A study to determine patient safety awareness and attitudes among medical students in a Malaysian University

INTRODUCTION

Patient safety is defined as the “prevention of errors and adverse effects on patients associated with health care” World Health Organization (WHO). Medical errors and the consequences of medical errors in health care are becoming frequent and are now well known both within the medical profession and to the general public. More importantly, medical errors are reported routinely in the media, including social media, and directly impacting doctor-patient relationships and trust.^[1]

Lately, various methods have been implemented to reduce errors by health-care personnel and to improve patient safety in practice. “To Err is Human,” was an influential report produced by the Institute of Medicine USA, in 1999. Over the past 2–3 decades, patient safety awareness has become an important part of health-care practices and commitment to patient safety methods has become imperative. However, a major hurdle to preventing errors has been the ingrained culture of refusal to accept responsibility among health-care practitioners.^[2]

Errors can occur when healthcare workers care for patients. Missed follow-up on investigation reports or poor medical records is common errors seen in health care. The occurrence of medical errors is around 10% of all hospital admissions. Such errors, when they do occur, can cause harm or even death.^[3]

All doctors and health-care professionals must be educated and trained in patient safety measures, and this still remains the basis for best practices in health care to prevent health care-related errors. However, education on patient safety is still a neglected field, as most educators feel that safety methods should be taught to practicing doctors and nurses only and students need not be involved in implementing or achieving patient safety. In today’s climate of responsible health care, it is now increasingly important to ensure that students learn about errors in health care and the methods to improve the delivery of safe health care by incorporating safety measures for patients.^[4]

At present, there are no published reports of other universities or medical schools in Malaysia having implemented patient safety into their undergraduate curriculum. International Medical University (IMU) is in the process of developing an online training module using content from MOH Malaysia’s patient safety awareness course for junior health care professionals (as reported in “IMU News” dated February 28, 2019).

We felt that after a series of lectures, practical teaching at the bedside and a patient safety project report of safety measures practiced by healthcare workers (literature review or observational report), the student’s knowledge and awareness of safety protocols in practice should be greatly enhanced, and their attitudes to patient safety measures should be positive. Our goal was to gather opinions through an established questionnaire, from medical students of year 4 about their ability to identify and practice patient safety issues, their confidence in meeting the relevant competencies and personal attitudes toward patient safety in healthcare.

RESEARCH METHODOLOGY

RESULTS

These results represent the data from 134 undergraduate medical students of year 4 at MAHSA University, Faculty of Medicine. All 134 responses were analyzed in the study.

In our study, the majority of study participants were females (65.4%) and 34.6% were males. The median age of study participants was 24 years (IQR = 1), the minimum age was 21 years, and the maximum was 30 years.

According to the WHO questionnaire, structured into five sections, error and patient safety and safety of the health-care system are to do with knowledge and awareness: Sections 3–5, personal influence over safety; personal attitudes to patient safety; and safety at the workplace address personal attitudes toward patient safety.

Table 1 shows that the majority of study participants had a medium level of knowledge on an error and patient safety. Of all the different aspects of errors in health care, most students knew about factors contributing to health-care errors and factors responsible for the safety of patients. However, the level of agreement of the occurrence of errors in health care was medium to high. About 48.5% of the respondents agreed that healthcare workers make errors. About 47% felt that health care was practiced safely. The agreement on medication errors occurring rarely was 48.5%. However, 50% of respondents agreed that one in ten hospital patients will experience errors [Table 2].

Table 3 shows that 47% of respondents felt they could easily tell others about an error they made, but on average, student opinion on blaming others rather than focusing on the cause of error was evenly balanced between very low, low, medium, and high. About 77% were confident (medium and high) that they could easily speak to someone showing little regard for a patient’s safety. A majority of the students (83.6%) also felt that they are able to make sure that patient safety is not put in jeopardy. Moreover, a majority (53%) felt written reports will help in patient safety and talking about errors is easy.

Table 4 shows that most students felt they will learn from their mistakes and deal with their errors well (84.3%). Here, their agreement on focusing on the cause of the error and remedying that was high (57.5%).

Furthermore, the expectation on safety at the workplace was medium to high among all our study participants [Table 5].

Median score of level of knowledge was 21 (IQR = 4, min. 7 max. 30), while the median score of level of agreement on safety of the health-care system was also 21 (SD = 3, min. 6 max. 35); median score of personal influence over safety was 23 (IQR = 4, min. 7, max. 30); and the median score of attitudes to patient safety and the expectation on safety at the workplace were 16 (IQR = 3, min. 6, max. 20) and 28 (IQR = 5, min. 17, max. 47), respectively.

Mann–Whitney U-tests showed no significant differences in the score of five domains between males and females (P > 0.05) [Table 6].

There was a definite positive correlation between the awareness of the safety of the health-care system and personal influence over safety and attitudes to patient safety (P < 0.05). In addition, there was a positive correlation between attitudes to patient safety and safety at the workplace (P < 0.05). There was no significant correlation between the level of knowledge and the other three domains [Table 7].

DISCUSSION

The cornerstone of improved patient care in practice is to educate medical students about patient safety. An investigational study was performed in the USA to ascertain the present status of patient safety in medical education curricula and also identify areas for improvement. The results of this study found that <50% of all medical schools in North America offer formal teaching on medical safety. This remains a major gap in medical education.^[6]

In a systematic review performed by Nie et al. from Medline and Chinese databases, they found that there was appreciable variation in content, methods of teaching as well as teaching staff knowledge on patient safety. They concluded that the existing curriculum in medical schools all over the world still has sizeable challenges.^[7] Madigosky et al. studied the knowledge, attitudes, and skills of the effects of medical errors on year 2 medical students at the School of Medicine, the University of Missouri, Columbia in 2003–2004. The study found that of the students who undertook patient safety teaching as part of their medical curriculum, attitudes improved after instruction, but those improvements had declined after a year. They concluded that the methodology of instruction needed to be reassessed to see sustainable results.^[8]

In a study performed in South Korea, the researchers found that many students had difficulty opening up about medical errors. They concluded that error reporting guidelines and educational methods aiming to develop better communication skills need to be taught at the undergraduate level to improve patient safety.^[9] Awareness of the protocols of safety being used in a health-care organization is the first step to identifying any areas for improvement, since the knowledge, attitudes, and behaviors of health-care staff are critical in the culture of safety, as seen in an Italian study.^[10]

In a study published in the Journal of Surgical Education, the authors delivered a patient safety course for 1 week–2^nd-year medical students. Students completed a questionnaire on their awareness of patient safety before and after the delivery of the module. They found that the course on patient safety increased the medical students’ awareness of safety in patient care and the occurrence of medical errors. The authors concluded that the application of a patient safety curriculum will make medical students better prepared for correct practices and safer health-care services.^[11]

Patient safety is essentially detection, prevention, and restoration of adverse outcomes or injuries occurring during health care. It also refers to medical interventions to deal with any medical error that has occurred. There is the added need to care for and support the unfortunate staff involved (called the “second victim of medical errors”).^[12] This can only occur when the young doctor is aware of their approach to errors committed. Therefore, the best time to teach doctors about patient safety is when they are still undergraduate students. Then, once they graduate, their knowledge, awareness, and attitudes toward observing patient safety measures to prevent errors will be positive, right from the beginning of their medical careers.

To ensure some uniformity into the methods and content of teaching patient safety in medical education, the WHO has developed a comprehensive patient safety curriculum. The WHO curriculum guide topics include: What is patient safety; why applying human factors is important for patient safety; understanding systems and the effect of complexity on patient care; being an effective team player; learning from errors to prevent harm; understanding and managing clinical risk; using quality-improvement methods to improve care; engaging with patients and carers; infection prevention and control; patient safety and invasive procedures; and improving medication safety.^[4]

The Declaration of Helsinki on patient rights has now recommended education in patient safety: “Education plays an important role in improving the safety of patients and we entirely support patient safety teaching.”^[13]

To assess the effectiveness of the WHO curriculum, the WHO data collected and analyzed from ten schools in the six WHO regions that have implemented the WHO patient safety curriculum. The ten schools came from nine different countries. On analysis, this data showed that even though these students came from many different backgrounds, their knowledge, and perception about patient safety issues (WHO questionnaire section 1) had increased tremendously after the implementation of the WHO curriculum into the students’ existing MBBS curriculum.^[14]

Therefore, medical students can be taught about how different health-care systems affect the safety of patients, how adverse events can be caused by poor communication, and how errors can be made inadvertently. Students can learn to manage these challenges at an early stage of their education so that their awareness level is high in mitigating medical errors. A healthy educational environment and opportune training on patient safety matters are necessary to improve health care and respond to present public expectations.^[15]

In Malaysia, the Ministry of Health has a “Vision for Health” which mandates the development of a safe health- care system implemented through the coordinated efforts of all the major health-care stakeholders. In recognition of errors by health-care staff, the Patient Safety Council was set up in 2003 by the Malaysian Cabinet. This council has been entrusted with the responsibility of looking into and encouraging all hospitals, clinics and health-care institutions in ensuring a safe Malaysian health-care system. In Malaysia, the first national patient safety campaign was started on June 24, 2013. “Malaysian Patient Safety Goals: Guidelines on Implementation and Surveillance” lists in detail the national patient safety goals as well as the methods of implementation and related surveillance for each of their key performance indicators. At present, the Patient Safety Council of Malaysia explains 13 patient safety goals. A safe culture can only be incorporated when health-care staff accept a fair and non- blame culture. It is more important to look into the causes and preventive methods of the error rather than stand judgment on the person who committed it. One of the important points in a non-blaming culture is an “Incident Reporting and Learning System” where a “Root Cause Analysis” is investigated into the incidents to ascertain all the contributory factors causing the incident. The Malaysian Ministry of Health believes that “A wise person learns from the mistakes of others while a clever person learns from only his or her own mistake.”^[16]

Willingness to take responsibility for any error committed depends on the knowledge that the focus will be on prevention rather than blame, and this can be improved by improving education in medical schools.^[17] Medical students should not be overlooked as participants in the implementation of patient safety. Unfortunately, their inexperience, limited clinical knowledge, and fear (of negative evaluation in exams or of being scolded by their teachers) can lead to hesitation to speak up. Education is the best strategy to improve student knowledge and attitudes toward patient safety at an early stage before any ingrained biases can occur. Faculty and nursing staff who are involved in teaching students should encourage students to observe and actively convey to responsible staff when they see any errors or near misses. This will help all healthcare workers to work toward eliminating errors in patient care and allow and empower students to become advocates of patient safety.^[18]

MAHSA University, Faculty of Medicine, has introduced a module called “patient safety” into the MBBS curriculum. This module’s learning objectives focus on developing students’ knowledge, and attitudes relevant to patient safety. The module has been developed in a spiral learning platform where incremental knowledge is inculcated into the existing curriculum to gradually increase student awareness of patient safety methods. During Phase 1 (years 1 and 2 – preclinical phase), students are taught basic safety measures such as the importance of correct patient identification, consent taking, communicating risk, truth-telling, the importance and techniques of hand-washing, and adhering to safety in positioning a patient during examination procedures during their early clinical exposure module. These issues are also assessed at objective structured clinical examination sessions.

In year 3, students attend lectures or are shown videos followed by discussion on: Health and safety in health care; medical records and record keeping; patient safety in invasive procedures; errors in health care (WHO video); and medication safety, rational prescribing; and prescription writing. (Appendix 2a, Personal and Professional Development [PPD] study guide year 3, patient safety topics). In year 4, keeping the WHO and Malaysian society for quality in health goals in mind, the students have to study a topic of their choice, highlighting any ONE aspect of patient safety. (Appendix 2b, PPD study guide patient safety project lists the areas that are given to the students for their study). This module is compulsory for all medical students and they need to complete the project and present their report by the end of year 4 of their study.

Our analysis shows that with respect to the generation of medical errors, most of our respondents students felt that medical errors are common and inescapable, and as students, they were confident in their ability to influence those who are committing errors.

CONCLUSIONS AND RECOMMENDATIONS

A majority of students in this survey had developed a good level of knowledge, awareness, and a positive attitude toward safety measures observed in the health-care system at the hospital they were attached to for their studies. They also had a high expectation of fair play in workplace safety.

Our study therefore indicates that our teaching-learning methods are on average, helping to create awareness and knowledge of patient safety protocols in practice and the students’ attitudes to patient safety measures are positive.

We recommend that a further follow on the study should be performed on these same students once they start their clinical practice as housemen to know whether their attitudes change during practice.