Pharmacy Education Article

Perceived Benefit of Teaching Patient Safety to Pharmacy Students by Integrating Classroom Teaching With Introductory (IPPE) Visits

Journal of Pharmacy Practice 2017, Vol. 30(1) 115-120 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190015614478 journals.sagepub.com/home/jpp

Katy E. Trinkley, PharmD1,2, Edward T. Van Matre, PharmD1, Scott W. Mueller, PharmD1,2, Robert L. Page II, PharmD, MSPH1,2, and Kavita Nair, PhD1

Abstract Introduction: Ensuring a culture that prioritizes and implements patient safety requires educating all future health care professionals to prepare them for their active role in reducing medical errors. There is limited literature describing integration of patient safety education into the curriculum of health care professionals, including pharmacists. The purpose of this study was to evaluate the perceived benefit of integrating patient safety education into a pharmacy curriculum. Methods: Second-year pharmacy students (P2s) completed a patient safety self-study, followed by in-class and experiential application of a root cause analysis (RCA). An electronic, anonymous postsurvey was administered to P2s and third-year pharmacy students (P3s) who had not had formal patient safety education. Results: Of the 310 students, 53% responded to the survey. Significantly more P2s reported more confidence to describe patient safety and its purpose (P ¼ .0092), describe factors that influence patient safety (P ¼ .0055), and conduct an RCA (P < .001). P2s also reported significantly better ability to conduct a RCA compared to P3s (88.9% positive vs 58.7%, respectively; P  .001). Conclusions: Both classes perceived patient safety education to be valuable; however, formal education resulted in some significant improvements in perceived confidence and understanding, including ability to conduct an RCA. Keywords patient safety, pharmacy education, medication safety

Introduction Patient safety has always been at the forefront of the pharmacy profession and is an integral component of the pharmaceutical care process in all settings. Patient safety is defined as ‘‘the reduction in risk of unnecessary harm associated with healthcare to an acceptable minimum’’1 and is inclusive of medication safety. As the health care system advances, it becomes more complex, and therefore patient safety becomes increasingly important to prevent and mitigate patient harm. Practicing patient safety principles is pivotal to decreasing the alarming and increasing numbers of patients who are harmed from medical errors. When considering adverse events involving medications alone, 6.5 of 100 persons admitted to US hospitals2 and 25% of outpatients prescribed a medication3 experience an adverse drug event, many of which are preventable or ameliorable. It is estimated that 28% of adverse drug events are preventable3 and that medical errors cost the US 30 billion dollars annually.4 To ensure a workforce capable of practicing patient safety principles, it is imperative to teach healthcare professional trainees about patient safety. This is supported by the Institute for Medicine,4 the World Health Organization (WHO),1

and multiple health care professional accrediting bodies, including the Association of American Medical Colleges5 and the Accreditation Council for Pharmacy Education (ACPE).6 ACPE defines patient safety as ‘‘analysis of the systems- and human-associated causes of medication errors, and exploration of strategies designed to reduce/eliminate them’’ and explicitly states patient safety is a required element of the didactic doctor of pharmacy curriculum.6 An assessment of doctor of pharmacy curricula outcomes identified new pharmacy graduates should possess, at a minimum, the ability to identify errors and their causes and implement system changes to prevent or mitigate future errors.7

1 Department of Clinical Pharmacy, University of Colorado’s Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA 2 University of Colorado School of Medicine, Aurora, CO, USA

Corresponding Author: Katy E. Trinkley, University of Colorado’s Skaggs School of Pharmacy and Pharmaceutical Sciences and School of Medicine, 12850 E montview Blvd C238, Aurora, CO 80045, USA. Email: [email protected]

116 Other key aspects of patient safety in pharmacy curricula identified include communicating with patients when an error occurs and the impact of health information technology.8 In an effort to assist in integrating patient safety education into health care professionals’ training, WHO has developed a curriculum to be adapted and used across health care professional training programs.1 The curriculum was the product of contributions from multiple international health care professional organizations, including the International Pharmaceutical Federation. Despite the need for educating health care professionals on patient safety, there is limited literature describing integration of patient safety education into curriculum of health care professionals, including pharmacy. Methods described to teach pharmacy students patient safety are varied and range from didactic, simulation activities and experiential learning.9-13 However, there is no literature describing a method of teaching pharmacy students patient safety that integrates classroom learning with Introductory Pharmacy Practice Experiential (IPPE) learning. Incorporating such methods of interactive learning has been identified as an important component of teaching patient safety in pharmacy curricula. Integrating IPPE and classroom education would allow students the opportunity to apply what they learned in the classroom to their IPPE visits, reinforcing the concepts. Therefore, the proposed study evaluated the perceived benefit of teaching patient safety to pharmacy students by integrating classroom learning with IPPE visits.

Methods Patient safety education was integrated into a 3-credit hour Public Health and Health Outcomes course. A total of 151 second-year pharmacy students (P2s) were enrolled in this required course. This was the first offering of the course and formal patient safety education in the 4-year professional curriculum. Prior graduating classes had no formal patient safety education. The objectives for the patient safety education are listed in Table 1. The patient safety educational methods implemented included a self-study and active application of root cause analysis (RCA) skills. The RCA activities were 2-fold and included in-class activities followed by an experiential activity conducted during their IPPEs. Student performance was evaluated with 5 multiple-choice examination questions and the IPPE RCA assignment. The IPPE RCA assignment was worth 20% of their course grade.

Educational Intervention 1: Self-Study The self-study was an 18-page document based on the publicly available WHO patient safety curriculum. The self-study addressed each of the educational objectives and included 2 examples of the RCAs. The self-study was available to the students 2 weeks prior to the in-class activity session. In addition, prior to the in class RCA activities, the students were instructed to watch a 20-minute video from WHO depicting a medication error event.

Journal of Pharmacy Practice 30(1) Table 1. Patient Safety Educational Objectives. 1. Describe the practice of patient safety and its role in minimizing the incidence and impact of adverse events in health care 2. Understand and describe how various factors influence patient safety, including human factors, systems and complexity of patient care, effective team work, learning from errors to prevent harm, understanding and managing clinical risk, quality improvement methods, and engaging patients 3. Evaluate the role of the pharmacist and other health care professionals in the practice of patient safety and in specific medication safety issue case scenarios 4. Identify and describe factors that can contribute to medication safety issues and methods all health care professionals should implement to make medication use safer 5. Conduct a root cause analysis, including a fish bone diagram and formulate solutions to prevent similar medication safety issues

Educational Intervention 2: In-Class RCA Activities In the 2-hour class session, the students worked in groups of 5 to 6 to complete 2 RCAs. The first in-class RCA activity required the students to complete an RCA for a less complex, paper case-based patient safety situation and then compare their answers to an answer key for formative feedback. Once the first RCA was completed and the answer key reviewed, students were instructed to move onto the second RCA activity. The second activity required the students to complete an RCA for a more complicated patient safety situation, which was based on the 20-minute video they watched prior to class. The students were provided with detailed instructions to complete this second RCA, which were almost identical to the instructions they would receive for the IPPE activity. Figure 1 describes the structured instructions the students were given to complete the RCA. In class, students were provided a brief paper-based description summarizing the video, and no measures were taken to prevent them from reviewing the video in class again. After the students had completed both RCAs, the instructors debriefed with the class as a whole. During the debrief, the instructors facilitated conversation regarding the students’ answers to the activities.

Educational Intervention 3: IPPE RCA Activity At the end of the debrief, the instructors presented the IPPE RCA activity to the students (Figure 1). The students were given the instructions and expectations for the RCA, which were closely aligned with the second, in-class RCA and were given an opportunity to ask any questions. The IPPE RCA was to be completed independently and based on a potential or actual patient safety issue that was identified while on one of their IPPE visits. The students had 3 months from the in-class activity to submission of the IPPE RCA activity. The students were instructed to work with their IPPE preceptors to discuss the situation and conduct an RCA. The IPPE preceptors did not grade the activity but were required to confirm completion of the activity. Prior to submitting the final assignment, students were required to submit a brief, 1-paragraph description of the situation to the faculty for

Trinkley et al



117

Conduct a RCA, including a fish bone diagram to describe factors that contributed to the safety issue.  The RCA should answer the following questions: What happened? Identify and describe the medication safety issue thoroughly. Who was involved? Describe the role of the pharmacist and other health care professionals that led to this medication safety issue. When did it happen? Where did it happen? How severe was the actual or potential harm? Severity of the actual and/or potential harm should be characterized as:  Fatal or life-threatening  Serious  Significant What was the likelihood of recurrence? What were the consequences? The fish bone diagram should be completed using  this general template: Individual Factors: Patient Factors: Task Factors: Education and Training: Team and Social Factors: Equipment and Resources: Communication: Organizational and Strategic Factors: Characterize the medication safety issue according to preventability, and type.  Preventability should be characterized as: Preventable (drug events that produced injury and were the result of a medication error and could have been entirely avoided) Ameliorable (those whose severity or duration could have been substantially reduced had different actions been taken) Not preventable and not ameliorable  Medication safety issue type should be characterized as: Human error At-risk behavior Reckless behavior Describe what could have been done to prevent the error including the role of the pharmacist and other health care professionals. Describe what can be done to prevent future medication safety issues of this nature. Discuss your findings and performance with your preceptor. &

&

Table 2. Medication Safety IPPE Activity Grading Rubric. Deadlines Submitted medication safety issue description by deadline for faculty review of appropriateness of issue (max. 1 paragraph) Granted IPPE preceptor access to sign off on IPPE activity completion by deadline Submitted final written assignment by deadline

/5 /5 /5

Formatting (Must adhere to all of the following criteria to receive full points)

& & &

 Max. 2 pages, double-spaced, 1 inch margins, Arial 11-point font  Typed fishbone and used template provided (may be in addition to 2 page limit)  Name and ID number in upper left

/5

Written assignment (Grading based on appropriateness, accuracy and thoroughness of following criteria.)

& &

& & & & & & & &



&

&

&

& & &



 

Figure 1. Root cause analysis (RCA) activity instructions.

Completed RCA Described the medication safety issue and what happened Described who was involved and their roles Described when and where it happened Described severity of actual and/or potential harm Described likelihood of recurrence Described consequences Completed fishbone diagram Characterized preventability Characterized type of medication safety issue Described what could have been done to prevent the error or mitigate the harm of the medication safety issue, including the role of the pharmacist and other health care professionals in preventing the medication safety issue Described what can be done to prevent future errors of this nature or mitigate the harm

/10 /5 /2.5 /10 /2.5 /5 /16 /5 /5 /14

/5

Abbreviations: IPPE, Introductory Pharmacy Practice Experiential; RCA, root cause analysis.  Not completing the IPPE activity at your experiential site will result in a full letter grade reduction of your final course grade.  Not submitting the written assignment will result in a full letter grade reduction of your final course grade.  Not completing the IPPE activity at your experiential site and not submitting the written assignment will result in a zero.

review to ensure appropriateness. The final product of the IPPE RCA activity was submission of the assignment, which included a summary of the patient situation, a completed RCA and fish bone diagram, and characterization of the safety issue according to preventability and type. The instructors graded the assignments based on a standardized rubric, which was available to the students at the same time as the assignment instructions and included in Table 2. The students were given over 3 months to complete the IPPE assignment. The mean percentage grade for the assignment was 98% (range 69%-100%).

Outcome Measures To determine the perceived benefit of the formal patient safety education, an electronic, anonymous, voluntary postsurvey was

118

Journal of Pharmacy Practice 30(1)

Table 3. Demographics of Students Who Responded.

n (%)

P3 students, 2015 P2 Students, anticipated 2016 anticipated graduation graduation (n ¼ 75) (n ¼ 90)

compared to P3s (88.9% positive vs 58.7%, respectively; P  .001). Although positive, there were no differences in perceived benefit of the education on their future careers or desire for such additional education when considering either ordinal or binary responses.

Race Caucasian Black Asian/Pacific Islander American Indian/Alaska native Other/unknown Ethnicity (Hispanic) Female Year admitted into program 2010 2011 2012 Other Went straight from high school to complete your pharmacy prerequisites and then go straight into pharmacy school

63 (70) 2 (2.2) 18 (20) 2 (2.2) 5 (5.6) 8 (8.9) 50 (56)

47 (62.7) 4 (5.3) 16 (21) 0 (0) 8 (11) 9 (12) 49 (65.3)

0 (0) 8 (9) 82 (91) 0 (0) 35 (61)

12 (16) 62 (82.7) 0 (0) 1 (1.3) 24 (32)

administered to all 151 P2s and 159 third-year pharmacy students (P3s) in parallel using Qualtrics (2015 Qualtrics, LLC, USA). The P3s served as a control group, given they had no formal patient safety education in the curriculum. The survey consisted of 5 demographic and seven, 4-point Likert-type scale questions to assess perceived benefit and abilities (1 ¼ very unconfident or not strong at all; 4 ¼ very confident or very strong). Likert-type scale questions were also grouped into positive (3 and 4) and negative (1 and 2) binary responses. Five of the Likert-type scale questions directly addressed the educational objectives. The instrument was reviewed for content validity by 4 content experts, however no psychometric testing was performed. The survey instrument forced responses to all questions before submission to avoid missing variables. Postcard consent was completed upon survey submission. Ordinal data were compared using Wilcoxon rank-sum test and binary data using the 2-tailed Fisher’s exact test. This study was deemed exempt from the Institutional Review Board.

Results The survey response rate was 53%, with 90 of 151 P2s and 75 of 159 P3s completing the survey. Of the responders, 56% were female, 70% caucasian, 20% Asian, and 91% non-Hispanic. Table 3 describes the demographics by graduating class. There were no differences in demographics between the 2 classes, with the exception of admission year into the program. Considering ordinal responses, significantly more P2s reported better ability to describe patient safety and its purpose (P ¼ .0092), describe factors that influence patient safety (P ¼ .0055), and conduct an RCA (P < .001). Table 4 describes the students overall responses to the survey questions, and Table 5 describes the binary responses. Considering binary responses, P2s also reported significantly better ability to conduct an RCA

Discussion In comparison to other published educational interventions incorporating patient safety into the curriculum of pharmacy students, this method is unique in that it integrates classroom learning with IPPE learning. This educational method was overall perceived to be beneficial by the students, which are similar findings to prior literature describing patient safety educational methods. Although not significantly different, it is encouraging to see that students who did not receive formal patient education more strongly desired additional patient safety education compared to those who did have formal training. It is also affirming to see that students who received formal training felt more confident in their abilities to conduct an RCA, a more formalized process for evaluating areas for improvement in patient safety. While students did not perceive higher confidence in all abilities surveyed, they did perceive greater confidence in conducting an RCA, which may be the result of the amount of time dedicated to it and the active learning methods implemented. However, confidence in some abilities were not significantly different between the classes, such as evaluating the role of the pharmacist and identifying and describing factors that can contribute to medication safety issues, which were incorporated into the RCA active learning. Therefore, it is possible students who did not receive formal training reported less confidence with conducting an RCA because the term was not intuitive compared to the other survey questions. The results of the survey are limited in that prior experiences and exposures to patient safety were not controlled for or assessed. Whether students had prior experiences or learning opportunities in patient safety is unknown, but it is likely some of the students have had prior exposures. It is also possible the impact of the patient safety education was underestimated by the survey, given the more advanced education of the P3 s may have contributed to more confidence or perceived knowledge of the topic even though it was not specifically taught. Further limiting generalizability of the results is those who responded to the survey likely feel stronger about the subject than those who did not. However, given this survey was voluntary, the response rate was high overall and similar between each graduating class. Although the average grade on the IPPE RCA activity was high at 98%, the range was as low as 69%. This activity was designed to provide a structured experience in patient safety and as long as the students followed instructions and put forth effort, they performed very well, thus the grades were high. The grading rubric afforded 20 of 100 total possible points to following the instructions, which may be a limitation of the grading, but it facilitated consistency in the final written assignment across students.

Trinkley et al

119

Table 4. Survey Responses of Student Perceived Ability and Benefit. P2 responses, n ¼ 90

Likert-type scale score (1 ¼ very unconfident or not strong at all; 4 ¼ very confident or very strong) Question 1 responses (Describe the practice of patient safety and its role in minimizing the incidence and impact of adverse events in healthcare) Question 2 responses (Describe how various factors influence patient safety, including human factors, systems and complexity of patient care, effective team work, learning from errors to prevent harm, understanding and managing clinical risk, quality-improvement methods, and engaging patients) Question 3 responses (Evaluate the role of the pharmacist and other healthcare professionals in the practice of patient safety, and in specific medication safety issue case scenarios) Question 4 responses (Identify and describe factors that can contribute to medication safety issues and methods all healthcare professionals should implement to make medication use safer) Question 5 responses (Conduct a root cause analysis, including a fish bone diagram and formulate solutions to prevent similar medication safety issues) Question 6 responses (The patient safety education you received will be beneficial in your future pharmacy career) Question 7 responses (I would like to have more patient safety education during my doctor of pharmacy curriculum)

1

2

3

4

Median

1

2

3

4

Median

P value

1

3

50

36

3

3

5

50

17

3

.0092

1

4

54

31

3

2

8

52

13

3

.0055

1

6

51

21

3

3

4

40

28

3

.96

1

5

53

31

3

3

5

48

19

3

.15

1

9

53

27

3

12

19

33

11

3

.0001

5

3

44

38

3

3

6

37

29

3

.56

8

17

44

21

3

3

16

34

22

3

.38

Table 5. Binary Survey Responses of Student Perceived Ability and Value. Likert scale Question

Positive or negative binary response

P2 responses, n (%)

P3 responses, n (%)

Positive Positive Positive Positive Positive Positive Positive

86 (95.6) 85 (94.4) 83 (92.2) 84 (93.3) 80 (88.9)a 82 (91.1) 65 (72.2)

67 (89.3) 65 (86.7) 68 (90.7) 67 (89.3) 44 (58.7)a 66 (88.0) 56 (74.7)

1 2 3 4 5 6 7

P3 responses, n ¼ 75

a

P ¼ .001 for comparison of P2 to P3 responses.

While no differences were perceived in benefit or ability to evaluate the role of a pharmacist in the practice of patient safety, identifying factors contributing to medication safety, or benefit of patient safety education on future careers, these perceptions may change as pharmacy trainees gain further clinical experience. As students gain more pharmacy practice experiences and have a better context for the practice of pharmacy, it is hoped that they will perceive the formal patient safety education to be of greater benefit on their future careers.

Conclusion Both classes perceived patient safety education to be beneficial; however, formal patient safety education specifically

resulted in greater perceived confidence in ability to describe patient safety and its purpose, describe factors that influence patient safety, and conduct an RCA. Integration of IPPE and classroom learning to teach patient safety education to pharmacy students is an effective educational method. Evaluation of additional educational methods are needed to determine the most effective method of incorporating patient safety into curriculum of pharmacy programs. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. World Health Organization. WHO Multi-professional Patient Safety Curriculum Guide. 2011. Web site. http://www.who.int/ patientsafety/education/curriculum/en/index.html. Accessed October 21, 2015. 2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1): 29-34.

120 3. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564. 4. Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System Free Executive Summary. Washington, D.C.: National Academies Press (US); 2000. 5. Colleges Association of American Medical. Report V: Contemporary issues in medicine: Quality of care. 2001. Web site. http:// faculty.ksu.edu.sa/hisham/Documents/Medical%20Education/ English/Medical%20Education/16.pdf. Accessed October 21, 2015. 6. American Council for Pharmacy Education. Accreditation Standards and Guidelines Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. 2015. Web site. https://www.acpe-accredit.org/pdf/Standards2016 FINAL.pdf. Accessed October 21, 2015. 7. Warholak TL, Holdford DA, West D, et al. Perspectives on educating pharmacy students about the science of safety. Am J Pharm Educ. 2011;75(7):142-147.

Journal of Pharmacy Practice 30(1) 8. Holdford DA, Warholak TL, West D, et al. Teaching the science of safety in US colleges and schools of pharmacy. Am J Pharm Educ. 2011;75(4):77-84. 9. Schafer JJ. A root cause analysis project in a medication safety course. Am J Pharm Educ. 2012;76(6):116-121. 10. McCulloh R, Dyer C, Gregory G, et al. An interprofessional course using human patient simulation to teach patient safety and teamwork skills. Am J Pharm Educ. 2012;76(4):176-186. 11. Sukkari SR, Sasich LD, Tuttle DA, et al. Development and evaluation of a required patient safety course. Am J Pharm Educ. 2008;72(3):65-72. 12. Kiersma ME, Plake KS, Darbishire PL. Patient safety instruction in US health professions education. Am J Pharm Educ. 2011; 75(8):162-173. 13. Vyas D, Bhutada NS, Feng X. Patient simulation to demonstrate students’ competency in core domain abilities prior to beginning advanced pharmacy practice experiences. Am J Pharm Educ. 2012;76(9):71-80.

Perceived Benefit of Teaching Patient Safety to Pharmacy Students by Integrating Classroom Teaching With Introductory (IPPE) Visits.

Ensuring a culture that prioritizes and implements patient safety requires educating all future health care professionals to prepare them for their ac...
131KB Sizes 2 Downloads 7 Views