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Patient Safety Knowledge and Its Determinants in Medical Trainees

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Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Background

Patient safety is a core educational topic for medical trainees.

Objectives

To determine the current level and determinants of patient safety knowledge in medical trainees.

Design

Multi-institutional cross-sectional assessment of patient safety knowledge.

Participants

Residents and medical students from seven Harvard-affiliated residencies and two Harvard Medical School courses.

Measurements

Participants were administered a 14-item validated test instrument developed based on the patient safety curriculum of the Risk Management Foundation (Cambridge, MA). The primary outcome measure was the amount of patient safety knowledge demonstrated by trainees on the validated test instrument. The secondary outcome measure was their subjective perceptions as to their baseline knowledge level in this domain.

Results

Ninety-two percent (640/693) of residents and medical students completed the patient safety test. Participants correctly answered a mean 58.4% of test items (SD 15.5%). Univariate analyses show that patient safety knowledge levels varied significantly by year of training (p = 0.001), degree program (p < 0.001), specialty (p < 0.001), country of medical school (p = 0.006), age (p < 0.001), and gender (p = 0.050); all but the latter two determinants remained statistically significant in multivariate models. In addition, trainees were unable to assess their own knowledge deficiencies in this domain.

Conclusions

Patient safety knowledge is limited among medical trainees across a broad range of training levels, degrees, and specialties. Effective educational interventions that target deficiencies in patient safety knowledge are greatly needed.

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Acknowledgements

We thank the RMF (Cambridge, MA) for use of their web-based educational materials; Robert B. Hanscom and Elizabeth G. Armstrong for their support of the program; Lucean L. Leape and Saul N. Weingart for editing and content validation of the patient safety test items; Ronald A. Arky, Stanley W. Ashley, Christopher C. Baker, Eugene Beresin, Lori R. Berkowitz, Charlie M. Fergusen, Joel T. Katz, Hope A. Riccotti, William Taylor, and Carrie D. Tibbles for including their programs/courses in the web-based program; Daniel D. Federman for support in the conception of the program and assistance in its financial administration; and Susan Herlihy, Jessica E. Hyde, and Colleen E. Graham for administrative support. The views expressed in this article are those of the authors and do not necessarily reflect the position and policy of the United States Federal Government or the Department of Veterans Affairs. No official endorsement should be inferred. This study was supported by a grant from the RMF, Cambridge, MA. Additional support was obtained from the Research Career Development Award Program and research grants TEL-02-100 and IIR-04-045 from the Veterans Affairs Health Services Research & Development Service, the American Urological Association Foundation (Linthicum, MD), Astellas Pharma U.S., the National Institutes of Health (K24 DK63214 and R01 HL77234), and the Academy at Harvard Medical School. The study protocol was reviewed and approved by the institutional review board at Harvard Medical School.

Conflict of interest

None disclosed.

Author Contributions

Dr. Kerfoot had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Conception and design: Kerfoot, Conlin, Travison, and McMahon. Acquisition of data: Kerfoot and McMahon. Analysis and interpretation of data: Kerfoot, Conlin, Travison, and McMahon. Drafting of the manuscript: Kerfoot and Travison. Critical revision of the manuscript for important intellectual content: Conlin and McMahon. Statistical analysis: Kerfoot and Travison. Obtaining funding: Kerfoot and Conlin. Administrative, technical, or material support: Conlin, Travison, and McMahon. Supervision: Conlin and McMahon

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Authors

Corresponding author

Correspondence to B. Price Kerfoot MD, EdM.

Appendix

Appendix

Items on the Validated Test of Patient Safety Knowledge

Test items were developed based on the content-validated patient safety curriculum (error prevention and systems theory) from the RMF (Cambridge, MA). Difficulty refers to the percentage of participants who answered an item correctly.

1. What is the reported frequency of serious adverse events (injuries that results from medical care) among hospitalized patients in the United States?

(A) <1 percent.

(B) 1–5 percent.

(C) 6–10 percent.

(D) >10 percent.

Answer: B

Difficulty: 55%

2. Two different paralytic agents, one with a long half-life and the other with a short half-life, are packaged in similar glass vials with yellow caps. This is an example of

(A) a forcing function.

(B) a latent error.

(C) a medication error.

(D) description error.

Answer: B

Difficulty: 55%

3. If the process of ordering and administering a medication has 20 steps, each with 99% accuracy, what is the likelihood of a medication error occurring each time the medication is ordered and administered?

(A) 0.2 percent.

(B) 1 percent.

(C) 2 percent.

(D) 20 percent.

Answer: D

Difficulty: 61%

4. A 21 year-old college student with a documented penicillin allergy is given doxycycline for yet another episode of chlamydia. He develops a rash from the medication. This incident is best described as

(A) a potential adverse drug event.

(B) a preventable adverse drug event.

(C) a nonpreventable adverse drug event.

(D) a latent error.

Answer: C

Difficulty: 42%

5. A harried resident connects the oxygen tubing to the intravenous (IV) line of a pediatric patient who subsequently dies from a massive gas embolus. This tragedy is best described as

(A) a latent error.

(B) an active failure.

(C) a forcing function.

(D) a knowledge deficit.

Answer: B

Difficulty: 72%

6. In general, blaming the individual who makes an error does not help fix the problem or prevent it in the future. Even so, under the framework proposed by error theorist James Reason, two types of misconduct by practitioners should be punished. One is intentional injury to a patient (or anyone else, for that matter), and the other is...

(A) injury from willful disobedience of practice guidelines.

(B) injury from provider incompetence.

(C) injury caused by substance abuse.

(D) injury from violation of an unworkable rule.

Answer: C

Difficulty: 24%

7. Which one of the following is the best example of an active failure?

(A) Different chemotherapy medications with similar bottles and labeling.

(B) An infusion pump that requires complex dosage calculations.

(C) Scheduling residents to work more than 60 hours in a row to cover a “power weekend.”

(D) Overlooking a pneumothorax on a postcentral line chest film.

Answer: D

Difficulty: 73%

8. Which one of the following is the best example of a latent error?

(A) Ordering of a chest radiograph on the wrong patient.

(B) Using bar codes as patient-identifiers.

(C) Confirming a drug dose on a computerized directory.

(D) Understaffing an intensive care unit.

Answer: D

Difficulty: 67%

9. Anesthesia machines are designed so that the tube carrying the anesthetic gas physically cannot be attached to the oxygen port. What Human Factors Principle does this best exemplify?

(A) Constraint.

(B) Forcing function.

(C) Reduced reliance on memory.

(D) Elimination of look-alikes.

Answer: B

Difficulty: 58%

10. A computerized medication order-entry system has been implemented which presents a limited range of doses to the ordering practitioner. What Human Factors Principle does this best exemplify?

(A) Constraint.

(B) Forcing function.

(C) Simplification.

(D) Reduced reliance on vigilance.

Answer: A

Difficulty: 43%

11. Most preventable errors are caused by

(A) Factual deficiencies.

(B) Process deficiencies.

(C) Performance deficiencies.

(D) Defensive practices.

Answer: B

Difficulty: 83%

12. What are latent errors?

(A) The injuries caused by medical management rather than the underlying disease.

(B) The faulty interrelationships between humans, the tools they use, and the environment in which they live and work.

(C) The unsafe acts of front-line workers.

(D) The hidden properties of a system that permit individuals to make mistakes.

Answer: D

Difficulty: 81%

13. Which one of the following is the most frequent error of daily life?

(A) An arithmetic miscalculation.

(B) Misreading of a label.

(C) Forgetting to turn off a switch.

(D) Mixing drug dosages.

Answer: A

Difficulty: 24%

14. When describing how errors occur, the proximal cause refers to which one of the following?

(A) The unsafe acts of front-line workers

(B) The individual responsible for the error.

(C) The apparent reason the error was made.

(D) The pharmaco-physiological interactions that occurred in the affected patient.

Answer: C

Difficulty: 79%

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Kerfoot, B.P., Conlin, P.R., Travison, T. et al. Patient Safety Knowledge and Its Determinants in Medical Trainees. J GEN INTERN MED 22, 1150–1154 (2007). https://doi.org/10.1007/s11606-007-0247-8

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