REVIEWARTICLE

To the Point: Integrating Patient Safety Education Into theObstetrics and Gynecology Undergraduate Curriculum

Jodi F. Abbott, MD,* Archana Pradhan, MPH, MD,† Samantha Buery-Joyner, MD,‡ Petra M. Casey, MD,§Alice Chuang, MD,|| Lorraine Dugoff, MD,¶ John L. Dalrymple, MD,** David A. Forstein, DO,††Brittany S. Hampton, MD,‡‡ Nancy A. Hueppchen, MSc, MD,§§ Joseph M. Kaczmarczyk, DO,||||

Nadine T. Katz, MD,¶¶ Francis S. Nuthalapaty, MD,*** Sarah Page-Ramsey, MD,††† Abigail Wolf, MD,‡‡‡Amie J. Cullimore, MSc, MD,§§§ and for the APGO Undergraduate Medical Education Committee

Abstract: This article is part of the To the Point Series prepared by theAssociation of Professors of Gynecology and Obstetrics UndergraduateMedical Education Committee. Principles and education in patient safetyhave been well integrated into academic obstetrics and gynecology prac-tices, although progress in safety profiles has been frustratingly slow. Med-ical students have not been included in the majority of these ambulatorypractice or hospital-based initiatives. Both the Association of AmericanMedical Colleges and Accreditation Council for Graduate Medical Educa-tion have recommended incorporating students into safe practices. The Ac-creditation Council for GraduateMedical Educationmilestone 1 for enteringinterns includes competencies in patient safety. We present data and initia-tives in patient safety, which have been successfully used in undergraduateand graduate medical education. In addition, this article demonstrates howusing student feedback to assess sentinel events can enhance safe practiceand quality improvement programs. Resources and implementation toolswill be discussed to provide a template for incorporation into educationalprograms and institutions. Medical student involvement in the culture ofsafety is necessary for the delivery of both high-quality education andhigh-quality patient care. It is essential to incorporate students into the ongo-ing development of patient safety curricula in obstetrics and gynecology.

Key Words: patient safety, medical education, quality improvement,learning from errors

(J Patient Saf 2016;00: 00–00)

Aculture of patient safety has never been more present in healthcare and medical education. Patient safety initiatives in health

care facilities are very visible. Hand washing initiatives, surgicalchecklists, standardization of emergency overhead page codes,restriction of elective inductions and cesarean deliveries before39 weeks of gestation are just a few. In 2009, the World HealthOrganization (WHO)1 published a patient safety curriculum formedical students that it implemented at 10 medical schools in9 countries (Table 1). In 2010, a report using data from the

From the *Boston University School of Medicine, Boston, Massachusetts;†Rutgers-Robert Wood JohnsonMedical School, New Brunswick, New Jersey;‡Virginia Commonwealth School ofMedicine Inova Campus, Fairfax, Virginia;§Mayo Clinic School of Medicine, Rochester, Minnesota; ||University of NorthCarolina School of Medicine, Chapel Hill, North Carolina; ¶Perelman School ofMedicine University of Pennsylvania, Philadelphia, Pennsylvania; **HarvardMedical School, Boston, Massachusetts; ††University of South Carolina Schoolof Medicine Greenville, Greenville, South Carolina; §§Johns Hopkins School ofMedicine, Baltimore, Maryland; ||||Philadelphia College of Medicine, Philadelphia,Pennsylvania; ¶¶Albert Einstein College of Medicine, New York City, New York;***University of South Carolina School of Medicine Greenville, Greenville,South Carolina; †††University of Texas Health Science Center San Antonio,San Antonio, Texas; ‡‡‡Kimmel Medical College -Thomas Jefferson University,Philadelphia, Pennsylvania; and §§§McMaster University, Ontario, Canada.Correspondence: Jodi F. Abbott, MD, 30 Newbury Park, Needham MA 02492

(e‐mail: jabbott@bu.edu).The authors disclose no conflict of interest.Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

J Patient Saf • Volume 00, Number 00, Month 2016

Association of American Medical Colleges (AAMC) CurriculumManagement and Information Tool found that only 10.4% ofmedical schools documented patient safety/quality improvement(PS/QI)–specific content.2 The AAMC has stressed that the needfor faculty development in patient safety is critical for the educa-tion of our future physicians. In January 2013, the AAMC studentgroup, Teaching for Quality, published the report of an expertpanelwith a planned schedule for the integration of PS/QI into un-dergraduate medical curriculum.3 In November 2013, the AAMCpublished a draft of the Core Entrustable Professional Activities(EPA) for Entering Residency,4 which is a description of activitiesthe undifferentiated postgraduate year 1 should be expected to per-form independently at the start of internship without supervision.Despite the increased visibility and drivers for patient safety edu-cation, limited evidence exists with respect to the implementationof patient safety curricula, assessment of the curricula, or howtranslation of learning into practice might occur. The purpose ofthis article was to review what evidence, relevant to obstetricsand gynecology (Ob/Gyn), exists to support the implementationof patient safety into undergraduate medical education and pro-vide potential curricular resources.

In 2013, the Accreditation Council for Graduate MedicalEducation (ACGME) charged residency programs to movetoward competency-based education. They termed this initia-tive the Milestones Project.5 They defined the milestones as“competency-based developmental outcome expectations thatcan be demonstrated progressively by residents and fellowsfrom the beginning of their education through graduation to theunsupervised practice of their specialty.”Amilestone level 1 com-petency is defined as those attitudes, knowledge, skills, and be-haviors that are expected of an entry-level postgraduate year 1.Thus, they assume that a graduating medical student will haveattained at least this level of competency. In 2013, the milestonesfor Ob/Gyn were published on the ACGME Web site6 and in-cluded patient safety competencies. This article is intended to pro-vide examples of valid reliable assessment tools, which whenavailable, can facilitate meeting this milestone.

METHODS

Patient Safety in Undergraduate EducationMultiple publications6–8 exist describing various curricula

for teaching patient safety to medical students. What is lackingin the literature are outcome studies demonstrating that a specificcurriculum produces a change in student behavior. We conducteda literature review using level 1 milestone competencies in patientsafety. Search terms included patient safety, teamwork, harm, in-fection control, universal precautions, aseptic technique, medicaleducation, medical student, learning from errors, root cause

www.journalpatientsafety.com 1

TABLE 1. World Health Organization Patient Safety MedicalSchool Curriculum Topics1

1. What is patient safety?2. What are human factors, and why is it important to patient safety?3. Understanding systems and the impact of complexity on patient care4. Being an effective team player5. Understanding and learning from error6. Understanding and managing clinical risk7. Introduction to QI methods8. Engaging patients and caretakers9. Minimizing infection through improved infection control10. Patient safety and invasive procedures11. Improving medication safety

Abbott et al J Patient Saf • Volume 00, Number 00, Month 2016

analysis, informed consent. The following is a summary of resultsand best practices identified.

RESULTS

Systems-Based Practice

TeamworkIn 2009, Lerner et al9 published a review of the literature ex-

amining teaching teamwork in medical education. In the review,they defined the meaning of team and the science of teamwork.They drew examples from medicine, aviation, and business. Theauthors stressed the importance that teamwork be taught at anearly stage in medical education and provided examples of wherethe knowledge, attitudes, and behavior of teamwork are practicedin undergraduate medicine. For example, the authors explainedhow problem-based learning requires that student work togetherto explore an area of health care so that ultimately, all membersof a tutorial group are comfortable with the learning objectives.This requires the group to listen carefully to the contributions ofeach member and provide feedback to each other. Lerner et al de-scribed how team-based learning in undergraduate education pro-motes working toward a common goal such that the entire team isevaluated.7 The authors were unable to identify any outcomes datato examine whether the skills learned in problem-based learningor team-based learning translate into improved effectivenessworking in a health care team later. Team training curricula haveevaluated the learners in debriefing sessions, facilitated reflection,pretest/posttest evaluation designs. Interprofessional education(IPE) involves bringing learners from a variety of areas such asnursing, pharmacy, midwifery, and medicine in an attempt to helpeach better understand the importance of communication andteamwork. The Institute of Medicine has called for broadeningthe use of IPE in foundational and clinical training for healthprofessions students, as well as proposals of how to addressoutcomes.10 Kyrkjebø et al11 and Brock et al12 both evaluatedfocused IPE teamwork sessions to assess communication effec-tiveness and learner satisfaction and both found increased ap-preciation for integrated simulations and training in effectivecommunication. Costa et al13 have indicated, however, that forIPE to be successful, it may be important to begin this type ofcurricula early in training as understanding and attitudes towardthis type of learning may decline with time. In the arena of assess-ment, Lerner et al reviewed the literature and concluded that teamskill development required dynamic, interactive context.

Although traditional labor and delivery teams training hasbeen widely used in inpatient units and shown to be effectiveas a patient safety intervention (as discussed earlier), it is

2 www.journalpatientsafety.com

generally not practical to require a complete teams trainingcourse for clerkship students rotating only 4 to 6 weeks througha department. Providing students with team communication toolsinvolves teaching knowledge of the language of the system, theability to use these tools in stressful situations, and their integra-tion into the collaborative goal of successful completion of a taskunder pressure. Simulations involving these criteria can be eitherhigh or low fidelity but are ideally interprofessional and can belimited by time or resources.14 There are multiple Web-based re-sources for this type of activity.15,16 When an element of analysisof each team's effectiveness is included in the educational process,the team communication workshop can also be used to teach a QIprinciple such as establishing measures. When public health,nursing, or physician assistant students are included in the work-shop, perspectives of other professionals can be used, and corre-lations with process effectiveness can be better framed. Safetransitions are now a focus of both medical student and residenteducation. There are many resources developed to teach theseskills,17 but none is published specific to Ob/Gyn. For students,it is important to frame sign-outs as safe transitions and to includethe students in understanding the tools (e.g., spreadsheets, tem-plates, electronic patient database) used in each department tostreamline interprofessional communication.

Patient Care

Universal PrecautionsLittle literature exists on what effective curricular methods

can be used to teach universal precautions. Certainly, medicalstudents in Ob/Gyn are in situations where they are at risk ofbeing exposed to bodily fluids. Patterson et al18 conducted asurvey of medical students at their institution. Of the 146 respon-dents, 30% reported needle stick injuries, most of which occurredin the operating room. Askew19 (2007) performed a retrospectivechart review of self-reports of exposure to blood and body fluidin health professions students from 2001 to 2005 at 2 Virginiamedical schools. In the population of medical students, there were68 reports of exposure. The majority of the exposures were fromneedle stick and sharps injuries (80.9%), with 52.9% of the inju-ries occurring in the operating room. Jeffe et al20 recognized theimportance of skills training in universal precautions. They per-formed a prospective study evaluating a skills program for pre-clinical medical students. Second-year medical students weregiven a 45-minute lecture on occupational exposure and riskreduction. They then had 2.5 hours of hands-on skill training.Third-year students acted as the control group where they re-ceived the usual 30-minute lecture on infection control. Fourth-year students served as historical controls. The experimentalgroup and all third-year students received a baseline survey, andat 1 year, follow-up surveys were distributed. Baseline responserates were for the experimental group, third-year controls, andfourth-year historical controls (96%, 70%, and 58% respectively),with a follow-up response rate of 81% for the experimental groupand 72% for the third-year controls. Results showed that theirknowledgewas only different between the control and experimen-tal group when baseline scores were controlled (the experimentalgroup had a higher knowledge base before the intervention).There was no change in knowledge base from baseline tofollow-up with the experimental group. What the study did sug-gest, however, was a difference in practice. The second-year exper-imental group was more likely to double glove, wear protectiveeyewear, dispose of sharps, and report exposures compared withthe third-year control group. Observations of the second-yearstudents were undertaken in the operating room at baseline andat follow-up. Students double-gloved more often at follow-up

© 2015 Wolters Kluwer Health, Inc. All rights reserved.

J Patient Saf • Volume 00, Number 00, Month 2016 Obstetrics and Gynecology Undergraduate Curriculum

compared with baseline (relative risk, 1.95; 95% confidence inter-val, 1.06–3.59), but the use of protective eye equipment did notsignificantly change (relative risk, 1.17, 95% confidence interval,0.62–2.12). Kobets et al report that at their institution, medical stu-dents meet with key faculty members at orientation and again justbefore starting clerkships.21 Key concepts in universal precautionsare reviewed and postexposure management is discussed. Studentsare then given a laminated card for reference. The authors surveyedgraduating students about their experiences in the clinical years.Two hundred forty-five students were surveyed with a 92% responserate. Eighty-two students reported exposure that is similar to otherreports. Eighty-two students (57%) reported the exposure, and52 (56%) had their laminated reference with them at the time ofexposure. Fifteen students obtained postexposure therapy. Ofthose who did not report exposure, the most common reasonswere low risk exposure, a sense of embarrassment, and perceiveddifficulty in obtaining appropriate care. The authors conclude thatmore education around postexposure care be provided in medicaleducation, in addition to educating faculty and residents aboutencouraging medical students to report injury/exposure and seek-ing postexposure care.

Aseptic TechniqueIn the last 5 years, there has been an ever-increasing aware-

ness of the need for aseptic techniques including hand washing.Mittal et al22 used an innovative method to impress on medicalstudents the importance of proper hand washing and asepsis be-fore performing urinary catheterization. They used a germ simula-tion exercise using a safe nontoxic product that simulated bacterialload to help reenforce proper hand-washing techniques. Seventy-five clinical clerks with no previous experience or training in uri-nary catheterization were recruited to the study and were trainedusing the simulation. Junior residents credentialed for catheteriza-tion served as controls. Sixty-four of the clinical clerks agreed tohave their asepsis scores compared with the control group of 21junior residents. The simulated germs were used to quantify handwashing and maintenance of asepsis during urinary catheteriza-tion. Students performed equally as well at baseline when com-pared with the residents. Students maintained better sterility andhad a higher proficiency score during catheterization. The simula-tion was rated highly, and 97% of the students felt that they wouldpay more attention to hand washing. Jackson et al23 determinedthe effectiveness of teaching Aseptic Non-Touch Techniques tomedical students and then sought to find out what factors were in-volved in medical students failing to learn the skill. They foundthat performance significantly deteriorated after 7 to 10 weeks.Student questionnaires and semistructured interviews suggestedthat there were a variety of reasons for the decline. These includeda focus on assessment, poor role modeling by staff, lack of re-sources at site, acceptance of hierarchy, and lack of belief in theaseptic techniques taught. The authors suggested that when teach-ing asepsis, educators must consider factors such as the hiddencurriculum and informal education, not just the formal teaching.

Patient PositioningLittle information exists on formal or informal teaching of

appropriate patient positioning to postgraduate or undergraduatemedical trainees. Yet, the ACGME has included this area of patientsafety in theMilestones Project—gynecology technical skills: lapa-rotomy (e.g., hysterectomy, myomectomy, adnexectomy)—patientcare (level 1). Akhtar et al24 expressed the lack of formal curriculafor medical trainees. The authors surveyed the colleges of sur-gery in the United Kingdom and confirmed their suspicions.Patient positioning is taught informally as part of the Ob/Gyn

© 2015 Wolters Kluwer Health, Inc. All rights reserved.

apprenticeship model in postgraduate training. Schweitzer et al25

described an electronic resource for reference in the operatingroom. The referencewas developed for nurses and operating roomtechnicians who may not always be familiar with setups for emer-gency procedures such would be the case for weekends or nighttime cases. They described the development of the resourcefor surgical cases such as laparoscopic vaginal hysterectomy.Using power point slides, the user can quickly review setupand patient positioning methods for specific cases. Te Linde's Op-erative Gynecology described appropriate patient positioning for avariety of gynecologic surgeries26 and Gendy described the impor-tance of positioning and possible complications arising from im-proper patient positioning during gynecologic laparoscopy.27 Schiffand Lim28 reported on a study in which she gave resident groups achecklist on patient positioning before a simulation of laparoscopicsurgery positioning. The residents used a technique called mentalpreparedness to anticipate how to use teamwork to raise awarenessof patient safety issues when positioning for laparoscopic surgery.

Practice-Based Learning and ImprovementIn terms of patient safety and undergraduate medicine,

practice-based learning and improvement includes the student'sability to become a lifelong learner, his or her integration of con-structive feedback, and the skill of self-evaluation. There are avariety of ways that these competencies can be integrated intothe undergraduate curriculum, and one such example would bethe morbidity and mortality (M&M) conference. Every residencytraining program has an ACGME mandated M&M conference atwhich residents present; many, but not all, departments allowmedical students to attend. Because the purpose of theM&M con-ference is to review clinical cases to identify sources of error andto learn from complications, it is the perfect venue to include in athoughtful medical student curriculum. If your school does not in-clude an overview of systems-based practice, a framework isneeded for medical students to benefit from the case discussions.The literature from other specialties provides numerous discus-sions of how best to structure M&M conferences to maximizeresident insight into the purpose of their presentations, somefocusing on systems-based practice29,30 and others focusing onidentification of more general causes of error.30 The Universityof Colorado31 proposed the use of an educational template for res-idents combined with the use of a checklist used by trainees dur-ing the conference to assess the ability of the presenting residentto successfully identify the issues and to frame the discussion.Another proposed method is a curriculum that includes didacticinformation, a flow sheet for students to use during the confer-ence, and is followed by a debrief with a faculty member. Thisprocess allows the students to become active learners who willlearn both the principles and process of how cases are evaluatedalong with the opportunity to review language, chronology, orstandards not understood during the meeting. Faculty can assessstudent comprehension of the content and the process in a non-threatening environment.

Root cause analysis and/or process mapping can both be par-ticularly valuable as part of an Ob/Gyn curriculum because manyunplanned clinical events in our field can be characterized asevents with rapidly changing clinical scenarios with incompleteinformation, rapid decision making, and myriad possibilitiesfor miscommunication, potentially leading to devastating con-sequences. The introduction of both the concepts and methods forroot cause can be performed in several ways. The Institute forHealthcare Improvement Open School32 has online learning mod-ules available without cost to medical students, and the moduleshave become a required component of many medical schools'

www.journalpatientsafety.com 3

TABLE 2. Institute for Healthcare Improvement Open SchoolModules32

Improvement capabilityFundamentals of improvementThe model for improvement: your engine for changeMeasuring for improvementPutting it all togetherThe human side of QIPatient safetyIntroduction to patient safetyFundamentals of patient safetyHuman factors and safetyTeamwork and communicationRoot cause and systems analysisCommunicating with patients after adverse eventsIntroduction to the culture of safetyPartnering to heal: teaming up against health care–associatedinfections.

Preventing pressure ulcersLeadership

Becoming a leader in health carePerson- and family-centered careDignity and respectA guide to shadowing: seeing care through the eyes of patients andfamilies

Having the conversation: basic skills for conversations about end-of-life care

Quality, cost, and valueAchieving breakthrough quality, access, and affordability

Triple aim for populationsIntroduction to population healthImproving health equity

Graduate medical educationWhy engage trainees in quality and safety?A guide to the clinical learning environment review (CLER) programThe faculty role: understanding and modeling fundamentalsof safety

The role of didactic learning in QIA roadmap for facilitating experiential learning in QIAligning graduate medical education with organized learning in QIFaculty advisor guide to the Institute for Healthcare ImprovementOpen School QI Curriculum

Abbott et al J Patient Saf • Volume 00, Number 00, Month 2016

PS/QI curricula.33 The available modules are shown in Table 2.After mastering the didactic aspects of root cause analysis, a1-or 2-session review with the students and either a “local” case(adapted from your department) or one published or devised forteaching purposes can be used.34 The Harvard Risk ManagementFoundation Video “First do No Harm,”35 a video adaptation of aseries of obstetric sentinel events, is a compelling and memorabletool for the students. After reviewing or being presented with thedidactic material, the students view the video (or read the case)and work through a root cause analysis in large or small groupswith discussion of potential interventions. An evaluation of thegroup's ability to apply the principles to the case can also be usedto assess their understanding of this method.

ProfessionalismIt is beyond the scope of this article to review the literature on

professionalism. Jha et al36 in their systematic review of studies

4 www.journalpatientsafety.com

evaluating professionalism assessment described the strengthand weakness of each assessment tool regarding their psychomet-ric attributes. The inherent value of professionalism education iscritical to ensure incorporation of patient safety methods into un-dergraduate education.

Interpersonal and Communication SkillsFailures in communication arewell-known to be the root cause

of sentinel events in obstetrics.37,38 Although the importance ofeach teammember contributing his or her expertise to avoid patientharm is a well-known requirement of a safe workplace, compari-sons between pilots' (>90%) and surgeons' (<50%) affirmative re-sponses to the statement, “Junior staff should be able to questionsenior staff decisions,”39 revealed an underlying cultural barrier tosafety in the medical community. The term “authority gradient”has been used in aviation and medical fields to describe communi-cation errors in stressful situations that occur because of differencesin the experience, perceived expertise, or authority in a team. Thereare several examples in the literature, including Ob/Gyn, describinghow dismissal of resident input has led to negative patient out-comes.40,41 Lucien Leape, in a recent review, suggested that thearrest of progress in improving patient safety parameters is due toa persistent culture of disrespect in medicine.42 An ideal cultureof safety requires active participation and communication of allteam members.43 If students feel a perceived (or real) repercussionto their participation in communication when clinical situations aretense, they will be less likely to contribute an important perspectiveto the care of the patient, potentially failing to prevent medical error.It is well documented that physicians who are poor communicators(as reported by patient complaints) are more likely to be involved inboth medical errors and malpractice suits.44,45 Leape pointed outthat disrespect is a learned behavior and, if not identified and ad-dressed among faculty, it will continue in an institution over timeand potentially compromise patient safety.46 Departmental leader-ship and patient safety officers may not perceive the value ofstudent observations of the hierarchy. Medical students, eithernew to clinical teams or advanced clerks, may not be engagedin team communications if they feel their perspective is notexpected or respected. Safe organizations have been shown toprioritize and value transparency and mutual respect.43 Clerkshipdirectors, PS/QI officers, residents, and faculty need to make clearhow and when students can appropriately add to team communi-cations and to make sure that all team members are receptive toinput from students as junior colleagues. Role-playing exerciseswith students and faculty to simulate clinical scenarios in whichstudent input is vital to safe care are one opportunity to demon-strate departmental commitment to open communication in clini-cal settings. Student evaluations of their rotation should includeassessment of team and educator communication skills withopen-ended questions to allow feedback on observed or experi-enced mistreatment during the rotation. Student reports of disre-spect from team members toward patients, residents, or studentsshould be taken seriously by leadership as an opportunity to iden-tify “near misses” regarding patient care. Involvement of institu-tional resources such as QI or medical staff offices should beconsidered a necessity in maintaining an environment safe for pa-tient care.

As women's health advocates, Ob/Gyn educators are wellaware of the importance of prioritizing communication withtheir patients, but as the structure of hospital-based care andlength of stay have changed, students may no longer be presentfor office visits when surgical care plans and surgical consents arediscussed. If it is not feasible to include students in difficult pa-tient discussions, using simulated cases with students exploring

© 2015 Wolters Kluwer Health, Inc. All rights reserved.

TABLE

3.Pa

tient

Safety,A

CGMECom

petenc

ies,Mileston

e1,

APG

OUnd

ergrad

uate

Med

icalStud

entsObjectiv

es,a

ndPo

ssibleClerkship

IntegrationExercises

ACGMECom

petency

Patient

Safety

Mileston

e1

EPA

ActivityTop

icAPGO

Medical

Stud

ent

ObjectivesEdu

cation

alTop

ics

Possible

Instructiona

lMetho

dPossible

Assessm

entTool

System

s-basedpractice

Team

work

9.Participateas

acontributin

gandintegrated

mem

ber

ofateam

5Simulationandlecture

Team

OSC

ETeam

-based

learning

Group

debriefusingchecklist

IPE

Patient

Care

Universalprecautio

nsAseptictechnique

Patient

positio

ning

13.E

ngagein

daily

safety

habits

41(B)

Directo

bservatio

nObservedcompetency

Simulationof

positio

ning

for

differentcases

Team

OSC

EGroup

debriefchecklist

Practice-basedlearning

andim

provem

ent

Criticalappraisalo

ftheliterature;

demonstratesresponsiveness

tofeedback;systemsapproach

tomedicalerrors

7.Form

clinicalquestio

nsand

retrieve

evidence

13.Identifysystem

failu

res

andcontributeto

acultu

reof

safety

andim

provem

ent

5JournalC

lubcurricula;case-based

teaching;M

&M

modules

andcase

discussion;root

causeanalysis

OSC

Eallowingaccess

ofresources;evaluatio

nof

EBM

presentatio

n

Professionalism

Accountability,respectfor

patient

autonomy,wom

en's

health

advocacy

1–13

1,2,10

(I),32(E)

1,2,34(A

),56(A

),57(A

)36(A

)

Roleplays,simulations,

selfreflectio

n360evaluatio

n,includingpeers

Interpersonaland

communicationskills

Inform

ationgatheringandsharing

Relationshipdevelopm

ent

Inform

edconsent

8.Giveapatient

handover

11.O

btaininform

edconsent

1,2,32(E),41(E)

1,2,5,57,58(C)

4,23(F),32(A

),41(A

)

Simulations

andclinical

transitio

nsof

care,Informed

consentw

orkshops

Team

OSC

E,clin

ical

competencytool,g

roup

debriefOSC

EMedicalknow

ledge

Cost-effectivecare

4.Enter

anddiscusspatient

ordersandprescriptio

nUse

ofEHRsimulations,

interprofessionalw

orkshops,

modules

EHROSC

E,clin

ical

competencyassessment

EBM

indicatesEvidenceBased

Medicine;EHR,E

lectronicHealth

Record;

OSC

E,O

bservedStructured

Clin

icalExam.

J Patient Saf • Volume 00, Number 00, Month 2016 Obstetrics and Gynecology Undergraduate Curriculum

© 2015 Wolters Kluwer Health, Inc. All rights reserved. www.journalpatientsafety.com 5

Abbott et al J Patient Saf • Volume 00, Number 00, Month 2016

treatment options and informed consent can allow more engage-ment of students. Online modules for scenarios are available atthe Institute for Healthcare Improvement Web site. Competencyin counseling patients under the supervision of faculty in com-mon scenarios (i.e., contraceptive methods) requires the studentto demonstrate aspects of expected medical knowledge as wellas principles of autonomy. When unplanned outcomes occur andare discussed with patients and families, students have often been“left in the hallway” during these sensitive conversations. As thecurrent standard of The American Congress of Obstetricians andGynecologists is transparency in communicating errors to pa-tients, role-playing disclosures in structured clinical encountersor simulations can identify the trainee's ability to demonstratethese skills.

Informed ConsentThe AAMCproposes that all entering interns be able to dem-

onstrate competence in obtaining informed consent in procedurescommon to their entering specialties. Although there is a lack ofoutcomes data regarding their effectiveness, models of teachinginformed consent exist. The WHO curriculum provides an ap-proach to teaching informed consent in topic 8, engaging withpatient and caretakers. Bassuner and Fleming47 described a caseof resident-student mentoring whereby both the resident and themedical student together obtain consent from a patient. Theysuggested that while the student is able to learn and practicethe skill of obtaining consent, legal and ethical obligationsare still met. Two modules for teaching informed consent existon MedEdPORTAL. Doyle48 provided a framework of the neces-sary components to be included in a patient safety curriculum,whereas Diemer49 provided a module for using standardized pa-tients to teach informed consent and multiple-choice questionsto assess student's knowledge. In the future, work in this areashould include outcome data for translation into practice.

Safe Prescribing and Medication SafetyThis topic is not specifically delineated in the ACGME com-

petencies; however, it is identified in the EPA of the AAMC andthe WHO Patient Safety Curriculum for Medical Schools. Karpaand Haidet presented medication reconciliation clinical cases.50

The students enrolled in the study showed no difference at base-line; however, students in the intervention group (those who par-ticipated in the reconciliation module) demonstrated improvedability to identify medication problems in the order sets. Rossand Maxwell51 provided an excellent review of the literature inwhich they reviewed some on the challenges of teaching prescrib-ing as well as proposed a possible curriculum for clinical pharma-cology and prescribing. The WHO curriculum provides anindependent module on medication safety that is available to allmedical schools.

CONCLUSIONSGiven the mandate of the WHO, AAMC, and the ACGME

Milestones Project to address patient safety and QI in undergrad-uate medical education, it is imperative that medical educatorsmove to consciously label the curriculum for medical students,who may not recognize components of safe practice in clinicalcare. For patient safety curricula to be successfully implementedinto undergraduate medical education, there needs to be opencommunication with senior educational leadership, clerkship di-rectors from core specialties, and quality officers in each depart-ment. Table 3 provides medical educators a summary of theAAMC, ACGME Milestones, the Association of Professors ofGynecology and Obstetrics (APGO) Medical Student Objectives

6 www.journalpatientsafety.com

for patient safety and provides suggested teaching and assessmentmethods. Faculty development is critical in the process. Demon-strating to faculty the importance of including students in teambuilding, revealing how the authority gradient can negatively im-pact patient care, and modeling strategies in disclosure to patientswill strengthen each academic department and the curriculum. Asa specialty, Ob/Gyn has a unique setting to address multiple areasof patient safety medical education. Future directions in medicalstudent education in patient safety should focus on the evaluationof curricula and student proficiency in this area.

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3. Headrick L, Baron R, Pingleton Skeff K, et al. Teaching for QualityImprovement and Patient Safety Across the Continuum of MedicalEducation Report of an Expert Panel. Baltimore, MD: Association ofMedical Colleges; 2013.

4. Flynn T, Call S, Carraccio C, et al.Core Entrustable Professional Activitiesfor Entering Residency (CEPAER). Baltimore, MD: Association ofAmerican Medical Colleges, 2013.

5. ACGME Outcomes Project. Available at: http://www.acgme.org/acgmeweb/tabid/259/GraduateMedicalEducation/GraduateMedicalEducationDataResourceBook.aspx. AccessedSeptember 2, 2015.

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