Table 1

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

Organizational defencesHolesProposed 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

  • 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