Objectives To develop, implement and evaluate a novel patient safety training programme for junior doctors across a Foundation School—‘Lessons Learnt: Building a Safer Foundation’.
Design, setting and participants Prospective preintervention /postintervention study across 16 Foundation Programmes in North West England, UK. 1169 participants including all Foundation Programme Directors, Administrators, Foundation trainees and senior faculty.
Interventions Half-day stakeholder engagement event and faculty development through recruitment and training of local senior doctors. Foundation trainee-led monthly 60-min sessions integrated into compulsory Foundation teaching from January to July 2011 comprising case-based discussion and analysis of patient safety incidents encountered in practice, facilitated by trained faculty.
Main outcome measures Participants’ satisfaction and Foundation trainees’ patient safety knowledge, skills, attitudes and behavioural change.
Results Participants reported high levels of satisfaction with ‘Lessons Learnt’. There was a significant improvement in trainees’ objective patient safety knowledge scores (Meanpreintervention=51.1%, SD=17.3%; Meanpostintervention=57.6%, SD=20.1%, p<0.001); subjective knowledge ratings and patient safety skills. Trainees’ perceived control and behavioural intentions regarding safety improved significantly postintervention. Feelings and personal beliefs about safety did not shift significantly. Trainees reported significantly more patient safety incidents in the 6 months following introduction of ‘Lessons Learnt’ (Meanpreintervention=0.67, SD=1.11; Meanpostintervention=1.18, SD=1.46, p<0.001). 32 quality improvement projects were initiated by trainees, spanning the development of novel clinical protocols; implementation of user-informed teaching and improved rota design
Conclusions Patient safety training can be implemented and sustained to deliver significant improvements in patient safety knowledge, skills and behaviours of junior doctors—with potential for wider positive organisational impact. Medical education commissioners and providers could adopt and build upon the ‘Lessons Learnt’ approach as a springboard to promote medical engagement in quality and safety improvement.
- Patient safety
- Medical education
- Root cause analysis
- Quality improvement
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Recent years have seen a rapid proliferation of training curricula and interventions in patient safety and quality improvement (QI).1 ,2 These interventions have targeted diverse audiences, employed a variety of educational approaches, and have been evaluated to varying degrees, with core content spanning root cause analysis,3 systems-based practice4 and non-technical skills.5 However, while the evidence base for such training is growing, the wider translation and uptake of such interventions remains poor, with documented barriers to implementation including organisational resistance, lack of trained faculty and poor learner engagement.1 Moreover, despite the professional regulators and many medical curricula now stipulating core requirements and competencies relating to patient safety and QI,6 ,7 there is limited opportunity to develop and demonstrate these ‘safety skills’ in practice.
With over 55 000 doctors in training in the UK at any one time, junior doctors (trainees) are being increasingly recognised as an underused resource in driving safety improvement efforts.8 While formal incident reporting among trainees is low due to various factors,9 they commonly reflect on patient safety issues10 and express a desire and ability to engage in QI.11 Previous studies targeting trainees have employed incident analysis as an effective means of engaging doctors and providing a foundation for educational interventions in patient safety. However, these studies involved small numbers of participants,4 were specialty-specific12 or struggled to elicit improvements in patient safety competencies.3 Moreover, barriers to sustainability of the interventions were inadequately addressed.
We report the development, delivery and evaluation of a novel large-scale patient safety training programme for Foundation Trainees—junior doctors at the very start of their careers, designed to formalise the opportunity for trainees to discuss and learn from authentic patient safety incidents (PSIs) encountered in practice. The programme, termed ‘Lessons Learnt: Building a Safer Foundation’ (Lessons Learnt) aims to improve trainees’ knowledge, attitudes, skills and behaviours in patient safety. In order to promote sustainable integration of the programme, the broader aims of this study were to engage clinical training commissioners and providers and to develop a core faculty in patient safety education.
This was a prospective, preintervention /postintervention study across an entire trainee population.
The study was conducted across all 16 Foundation Programmes in the North Western Foundation School, UK. The Foundation Programme is a structured 2-year training programme, which forms the bridge between medical school and specialty training. Foundation trainees are junior doctors in the first 2 years of clinical practice following graduation and rotate through clinical placements across primary (community) and secondary (hospital) care. The North Western Foundation School oversees Foundation training in the Greater Manchester, Cumbria and Lancashire regions of north-west England. Foundation programmes in this School range in size from 32 to 136 Foundation trainees across two cohorts (Foundation Year 1 and Foundation Year 2). Delivery of the Foundation Programme at each site is overseen by a Foundation Programme Director (FPD), supported by a Foundation Programme Administrator (FPA). Foundation trainees attend protected teaching sessions (typically a half-day/week) targeted towards augmenting the Foundation Programme curriculum competencies achieved in clinical placements.13 Attendance for teaching is compulsory, and averages 70% across the School. Prior to our intervention, there was no explicit patient safety training offered to Foundation trainees in the North Western Foundation School.
We used a ‘census approach’ to sampling whereby the intervention was targeted at the whole population of the North Western Foundation School. This comprised 1169 participants—including all Foundation trainees (n=1076), FPDs (n=18), and FPAs (n=18). Previously trained senior doctor faculty were also part of the study (n=57)—see implementation section below.
The ‘Lessons Learnt’ patient safety training programme comprises a series of five monthly 60-min sessions integrated into the compulsory Foundation teaching programme, during which Foundation trainees lead a peer-group discussion and analysis of a PSI in a safe, facilitated forum (figure 1). ‘PSI’ is defined as per the National Health Service National Patient Safety Agency's guidance as ‘any unintended or unexpected incident that could have or did lead to patient harm’.14 ‘Lessons Learnt’ aims to be an adjunct to incident reporting and as such trainees are encouraged to report PSIs through local reporting systems, with serious concerns escalated by faculty according to General Medical Council guidance.15 We sought and were exempted from formal ethical approval.
Development of the intervention
The ‘Lessons Learnt’ intervention replaced teaching considered redundant within the Foundation teaching programme. The learning outcomes for ‘Lessons Learnt’ were mapped to core patient safety competencies as stipulated in the 2010 UK Foundation Programme Curriculum13 (box 1). Preliminary research by our group demonstrated the feasibility of using real-life examples of PSIs encountered by Foundation trainees as core learning material for patient safety training.10 Combined with a collaborative case-based learning approach, this would encourage deeper, experiential learning from authentic PSIs.16 In order to maximise learning from every case, a ‘PSI pro forma’ was developed from a validated root cause analysis tool (the London Protocol)17 to guide structured discussion of contributing factors to the PSI, key lessons learnt and solutions for improvement (see web appendix 1). Informed by an initial pilot, a target of five ‘Lessons Learnt’ sessions was set for each cohort (FY1 and FY2) at each site (n=16) from January 2011 to July 2011, with the first of these comprising an introductory launch session to orient trainees to ‘Lessons Learnt’ (see ‘capacity-building’ below). Subsequently, trainees volunteered to present examples of PSIs encountered in practice. Each 60-min session involved a case presentation (10 min), root cause analysis (30 min) and discussion of lessons learnt and next steps (20 min).
Learning outcomes for ‘Lessons Learnt: Building a Safer Foundation’
Patient safety knowledge
At the end of the programme participants will be able to:
Define a ‘patient safety incident’ (PSI)
Describe the rates and types of PSIs in healthcare
Understand the nature of human error and the importance of systems factors in relation to patient safety
Understand the contributing factors to PSI
Patient safety skills
At the end of the programme participants will be able to:
Recognise a PSI
Analyse a PSI using a London Protocol-driven approach (root cause analysis)
Identify actions and recommendations to prevent future PSIs
Patient safety attitudes
At the end of the programme participants will acknowledge the need to:
Foster an open and learning culture to improve patient safety
Raise and act on concerns about patient safety
Reflect and learn from error and PSIs
Implementation of the intervention
Our approach to implementation aimed to address the well-documented barriers to delivery of patient safety training, in order to promote the sustainable integration of ‘Lessons Learnt’ beyond the life of the study. This comprised two key facets: stakeholder engagement and capacity-building: (figure 2 depicts key milestones in implementation).
1. Stakeholder engagement
Organisational resistance is a recognised barrier to the integration of patient safety training.1 In order to gain high-level support for ‘Lessons Learnt’, a study steering group was developed with representation from the regional training commissioner (North Western Deanery) and the Imperial Centre for Patient Safety and Service Quality. Together, this group held a half-day launch conference in September 2010 inviting FPDs, FPAs, Foundation trainee representatives and prospective faculty from each of the 16 Foundation Programmes to gain ‘buy-in’ right from study initiation and outline key roles and responsibilities. FPDs were tasked with endorsing ‘Lessons Learnt’ locally and FPAs to administer the sessions and support local evaluation.
In order to maximise trainee engagement and ownership of the intervention, Foundation trainee ‘Leads’ were appointed for each cohort (FY1 and FY2) at each site through competitive application. Their role was to lead implementation of ‘Lessons Learnt’ locally by leading the local launch session (see below), recruiting peers to present cases and facilitating evaluation. A recruitment flyer was disseminated via FPAs to all trainees across the Foundation School (see web appendix 2) requiring prospective Leads to submit a 250-word statement on why they wished to undertake the role and what they would bring to it. Eighty applications were received and 34 trainee Leads were appointed (two extra at each of two larger sites). Wider trainee engagement in ‘Lessons Learnt’ was incentivised with a certificate of participation for every trainee that presented a case.
Lack of expert faculty is a well-recognised barrier to the delivery of patient safety training.18 A senior medical faculty was developed by recruiting senior doctors (consultants and senior specialty trainees) from across Trusts in the North Western Foundation School. A recruitment flyer detailing the role description and benefits of the role was disseminated via FPAs. The target was to recruit at least three faculty members per site. In fact we were overwhelmed with interest. A hundred and one senior doctors volunteered (80% consultants, 20% specialty trainees) of which 57 were appointed as faculty, on a first-come first-served basis.
Trainee Leads and faculty received free half-day training in November 2010 delivered by patient safety faculty from Imperial's Centre for Patient Safety and Service Quality and accredited by the Royal College of Physicians. Course content included (1) patient safety essentials (theory, evolution, policy context) (2) root cause analysis of PSI and (3) the ‘Lessons Learnt’ project and roles and responsibilities. Comprehensive handbooks were developed by our team to assist trainee Leads and faculty in their roles (copies available through the corresponding author). These included training materials, advice on engaging trainees and escalating concerns, and further resources. Further details regarding faculty recruitment and development is reported in our previously published study.18
Following training, trainee Leads and faculty launched ‘Lessons Learnt’ locally at their respective sites in January 2011. A standardised local ‘launch-pack’ was developed incorporating a preintervention evaluation (10 min), lecture on patient safety essentials (20 min) (key patient safety terminology and policy, the nature and scale of harm, person vs systems approach to error, and the rationale to ‘Lessons Learnt’) and a mock ‘Lessons Learnt’ interactive session (30 min) (copy of local launch-pack provided in web appendix 3).
Evaluation of the programme
Evaluation of ‘Lessons Learnt’ was conducted in parallel to implementation and aimed to assess all four levels of Kirkpatrick's framework for evaluating educational interventions.19 The four levels of educational outcomes are: Level 1: Reaction (learner satisfaction), Level 2: Learning (of knowledge, skills and attitudes), Level 3: Changes in learner behaviour and Level 4: Organisational change (ie, the results of the learning opportunity).
Level 1: Participant satisfaction
All Foundation trainees, faculty, FPDs and FPAs were invited to complete a short satisfaction questionnaire postintervention eliciting responses on a 5-point Likert scale (1=strongly disagree to 5=strongly agree). Free text feedback was invited to explore strengths and limitations of ‘Lessons Learnt’.
Level 2: Patient safety knowledge, attitudes and skills
This was assessed in Foundation trainees preintervention and postintervention (in January and July 2011). Patient safety knowledge was assessed objectively through multiple-choice questions mapped onto the intervention learning objectives. Subjective knowledge and patient safety attitudes were assessed using a modified questionnaire (‘Medical Student Patient Safety Questionnaire’) developed by Patey et al.20 The attitudes/behaviour section of this questionnaire is informed by Azjen's well-validated ‘theory of planned behaviour’,21 which proposes that behavioural intentions can be predicted from attitudes towards the behaviour, perceived behavioural control and subjective norms. For the purpose of our evaluation, we selected four of the five attitude scales (‘feelings about making errors’, ‘personal beliefs about patient safety’, ‘personal influence over patient safety’ and ‘intentions regarding patient safety’). We modified the terminology of some items to reflect our focus on PSI versus error. In addition, we devised items to assess self-reported confidence in safety skills. Items included confidence in ‘analysing a PSI’ and ‘identifying actions to be taken to prevent future PSIs’ assessed on a 5-point Likert scale (1=very low confidence to 5=very high confidence).
Level 3: Patient safety behaviours
This was assessed through a self-report questionnaire exploring trainees’ awareness, reflection, reporting and disclosure of PSIs in the 6 months prior to and 6 months following introduction of ‘Lessons Learnt’. For each item, trainees were asked to indicate the frequency with which they had demonstrated each particular behaviour in the previous 6 months. The response scale ranged from ‘0’ to ‘5 or more’.
Level 4: Wider organisational impact
Although the primary aim of ‘Lessons Learnt’ was to improve trainees’ learning (Level 2) and safety-related behaviour (Level 3), we also wanted to examine the wider organisational impact of the intervention. As a first step, trainee Leads at each site were asked to submit a ‘QI database’ (Excel spreadsheet) detailing progress on QI projects (defined as any project resulting from ‘Lessons Learnt’ and aiming to improve, streamline or clarify hospital, clinical or educational services) and other actions/ recommendations proposed as a result of each ‘Lessons Learnt’ session.
The trainees’ assessment was incorporated into a single evaluation tool. In order to maximise response rate, the preintervention evaluation was incorporated into the local launch session in January 2011 and postintervention evaluation into the final session in July 2011. Given the large scale of the intervention, trainee Leads (supported by FPAs) were tasked to coordinate data collection at their respective site (guidance was provided—see web appendix 4). The satisfaction questionnaire for FPDs, FPAs and faculty was administered electronically using ‘SurveyMonkey’ software. Non-respondents were sent fortnightly email reminders for 6 weeks.
Independent t tests were used to compare statistically objective knowledge scores and behavioural measures. For outcomes evaluated on a Likert scale (subjective knowledge, confidence in skills and attitudes), the percentage agreement (ie, % of scores of 4=agree/high or 5=strongly agree/very high) was first calculated and independent proportions tests were used to test for a significant difference preintervention/postintervention. Cronbach's α was used to assess the internal consistency (scale reliability) of survey subscales (self-report knowledge, skills and attitudes). SPSS V.19.0 was used for all analyses. The ‘QI databases’ were analysed for content by two clinical researchers (MA and ST). Both reviewers systematically reviewed each database to identify QI projects that were reported by trainee Leads to be in progress or complete. A senior clinical reviewer (PB) further reviewed projects when reporting or project aims were unclear. The projects identified were subsequently themed into categories, based on reviewer consensus.
Eighty-one per cent of sites (13/16 Foundation Programmes) successfully held five or more ‘Lessons Learnt’ sessions from January to July 2011. At the three sites that did not meet the target, it was the FY2 cohort that had struggled, running either three or four sessions only. Overall, 165 ‘Lessons Learnt’ sessions were held between January and July 2011. The 57 faculty members facilitated an average of three sessions each (range: one to eight).
Response rates for the satisfaction questionnaire were 100% for FPDs (n=18/18), 100% for FPAs (n=18/18), 49% for faculty (n=28/57) and 40% for Foundation trainees (n=428/1076). The majority of participants agreed/strongly agreed that ‘Lessons Learnt’ promoted an open and learning safety culture. They supported its continuation in the North-west and its wider adoption across the UK (figure 3). Participants’ testimonials are displayed in box 2. Commonly reported challenges included difficulties in securing a trainee presenter and/or faculty and lack of support in following up actions stemming from the case discussions.
“...The greatest strength of Lessons Learnt is in making changes and improvements from the ground upwards via the foundation trainees, allowing them to become actively involved in making patient safety better...” Foundation Programme Director
“...Lessons Learnt sends a clear message that the blame culture has been laid to rest; that patient safety is more important than naming and shaming...” Faculty
“...Lessons Learnt has been such an empowering tool for us, as a platform for us to share our experiences and it has given junior doctors a voice and challenged us to make a difference...” FY2 trainee
“...With organised trainee Leads, these sessions are valuable and easy to schedule into the programme...” Foundation Programme Administrator
“...Unlike some of the other Foundation teaching, we get to run this ourselves—teaching which is relevant and useful to us and has the potential to actually improve practice...” FY1 Lead
“...I absolutely love these sessions. I learn from them as much as the trainees...” Faculty
“...Lessons Learnt makes you feel more human—we all make mistakes. It's a chance to investigate why things are done in a certain way and to make changes for the better...” FY1 trainee
“...Lessons Learnt fosters openness and is potentially encouraging a generation of doctors who are prepared to discuss patient safety issues...” FY2 trainee
Trainees’ patient safety knowledge, attitudes and skills
Trainees’ response rate for the preintervention evaluation was 72% (n=775/1076) and 43% (n=464/1076) for the postintervention evaluation. There was a significant improvement in objective scores of patient safety knowledge from 51.1% (SD=17.3%) to 57.6% (SD=20.1%), p<0.001. There was also a significant improvement in subjective scores of patient safety knowledge, with an average 32% increase in the proportion of trainees agreeing/strongly agreeing with a perceived improvement in knowledge (table 1). Prior to the intervention, trainees generally reported positive attitudes towards patient safety, apart from in the domain of ‘personal influence over patient safety’ (perceived control) (table 1 and see web appendix 5a). Postintervention, although trainees’ feelings and personal beliefs about patient safety did not shift significantly, there was a significant improvement in trainees’ perceived influence and behavioural intentions regarding patient safety (table 1). A significant improvement was also obtained in self-reported confidence in patient safety skills for each item, most notably in the ability to analyse a PSI (26% increase in proportion of trainees reporting high/very high confidence) (table 1).
With regards to scale reliability, the internal consistency of the subjective knowledge scale was very high (Cronbach αPreintervention=0.862, Cronbach αPostintervention=0.910), as was the internal consistency for the self-reported confidence in skills scale (Cronbach αPreintervention=0.856, Cronbach αPostintervention=0.922). Internal consistency for the various attitude scales ranged from Cronbach α 0.660 to 0.905) (full results in web appendix 5b).
Trainees’ behavioural change
Trainees’ response rate for the behavioural items was 68% (n=737/1076) preintervention and 40% (n=428/1076) postintervention. Significant improvements were obtained across all self-reported measures of behavioural change including increased reflection and disclosure of PSIs and formal incident reporting (table 1).
Wider organisational impact
‘QI databases’ were received from 17 trainee Leads (50%). Analysis of these identified 32 QI projects as being in various stages of implementation. Three key themes were identified: (1) projects to develop novel clinical protocols and pathways to improve care (2) projects to improve working conditions and (3) projects to deliver user-informed teaching sessions. Examples of the QI projects are listed in box 3. Other notable outcomes included trainees being invited to join the Trust Patient Safety Board at one site, and the development of a Junior Doctor QI group at another site. The follow-up of these QI projects and a detailed analysis of other actions/recommendations proposed as a result of ‘Lessons Learnt’ sessions are currently in progress.
Examples of quality improvement (QI) projects undertaken by trainees
Development of novel clinical pathways/protocols to improve care
Development of streamlined protocol for insulin sliding scale across the Trust
Development of protocol for crash call on psychiatric ward
Development of referral protocol to oncology for malignancy with unknown primary
Initiation of regular orthogeriatric reviews on orthopaedic ward
Escalation protocol for junior doctors developed and disseminated in all wards
Improved working conditions
Protected handover on Medical Assessment Unit
Larger desk provided in work space and overall more organised work area
Reduced number of patient beds on ward, higher nursing levels
Improved patient record management in Surgery
Improved access to confidential waste bins
Advanced Life Support update incorporated into teaching programme
Induction to include tour of all areas covered by crash team
Teaching on hyperkalaemia
Teaching on insulin prescribing
Teaching session on consent, confidentiality and chaperoning
We have demonstrated that a large-scale patient safety training programme (delivered to all Foundation trainees across 16 sites in North-west England) achieved significant improvements in trainees’ patient safety knowledge, skills and attitudes related to patient safety. Modest improvements in safety related behaviours were also reported, with trainees discussing, disclosing and reporting more incidents in the 6 months following introduction of ‘Lessons Learnt’. Moreover, ‘Lessons Learnt’ resulted in wider organisational impact through trainees engaging in QI projects, which spanned the development of novel protocols, improved working conditions and the implementation of user-informed teaching. Following our study, the ‘Lessons Learnt’ programme now forms part of routine teaching across the North Western Foundation School and is in its third year of roll-out (2012–2013), with over 150 trained faculty members supporting its delivery.
To the best of our knowledge, this is the largest study of a patient safety training intervention in the UK. Much of the evidence relating to patient safety and QI education comes from the USA.1 As with our findings, the majority of studies demonstrate high participant satisfaction and significant improvements in knowledge scores.1 As found in previous studies,1 ,20 ,22 patient safety attitudes among trainees were generally positive prior to the intervention, leaving minimal room for improvement, as noted in the ‘feelings’ and ‘personal beliefs’ domains. However the impact of the ‘hidden curriculum’ on counteracting the intended influence of ‘Lessons Learnt’ on trainees’ attitudes cannot be ruled out.23 Importantly, we found significant improvements in perceived control over safety, behavioural intentions and self-reported safety-related behaviours, in accordance with Azjen's theory of planned behaviour.21 We believe that using authentic scenarios brought forward by trainees as opposed to hypothetical scenarios as in previous studies3 ensured relevance to trainees and furthermore, stimulated trainee engagement in QI work.
The main limitation of this study pertained to its pre–post intervention design and lack of a comparator group. The contractual obligation to establish and deliver ‘Lessons Learnt’ across the Foundation School meant that it was not possible to conduct a comparative trial at this stage. Evaluation of trainees’ patient safety skills and behaviours relied on self-report, which is prone to recall and also self-presentation biases; employing objective measures where possible would be desirable in future studies. The response rate among trainees for the postintervention evaluation ranged from 40% to 43%, thus risking selection bias. We believe that the length of the survey and ‘questionnaire fatigue’ impacted on data collection and this reflects a necessary trade-off in aiming for as comprehensive evaluation as possible given the resource constraints. Notably, postintervention data were received from all but one site. This site had also struggled to implement the programme due to unavailability of trained faculty and poor trainee engagement. A comparative analysis between this site and the remaining sites would have been useful—but was beyond the scope/logistics of this study.
The main challenges to implementation of ‘Lessons Learnt’ related to difficulties in securing trainee presenters and faculty. Notably, of the sites that failed to meet the target of holding five ‘Lessons Learnt’ sessions, it was the FY2 cohort that had struggled. We believe that this may be due to a lack of incentive for FY2 trainees to ‘portfolio-build’ once subsequent jobs have been secured (typically by March). As our previously published study reports, the main barrier to faculty engagement in ‘Lessons Learnt’ was competing clinical commitments.18 Importantly, empowering trainees to lead local implementation and capitalising on the existing Foundation training infrastructure meant that the cost of delivering ‘Lessons Learnt’ was modest. The main ‘additional’ costs related to central project management (0.2 full-time equivalent) and the cost of the launch conference and faculty training (to cover venue hire, catering, speaker costs and materials).
Regarding implications of our study, we have demonstrated that through addressing key barriers to the implementation of patient safety training experienced in other studies,1 it is possible to embed patient safety training across a Foundation School, engaging a large cohort of senior and junior doctors in patient safety. Importantly, the latest iteration of the UK Foundation Programme curriculum stipulates additional patient safety and QI competencies for trainees including ‘discussion of safety issues in the framework of case-based discussions’24 and a requirement for trainees to conduct a QI project. ‘Lessons Learnt’ potentially offers an ‘off-the-shelf’ solution for Foundation training commissioners to deliver patient safety training to their trainees and provides a strong basis from which to support QI activities. Regarding future development, alignment with hospital quality agendas and clear recognition and support for senior doctor engagement would facilitate more QI work to be undertaken by trainees. Moreover, a multiprofessional model (to include, eg, nurses in the programme) would enable more holistic incident analysis, especially given recommendations that ‘teams that work together should train together’25 and facilitate multidisciplinary QI efforts.
This is the largest multicentre study of a patient safety training intervention in the UK to our knowledge, demonstrating significant improvement in the patient safety knowledge, skills and behaviours of Foundation trainees—and also positive wider organisational impact. ‘Lessons Learnt’ is well-accepted by trainees, programme directors and administrators, and presents a feasible means of delivering core patient safety education across a Foundation School. We would encourage other training providers to adopt and build upon the ‘Lessons Learnt’ approach as a springboard to engage and enable the next generation of medical leaders in improving the safety and quality of healthcare.
The authors would like to thank all participants in the study, especially the ‘Lessons Learnt’ Leads and faculty across the study sites. We also thank Simon Carley for facilitating the pilot, James Reason for supporting the study launch conference, and Fizza Ahmed and Sally Hussey for providing administrative support.
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Contributors MA conceived and designed the study, analysed and interpreted the data and drafted the manuscript. SA, NS and CV designed the study, interpreted the data and revised the manuscript for important intellectual content. PB, JH and ST acquired and interpreted the data and revised the manuscript for important intellectual content. MA and NS had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final version to be published. MA is guarantor.
Funding This study was funded through the ‘NHS North West Junior Doctor Innovation Award in Education and Training’ and the National Institute for Health Research (NIHR) via the Imperial Centre for Patient Safety and Service Quality. Additional event sponsorship was received from the Medical Protection Society, the Medical and Dental Defence Union of Scotland, Wesleyan Medical Sickness and the Medical Defence Union. Subsequent funding was awarded from the Greater Manchester Health Innovation and Education Cluster (HIEC) to support delivery of the intervention beyond study completion. The funders had no role in the design and conduct of the study; the collection, management, analysis and interpretation of the data; and the preparation, review or approval of the manuscript.
Competing interests All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author). MA, SA, NS and CV are affiliated with the Imperial Centre for Patient Safety and Service Quality which is funded by the National Institute for Health Research, UK. MA, SA and NS received consultancy fees for this project from NHS North West via Central Manchester Foundation Trust. MA and JH are Education Associates at the General Medical Council. JH is Dean of Postgraduate Medical Studies, North Western Deanery. MA is a member of the Strategic Advisory Board, BMJ Quality and has previously undertaken consultancy work for Medical Education England. CV conducts occasional consultancy work as part of Vincent Burnett and receives book royalties from Wiley-Blackwell. This study is part of the ‘Lessons Learnt: Building a Safer Foundation’ programme which won the BMJ Group Excellence in Healthcare Education Award, 2012.
Patient consent Obtained.
Ethics approval Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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