or perhaps training in reporting incidents but few actually specified they had patient safety training. Nurses reported training in manual handling, cardiac arrest training, communication and listening skills, handling complaints, transferring patients, infection control and yearly health and safety training. Doctors recalled training on medico-legal issues, communication skills and risk management.[197]

Conclusion

195. There are serious deficiencies in the undergraduate medical curriculum, which are detrimental to patient safety, in respect of training in: clinical pharmacology and therapeutics; diagnostic skills; non-technical skills; and root-cause analysis. These must be addressed in the next edition of Tomorrow's Doctors. The DH and GMC must monitor the quality of new medical graduates' use of the skills listed above. Elements of patient safety are taught, but this tends to be done implicitly rather than explicitly; this should also be addressed in the curriculum, which must make clear that patient safety is the first priority of medical practice. Patient safety must also be fully integrated into postgraduate medical education and training as a core element, not an optional extra.

196. Patient safety, including Human Factors, has yet to be fully and explicitly integrated into the education and training curricula of healthcare workers in general. This training should include the recognition that errors will inevitably occur in certain circumstances. There are convincing arguments for interdisciplinary training to foster good teamwork skills across professional boundaries: those who work together should train together.


185   Ev 90, 93 Back

186   Ev 95 Back

187   Q 392 Back

188   Q 747 Back

189   Q 623 Back

190   Q 644 Back

191   Ibid. Back

192   Q 648 Back

193   Q 226 Back

194   Ev 121 Back

195   Q 333 ff. See also PS 90 and PS (BP 01). Back

196   Q 331 Back

197   Centre for Patient Safety and Service Quality, Imperial College, commissioned research Back


 
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