Key Performance Outcomes of Patient Safety Curricula: Root Cause Analysis, Failure Mode and Effects Analysis, and Structured Communications Skills

By Fassett, William E. | American Journal of Pharmaceutical Education, October 2011 | Go to article overview

Key Performance Outcomes of Patient Safety Curricula: Root Cause Analysis, Failure Mode and Effects Analysis, and Structured Communications Skills


Fassett, William E., American Journal of Pharmaceutical Education


The 1995 background papers of the Commission to Implement Change in Pharmaceutical Education set forth key elements to train pharmacists capable of participating in the healthcare system of the future. (1) Yanchick demonstrated that the broad competency categories identified in background paper 52 aligned well with the 2003 recommendations of the Health Professions Education Summit, which called for all health professionals to be able to demonstrate proficiency in delivering patient-centered care, working in interdisciplinary teams, employing evidence-based practice, applying quality improvement approaches, and using informatics. (3) As pharmacy programs establish coursework to prepare student pharmacists to participate in patient safety and quality improvement activities, both knowledge-based outcomes and performance outcomes must be developed. This paper discusses 3 performance outcomes that should be included and assessed at the course level to ensure that pharmacists on health care teams are able to effectively implement quality assurance programs and communicate patient safety concerns. Two of the competencies deal with widely-adopted formal approaches to assessing or predicting potential medical errors: root cause analysis (RCA) and failure mode and effects analysis (FMEA). The third competency is the ability to effectively use situational briefing formats; specifically, the Situation-Background-Assessment-Recommendation (SBAR) model, which is becoming the primary format for communication among nurses, physicians, and other health care providers regarding specific patient care situations.

RESIDENCY COMPETENCIES AS GUIDES FOR A PATIENT SAFETY CURRICULUM

In response to the growing awareness of morbidity and mortality arising from medical errors, and to the recommendations of the Health Professions Education Summit, health professions residency directors have increased their programs' attention to patient safety skills and behaviors. The Accrediting Council on Graduate Medical Education (ACGME) has established 6 core competencies that should form the basis of medical residency training: patient care, medical knowledge, practice-based learning, communication, professionalism, and system-based practice. (4) Patient safety competencies are imbedded in each of these areas.

Two reports have examined specific performance outcomes that should be included in a medical residency. A needs assessment for a patient safety curriculum for residencies at the Mayo School of Graduate Medical Education surveyed the medical directors and key informants in 8 of the school's largest specialty programs. (5) Four content areas were identified as critical by all of the programs: training the resident to explicitly seek help when in doubt; achieving residents' understanding of the role of fatigue in medical error; life support skills; and sentinel event reporting and management.

Faculty members from the schools of medicine, nursing, and pharmacy at the State University of New York Buffalo developed the following patient safety performance objectives, which correspond to the 6 ACGME competencies, for their family medicine residency program (6):

* Patient care: (a) recognize and understand team behaviors that strengthen/weaken patient safety; (b) Incorporate effective team behaviors into their practices

* Medical knowledge: (a) recognize and analyze inappropriate prescribing in elderly patients; (b) practice appropriate prescribing for elderly patients

* Practice-based learning: (a) identify errors in their practices, analyze them, and learn from them; (b) develop system-based strategies to prevent recurrence of errors

* Communication: (a) recognize and understand communication behaviors that strengthen/weaken patient safety; (b) incorporate effective communication behaviors into their practices

* Professionalism: (a) understand ethical and legal issues surrounding error disclosure; (b) provide appropriate disclosure to patients when errors occur

* System-based practice: (a) identify and prioritize vulnerabilities in their practice systems; (b) develop and implement system-based solutions to the identified vulnerabilities

The curriculum is divided into 3 modules taught across the 3 residency years. …

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