Patient safety curricular inclusion
Ninety percent of respondents reported that their nursing school has incorporated some form of patient safety education into the curricula. Still, 10% of respondents reported having no patient safety education. This is unacceptably high. Given the tendency of selection bias of survey research and the good subject effect, it is likely that we have selected for schools that have already incorporated topics on patient safety into their curricula; if so, the true rate of nursing schools incorporating patient safety is probably even lower.
Total hours (Figure 1)
Most schools devoted more than 5 hours to patient safety and some schools more than 20. Private schools reported devoting more time to patient safety education than public schools. However, the overall participation rate was lower for private schools, and this difference in time devoted may be overestimated. In any case, if acquisition of knowledge and skills to maximize patient safety requires adequate exposure, and acquisition of such skills leads to increased patient safety, it is paramount that nursing students receive adequate exposure to this topic. While it would be impractical to definitively prove that safety education increases patient safety, it makes sense that such education would improve patient safety . Schools should devote more time to the topic.
With regards to how much time needs to be devoted, it is first necessary to establish what topics need to be covered. In 2009, the WHO published the "Patient Safety Curriculum Guide for Medical Schools" . In Japan, The Japanese Ministry of Education also has published a guideline for medical education called the Model Core Curriculum (MCC) that was revised in 2008 to include patient safety as part of the core medical curriculum . This medical school core curriculum focuses on the prevention of error. However, because errors will happen , an important part of patient safety is responding to adverse events [24, 29], for example, the concepts of apology, management of medical personnel following an adverse event, and autopsy (Additional file 1). We think that it is important to incorporate these topics into any future curricular guidelines. The WHO is updating their guideline to include input from the areas of dentistry, midwifery, nursing, pharmacy and related health-care professions with the aim of developing a multi-professional edition to inform, support and assist the inclusion of patient safety in the curricula of all health professionals . The Japanese government is planning to develop guidelines for nursing schools in Japan, too . As these guidelines are created, the number of topics that need to be covered is expanding. The subjects we included in our survey would be a reasonable array of topics to cover in a basic patient safety curriculum. We believe that at least one educational unit, defined in Japan as 15 periods of 90 minutes, or 22.5 hours of education time, would be required to minimally cover these topics.
Teaching methods (Table 2)
Traditional lecture-based education has been heavily employed in many educational settings because of the efficiency in mass information transmission while using few resources in terms of educators, preparation time, and classroom space. All schools that teach patient safety use lecture-based methods. Yet, other teaching methods such as role-playing are probably more effective in training students to apply the theoretical and practical skills in real life settings [10, 12]. About 50% of nursing schools use group discussions as a means of enhancing the "skills" part of education. We suggest nursing schools explore other teaching methods to increase the quality of education on safety.
Patient safety topics (Additional file 1)
Topics covered by more than three quarters of schools
Topics covered by more than three quarters of schools are theories and models of error, human factors, verifying patient identity, double-checking, communication with senior stuffs and criminal liability.
In Japan, two serious medical accidents occurred in 1999: the Yokohama City University Hospital case (Jan. 1999) and the Hiroo General Hospital case (Feb. 1999). These cases became national impetus for patient safety improvement and nursing errors were major contributors to patient harm in both cases. In the Hiroo case, for example, a nurse administered an antiseptic (chlorhexidine) intravenously. The nurse mistook it for heparin sodium after another nurse had left it on the cart. The patient died immediately. The case received national media attention, prompting police involvement. In the wake of these cases, investigators emphasized the need for education on theories and models of error, human factors contributing to error, and practical error prevention strategies like verifying patient identity and double checking. Consequently, these topics have been incorporated into the curricula of more than three quarters of schools. The Hiroo case was a sentinel case handled through the Japanese criminal legal system, and subsequent cases of medical error have been handled likewise; prior research has shown the total number of healthcare provider criminal prosecutions for medical error leading to patient death has been on the rise for over 10 years . This may be why so many nursing schools cover the topics of criminal liability.
Topics covered by less than one quarter of schools
Less than one quarter of schools covered reporting unnatural patient deaths to the police, autopsy, cross-institutional data sharing for error prevention, or failure mode and effects analysis.
In Japan, physicians are currently required to report healthcare-associated patient deaths to the police under the Japanese Medical Practitioner's Law. Article 21 of the law states, "In the course of pronouncing death of any person or fetus over the age of 4 months should the physician find anything unnatural, he or she must report that death to the police within 24 hours." Therefore, Japanese physicians grapple much with how to handle patient death in the setting of possible medical error. When patients die unexpectedly during the course of medical care, such deaths can be classified based on the presence or absence of medical error. When it is unclear if medical error is present or how medical care rendered and unexpected patient death are related, autopsy becomes an important tool for detailing the cause and manner of death. Nurses, as mentioned, are often central to cases of medical error leading to patient death. When a patient dies unexpectedly, they are often the provider who spends the most time talking with the patient's family and potentially play a roll in helping families decide about autopsy. However, autopsy and error reporting to the police are responsibilities charged directly to physicians, not to nurses. This is likely the reason many nursing schools don't cover the topics of autopsy or reporting patient deaths to the police.
Likewise, sharing information regarding adverse events with other institutions for the purpose of learning and error prevention is considered the responsibility of risk managers, not to nurses, and thus many nursing schools do not cover this topic.
Failure mode and effects analysis is an advanced and somewhat in-depth topic that requires expertise and experience to teach effectively. Lack of nursing educators trained in this area may be the reason many nursing schools do not cover this topic.
When compared to public schools, statistically greater private schools covered the topic of root cause analysis while other topics were covered equally. While the reason for this is unclear, perhaps the educational goals of private and public schools differ; we do not know of any differences in incentives (e.g. compensation payout) that differ between private and public schools; exploring these reasons could be a topic of future research.
For the future
This survey research suggests which topics are covered and which are not in regards to patient safety education. We are providing the results of this study to all Japanese nursing schools, the MEXT, and the MHLW. The topics that are not covered will be of particular relevance in creating curricular guidelines. Once a guideline is created, further research should be conducted to monitor for change in the medical safety curricula.
Our study has several limitations. First, the results are derived from a cross-sectional survey that is subject to bias and the good-subject effect. Second, our participation rates were modest and it is possible that non-responders differ significantly from responders, namely non-responders may be more likely to lack a medical safety program. However, it should be noted that our response rates are not atypical for postal survey research of healthcare professionals and nurses [32–34]. If we assume that all non-responders do not cover patient safety education, we could estimate that only 39% of nursing schools cover the topic. On the other hand, it may be possible that non-responders did not have any one person leading patient safety but do include patient safety education within the curricula. Finally, the validity of our assessment has not been verified. As respondents are simply giving their perceptions of the nursing school's curriculum, this may or may not truly reflect the curricula absolutely.