551781
research-article2014
AJMXXX10.1177/1062860614551781American Journal of Medical QualityDoering et al
Commentary
Can Medical Students Identify Problems in Patient Safety?
American Journal of Medical Quality 1–2 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614551781 ajmq.sagepub.com
Andrew Doering1, Jeremy Stueven, MD1, Summers Kalishman, PhD1, Sharon Wayne, MPH1, and David Sklar, MD1 Since the Institute of Medicine’s 1999 report, To Err Is Human, highlighted the concept of patient safety (PS) through discussion of preventable medical errors, there has been growing interest in quality improvement (QI) and PS, with added emphasis on how to involve residents and medical students.1 Since 2007, the University of New Mexico Health Science Center (UNMHSC) has surveyed residents about their perceptions of PS to drive QI. The goal of our study was to evaluate the similarities and differences between third- and fourth-year medical students and residents regarding their perceptions of PS and to evaluate the applicability and validity of student contributions to QI. We hypothesized that students would provide reliable insights into QI/PS as a result of their clinical training and knowledge, their hours of observation, and their involvement in patient care along with residents and attendings. Institutional review board approval was obtained. During the fall of 2010, third- and fourth-year medical students at UNMHSC were approached about participating in an anonymous PS survey. Survey questions were identical to those that residents completed as part of a long-term PS initiative that has been described previously.2,3 Concerns were rated using a 5-point Likert-type scale, with 1 representing not a concern and 5 representing a very significant concern. The survey also included an open-ended comments section, allowing participants to write about the most important concern they had with PS. With an α value of .05 and a power of .8, our sample size of 154 residents and 95 medical students was able to detect a difference in group responses of about 18%, which we considered significant. The survey was administered online and maintained anonymity for the participants. Out of 150 possible medical students (75 per thirdand fourth-year classes), 95 responded to the survey (63%)—51 third-year students and 44 fourth-year students. Student responses were compared with those of 154 residents; resident data are described in more detail in previous publications.2,3 A comparison of the percentage of responses reported as a significant concern or very significant concern from 2010 resident and student data can be found in online Appendix Table 1, available at http://ajmq.sagepub.com/supplemental. Both students
and residents were most concerned with emergency department crowding and boarding. Identification of this and other safety concerns listed as priorities by residents and medical students (see Appendix Table 1) led to the establishment of multidisciplinary teams and action plans designed to improve the risk to PS in these areas. Medical students differed significantly from residents in only 3 categories out of 29: fatigue caused by lack of sleep, appropriateness of discharge from the hospital, and seasonal variation in workload. Students differed most significantly in their perception of fatigue caused by lack of sleep (40.0% of students vs 22.7% of residents reported significant or very significant concern). Medical students also had greater concern than residents about appropriateness of discharge (16.8% of students vs 7.1% of residents reported significant or very significant concern). Medical students were less concerned when it came to seasonal variation in workload (5.3% of students vs 14.3% of residents reported significant or very significant concern). The results demonstrate that medical students and residents have similar views concerning PS in most areas. Although we cannot yet speak to the validity of these perceptions, the data demonstrate that medical students are interpreting PS issues in a way that is similar to residents. There were a few areas wherein medical students’ perceptions differed significantly from resident perceptions. The reason for these differences is unclear and we can only speculate. When it comes to fatigue, students may be more concerned because of the newness of clinical rotations and a heightened sense of awareness in their new environment, causing them to be more conscious of fatigue. Resident work hour restrictions are not uniformly enforced on students, and students may, in some cases, be working more than residents causing the high level of concern about fatigue demonstrated in the survey results.
1
University of New Mexico, Albuquerque, NM
Corresponding Author: Andrew Doering, 1313 21st Avenue S, 703 Oxford House, Nashville, TN 37232-4700. Email: [email protected]
Downloaded from ajm.sagepub.com at UNIV OF CONNECTICUT on May 28, 2015
2
American Journal of Medical Quality
Students also were more concerned than residents about appropriateness of discharge. One possible explanation for this discrepancy is that students have seen less disease and may not completely understand many disease processes, causing them to believe inpatient treatment is warranted when it is not the standard of care. However, students may be recognizing a real problem with inappropriate discharges. Medical students were less concerned about the safety risk associated with “seasonal variation in workload.” This may have to do with the time of year students take certain rotations and the lack of seeing the patient population on a continuous basis; for example, missing flu season while on a pediatrics rotation. Despite the differences noted, the data demonstrate little overall difference between students and residents when it comes to perceptions of PS. The areas of student concern were addressed at the UNMHSC 2010 Patient Safety Retreat alongside the concerns of the residents. Medical students were invited to attend this retreat to better understand what the survey accomplished and the issue of QI/PS. After the retreat the survey results along with a 15-minute QI tutorial were presented to the medical students. The students also participated in an open forum discussion about the results and made further suggestions about how QI/PS should be included in the undergraduate medical curriculum. Curricular changes to incorporate these suggestions are currently being developed based on student comments. We did not formally evaluate whether the QI presentation or having the results explained improved student knowledge or attitudes when it comes to QI/PS, but we feel that this would be a rich area for research in the future. The results demonstrate that student input may be valuable when it comes to QI/PS. Students’ perception of fatigue as a PS risk is intriguing. The Accreditation Council for Graduate Medical Education recognized a problem and addressed resident work hours,4 though a
similar set of national requirements is not used for medical students. We believe our data justify further research into the question of student fatigue and whether student work hour restrictions could be beneficial to PS or student education. We believe that medical students should continue to be involved in QI, and we would like to encourage including medical students in PS surveys because participating in QI/PS surveys may prepare students for future QI surveys as residents, encourage their educational development, and improve the quality of health care. Presentation of the survey results to the students also may serve as a stimulus for students to learn about QI/PS and may spark discussions that lead to new ideas in PS, such as implementing a medical student work hour restriction. Acknowledgments We would like to thank the University of New Mexico residents and students for their participation in this project.
Authors’ Note This article was presented in poster form at the AAMC Integrating Quality meeting held in Chicago, Illinois, in June 2012.
References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 2. Sklar DP, Levy B, Kalishman S, Jerabek R. Resident leadership in the patient safety initiative at the University of New Mexico Health Sciences Center. ACGME Bull. 2009;1: 10-16. 3. Stueven J, Sklar DP, Kaloostian P, et al. A resident-led institutional patient safety and quality improvement process. Am J Med Qual. 2012;27:369-376. 4. Choma NN, Vasilevskis EE, Sponsler KC, Hathaway J, Kripalani S. Effect of the ACGME 16-hour rule on efficiency and quality of care: duty hours 2.0. JAMA Intern Med. 2013;173:819-821.
Downloaded from ajm.sagepub.com at UNIV OF CONNECTICUT on May 28, 2015
research-article2014
AJMXXX10.1177/1062860614551781American Journal of Medical QualityDoering et al
Commentary
Can Medical Students Identify Problems in Patient Safety?
American Journal of Medical Quality 1–2 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614551781 ajmq.sagepub.com
Andrew Doering1, Jeremy Stueven, MD1, Summers Kalishman, PhD1, Sharon Wayne, MPH1, and David Sklar, MD1 Since the Institute of Medicine’s 1999 report, To Err Is Human, highlighted the concept of patient safety (PS) through discussion of preventable medical errors, there has been growing interest in quality improvement (QI) and PS, with added emphasis on how to involve residents and medical students.1 Since 2007, the University of New Mexico Health Science Center (UNMHSC) has surveyed residents about their perceptions of PS to drive QI. The goal of our study was to evaluate the similarities and differences between third- and fourth-year medical students and residents regarding their perceptions of PS and to evaluate the applicability and validity of student contributions to QI. We hypothesized that students would provide reliable insights into QI/PS as a result of their clinical training and knowledge, their hours of observation, and their involvement in patient care along with residents and attendings. Institutional review board approval was obtained. During the fall of 2010, third- and fourth-year medical students at UNMHSC were approached about participating in an anonymous PS survey. Survey questions were identical to those that residents completed as part of a long-term PS initiative that has been described previously.2,3 Concerns were rated using a 5-point Likert-type scale, with 1 representing not a concern and 5 representing a very significant concern. The survey also included an open-ended comments section, allowing participants to write about the most important concern they had with PS. With an α value of .05 and a power of .8, our sample size of 154 residents and 95 medical students was able to detect a difference in group responses of about 18%, which we considered significant. The survey was administered online and maintained anonymity for the participants. Out of 150 possible medical students (75 per thirdand fourth-year classes), 95 responded to the survey (63%)—51 third-year students and 44 fourth-year students. Student responses were compared with those of 154 residents; resident data are described in more detail in previous publications.2,3 A comparison of the percentage of responses reported as a significant concern or very significant concern from 2010 resident and student data can be found in online Appendix Table 1, available at http://ajmq.sagepub.com/supplemental. Both students
and residents were most concerned with emergency department crowding and boarding. Identification of this and other safety concerns listed as priorities by residents and medical students (see Appendix Table 1) led to the establishment of multidisciplinary teams and action plans designed to improve the risk to PS in these areas. Medical students differed significantly from residents in only 3 categories out of 29: fatigue caused by lack of sleep, appropriateness of discharge from the hospital, and seasonal variation in workload. Students differed most significantly in their perception of fatigue caused by lack of sleep (40.0% of students vs 22.7% of residents reported significant or very significant concern). Medical students also had greater concern than residents about appropriateness of discharge (16.8% of students vs 7.1% of residents reported significant or very significant concern). Medical students were less concerned when it came to seasonal variation in workload (5.3% of students vs 14.3% of residents reported significant or very significant concern). The results demonstrate that medical students and residents have similar views concerning PS in most areas. Although we cannot yet speak to the validity of these perceptions, the data demonstrate that medical students are interpreting PS issues in a way that is similar to residents. There were a few areas wherein medical students’ perceptions differed significantly from resident perceptions. The reason for these differences is unclear and we can only speculate. When it comes to fatigue, students may be more concerned because of the newness of clinical rotations and a heightened sense of awareness in their new environment, causing them to be more conscious of fatigue. Resident work hour restrictions are not uniformly enforced on students, and students may, in some cases, be working more than residents causing the high level of concern about fatigue demonstrated in the survey results.
1
University of New Mexico, Albuquerque, NM
Corresponding Author: Andrew Doering, 1313 21st Avenue S, 703 Oxford House, Nashville, TN 37232-4700. Email: [email protected]
Downloaded from ajm.sagepub.com at UNIV OF CONNECTICUT on May 28, 2015
2
American Journal of Medical Quality
Students also were more concerned than residents about appropriateness of discharge. One possible explanation for this discrepancy is that students have seen less disease and may not completely understand many disease processes, causing them to believe inpatient treatment is warranted when it is not the standard of care. However, students may be recognizing a real problem with inappropriate discharges. Medical students were less concerned about the safety risk associated with “seasonal variation in workload.” This may have to do with the time of year students take certain rotations and the lack of seeing the patient population on a continuous basis; for example, missing flu season while on a pediatrics rotation. Despite the differences noted, the data demonstrate little overall difference between students and residents when it comes to perceptions of PS. The areas of student concern were addressed at the UNMHSC 2010 Patient Safety Retreat alongside the concerns of the residents. Medical students were invited to attend this retreat to better understand what the survey accomplished and the issue of QI/PS. After the retreat the survey results along with a 15-minute QI tutorial were presented to the medical students. The students also participated in an open forum discussion about the results and made further suggestions about how QI/PS should be included in the undergraduate medical curriculum. Curricular changes to incorporate these suggestions are currently being developed based on student comments. We did not formally evaluate whether the QI presentation or having the results explained improved student knowledge or attitudes when it comes to QI/PS, but we feel that this would be a rich area for research in the future. The results demonstrate that student input may be valuable when it comes to QI/PS. Students’ perception of fatigue as a PS risk is intriguing. The Accreditation Council for Graduate Medical Education recognized a problem and addressed resident work hours,4 though a
similar set of national requirements is not used for medical students. We believe our data justify further research into the question of student fatigue and whether student work hour restrictions could be beneficial to PS or student education. We believe that medical students should continue to be involved in QI, and we would like to encourage including medical students in PS surveys because participating in QI/PS surveys may prepare students for future QI surveys as residents, encourage their educational development, and improve the quality of health care. Presentation of the survey results to the students also may serve as a stimulus for students to learn about QI/PS and may spark discussions that lead to new ideas in PS, such as implementing a medical student work hour restriction. Acknowledgments We would like to thank the University of New Mexico residents and students for their participation in this project.
Authors’ Note This article was presented in poster form at the AAMC Integrating Quality meeting held in Chicago, Illinois, in June 2012.
References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 2. Sklar DP, Levy B, Kalishman S, Jerabek R. Resident leadership in the patient safety initiative at the University of New Mexico Health Sciences Center. ACGME Bull. 2009;1: 10-16. 3. Stueven J, Sklar DP, Kaloostian P, et al. A resident-led institutional patient safety and quality improvement process. Am J Med Qual. 2012;27:369-376. 4. Choma NN, Vasilevskis EE, Sponsler KC, Hathaway J, Kripalani S. Effect of the ACGME 16-hour rule on efficiency and quality of care: duty hours 2.0. JAMA Intern Med. 2013;173:819-821.
Downloaded from ajm.sagepub.com at UNIV OF CONNECTICUT on May 28, 2015
