Table 1

Organizational defences, holes, and proposed means to strengthen the defences

Organizational defences	Holes	Proposed means to strengthen the defences
Entrance requirements	Score based selection criteria may not identify individuals with ability to reflect on practice, work with others and continually improve their performance	Include an assessment of prior experience and skills in these areas as part of student selection

Curriculum	Lack of attention to the skills needed to improve one's practice, including collaboration, interdisciplinary teamwork and the ability to admit and discuss error	Modify content to include core content in improvement, including team training Emphasize value of learning from error

Organizational culture	Overemphasis on physician/physician interaction, chronic fatigue and other threats to professionalism Insufficient value placed on scholarship of teaching and improvement Person oriented model of error	Address threats to profssionalism Align organizational values with desired goals Seek training opportunities in organizations with cultures that support safety and improvement

Student assessment	Mismatch between what we measure and our real objectives Lack of assessment related to improvement and patient safety	Develop approaches to student assessment that address all required competencies

Program evaluation	Accreditation standards do not address sufficiently the skills needed by physicians to improve care and safety	Develop broader approaches to program evaluation Increase accountability for outcomes